Clinical presentation: A 27-year-old woman was referred for aspiration cytology of a thyroid nodule. The patient has been treated for hypothyroidism for six months. On ultrasound multiple nodules including two suspicious were detected. the neck. The patient noticed the tumor first 6 weeks ago.

Palpation: a painless, very hard mass in the left thyroid lobe.

Laboratory examination: TSH 1.08 mIU/L on daily 75 microgram levothyroxine. The aTPO level was 656 U/mL at the time of initiation of replacement therapy.

Ultrasonography. The thyroid was echonormal and contained several hypoechogenic areas. The echogenicity index was around 20%. Two of the discrete areas had punctate echogenic foci. Both were avascular. The right lesion was partly while the left entirely hard on strain elastography.

Cytological diagnosis: suspicion of papillary carcinoma and papillary carcinoma, right and left lesion, respectively.

Histopathology: papillary carcinoma according to both nodules and Hashimoto's thyroiditis in the extranodular part of the thyroid.