Three years prior to present examination (first row of images)

Clinical data: A 36-year-old woman was referred for evaluation of nodular goiter. On evaluation of progressive difficulties in swallowing, palsy of the left recurrent nerve and a nodular goiter was discovered.

Palpation: no abnormality.

Functional state: euthyroidism with TSH 2.87 mIU/L.

Ultrasonography. The thyroid was echonormal and contained small hypoechogenic areas. The echogenicity index was around 20%. There was an echonormal nodule presenting hypoechogenic parts in the right lobe. The presence of halo sign and perinodular blood flow was doubtful, while the intranodular blood flow was increased.

Cytology of the echonormal nodule resulted in benign lesion.

Present examination (second and third rows of images)

Clinical data: The palsy of the left recurrent nerve had spontaneously resolved three months after the previous examination. Hypothyroidism has developed one year after the previous examination and the patient was treated with levothyroxine. She was referred for ultrasound follow-up examination.

Palpation: a firm, enlarged thyroid. The presence of nodule was equivocal.

Functional state: euthyroidism on daily 100 microgram levothyroxine (TSH 0.47 mIU/L).

Ultrasonography. The thyroid became hypoechogenic. The right lobe was composed of large discrete lesions divided by connective tissue. The nodule in question increased in size over the three years. It became hypoechogenic and presented non-specific granules and a few more bright granules. The intrathyroidal vascularization has decreased.

Cytology of the nodule resulted in papillary carcinoma.

Histopathology disclosed papillary carcinoma. The tumor broke the capsule of the thyroid but the extrathyroidal extension was only minimal.

Comment. The tumor contour was abutting. The capsule of the lobe was continuous except for at the medial part of the tumor.