Clinical presentation: a 58-year-old woman who underwent bilateral thyroid operation 12 years earlier for a benign multinodular goiter. She requested a follow-up examination of a recurrent nodule known for years. She had no complaints.

Palpation: no abnormality.

Functional state: hyperthyroidism with TSH-level 0.01 mIU/L, FT4 41.9 pM/L.

Ultrasonography: the right lobe was hypoechogenic with an echonormal area. There were multiple hypoechogenic and hyperechogenic nodules in the left lobe. The hypoechogenic nodule in the lower pole of left lobe presented increased intranodular blood flow. This lesion was examined cytologically. In contrast with the usual finding in an operated thyroid the vascularization of the extranodular part of the thyroid was increased.

Cytological picture: no colloid in the background. Thyrocytes in small groups predominantly in normofollicles. Thyrocytes present anisonucleosis and vacuolization and oxyphilic metaplasia.

Combined clinical-sonographic-cytological diagnosis: a benign lesion with great probability.

TSAb: yielded elevated level.

Scintigraphy disclosed an autonomously functioning in the left thyroid.

Clinical diagnosis: hyperthyroidism caused by Marine-Lenhart syndrome, i.e. combination of Graves' disease and autonomously functioning nodular goiter. Recurrent multinodular goiter.

In order to avoid repeated surgery, we sent the patient for radioiodine treatment. The isotope therapy could not resolve the hyperthyroidism, therefore the patient underwent surgery.

Histopathology: benign, hyperplastic nodular goiter with extensive oxyphilic metaplasia in the left thyroid. Diffuse hyperplasia in the right lobe.

Comments.

1. The real question is whether this patient may have malignant lesion with high enough probability to suggest a second operation with greater risk. The possibility of Hürthle-cell tumor cannot be excluded on cytopathology. The risk of a papillary cancer is extremely low because of the lack of nuclear atypia. The risk of a follicular variant of oxyphilic cancer is also low because the nodule did not exhibited halo sign or perinodular flow. To summarize: the data we estimated - the risk of a cancer with less than 1:100 chance.
   I am of the opinion that such small risk does not indicate itself surgical provcedure and in such cases the follow-up examinations instead of immediate surgery seems an acceptable suggestion.

2. This case is an excellent example which demonstrates the need for a new diagnostic system. Following the conventional protocol this patient would be operated because the cytological diagnosis cannot be other than suspicion of oxyphilic tumor. After this cytodiagnosis patient had to be operated. If we gave a common clinical-ultrasonographic-cytological diagnosis, the patient would have the chance not to be operated unnecessarily.