Clinical data: A 57-year-old man was referred for evaluation of an enlarged nodule which was discovered by himself 3 months ago. He was operated on thyroid carcinoma. He was a refugee from the Middle East and he had no medical records. The patient did not remember which type of thyroid carcinoma he was operated on. Except for surgery he got no additional therapy.

Palpation: There were multiple lymph nodes in the left submandibular area.

Functional state: hypothyroidism on daily 75 microgram levothyroxine with TSH 11.9 mIU/L.

Ultrasonography. There was no parenchyma in the thyroid bed. There was a mass in the left submental area while 3 lymph nodes were detected close to each other along the left sternocleidomastoid muscle. One of the latter presented both hyperechogenic patches and coarse calcifications, too. Another one contained microcalcifications. Neither of the nodes presented hilum while the vascularization ranged from avascular to increased.

US-guided aspiration was performed from the submental and from two of the lateral nodes. Cytology resulted in all three cases in metastatic carcinoma.

Serum-calcitonin was 21.9 pM/L (normal value below 3.36).

A modified radical neck dissection including central neck compartment was performed. Histopathology disclosed metastasis of medullary thyroid carcinoma in 11 lymph nodes.