Thyroid nodules are a common clinical problem and the differentiated thyroid cancer is becoming increasingly prevalent. About 10% of patients may present with metastatic disease at initial presentation.

We present a case of a 55-year-old woman with an asymptomatic thyroid follicular neoplasm. The neck utrasound described a 43x17mm, heterogenous, hypoechoic nodule in the left lobe with calcifications, no suspicious lymph nodes. At the consultation, in clinical examination a hard nodule on the left lobe was notticed, so we performed a new ultrasound and this nodule had poorly defined border and a suspicious contact with the trachea, carotid artery and pre-thyroid muscles, and multiple suspicious left neck lymph nodes. The fine needle aspiration biopsy of a lymph node revealed metastatic papillary thyroid carcinoma. The CT scan excluded invasion of the left common carotid arteryand trachea, but diagnosed lung metastasis. The vocal cord evaluation was normal. Thus, we proposed total thyrodectomy and lymph node dissection (levels 2-7).

At the operation day the patient had new complaints of dysphonia. In the surgery we detected invasion of the pre-thyroid muscles, the recurrent laryngeal nerve (RLN) and the muscular layer of the esophagus, all ressected in bloc with the tumor. The patient needed a transient tracheostomy due to paresia of the right RLN. Now she has recovered from the surgery and submited to radioactive iodine therapy.

Our aim was to emphasize the importance of a complete evaluation of these patients because sometimes it's not a simple nodule and the treatment may be complex.