A Not-So-Simple Thyroid Nodule

A 50-year-old woman presented with a 2-month history of a neck mass that was associated with hoarseness of voice and globus sensation. Physical examination showed thyromegaly (right greater than left) with an approximately 5-cm palpable nodule in the right lobe. There was no tenderness or cervical lymphadenopathy. There was no prior radiation exposure to the head and neck area. Thyroid function test results were normal, and she did not take thyroid medications. A relative had received a diagnosis of papillary thyroid cancer at age 50 years. There was no other pertinent family history, including a history of multiple endocrine neoplasia. Ultrasonography results showed a multinodular goiter with a dominant 4.6-cm right thyroid nodule, 1.6-cm left-sided thyroid nodule, and suspect left level IV lymph node. Ultrasonography-guided fine-needle aspiration biopsy results showed papillary thyroid carcinoma (PTC) (Bethesda VI) with a BRAFV600E variation in the left nodule and lymph node, and atypia of undetermined significance (Bethesda III) with a suspicious Afirma genomic sequence classifier in the right nodule. She underwent total thyroidectomy with modified left lateral neck dissection. Gross examination of the specimen showed a 2.9-cm pale-tan, partially circumscribed, soft nodule in the right thyroid lobe; a 1.4-cm pale-tan, fibrotic, centrally brown nodule in the left lobe; and a 1.8-cm pale-tan, rubbery, partially circumscribed nodule in the isthmus. Histologic examination of the right thyroid lesion was performed (Figure), with ancillary testing.