The solitary thyroid nodule with solid heterogeneous appearance, scattered suspicious microcalcification and taller than wider configuration make the lesion U4/U5 as per 'u scoring' of thyroid nodule recommended by BTA (British Thyroid Association) and certainly required further assessment by FNA/biopsy. Regarding adjacent tiny nodules, differential as per anatomic location could be lymph nodes but having no obvious lymph node characteristics. Satellite thyroid nodules could be another differential due to identical characteristics.  No other lymph nodes identified in the neck on either side.

Micro calcification in metastatic lymph nodes from primary papillary carcinoma is common but the initial appearance was atypical for lymph nodes. Staging CT didn’t show any other cervical or mediastinal lymphadenopathy of significant size nor any lung metastasis.

Pathological specimen:

Right hemithyroidectomy - Lobe of thyroid weighing 42 g and measuring 70 x 50 x 35 mm.  On sectioning much of the surface is composed of a single nodule with colloid-like appearance 45 mm in maximum dimension.

Microscopical examination: The nodule seen macroscopically is a neoplasm composed of papillary structures and colloid filled lakes. The architecture is of a papillary carcinoma. Malignant cells are large with plentiful cytoplasm and pale nuclei with occasional nucleoli. In areas greater than 30% of tumor volume the cells are 3 times is tall as they are wide with.

Nuclear inclusions and nuclear grooves are not evident, but the cells have the classical papillary type pale nuclei. The appearances are those of a papillary thyroid carcinoma tall cell variant. The tall cell variant is considered a more aggressive variant than classical papillary carcinoma and metastatic disease is more frequent.   

Microscopic examination:                                                                                          
2. (Left hemi-thyroid): This is normal thyroid tissue. There is no neoplasia.

3. (Right selective neck dissection):4 out of 39 nodes contained metastatic papillary thyroid carcinoma.                                                                   

 Level     Total         Involved
 IIb           18             1                                       
 III           13             1                                       
 IV             8             2                                       
                                                                      
Summary of right neck dissection:

• total number of nodes: 39                                            
• total nodes involved: 4                                              
• extracapsular extension: no                                          
• diameter of largest node involved: 18 mm (in Level IV)               

                                                                    
Diagnosis:                                                            
Tall cell variant of papillary carcinoma of right lobe of thyroid.
Right neck dissection- 4/39 Metastatic papillary carcinoma; pN1b