A 71 year old Caucasian female with a remote history of PTC presented with a 2-month history of palpable left-sided neck mass. Physical examination revealed a non-tender mass in the left lateral neck. There were no other abnormalities identified in a full head and neck examination. There was no palpable mass in the thyroid bed. Ultrasonography of the neck revealed an absence of normal thyroid tissue, consistent with patient’s history of distant thyroidectomy, and a solid mass in the left side of the neck superolateral to the expected location of the thyroid, in level III. This inhomogeneous mass appeared vascular and measured 2.8 cm in length by 1.7 cm in diameter. It was not felt to resemble a normal lymph node in ultrasonographic features. Nonetheless, from its appearance and anatomical location, this new mass was initially suspected to represent a lymph node or a carotid body tumour. Computed Tomography (CT) ruled out non-nodal neck pathology, and identified the mass as being consistent with an enlarged lymph node. Again, this study revealed no evidence of recurrence in the thyroid bed, nor other evidence of neoplastic disease. Two fine needle aspiration biopsies (FNAs) were performed. The specimens were cellular and consisted of groups of epithelial cells in flat sheets and papillary-like clusters. The cells showed enlarged nuclei with nuclear grooves and a few intranuclear inclusions. Immunohistochemistry on the cell block was positive for TTF-1 (thyroid transcription factor 1), consistent with cells of thyroid origin. A positron emission tomography (PET) study was performed to rule out distant metastatic disease. Apart from the known mass in the left neck, the PET study showed no other Fluorodeoxyglucose (FDG) avid lesions. Given these diagnostic findings, the patient was scheduled for a left lateral neck dissection after obtaining informed consent. The patient subsequently underwent an uncomplicated left level II-III neck dissection under general anesthesia. A timeline of events is presented in Table. Two of the 10 nodes sent for surgical pathology in the lymphadenectomy specimen returned positive for metastatic papillary thyroid carcinoma of tall cell variant. The larger of the 2 nodes measured 3.5 cm with focal extranodal extension. The patient recovered well from the operation and was seen for follow-up three weeks following the left neck dissection. Given the findings from surgical pathology, it was decided that the patient would benefit from radioactive iodine ablation and the patient was referred for adjuvant therapy.