The follicular thyroid carcinoma (FTC) may present with synchronous metastases. Rarely, the metastatic lesion is the only finding at the time of presentation (as in our case) leading to a diagnostic dilemma. We report an occult metastatic FTC case of a 68-year-old man who underwent excision of a rib tumor 10 years back. The histopathology confirmed the metastatic thyroid carcinoma but clinicoradiological evaluation did not reveal any thyroid nodule. He did not undergo a total thyroidectomy at that time. Now, he presented with pulsatile scalp swelling for 6 months. On examination, he was found to have a solitary thyroid nodule also. Fine needle aspiration cytology from scalp swelling and thyroid nodule demonstrated thyroid cells and follicular neoplasm, respectively, establishing the diagnosis of metastatic follicular thyroid cancer. The radioactive iodine (RAI) is given after total thyroidectomy. Total thyroidectomy followed by RAI is indicated even in cases of occult metastatic follicular thyroid carcinoma.
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