A 32-YEAR-OLD WOMAN with fatigue and insomnia reported intermittent neck swelling for 2 years. A 2-cm nodule was palpable in the submandibular area as was a firm 4-cm nodule in the right thyroid lobe. TSH and fT4 were normal. Neck computed tomography showed bilateral cervical and supraclavicular lymph node enlargement (Fig. 1), and a complex mass that replaced most of the thyroid parenchyma extended into the cervical esophagus, trachea, and superior mediastinum. Neck ultrasonography showed multiple cystic intrathyroidal lesions (Fig. 2) with cystic lymph nodes in level II through IV bilaterally. Fine needle aspiration of the largest lymph node yielded cells consistent with papillary thyroid carcinoma. The woman was treated with total thyroidectomy (Fig. 3) followed by radioactive iodine. Although it is not uncommon for papillary thyroid cancer to present as a partly cystic lesion within the thyroid gland, it is rare to see entirely cystic tumors involving both the thyroid and metastases, underscoring the need for careful cytologic evaluation of cystic thyroid lesions.