{"product_id":"low-risk-papillary-thyroid-carcinoma-understanding-your-treatment-options","title":"Low-Risk Papillary Thyroid Carcinoma: Understanding Your Treatment Options","description":"\u003cp\u003eMost people diagnosed with papillary thyroid carcinoma (PTC)—the most common form of thyroid cancer—have a low risk of dying from their disease or experiencing a recurrence. This position statement, developed by the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM), presents current evidence-based recommendations that favor less aggressive approaches for carefully selected low-risk patients, including active surveillance (monitoring without immediate surgery), thyroid lobectomy (removing only part of the thyroid) instead of total thyroidectomy, and restricted use of radioactive iodine therapy. The statement details the precise criteria that define low-risk disease, explains changes to the cancer staging system, and provides practical guidance on follow-up strategies that keep patients safe while avoiding unnecessary treatment.\u003c\/p\u003e\n\n\u003ch1\u003eLow-Risk Papillary Thyroid Carcinoma: Understanding Your Treatment Options\u003c\/h1\u003e\n\n\u003ch2\u003eTable of Contents\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\u003ca href=\"#ddn-key-points\"\u003eKey Points\u003c\/a\u003e\u003c\/li\u003e\n\n  \u003cli\u003e\u003ca href=\"#background\"\u003eWhy This Research Matters\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#mortality-risk\"\u003eHow Doctors Assess Risk: The TNM Staging System\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#recurrence-risk\"\u003eUnderstanding Disease Persistence and Recurrence Risk\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#definition\"\u003eWhat Exactly Does \"Low-Risk\" Mean?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#active-surveillance\"\u003eActive Surveillance: Monitoring Instead of Surgery\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#who-eligible\"\u003eWho Can Consider Active Surveillance?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#special-situations\"\u003eSpecial Situations: Family History, Pregnancy, and Other Thyroid Conditions\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#follow-up-as\"\u003eFollow-Up During Active Surveillance\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#implementation\"\u003eBefore Starting Active Surveillance: What Medical Centers Need\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#surgery\"\u003eSurgery: Lobectomy or Total Thyroidectomy?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#rai\"\u003eRadioactive Iodine Treatment: When Is It Really Needed?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#implications\"\u003eWhat These Findings Mean for Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#limitations\"\u003eStudy Limitations\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#recommendations\"\u003eRecommendations for Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#ddn-faq\"\u003eFrequently Asked Questions\u003c\/a\u003e\u003c\/li\u003e\n\u003cli\u003e\u003ca href=\"#source\"\u003eSource Information\u003c\/a\u003e\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003c!-- ddn:keypoints:start --\u003e\n\u003ch2 id=\"ddn-key-points\"\u003eKey Points\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003eActive surveillance is a safe option for many small, low-risk papillary thyroid cancers, especially in patients older than 60.\u003c\/li\u003e\n\u003cli\u003eMore than 90% of patients are now stage I or II, with a cancer-related death risk below 1%.\u003c\/li\u003e\n\u003cli\u003eLobectomy has survival outcomes comparable to total thyroidectomy for low-risk tumors, with lower surgical risks.\u003c\/li\u003e\n\u003cli\u003eSkipping radioactive iodine was as safe as receiving it in a 3-year French study of low-risk thyroid cancer patients.\u003c\/li\u003e\n\u003cli\u003eDuring active surveillance, ultrasound is recommended every 6 months for 2 years, then annually if stable.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c!-- ddn:keypoints:end --\u003e\n\n\n\u003ch2 id=\"background\"\u003eWhy This Research Matters\u003c\/h2\u003e\n\u003cp\u003eThe past decade has witnessed a fundamental shift in how doctors approach papillary thyroid carcinoma (PTC). Instead of a one-size-fits-all treatment plan, physicians now use an individualized approach based on a careful assessment of each patient's specific risk. This change was driven by three developments: increasingly sensitive diagnostic methods, a better understanding of the molecular biology of thyroid cancer, and well-conducted prospective studies that tracked patient outcomes over time.\u003c\/p\u003e\n\u003cp\u003eThese advances have led to the development of risk assessment tools that help doctors predict, early in the course of the disease, which patients are likely to have meaningful outcomes—such as death from the disease or structural disease persistence\/recurrence (the cancer coming back).\u003c\/p\u003e\n\u003cp\u003eThe result is that the majority of patients with PTC are now classified as having a \u003cstrong\u003elow risk of mortality\u003c\/strong\u003e (death) and a low risk of disease persistence or recurrence. For these patients, current treatment recommendations favor \u003cstrong\u003eless invasive and less intensive therapies\u003c\/strong\u003e. This position statement from the Brazilian Society of Endocrinology and Metabolism translates the latest scientific evidence into practical guidance for doctors managing patients with low-risk PTC.\u003c\/p\u003e\n\n\u003ch2 id=\"mortality-risk\"\u003eHow Doctors Assess Risk: The TNM Staging System\u003c\/h2\u003e\n\u003cp\u003eThe first thing patients often worry about after a cancer diagnosis is whether they could die from the disease. To address this concern, doctors use a staging system to predict cancer-specific mortality (the risk of dying from the cancer itself).\u003c\/p\u003e\n\u003cp\u003eThe most widely used system worldwide is the American Joint Committee on Cancer (AJCC) staging system, commonly known as \u003cstrong\u003eTNM\u003c\/strong\u003e—which stands for \u003cstrong\u003eT\u003c\/strong\u003eumor (size and extent of the primary tumor), \u003cstrong\u003eN\u003c\/strong\u003eode (whether the cancer has spread to lymph nodes), and \u003cstrong\u003eM\u003c\/strong\u003eetastasis (whether the cancer has spread to distant organs). The TNM system divides patients by age group and has been shown to perform well compared with other staging classifications.\u003c\/p\u003e\n\u003cp\u003eThe recent \u003cstrong\u003eAJCC 8th edition\u003c\/strong\u003e introduced several important changes that improve the accuracy of predicting disease-specific mortality:\u003c\/p\u003e\n\u003col\u003e\n  \u003cli\u003e\n\u003cstrong\u003eA higher age cutoff.\u003c\/strong\u003e The age threshold at diagnosis was increased from 45 to 55 years. This change was supported by an international multicenter study of nearly 10,000 patients, which showed that age 55 was better at separating patients with stage III versus stage IV disease.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eReclassification of minor extrathyroidal extension (mETE).\u003c\/strong\u003e Minor extrathyroidal extension means microscopic invasion of tissue just outside the thyroid gland that is only detectable under a microscope—not visible during surgery or on imaging. The previous AJCC 7th edition classified any tumor with mETE as T3. However, studies have shown that mETE alone has no influence on disease-free survival or cancer-specific survival. The 8th edition now divides the T3 classification into T3a (tumors larger than 4 cm confined to the thyroid gland) and T3b (tumors with gross extrathyroidal extension, defined as invasion of the strap muscles of the neck).\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eReclassification of mediastinal lymph nodes.\u003c\/strong\u003e Metastatic lymph nodes in the mediastinum (the area between the lungs, known as level VII) were previously not classified as N1a. Now, metastases to these mediastinal lymph nodes are classified as N1a, while N1b is used only for metastatic lymph nodes in the lateral neck.\u003c\/li\u003e\n\u003c\/ol\u003e\n\u003cp\u003eAdditionally, older patients with lymph node disease (N1) are no longer automatically upstaged to stage III or IV disease. Patients with N1 disease who are younger than 55 years are now classified as having stage I disease, while those 55 years or older are classified as stage II.\u003c\/p\u003e\n\u003cp\u003eMultiple publications have demonstrated that, compared with the AJCC 7th edition, the 8th edition \u003cstrong\u003edownstages a substantial number of low-risk patients\u003c\/strong\u003e and provides better separation between stage groups. The practical impact of this is significant: \u003cstrong\u003emore than 90% of patients are now categorized into stages I and II\u003c\/strong\u003e, and their risk of cancer-related death is \u003cstrong\u003ebelow 1%\u003c\/strong\u003e.\u003c\/p\u003e\n\n\u003ch2 id=\"recurrence-risk\"\u003eUnderstanding Disease Persistence and Recurrence Risk\u003c\/h2\u003e\n\u003cp\u003eBecause patients with differentiated thyroid cancer (the most common type) have such low mortality rates, doctors realized that assessing the risk of \u003cstrong\u003edisease persistence or recurrence\u003c\/strong\u003e (the cancer coming back or remaining after treatment) is more useful for guiding treatment decisions than mortality risk alone.\u003c\/p\u003e\n\u003cp\u003eThe American Thyroid Association (ATA) developed a widely used risk-stratification system that classifies patients into three categories based on the risk of disease recurrence:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eLow-risk:\u003c\/strong\u003e less than 5% chance of recurrence\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eIntermediate-risk:\u003c\/strong\u003e 5% to 20% chance of recurrence\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eHigh-risk:\u003c\/strong\u003e greater than 20% chance of recurrence\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eThis risk assessment is based on histopathological features of the tumor (what the tumor looks like under the microscope) and will likely include molecular features in the near future. Doctors also consider operative findings that may not appear in the pathology report, such as vocal cord paralysis, the extent of gross extrathyroidal invasion (visible invasion beyond the thyroid during surgery), and how completely the tumor was removed.\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eLow-risk disease accounts for about 57% of all patients with PTC.\u003c\/strong\u003e This means that more than half of all papillary thyroid cancer patients fall into a category where less aggressive treatment can be safely considered.\u003c\/p\u003e\n\n\u003ch2 id=\"definition\"\u003eWhat Exactly Does \"Low-Risk\" Mean?\u003c\/h2\u003e\n\u003cp\u003eAccording to the ATA guidelines, the category of low-risk disease includes the following specific situations:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003ePatients with a \u003cstrong\u003every low risk of recurrence\u003c\/strong\u003e (less than 1%): those with a unifocal (single) tumor smaller than 1 cm\u003c\/li\u003e\n  \u003cli\u003ePatients with PTC that is completely inside the thyroid (intrathyroidal), with tumors smaller than 4 cm, \u003cstrong\u003ewithout clinical evidence of lymph node metastases\u003c\/strong\u003e or with \u003cstrong\u003e5 or fewer microscopic lymph node metastases\u003c\/strong\u003e (each smaller than 2 mm) found only on pathology, without vascular invasion (cancer cells in blood vessels), and without an aggressive variant of PTC\u003c\/li\u003e\n  \u003cli\u003ePatients with well-differentiated follicular thyroid cancer that has capsular invasion alone (invasion of the capsule surrounding the tumor) or with \u003cstrong\u003efewer than four foci of vascular invasion\u003c\/strong\u003e\n\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eMolecular characterization of the tumor (testing for genetic mutations) has not yet been routinely adopted. The impact of BRAF or TERT mutations on risk assessment is still a matter of debate among experts. However, patients classified as having AJCC\/TNM stage I or II disease—based on age, tumor size with no extrathyroidal invasion, and lymph node status (fewer than 5 involved nodes, all smaller than 0.2 cm)—are considered to be at low risk for structural disease recurrence and disease-specific death.\u003c\/p\u003e\n\n\u003ch2 id=\"active-surveillance\"\u003eActive Surveillance: Monitoring Instead of Surgery\u003c\/h2\u003e\n\u003cp\u003eOne of the most significant changes in thyroid cancer management is the concept of \u003cstrong\u003eactive surveillance (AS)\u003c\/strong\u003e—a strategy of carefully monitoring a low-risk tumor without immediately performing surgery. This approach was initially recommended for micropapillary thyroid carcinoma (microPTC, tumors smaller than 1 cm) and gained international recognition in 2010, when a pioneer group in Japan published the first data showing that patients with microPTC could be followed safely without intervention, provided the tumor could be clearly visualized on ultrasound.\u003c\/p\u003e\n\u003cp\u003eGuidelines, including the ATA recommendations, endorse AS as the initial approach in selected patients with microPTC. The ATA also recommends AS for low-risk, completely intrathyroidal tumors measuring up to \u003cstrong\u003e1.5 to 2 cm\u003c\/strong\u003e.\u003c\/p\u003e\n\u003cp\u003eWhy is this approach so attractive? It prevents excessive early treatment, along with the surgical risks and lifelong consequences of thyroid removal. Studies from several different countries have confirmed the original Japanese data, showing:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eNodular growth (the tumor getting bigger) occurs in approximately \u003cstrong\u003e10%\u003c\/strong\u003e of patients with microPTC\u003c\/li\u003e\n  \u003cli\u003eLymph node metastasis develops in \u003cstrong\u003eless than 5%\u003c\/strong\u003e of patients\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eNo studies\u003c\/strong\u003e have described distant metastases or death from thyroid cancer during active surveillance\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eFewer studies have included tumors measuring up to 1.5 or 2.0 cm, so more data are needed for larger tumors. Notably, these nodules have an approximate \u003cstrong\u003e50% chance of growth over 10 years in patients younger than 40 years\u003c\/strong\u003e, particularly in those closer to age 20. However, the prognosis is not affected if AS is chosen and future surgery becomes necessary due to nodular growth—meaning surgery performed later appears to be just as effective as immediate surgery.\u003c\/p\u003e\n\n\u003ch2 id=\"who-eligible\"\u003eWho Can Consider Active Surveillance?\u003c\/h2\u003e\n\u003cp\u003eBefore starting active surveillance, doctors evaluate three main areas: the characteristics of the nodule, the characteristics of the patient, and the characteristics of the medical team that will follow the patient. Based on this analysis, patients are classified as \u003cstrong\u003eideal\u003c\/strong\u003e, \u003cstrong\u003eappropriate\u003c\/strong\u003e, or \u003cstrong\u003einappropriate\u003c\/strong\u003e candidates for AS.\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eIdeal candidates\u003c\/strong\u003e for active surveillance have:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eA solitary (single) nodule with well-defined margins, no evidence of lymph node or distant metastases (cN0, cM0), and no extrathyroidal extension\u003c\/li\u003e\n  \u003cli\u003eAge greater than 60 years\u003c\/li\u003e\n  \u003cli\u003eAcceptance of the approach by both the patient and family members\u003c\/li\u003e\n  \u003cli\u003eLife-threatening comorbidities (other serious health conditions that make surgery riskier)\u003c\/li\u003e\n  \u003cli\u003eAn experienced multidisciplinary team with high-quality ultrasound and a reminder program to ensure follow-up\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAppropriate candidates\u003c\/strong\u003e include:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003ePatients aged 18 to 59 years\u003c\/li\u003e\n  \u003cli\u003eThose with multifocal nodules (multiple nodules) or nodules in a subcapsular location (not adjacent to the recurrent laryngeal nerve, which controls the vocal cords)\u003c\/li\u003e\n  \u003cli\u003ePatients with a strong family history of PTC or childbearing potential\u003c\/li\u003e\n  \u003cli\u003ePatients with follow-up at a center with an experienced endocrinologist or surgeon and routine ultrasound availability\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003e\u003cstrong\u003eInappropriate candidates\u003c\/strong\u003e—who should be referred directly for surgery—include:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003ePatients under 18 years of age\u003c\/li\u003e\n  \u003cli\u003eThose with aggressive cytology (concerning features on biopsy), evidence of lymph node or distant metastases (cN1, cM1), or extrathyroidal extension\u003c\/li\u003e\n  \u003cli\u003eNodules in a subcapsular location adjacent to the recurrent laryngeal nerve, or with obtuse angles between the tumor and the trachea (windpipe)—a sign that the tumor may be invading the airway\u003c\/li\u003e\n  \u003cli\u003ePatients unlikely to comply with follow-up or who do not accept the approach\u003c\/li\u003e\n  \u003cli\u003eCenters without ultrasound availability or with little experience managing thyroid cancer\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003ePatients who are ideal candidates should be offered AS along with information that future surgery may be necessary if the nodule grows, if signs of lymph node or distant metastases emerge, or at the patient's discretion.\u003c\/p\u003e\n\n\u003ch2 id=\"special-situations\"\u003eSpecial Situations: Family History, Pregnancy, and Other Thyroid Conditions\u003c\/h2\u003e\n\u003cp\u003e\u003cstrong\u003eFamily history of thyroid cancer.\u003c\/strong\u003e Familial nonmedullary thyroid carcinoma (thyroid cancer that runs in families) has a prevalence of around \u003cstrong\u003e3% to 10%\u003c\/strong\u003e and is defined as the presence of nonmedullary thyroid carcinoma in at least \u003cstrong\u003ethree first-degree relatives\u003c\/strong\u003e (parents, siblings, or children) in the absence of other known familial syndromes. Although some studies show that the risk of recurrence or mortality is comparable between familial and sporadic (non-inherited) cases, familial cases appear to have an increased risk of multifocal lesions (multiple tumors in the thyroid). Although AS may be a therapeutic option in confirmed cases of familial microPTC, \u003cstrong\u003esurgery is a better choice and total thyroidectomy is recommended\u003c\/strong\u003e in these cases.\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy and childbearing age.\u003c\/strong\u003e Some reports have associated levels of beta human chorionic gonadotropin (hCG)—the pregnancy hormone—with an increased number and volume of thyroid nodules during pregnancy. However, the aggressiveness of these tumors is not increased. Therefore, women of childbearing age or those who are pregnant and diagnosed with microPTC may also undergo AS using the same criteria, though more long-term studies are needed in pregnant women and those planning pregnancy.\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcomitant thyroid disorders.\u003c\/strong\u003e Evidence shows an increased risk of thyroid cancer in patients with autoimmune diseases such as Graves' disease and Hashimoto's thyroiditis. However, AS is currently not contraindicated in these patients. Two aspects must be kept in mind:\u003c\/p\u003e\n\u003col\u003e\n  \u003cli\u003ePatients should be maintained \u003cstrong\u003eeuthyroid\u003c\/strong\u003e (normal thyroid hormone levels) to prevent stimulation of nodular growth due to high TSH values (TSH is the hormone that stimulates the thyroid).\u003c\/li\u003e\n  \u003cli\u003eDoctors should assess whether the heterogeneity of the thyroid on ultrasound could impair the measurement and proper follow-up of the tumor.\u003c\/li\u003e\n\u003c\/ol\u003e\n\u003cp\u003eRegarding benign nodules found alongside the cancer, treatment is not required when these nodules are not clinically significant (for example, toxic nodules causing overproduction of thyroid hormone, or bulky nodules causing compressive symptoms).\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eTSH suppression therapy during AS.\u003c\/strong\u003e Some doctors previously used levothyroxine (thyroid hormone medication) to suppress TSH and theoretically slow tumor growth. However, evidence of benefit from this approach remains inconclusive, since no randomized trials have been conducted. The current recommendation is to maintain \u003cstrong\u003eTSH values within the normal range\u003c\/strong\u003e to prevent nodular growth while avoiding the harmful effects of excessive thyroid hormone, especially in elderly patients.\u003c\/p\u003e\n\n\u003ch2 id=\"follow-up-as\"\u003eFollow-Up During Active Surveillance\u003c\/h2\u003e\n\u003cp\u003ePatients undergoing AS must be reassessed at each visit, with attention to the characteristics of the nodule and the ability of both the patient and the medical staff to continue AS. Figure 1 in the original statement outlines this process.\u003c\/p\u003e\n\u003cp\u003eA neck CT scan may be helpful for nodules close to or in contact with the trachea, to better visualize the contact angle between them. An obtuse angle between the tumor and the trachea is an indication for surgery, as it suggests potential airway invasion.\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndications for surgery during active surveillance include:\u003c\/strong\u003e\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eGrowth of the tumor by more than \u003cstrong\u003e3 mm\u003c\/strong\u003e in size\u003c\/li\u003e\n  \u003cli\u003eGrowth of the tumor to a diameter of \u003cstrong\u003e13 mm (1.3 cm) or more\u003c\/strong\u003e\n\u003c\/li\u003e\n  \u003cli\u003eDetection of lymph node metastasis\u003c\/li\u003e\n  \u003cli\u003eDiagnosis of other thyroid or parathyroid disease\u003c\/li\u003e\n  \u003cli\u003eA change in the patient's therapeutic preference\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eBased on current recommendations, clinical and ultrasound assessments should be performed \u003cstrong\u003eevery 6 months for the first 2 years and annually thereafter\u003c\/strong\u003e, if there are no clinical or ultrasound changes.\u003c\/p\u003e\n\n\u003ch2 id=\"implementation\"\u003eBefore Starting Active Surveillance: What Medical Centers Need\u003c\/h2\u003e\n\u003cp\u003eBefore implementing active surveillance, a medical center must ensure that patients can be safely followed. The position statement emphasizes four key points:\u003c\/p\u003e\n\u003col\u003e\n  \u003cli\u003eThe medical team must be \u003cstrong\u003eexperienced in managing thyroid cancer\u003c\/strong\u003e, and there must be consensus regarding patient management both within the team and between the team and other doctors caring for the patient.\u003c\/li\u003e\n  \u003cli\u003eThe team must be prepared at all stages of follow-up to \u003cstrong\u003eclarify patients' concerns\u003c\/strong\u003e regarding treatment indications and contraindications, reassure patients, help them overcome their fears, and be available to talk to patients and their families.\u003c\/li\u003e\n  \u003cli\u003eThe center's infrastructure should facilitate follow-up, ensuring the \u003cstrong\u003eavailability of appointments\u003c\/strong\u003e within the specified follow-up period and access to \u003cstrong\u003equality ultrasound\u003c\/strong\u003e—ideally within its own premises.\u003c\/li\u003e\n  \u003cli\u003eCenters without experience with AS should choose to follow patients under a \u003cstrong\u003eresearch protocol\u003c\/strong\u003e to ensure careful data collection and oversight.\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003ch2 id=\"surgery\"\u003eSurgery: Lobectomy or Total Thyroidectomy?\u003c\/h2\u003e\n\u003cp\u003eWhen surgery is recommended, the next question is how much of the thyroid to remove. The choice between \u003cstrong\u003etotal thyroidectomy (TT)\u003c\/strong\u003e (removing the entire thyroid gland) and \u003cstrong\u003elobectomy\u003c\/strong\u003e (removing only the half of the thyroid containing the tumor, also called partial thyroidectomy or hemithyroidectomy) has little impact on recurrence rates or the risk of death from thyroid cancer.\u003c\/p\u003e\n\u003cp\u003eSolid evidence shows that simple observation of the opposite (contralateral) lobe is safe in patients with low-risk disease after lobectomy. According to the ATA consensus, partial thyroidectomy or lobectomy is considered sufficient treatment for \u003cstrong\u003eT1 and T2 tumors confined to the thyroid gland\u003c\/strong\u003e, considering that the extent of the thyroidectomy has no effect on survival in PTC and that recurrence after lobectomy can be successfully treated without a negative impact on overall survival.\u003c\/p\u003e\n\u003cp\u003eA notable systematic review and meta-analysis that included \u003cstrong\u003e13,801 patients with microPTC\u003c\/strong\u003e (8,812 who underwent total thyroidectomy and 4,989 who underwent partial thyroidectomy) from 11 different cohorts concluded that partial thyroidectomy had \u003cstrong\u003eequivalent results in terms of mortality\u003c\/strong\u003e, which is relatively low in these cases.\u003c\/p\u003e\n\u003cp\u003eIn the authors' opinion, either partial thyroidectomy or lobectomy is a good option for patients in Brazil, especially considering the limited number of head and neck surgeons with high surgical volume in the country.\u003c\/p\u003e\n\n\u003ch3\u003eAdvantages and Disadvantages of Lobectomy\u003c\/h3\u003e\n\u003cp\u003eChoosing the right surgical approach involves weighing the advantages and disadvantages. Here is a summary from the position statement:\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdvantages of lobectomy compared to total thyroidectomy:\u003c\/strong\u003e\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eLower surgical risks\u003c\/li\u003e\n  \u003cli\u003eThyroid hormone supplementation may not be necessary\u003c\/li\u003e\n  \u003cli\u003eComparable survival outcomes\u003c\/li\u003e\n  \u003cli\u003eCompletion surgery, if necessary, does not increase surgical risk or modify the outcome\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003e\u003cstrong\u003eDisadvantages of lobectomy compared to total thyroidectomy:\u003c\/strong\u003e\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eRisk of needing a completion surgery (a second surgery) to improve prognosis and\/or administer radioactive iodine\u003c\/li\u003e\n  \u003cli\u003ePatients may still require thyroid hormone supplementation (due to thyroiditis or little remaining thyroid tissue)\u003c\/li\u003e\n  \u003cli\u003eNo evidence of quality of life improvement\u003c\/li\u003e\n  \u003cli\u003eNot adequate for intermediate- and high-risk patients\u003c\/li\u003e\n  \u003cli\u003eThyroglobulin levels may not be appropriate for follow-up\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eThe maintenance of thyroid tissue in partial thyroidectomy avoids the need for thyroid hormone replacement that inevitably results from total thyroidectomy. In addition to increased physical and psychiatric burden, hypothyroidism (underactive thyroid) can lead to a substantial socioeconomic impact in the form of early retirement or loss of income. However, even after lobectomy, the need for hormone replacement is not uncommon—\u003cstrong\u003ehalf of patients undergoing hemithyroidectomy may develop hypothyroidism\u003c\/strong\u003e.\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompletion thyroidectomy\u003c\/strong\u003e may be required in cases of persistent or recurrent disease. After lobectomy, a pathology report showing lymph node or distant metastasis, or an increased number of risk factors for recurrence (such as extrathyroidal extension, aggressive variants, positive surgical margins, extensive blood vessel invasion, or lymphovascular or neural invasion), should prompt completion thyroidectomy and radioactive iodine treatment. The optimal time for completion thyroidectomy, with fewer complications, has been suggested to be \u003cstrong\u003e3 months\u003c\/strong\u003e after the initial surgery.\u003c\/p\u003e\n\u003cp\u003eRecent evidence suggests that \u003cstrong\u003elobectomy is a cost-effective strategy in middle-aged patients with low-risk PTC\u003c\/strong\u003e, while \u003cstrong\u003eactive surveillance becomes cost-effective starting at age 69\u003c\/strong\u003e. The decision regarding the extent of surgery must involve both the surgeon and the endocrinologist and should consider the patient's beliefs, socioeconomic and cultural characteristics, and access to adequate health services.\u003c\/p\u003e\n\n\u003ch2 id=\"rai\"\u003eRadioactive Iodine Treatment: When Is It Really Needed?\u003c\/h2\u003e\n\u003cp\u003eRadioactive iodine (RAI) therapy is a treatment where patients take a pill containing radioactive iodine, which is absorbed by remaining thyroid tissue or cancer cells and destroys them. However, RAI is no longer recommended for everyone. Postoperative RAI must be considered only in patients treated with total thyroidectomy and has four potential goals:\u003c\/p\u003e\n\u003col\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAblation:\u003c\/strong\u003e destruction of remaining thyroid tissue, which can improve the sensitivity of serum thyroglobulin (Tg) measurements during follow-up\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAdjuvant treatment:\u003c\/strong\u003e destruction of microscopic occult disease (cancer cells that can't be seen) to reduce the risk of recurrence\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eTreatment:\u003c\/strong\u003e destruction of persistent or metastatic disease to improve disease-free survival or overall survival\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eImproved staging:\u003c\/strong\u003e a post-treatment whole body scan (WBS) can provide additional staging information\u003c\/li\u003e\n\u003c\/ol\u003e\n\u003cp\u003ePreviously, the role of remnant ablation (destroying leftover thyroid tissue) was to facilitate postoperative follow-up and initial staging. But recent evidence has changed this practice dramatically.\u003c\/p\u003e\n\u003cp\u003eA landmark study—the \u003cstrong\u003eESTIMABL 2 trial\u003c\/strong\u003e, a large prospective study from France—showed that in patients with low-risk thyroid cancer who underwent thyroidectomy, a \u003cstrong\u003efollow-up strategy that did not involve radioactive iodine was noninferior to an ablation strategy with radioactive iodine\u003c\/strong\u003e regarding the occurrence of functional, structural, and biologic events at 3 years. In other words, skipping RAI did not lead to worse outcomes.\u003c\/p\u003e\n\u003cp\u003eAblation can still be considered in patients with detectable thyroglobulin antibodies (TgAb) and in those with increased postoperative thyroglobulin levels in the context of a normal cervical ultrasound. Notably, multivariate analyses from several studies have shown that \u003cstrong\u003epostoperative serum thyroglobulin level is an independent predictor of disease recurrence\u003c\/strong\u003e—meaning the Tg trend can help identify which patients might benefit from additional treatment.\u003c\/p\u003e\n\n\u003ch2 id=\"implications\"\u003eWhat These Findings Mean for Patients\u003c\/h2\u003e\n\u003cp\u003eThe paradigm shift described in this position statement has direct, practical implications for patients diagnosed with low-risk papillary thyroid carcinoma:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eYou may not need immediate surgery.\u003c\/strong\u003e Active surveillance is a safe, recommended option for many patients with microPTC (tumors under 1 cm) and even some tumors up to 1.5–2 cm, particularly in older patients. The risk of the tumor growing is about 10%, and even if surgery is needed later, outcomes are not affected.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eIf surgery is needed, removing only part of the thyroid may be enough.\u003c\/strong\u003e Lobectomy has equivalent survival outcomes to total thyroidectomy for low-risk tumors, with lower surgical risks and the possibility of avoiding lifelong thyroid hormone replacement—though about half of patients may still develop hypothyroidism.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eRadioactive iodine may not be necessary.\u003c\/strong\u003e For low-risk patients who undergo total thyroidectomy, skipping RAI is just as safe as receiving it, according to the ESTIMABL 2 trial. This avoids the side effects, cost, and inconvenience of RAI treatment.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eFollow-up is personalized.\u003c\/strong\u003e Whether you choose AS, lobectomy, or total thyroidectomy, your follow-up plan will be tailored to your specific risk category, with regular ultrasound and thyroglobulin measurements to ensure early detection of any problems.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003ch2 id=\"limitations\"\u003eStudy Limitations\u003c\/h2\u003e\n\u003cp\u003eThis position statement has several limitations that patients should understand when discussing their options with their doctors:\u003c\/p\u003e\n\u003cul\u003e\n  \u003cli\u003eThis is a \u003cstrong\u003econsensus document based on expert review of the literature\u003c\/strong\u003e, not a new prospective clinical trial. As such, the strength of the recommendations depends on the quality of the underlying studies.\u003c\/li\u003e\n  \u003cli\u003eFewer studies have evaluated active surveillance for tumors \u003cstrong\u003emeasuring between 1 and 2 cm\u003c\/strong\u003e than for microPTC (tumors under 1 cm), so the evidence base for larger low-risk tumors is less robust.\u003c\/li\u003e\n  \u003cli\u003eThe significance of molecular markers such as \u003cstrong\u003eBRAF and TERT mutations\u003c\/strong\u003e for risk stratification is still under debate, and these markers are not yet routinely incorporated into treatment decisions.\u003c\/li\u003e\n  \u003cli\u003eMore long-term studies are needed in \u003cstrong\u003epregnant women and those who want to become pregnant\u003c\/strong\u003e before active surveillance is fully validated in this population.\u003c\/li\u003e\n  \u003cli\u003eTSH suppression therapy during active surveillance has \u003cstrong\u003enot been tested in randomized trials\u003c\/strong\u003e, so the recommendation to maintain normal TSH levels is based on indirect evidence and expert opinion.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003ch2 id=\"recommendations\"\u003eRecommendations for Patients\u003c\/h2\u003e\n\u003cp\u003eBased on this position statement, here are the key takeaways for patients diagnosed with low-risk papillary thyroid carcinoma:\u003c\/p\u003e\n\u003col\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAsk about active surveillance.\u003c\/strong\u003e If you have a small (under 1 cm) tumor confined to the thyroid, with no lymph node involvement and no concerning features on biopsy, ask your endocrinologist whether active surveillance is an appropriate option for you. This is especially worth considering if you are over 60 years old or have other health conditions that make surgery riskier.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eUnderstand the staging system.\u003c\/strong\u003e Ask your doctor what your TNM stage is and what your ATA recurrence risk category is. More than 90% of patients are now classified as stage I or II, with a cancer-related death risk below 1%.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eConsider lobectomy before agreeing to total thyroidectomy.\u003c\/strong\u003e For tumors confined to the thyroid (T1 or T2), removing only the involved lobe may be sufficient. Ask your surgeon about the pros and cons of each approach for your specific situation, including the chance you might need a completion surgery later.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eQuestion the need for radioactive iodine.\u003c\/strong\u003e If you undergo total thyroidectomy and are classified as low risk, ask your doctor whether RAI is truly necessary. Recent evidence shows that skipping RAI is just as safe as receiving it for low-risk patients.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eCommit to follow-up.\u003c\/strong\u003e Whether you choose active surveillance or surgery, regular follow-up is essential. During AS, this means ultrasound every 6 months for the first 2 years and annually thereafter. Surgery triggers include growth of more than 3 mm, reaching 13 mm or more, or new lymph node involvement.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eChoose an experienced center.\u003c\/strong\u003e If you are considering active surveillance, ensure that your medical center has an experienced multidisciplinary team, high-quality ultrasound, and a system to ensure you don't miss follow-up appointments.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eMaintain normal thyroid function.\u003c\/strong\u003e During active surveillance, your TSH levels should be kept in the normal range—neither too high (which could stimulate growth) nor suppressed too aggressively (which can cause harmful side effects, especially in older patients).\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003c!-- ddn:faq:start --\u003e\n\u003ch2 id=\"ddn-faq\"\u003eFrequently Asked Questions\u003c\/h2\u003e\n\u003ch3\u003eWhat is active surveillance for low-risk papillary thyroid cancer?\u003c\/h3\u003e\n\u003cp\u003eActive surveillance means monitoring a low-risk thyroid tumor with regular ultrasound exams instead of removing it immediately. It is an accepted option for many small tumors under 1 cm and some up to 1.5–2 cm. The tumor grows in about 10% of patients, but later surgery appears just as effective if needed.\u003c\/p\u003e\n\u003ch3\u003eWho can be an ideal candidate for active surveillance?\u003c\/h3\u003e\n\u003cp\u003eIdeal candidates have a single, well-defined nodule confined to the thyroid, with no lymph node or distant spread and no extrathyroidal extension. They are older than 60 years, have serious health conditions that make surgery riskier, and have an experienced team providing high-quality ultrasound and reliable follow-up.\u003c\/p\u003e\n\u003ch3\u003eDoes having surgery later, after a period of active surveillance, affect my outcome?\u003c\/h3\u003e\n\u003cp\u003eNo. The article states that the prognosis is not affected if active surveillance is chosen and surgery becomes necessary later due to tumor growth. Delayed surgery appears to be just as effective as immediate surgery, so the choice to monitor first does not harm your long-term outlook.\u003c\/p\u003e\n\u003ch3\u003eWhat are the advantages of removing only part of the thyroid (lobectomy) instead of the whole gland?\u003c\/h3\u003e\n\u003cp\u003eLobectomy carries lower surgical risks, may avoid lifelong thyroid hormone replacement, and has survival outcomes comparable to total thyroidectomy for low-risk tumors confined to the thyroid. However, about half of patients still develop hypothyroidism, and a second completion surgery may be needed in some cases.\u003c\/p\u003e\n\u003ch3\u003eAfter a total thyroidectomy for low-risk cancer, is radioactive iodine always necessary?\u003c\/h3\u003e\n\u003cp\u003eNo. In a large French study called ESTIMABL 2, patients with low-risk thyroid cancer who did not receive radioactive iodine had outcomes no worse than those who did, at 3 years. Skipping radioactive iodine is considered as safe as receiving it for appropriately selected low-risk patients.\u003c\/p\u003e\n\u003ch3\u003eWhat does 'low-risk' papillary thyroid cancer mean for my chance of recurrence and death?\u003c\/h3\u003e\n\u003cp\u003eLow-risk means the chance of the cancer coming back is less than 5%. More than 90% of patients are now classified as stage I or II under the current staging system, and the risk of dying from the cancer is below 1% for these stages.\u003c\/p\u003e\n\u003c!-- ddn:faq:end --\u003e\n\n\u003ch2 id=\"source\"\u003eSource Information\u003c\/h2\u003e\n\u003cp\u003e\u003cstrong\u003eOriginal article title:\u003c\/strong\u003e Treatment strategies for low-risk papillary thyroid carcinoma\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors:\u003c\/strong\u003e Laura Sterian Ward, Rafael Selbach Scheffel, Ana O. Hoff, Carolina Ferraz, and Fernanda Vaisman\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003ePublication:\u003c\/strong\u003e Archives of Endocrinology and Metabolism (Arch Endocrinol Metab), 2022;66(4):522-32\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eDOI:\u003c\/strong\u003e 10.20945\/2359-3997000000512\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eReceived:\u003c\/strong\u003e February 11, 2022 | \u003cstrong\u003eAccepted:\u003c\/strong\u003e July 21, 2022\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eKeywords:\u003c\/strong\u003e Papillary thyroid carcinoma; position statement; active surveillance\u003c\/p\u003e\n\u003cp\u003e\u003cem\u003eThis patient-friendly article is based on peer-reviewed research.\u003c\/em\u003e\u003c\/p\u003e","brand":"DiagnosticDetectives.Com","offers":[{"title":"Default Title","offer_id":47400024801436,"sku":null,"price":0.0,"currency_code":"EUR","in_stock":true}],"url":"https:\/\/diagnosticdetectives.ae\/products\/low-risk-papillary-thyroid-carcinoma-understanding-your-treatment-options","provider":"DiagnosticDetectives.Com","version":"1.0","type":"link"}