Endocrinology and Metabolism

Review Articles

Thyroid
2025 Korean Thyroid Association Clinical Management Guideline on Active Surveillance for Low-Risk Papillary Thyroid Carcinoma: Eun Kyung Lee, Min Joo Kim, Seung Heon Kang, Bon Seok Koo, Kyungsik Kim, Mijin Kim, Bo Hyun Kim, Ji-hoon Kim, Shinje Moon, Kyorim Back, Young Shin Song, Jong-hyuk Ahn, Hwa Young Ahn, Ho-Ryun Won, Won Sang Yoo, Min Kyoung Lee, Jeongmin Lee, Ji Ye Lee, Kyong Yeun Jung, Chan Kwon Jung, Yoon Young Cho, Dong-Jun Lim, Sun Wook Kim, Young Joo Park, Dong Gyu Na, Jee Soo Kim; Endocrinol Metab. 2025;40(3):307-341. Published online June 24, 2025; DOI: https://doi.org/10.3803/EnM.2025.2461

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The increasing detection of papillary thyroid microcarcinoma (PTMC) has raised concerns regarding overtreatment. For low-risk PTMC, either immediate surgery or active surveillance (AS) can be considered. To facilitate the implementation of AS, the Korean Thyroid Association convened a multidisciplinary panel and developed the first Korean guideline. AS is recommended for adults with pathologically confirmed Bethesda V–VI PTMC who have no clinical evidence of lymph node or distant metastasis, gross extrathyroidal extension, invasion of the trachea or recurrent laryngeal nerve, or aggressive histology. A baseline assessment requires high-resolution neck ultrasound performed by experienced operators to exclude extrathyroidal extension, tracheal or recurrent laryngeal nerve invasion, and lymph node metastasis; contrast-enhanced neck computed tomography is optional. Patient characteristics, including age, comorbidities, and the capacity for long-term follow-up, should be thoroughly assessed. Shared decision-making should carefully weigh the benefits and risks of surgery versus AS, considering expected oncologic outcomes, potential complications, quality of life, anxiety, medical costs, and patient preference. Follow-up involves neck ultrasound and thyroid function tests every 6 months for 2 years and annually thereafter. Disease progression, defined as significant tumor growth or newly detected nodal or distant metastasis, warrants surgery. Despite remaining uncertainties, this guideline provides a structured framework to ensure oncologic safety and supports patient-centered AS.

Citations

Citations to this article as recorded by

Feasibility and Safety of Active Surveillance in Subcapsular Thyroid Nodules with High Suspicion for Malignancy
Yan Hu, Wei Zhou, Lu Zhang, Weiwei Zhan
Ultrasound in Medicine & Biology.2026; 52(4): 816. CrossRef
Combined Ultrasound and MRI Assessment in Patients Undergoing Reoperation for Recurrent Papillary Thyroid Carcinoma: Oncological Outcomes and Surgical Safety
Zimei Tang, Jie Liu, Rong Wang, Gang Tian, Anwen Ren, Jiexiao Li, Yiran Wang, Wen Yang, Peng Sun, Tao Huang, Ximeng Zhang, Jie Ming
Current Oncology.2026; 33(2): 98. CrossRef
Multidisciplinary team diagnosis and treatment of well-differentiated thyroid carcinoma: current landscape and future prospects
Yuanyuan Li, Peijie Wang, Jiaxin Cao, Haiyan Liu
The Oncologist.2026;[Epub] CrossRef
Controlled minimally invasive surgical interventions for the treatment of patients with thyroid carcinoma
David D. Dolidze, Zurab A. Bagatelia, Suren G. Laboyan, Arshak V. Vardanyan, Konstantin S. Titov, Ivan N. Lebedinsky, Georgi Genadi Melkonyan, Dmitriy V. Matveev, Nodar N. Gogitidze, Andrei Y. Lukin, Armen R. Oganyan, David G. Gogolashvili, Anastasia V. B
Journal of Experimental and Clinical Surgery.2026; 19(1): 45. CrossRef
Overdiagnosis and Overtreatment of Thyroid Cancer and Precision Mitigation Strategies—An Integrated Analysis Based on Evidence-Based Medicine and Risk Stratification Models
云菲李
Advances in Clinical Medicine.2026; 16(04): 4980. CrossRef
Active surveillance for low-risk papillary thyroid carcinoma: Integrating guidelines, emerging evidence, and directions
Zijing Wu, Kaiang Zhang, Huixian Zhou, Leyi Wan, Jingyuan Zhong, Chunhua Li, Lianggeng Gong, Yun Peng
iScience.2026; 29(6): 115832. CrossRef
Prognostic Factors and Recurrence in Papillary Thyroid Microcarcinoma
Aydan Farzaliyeva, Feride Pınar Altay, Ozlem Turhan Iyidir, Neslihan Bascil Tutuncu
Medicina.2026; 62(5): 981. CrossRef
Response to “Balancing Sensitivity and Overtreatment in Preoperative CT Evaluation for Papillary Thyroid Microcarcinoma”
Young Hun Jeon, Ji Ye Lee
Korean Journal of Radiology.2026;[Epub] CrossRef
A novel cartilage-based reference point for the recurrent laryngeal nerve: implication for preoperative risk stratification in posterior subcapsular thyroid tumors
Qianqian Lu, Feiliang Wang, Xiaoquan Zhu, Jiankun Li, Weijing Li, Dongdong Wang, Yao Li, Yanyang Zhao, Gang Miao
World Journal of Surgical Oncology.2026;[Epub] CrossRef
Risk factors associated with lymph node metastasis in cN0 papillary thyroid microcarcinoma
Shijie Zheng, Chuangwu Ke, Weijing Hao, Xiaohan Chen, Wenchao Zhang
Frontiers in Oncology.2026;[Epub] CrossRef
Papillary thyroid carcinoma in a patient with long‑standing chronic lymphocytic leukemia: A case report
Jiaxiang Ma, Tieying Gan, Ailin Song, Hongyou Tian, Shaoce Xu, Lei Zhao
Oncology Letters.2026; 32(4): 1. CrossRef
Prediction of Central Lymph Node Metastasis in Papillary Thyroid Microcarcinoma Using a Deep Learning Radiomics Model Based on SAM3 Automatic Segmentation of Ultrasound Images: A Multicenter Cohort Study
Jun Song, Yuan Zhang, Xiachuan Qin, Xiaoling Liu, Fanding He
Academic Radiology.2026;[Epub] CrossRef
Optimal cutoff value of fine-needle aspiration thyroglobulin of metastatic lymph node in thyroid cancer patients
Yang Yang, Xianfeng Jiang
European Journal of Surgical Oncology.2025; 51(11): 110428. CrossRef
Low-risk thyroid cancer: surgery or active surveillance—an application of shared decision-making: a narrative review
Min Joo Kim, Eun Kyung Lee, Sun Wook Cho, Yoo Hyung Kim, Kyu Eun Lee, Su-jin Kim, Woochul Kim, Eun-Jae Chung, Jungirl Seok, Yul Hwangbo, Young Ki Lee, Jinsun Jang, Junsun Ryu, Yuh-Seog Jung, Chang Hwan Ryu, Jae Hoon Moon, June Young Choi, Hyeong Won Yu, K
Journal of the Korean Medical Association.2025; 68(9): 573. CrossRef

Thyroid
Ultrasound Imaging Criteria and Protocols for Active Surveillance of Low-Risk Thyroid Cancer: A Review of International Consensus Guidelines: Ji Ye Lee, Dong Gyu Na; Endocrinol Metab. 2025;40(2):185-194. Published online March 27, 2025; DOI: https://doi.org/10.3803/EnM.2024.2319

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Given the indolent nature and favorable outcomes of papillary thyroid microcarcinoma (PTMC), active surveillance (AS) has been adopted as an alternative management option to immediate surgery. However, the meticulous selection of patients based on individual and tumor-specific characteristics, as well as ultrasound (US) findings, is crucial in AS. Regular US monitoring is performed during AS to detect indicators of tumor progression, such as growth, the emergence of new US features suggestive of gross extrathyroidal extension, and lymph node metastasis. Thus, imaging-based evaluations play a pivotal role in guiding the decision to continue AS or proceed with surgical intervention. This review introduces the Korean Society of Thyroid Radiology (KSThR) guideline for the standardized US imaging of patients with low-risk PTMC under AS, which provide practical recommendations for tumor assessment during the initiation and follow-up phases of AS. This review compared the key features of the KSThR guideline with those of major international guidelines and identified the similarities and differences in imaging methodologies and follow-up strategies. The primary objective of this review is to support the broader implementation of AS and improve outcomes for patients with low-risk PTMC by emphasizing imaging protocols.

Citations

Citations to this article as recorded by

Shared Decision-Making for Determining Treatment Strategies in Low-Risk Thyroid Cancer: Protocol of a Multicenter Cluster-Randomized Trial (MAeSTro-SDM)
Eun Kyung Lee, Min Joo Kim, Yul Hwangbo, Jae Hoon Moon, Sun Wook Cho, Young Jun Chai, June Young Choi, Yuh-Seog Jung, Kyu Eun Lee, Eun-Jae Chung, Kyungsik Kim, Su-jin Kim, Woochul Kim, Yoo Hyung Kim, Young Ki Lee, Jinsun Jang, Young Shin Song, Ka Hee Yi,
Journal of Korean Medical Science.2026;[Epub] CrossRef
Overdiagnosis and Overtreatment of Thyroid Cancer and Precision Mitigation Strategies—An Integrated Analysis Based on Evidence-Based Medicine and Risk Stratification Models
云菲李
Advances in Clinical Medicine.2026; 16(04): 4980. CrossRef
Reply to the Letter to the Editor: Microflow imaging for ultrasound risk stratification of thyroid nodules: potential roles and key considerations
Wanying Li, Luying Gao, Hongyan Wang, Jianchu Li
European Radiology.2026;[Epub] CrossRef
Letter to the Editor: Microflow imaging for ultrasound risk stratification of thyroid nodules: potential roles and key considerations
Dong Gyu Na
European Radiology.2026;[Epub] CrossRef
New Trends in Thyroid Malignancy: Minimally Invasive Thermal Ablation Percutaneous Techniques for T1 Papillary Thyroid Carcinomas
Pierre Yves Marcy
Current Oncology.2025; 32(8): 442. CrossRef
Ultrasound for Active Surveillance of Low-Risk Thyroid Carcinoma
Sang Yull Kang, Hyeong Eun Jeong, Ha Rim Ahn, Hyun Jo Youn
Journal of Surgical Ultrasound.2025; 12(2): 23. CrossRef

Original Article

Thyroid
Study Protocol of Expanded Multicenter Prospective Cohort Study of Active Surveillance on Papillary Thyroid Microcarcinoma (MAeSTro-EXP): Jae Hoon Moon, Eun Kyung Lee, Wonjae Cha, Young Jun Chai, Sun Wook Cho, June Young Choi, Sung Yong Choi, A Jung Chu, Eun-Jae Chung, Yul Hwangbo, Woo-Jin Jeong, Yuh-Seog Jung, Kyungsik Kim, Min Joo Kim, Su-jin Kim, Woochul Kim, Yoo Hyung Kim, Chang Yoon Lee, Ji Ye Lee, Kyu Eun Lee, Young Ki Lee, Hunjong Lim, Do Joon Park, Sue K. Park, Chang Hwan Ryu, Junsun Ryu, Jungirl Seok, Young Shin Song, Ka Hee Yi, Hyeong Won Yu, Eleanor White, Katerina Mastrocostas, Roderick J. Clifton-Bligh, Anthony Glover, Matti L. Gild, Ji-hoon Kim, Young Joo Park; Endocrinol Metab. 2025;40(2):236-246. Published online February 18, 2025; DOI: https://doi.org/10.3803/EnM.2024.2136

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Background
Active surveillance (AS) has emerged as a viable management strategy for low-risk papillary thyroid microcarcinoma (PTMC), following pioneering trials at Kuma Hospital and the Cancer Institute Hospital in Japan. Numerous prospective cohort studies have since validated AS as a management option for low-risk PTMC, leading to its inclusion in thyroid cancer guidelines across various countries. From 2016 to 2020, the Multicenter Prospective Cohort Study of Active Surveillance on Papillary Thyroid Microcarcinoma (MAeSTro) enrolled 1,177 patients, providing comprehensive data on PTMC progression, sonographic predictors of progression, quality of life, surgical outcomes, and cost-effectiveness when comparing AS to immediate surgery. The second phase of MAeSTro (MAeSTro-EXP) expands AS to low-risk papillary thyroid carcinoma (PTC) tumors larger than 1 cm, driven by the hypothesis that overall risk assessment outweighs absolute tumor size in surgical decision-making.
Methods
This protocol aims to address whether limiting AS to tumors smaller than 1 cm may result in unnecessary surgeries for low-risk PTCs detected during their rapid initial growth phase. By expanding the AS criteria to include tumors up to 1.5 cm, while simultaneously refining and standardizing the criteria for risk assessment and disease progression, we aim to minimize overtreatment and maintain rigorous monitoring to improve patient outcomes.
Conclusion
This study will contribute to optimizing AS guidelines and enhance our understanding of the natural course and appropriate management of low-risk PTCs. Additionally, MAeSTro-EXP involves a multinational collaboration between South Korea and Australia. This cross-country study aims to identify cultural and racial differences in the management of low-risk PTC, thereby enriching the global understanding of AS practices and their applicability across diverse populations.

Citations

Citations to this article as recorded by

Shared Decision-Making for Determining Treatment Strategies in Low-Risk Thyroid Cancer: Protocol of a Multicenter Cluster-Randomized Trial (MAeSTro-SDM)
Eun Kyung Lee, Min Joo Kim, Yul Hwangbo, Jae Hoon Moon, Sun Wook Cho, Young Jun Chai, June Young Choi, Yuh-Seog Jung, Kyu Eun Lee, Eun-Jae Chung, Kyungsik Kim, Su-jin Kim, Woochul Kim, Yoo Hyung Kim, Young Ki Lee, Jinsun Jang, Young Shin Song, Ka Hee Yi,
Journal of Korean Medical Science.2026;[Epub] CrossRef
Study Protocol of Expanded Multicenter Prospective Cohort Study of Active Surveillance on Papillary Thyroid Microcarcinoma (MAeSTro-EXP) (Endocrinol Metab 2025;40:236-46, Jae Hoon Moon et al.)
Eun Kyung Lee, Jae Hoon Moon, Young Joo Park
Endocrinology and Metabolism.2025; 40(4): 655. CrossRef
Study Protocol of Expanded Multicenter Prospective Cohort Study of Active Surveillance on Papillary Thyroid Microcarcinoma (MAeSTro-EXP) (Endocrinol Metab 2025;40:236-46, Jae Hoon Moon et al.)
Hoonsung Choi
Endocrinology and Metabolism.2025; 40(4): 653. CrossRef
Habitat imaging combined with multimodal analysis for preoperative risk stratification of papillary thyroid carcinoma
Jia-Wei Feng, You-Long Zhu, Lu Zhang, Yu-Xin Yang, An-Cheng Qin, Shui-Qing Liu, Yong Jiang
Insights into Imaging.2025;[Epub] CrossRef

Review Article

Thyroid
Active Surveillance for Low-Risk Thyroid Cancers: A Review of Current Practice Guidelines: Min Joo Kim, Jae Hoon Moon, Eun Kyung Lee, Young Shin Song, Kyong Yeun Jung, Ji Ye Lee, Ji-hoon Kim, Kyungsik Kim, Sue K. Park, Young Joo Park; Endocrinol Metab. 2024;39(1):47-60. Published online February 15, 2024; DOI: https://doi.org/10.3803/EnM.2024.1937

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The indolent nature and favorable outcomes associated with papillary thyroid microcarcinoma have prompted numerous prospective studies on active surveillance (AS) and its adoption as an alternative to immediate surgery in managing low-risk thyroid cancer. This article reviews the current status of AS, as outlined in various international practice guidelines. AS is typically recommended for tumors that measure 1 cm or less in diameter and do not exhibit aggressive subtypes on cytology, extrathyroidal extension, lymph node metastasis, or distant metastasis. To determine the most appropriate candidates for AS, factors such as tumor size, location, multiplicity, and ultrasound findings are considered, along with patient characteristics like medical condition, age, and family history. Moreover, shared decision-making, which includes patient-reported outcomes such as quality of life and cost-effectiveness, is essential. During AS, patients undergo regular ultrasound examinations to monitor for signs of disease progression, including tumor growth, extrathyroidal extension, or lymph node metastasis. In conclusion, while AS is a feasible and reliable approach for managing lowrisk thyroid cancer, it requires careful patient selection, effective communication for shared decision-making, standardized follow-up protocols, and a clear definition of disease progression.

Citations

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Shared Decision-Making for Determining Treatment Strategies in Low-Risk Thyroid Cancer: Protocol of a Multicenter Cluster-Randomized Trial (MAeSTro-SDM)
Eun Kyung Lee, Min Joo Kim, Yul Hwangbo, Jae Hoon Moon, Sun Wook Cho, Young Jun Chai, June Young Choi, Yuh-Seog Jung, Kyu Eun Lee, Eun-Jae Chung, Kyungsik Kim, Su-jin Kim, Woochul Kim, Yoo Hyung Kim, Young Ki Lee, Jinsun Jang, Young Shin Song, Ka Hee Yi,
Journal of Korean Medical Science.2026;[Epub] CrossRef
Feasibility and Safety of Active Surveillance in Subcapsular Thyroid Nodules with High Suspicion for Malignancy
Yan Hu, Wei Zhou, Lu Zhang, Weiwei Zhan
Ultrasound in Medicine & Biology.2026; 52(4): 816. CrossRef
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Lars J. Grimm, Danielle E. Kruse, Tina D. Tailor, Karen S. Johnson, Brian C. Allen, Marc D. Ryser
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Controlled minimally invasive surgical interventions for the treatment of patients with thyroid carcinoma
David D. Dolidze, Zurab A. Bagatelia, Suren G. Laboyan, Arshak V. Vardanyan, Konstantin S. Titov, Ivan N. Lebedinsky, Georgi Genadi Melkonyan, Dmitriy V. Matveev, Nodar N. Gogitidze, Andrei Y. Lukin, Armen R. Oganyan, David G. Gogolashvili, Anastasia V. B
Journal of Experimental and Clinical Surgery.2026; 19(1): 45. CrossRef
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Advances in Surgery.2026; 60(1): 115. CrossRef
Overdiagnosis and Overtreatment of Thyroid Cancer and Precision Mitigation Strategies—An Integrated Analysis Based on Evidence-Based Medicine and Risk Stratification Models
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Advances in Clinical Medicine.2026; 16(04): 4980. CrossRef
Active surveillance of highly suspicious thyroid nodules in the isthmus compared with non-isthmus locations: a multicenter retrospective study
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Frontiers in Endocrinology.2026;[Epub] CrossRef
Active surveillance for low-risk papillary thyroid carcinoma: Integrating guidelines, emerging evidence, and directions
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Original Article

Thyroid Thyroid Cancer Screening
Diagnostic Performance of Ultrasound-Based Risk Stratification Systems for Thyroid Nodules: A Systematic Review and Meta-Analysis: Leehi Joo, Min Kyoung Lee, Ji Ye Lee, Eun Ju Ha, Dong Gyu Na; Endocrinol Metab. 2023;38(1):117-128. Published online February 27, 2023; DOI: https://doi.org/10.3803/EnM.2023.1670

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Background
This study investigated the diagnostic performance of biopsy criteria in four society ultrasonography risk stratification systems (RSSs) for thyroid nodules, including the 2021 Korean (K)-Thyroid Imaging Reporting and Data System (TIRADS).
Methods
The Ovid-MEDLINE, Embase, Cochrane, and KoreaMed databases were searched and a manual search was conducted to identify original articles investigating the diagnostic performance of biopsy criteria for thyroid nodules (≥1 cm) in four widely used society RSSs.
Results
Eleven articles were included. The pooled sensitivity and specificity were 82% (95% confidence interval [CI], 74% to 87%) and 60% (95% CI, 52% to 67%) for the American College of Radiology (ACR)-TIRADS, 89% (95% CI, 85% to 93%) and 34% (95% CI, 26% to 42%) for the American Thyroid Association (ATA) system, 88% (95% CI, 81% to 92%) and 42% (95% CI, 22% to 67%) for the European (EU)-TIRADS, and 96% (95% CI, 94% to 97%) and 21% (95% CI, 17% to 25%) for the 2016 K-TIRADS. The sensitivity and specificity were 76% (95% CI, 74% to 79%) and 50% (95% CI, 49% to 52%) for the 2021 K-TIRADS_1.5 (1.5-cm size cut-off for intermediate-suspicion nodules). The pooled unnecessary biopsy rates of the ACR-TIRADS, ATA system, EU-TIRADS, and 2016 K-TIRADS were 41% (95% CI, 32% to 49%), 65% (95% CI, 56% to 74%), 68% (95% CI, 60% to 75%), and 79% (95% CI, 74% to 83%), respectively. The unnecessary biopsy rate was 50% (95% CI, 47% to 53%) for the 2021 K-TIRADS_1.5.
Conclusion
The unnecessary biopsy rate of the 2021 K-TIRADS_1.5 was substantially lower than that of the 2016 K-TIRADS and comparable to that of the ACR-TIRADS. The 2021 K-TIRADS may help reduce potential harm due to unnecessary biopsies.

Citations

Citations to this article as recorded by

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