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Eleonora Molinaro, Maria Cristina Campopiano, and Rossella Elisei

In the last decades, the incidence of thyroid cancer (TC) has more than doubled, but the disease-specific mortality rate was stable. To date 30-40% of all TC is represented by papillary microcarcinomas (mPTC), an indolent tumor, that probably remained undiagnosed before routine ultrasound use.

In 1993, Miyauchi was the first who hypothesized a conservative approach for low-risk mPTC and introduced the concept of active surveillance (AS) in its clinical management. The progression rate of mPTC during AS was low and delaying surgery did not impact on the efficacy of treatment or outcome. Since then, several authors from all over the world have reported their experience on AS in mPTCs.

As suggested by current guidelines, AS can be considered as an alternative to immediate surgery to avoid over-treatment in low-risk mPTC and may be the strategy to avoid complications from unnecessary surgery. In the last years, the AS inclusion criteria have been extended to both bigger tumors and to younger/healthier patients. The adoption of AS should take into consideration not only tumor characteristics, but also patient psychological profiles and medical team expertise.

Its safety and efficacy have been demonstrated in long-term outcome studies and in other types of tumors, however, scepticism in patients, families and physicians should be overcome by strong recommendations coming from scientific guidelines.

This review analyses the several and different experiences on AS and the potential obstacles in implementing it as a routine approach in mPTC patients.

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Maria Cristina Campopiano, Debora Podestà, Francesca Bianchi, Carlotta Giani, Laura Agate, Valeria Bottici, Virginia Cappagli, Loredana Lorusso, Antonio Matrone, Luciana Puleo, Laura Valerio, David Viola, Paolo Piaggi, Rossella Elisei, and Eleonora Molinaro


At present, recombinant TSH cannot be used for the treatment of metastatic differentiated thyroid cancer patients. The aim of this study was to evaluate if the type of TSH stimulation, recombinant or endogenous, had an impact on the outcome of these patients.

Design and methods:

We compared the outcome of two propensity score-matched groups of metastatic patients, stimulated by either only recombinant TSH (n = 43) or only endogenous TSH (n = 34).


As expected from the matching procedure, the clinical–pathological features and the cumulative 131-I activities administered to the two groups were very similar. After 4 years of follow-up, 4% of patients were cured, 3% had biochemical disease and 93% had structural disease. However, 91% of patients obtained a clinical benefit from this therapy in terms of stabilization of the disease or complete remission or partial response. When considering the two groups separately, we did not find any difference in their outcome. When considering the response to 131-I therapy of the single type of metastases, 8% of lymph node metastases and 8% of lung metastases disappeared but none of the bone metastases. The response to 131-I therapy of the single type of metastases was similar when we looked at the two groups separately.


This study shows (i) an overall clinical benefit of the 131-I therapy, since the majority of patients remained affected but with a stable disease, and (ii) that the preparation with either recombinant or endogenous TSH has no impact on the 131-I therapy efficacy and the outcome of our two groups of patients.