Endocrinology and Metabolism

Review Article

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.

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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
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

Original Articles

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

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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
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

Diabetes, obesity and metabolism
Comparison of Population Attributable Fractions of Cancer Incidence and Mortality Linked to Excess Body Weight in Korea from 2015 to 2030: Youjin Hong, Jihye An, Jeehi Jung, Hyeon Sook Lee, Soseul Sung, Sungji Moon, Inah Kim, Jung Eun Lee, Aesun Shin, Sun Ha Jee, Sun-Seog Kweon, Min-Ho Shin, Sangmin Park, Seung-Ho Ryu, Sun Young Yang, Seung Ho Choi, Jeongseon Kim, Sang-Wook Yi, Yoon-Jung Choi, Sangjun Lee, Woojin Lim, Kyungsik Kim, Sohee Park, Jeong-Soo Im, Hong Gwan Seo, Kwang-Pil Ko, Sue K. Park; Endocrinol Metab. 2024;39(6):921-931. Published online November 28, 2024; DOI: https://doi.org/10.3803/EnM.2024.2071

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Background
The increasing rate of excess body weight (EBW) in the global population has led to growing health concerns, including cancer-related EBW. We aimed to estimate the population attributable fraction (PAF) of cancer incidence and deaths linked to EBW in Korean individuals from 2015 to 2030 and to compare its value with various body mass index cutoffs.
Methods
Levin’s formula was used to calculate the PAF; the prevalence rates were computed using the Korean National Health and Nutrition Examination Survey data, while the relative risks of specific cancers related to EBW were estimated based on the results of Korean cohort studies. To account for the 15-year latency period when estimating the PAF in 2020, the prevalence rates from 2015 and attributable cases or deaths from 2020 were used.
Results
The PAF attributed to EBW was similar for both cancer incidence and deaths using either the World Health Organization (WHO) Asian-Pacific region standard or a modified Asian standard, with the WHO standard yielding the lowest values. In the Korean population, the PAFs of EBW for cancer incidence were 2.96% in men and 3.61% in women, while those for cancer deaths were 0.67% in men and 3.06% in women in 2020. Additionally, PAFs showed a gradual increase in both sexes until 2030.
Conclusion
The EBW continues to have a significant impact on cancer incidence and deaths in Korea. Effective prevention strategies targeting the reduction of this modifiable risk factor can substantially decrease the cancer burden.

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Review Articles

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.

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Feasibility and Safety of Active Surveillance in Subcapsular Thyroid Nodules with High Suspicion for Malignancy
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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
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Thyroid
The Concept of Economic Evaluation and Its Application in Thyroid Cancer Research: Kyungsik Kim, Mijin Kim, Woojin Lim, Bo Hyun Kim, Sue K. Park; Endocrinol Metab. 2021;36(4):725-736. Published online August 27, 2021; DOI: https://doi.org/10.3803/EnM.2021.1164

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Economic evaluation is a type of comparative analysis between interventions in terms of both their resource use and health outcomes. Due to the good prognosis of thyroid cancer (TC), the socioeconomic burden of TC patients post-diagnosis is increasing. Therefore, economic evaluation studies focusing on TC are recommended. This study aimed to describe the concept and methods of economic evaluation and reviewed previous TC studies. Several previous studies compared the costs of interventions or evaluated recurrence, complications, or quality of life as measures of their effectiveness. Regarding costs, most studies focused on direct costs and applied hypothetical models. Cost-minimization analysis should be distinguished from simple cost analysis. Furthermore, due to the universality of the term “cost-effectiveness analysis” (CEA), several studies have not distinguished CEA from cost-utility analysis; this point needs to be considered in future research. Cost-benefit analyses have not been conducted in previous TC research. Since TC has a high survival rate and good prognosis, the need for economic evaluations has recently been pointed out. Therefore, correct concepts and methods are needed to obtain clear economic evaluation results. On this basis, it will be possible to provide appropriate guidelines for TC treatment and management in the future.

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Original Articles

Thyroid
Association between Iodine Intake, Thyroid Function, and Papillary Thyroid Cancer: A Case-Control Study: Kyungsik Kim, Sun Wook Cho, Young Joo Park, Kyu Eun Lee, Dong-Wook Lee, Sue K. Park; Endocrinol Metab. 2021;36(4):790-799. Published online August 11, 2021; DOI: https://doi.org/10.3803/EnM.2021.1034

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Background
This study aimed to assess the effects of iodine intake, thyroid function, and their combined effect on the risk of papillary thyroid cancer (PTC) and papillary thyroid microcarcinoma (PTMC).
Methods
A case-control study was conducted including 500 community-based controls who had undergone a health check-up, and 446 overall PTC cases (209 PTC and 237 PTMC) from the Thyroid Cancer Longitudinal Study. Urinary iodine concentration (UIC), was used as an indicator of iodine intake, and serum for thyroid function. The risk of PTC and PTMC was estimated using unconditional logistic regression.
Results
Excessive iodine intake (UIC ≥220 μg/gCr) was associated with both PTC (odds ratio [OR], 18.13 95% confidence interval [CI], 8.87 to 37.04) and PTMC (OR, 8.02; 95% CI, 4.64 to 13.87), compared to adequate iodine intake (UIC, 85 to 219 μg/gCr). Free thyroxine (T4) levels ≥1.25 ng/dL were associated with PTC (OR, 1.97; 95% CI, 1.36 to 2.87) and PTMC (OR, 2.98; 95% CI, 2.01 to 4.41), compared to free T4 levels of 0.7 to 1.24 ng/dL. Individuals with excessive iodine intake and high free T4 levels had a greatly increased OR of PTC (OR, 43.48; 95% CI, 12.63 to 149.62), and PTMC (OR, 26.96; 95% CI, 10.26 to 70.89), compared to individuals with adequate iodine intake and low free T4 levels.
Conclusion
Excessive iodine intake using creatinine-adjusted UIC and high free T4 levels may have a synergistic effect on PTC and PTMC. Considering both iodine intake and thyroid function is important to assess PTC and PTMC risk.

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Clinical Study
Effects of Maternal Iodine Status during Pregnancy and Lactation on Maternal Thyroid Function and Offspring Growth and Development: A Prospective Study Protocol for the Ideal Breast Milk Cohort: Young Ah Lee, Sun Wook Cho, Ho Kyung Sung, Kyungsik Kim, Young Shin Song, Sin Je Moon, Jung Won Oh, Dal Lae Ju, Sooyeon Choi, Sang Hoon Song, Gi Jeong Cheon, Young Joo Park, Choong Ho Shin, Sue K. Park, Jong Kwan Jun, June-Key Chung; Endocrinol Metab. 2018;33(3):395-402. Published online September 18, 2018; DOI: https://doi.org/10.3803/EnM.2018.33.3.395

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Abstract PDF PubReader ePub

Background

Iodine is an intrinsic element of thyroid hormone, which is essential for childhood growth and development. The Ideal Breast Milk (IBM) cohort study aims to evaluate the effects of maternal iodine status during pregnancy and lactation on maternal thyroid function, offspring growth and development, and offspring thyroid function.

Methods

The IBM cohort study recruited pregnant women from Seoul National University Hospital between June 2016 and August 2017, followed by enrollment of their offspring after delivery. For the maternal participants, iodine status is evaluated by urinary iodine concentration (UIC) and dietary records in the third trimester and at 3 to 4 weeks and 12 to 15 months postpartum. For the child participants, cord blood sampling and UIC measurements are performed at birth. At 3 to 4 weeks of age, UIC and breastmilk iodine concentrations are measured. At 12 to 15 months of age, growth and development are assessed and measurements of UIC, a thyroid function test, and ultrasonography are performed.

Results

A total of 198 pregnant women in their third trimester were recruited. Their mean age was 35.1±3.5 years, and 78 (39.4%) of them were pregnant with twins. Thirty-three (16.7%) of them had a previous history of thyroid disease.

Conclusion

Korea is an iodine-replete area. In particular, lactating women in Korea are commonly exposed to excess iodine due to the traditional practice of consuming brown seaweed soup postpartum. The study of the IBM cohort is expected to contribute to developing guidelines for optimal iodine nutrition in pregnant or lactating women.

Citations

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