Active surveillance for low-risk papillary thyroid carcinoma: Integrating guidelines, emerging evidence, and directions

Active surveillance (AS) has emerged as an alternative to immediate surgery (IS) for patients with low-risk papillary thyroid carcinoma (PTC), against a background of rising thyroid cancer incidence but persistently low disease-specific mortality. More than three decades of follow-up data support that AS is oncologically safe and that patients undergoing conversion surgery (CS) achieve outcomes comparable to those with IS at diagnosis. This review synthesizes major international guidelines and consensus statements on AS published recently, with the foundational evidence that underpins current practice and interprets areas of convergence and divergence. Recent evidence on clinical outcomes under AS is summarized. Emerging data on risk prediction, management of special populations, and patient-centered perspectives are integrated to illustrate how current evidence is enabling more nuanced, risk-adapted decision-making. Finally, key priorities for the future development of AS are outlined, aiming to reduce overtreatment while supporting safer, more individualized and globally generalizable implementation of AS.