Reply to "comment on: Multifocal papillary thyroid microcarcinomas: is the total tumor diameter associated with the tumor behavior? A retrospective cohort study"

Dear Editor

We are deeply grateful to Dr. Ilker Sengul and Dr. Demet Sengul for their careful consideration of our article.(¹) We feel honored by their interest in our work, particularly given their recognized expertise in this field. Below we present our considerations regarding the comments they kindly provided.

Indeed, the use of total tumor diameter (TTD) as a potential marker of tumor behavior in multifocal papillary thyroid microcarcinoma (PTMC) has been a subject of ongoing debate in the literature. Studies using different methodologies and patient populations have reported variable findings regarding its prognostic significance.(²,³)

In our aforementioned study there was no association between TTD—or other parameters considered markers of tumor behavior—and the proposed outcomes.(¹) Several factors may account for this, including the rigorous selection of our sample in accordance with the inclusion criteria, as well as certain methodological limitations which are discussed in a specific paragraph of the original article.(¹) Therefore, we agree that studies with more robust designs and larger sample sizes are needed to further investigate this issue, and to more precisely define the role of TTD in the management of multifocal PTMC. We also agree that the observed association between the number of metastatic lymph nodes and greater initial aggressiveness is very interesting.(¹) Because this parameter has previously been associated with recurrence-free survival in PTMC,(⁴) its use in the risk assessment of relevant cases should indeed be considered.

We would like to conclude by once again thanking Dr. Ilker Sengul and Dr. Demet Sengul for their constructive comments, which have contributed to advancing discussion on this important topic.

DATA AVAILABILITY

After publication, data will be available from the authors upon request—this condition is justified in the manuscript.

REFERENCES

• ¹ Nardi LA, Coutinho AF, Soares CS, Terra SA, Oliveira CC, Koga KH, et al. Multifocal papillary thyroid microcarcinomas: is the total tumor diameter associated with the tumor behavior? A retrospective cohort study. einstein (São Paulo). 2025;23:eAO1724.
• ² Zhou B, Wei L, Qin J. Does Multifocal Papillary Thyroid Microcarcinoma With a Total Tumor Diameter >1 cm Indicate Poor Biological Behavior? The Evidence is Insufficient. Endocr Pract. 2021;27(2):131-6.
• ³ Jiang KC, Lin B, Zhang Y, Zhao LQ, Luo DC. Total tumor diameter is a better indicator of multifocal papillary thyroid microcarcinoma: A propensity score matching analysis. Front Endocrinol (Lausanne). 2022;13:974755.
• ⁴ Cho SY, Lee TH, Ku YH, Kim HI, Lee GH, Kim MJ. Central lymph node metastasis in papillary thyroid microcarcinoma can be stratified according to the number, the size of metastatic foci, and the presence of desmoplasia. Surgery. 2015;157(1):111-8.

• Associate Editor:
  Kenneth Gollob Hospital Israelita Albert Einstein, São Paulo, SP, Brazil ORCID: https://orcid.org/0000-0003-4184-3867

Publication Dates

• Publication in this collection
  16 Feb 2026
• Date of issue
  2026

History

• Received
  17 Nov 2025
• Accepted
  17 Nov 2025