Active surveillance is nowadays an accepted management for selected micropapillary thyroid carcinoma (MTC). But when signs of nodal involvement, metastasis or aggressive features are present, then surgery is still standard of care. There is no clear consensus on what to do in the setting of nodal persistence/recurrence after surgery.

We present 2 cases of MTC with nodal persistence/recurrence in Althaia Universitary Foundation and the subsequent management.

Case 1- 31 year-old man, presented a 5mm MTC. We performed total thyroidectomy and removal of 2 negative nodes on December 2021. Presented nodal recurrence confirmed by biopsy in September 2023. Active surveillance was decided. Case 2- 49 year-old woman, presented a repeated Bethesda 1 in a thyroid nodule of 4mm and enlarged nodes at VII compartment. We performed total thyroidectomy and central neck dissection on May 2021. Biopsy showed 3 focus of MTC and 2 metastatic nodes without extravascular extension. Radio-iodine was administered afterwards. At the follow-up new nodes were seen, so a laterocervical neck dissection was performed on November 2022. Biopsy showed 1/9 affected node with a metastasis of 3cm. She had a new recurrence on march 2023, so conservative treatment and active survelliance was decided.

• The main issue with micropapillary carcinoma is not the survival, but the nodal recurrence (up to 30%). • Active surveillance is a novel approach for nodal persistence/recurrence still lacking evidence of safety. • Management of this cases is unclear, so the recommendation is to individualize each case with the Thyroid Cancer Committee.