Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Sex differences in the prevalence of papillary thyroid carcinoma, risk factors, and imaging features: a narrative literature

review.

DOI: https://doi.org/10.46296/yc.v10i19.0990

DIFERENCIAS SEGÚN EL SEXO EN LA PREVALENCIA DEL CARCINOMA

PAPILAR DE TIROIDES, LOS FACTORES DE RIESGO Y LAS

CARACTERÍSTICAS POR IMAGEN: UNA REVISIÓN NARRATIVA DE LA

LITERATURA

SEX DIFFERENCES IN THE PREVALENCE OF PAPILLARY THYROID

CARCINOMA, RISK FACTORS, AND IMAGING FEATURES: A NARRATIVE

LITERATURE REVIEW

1

2

Galeas-Hernández Ana Patricia ; Faicán-Benenaula José Francisco ;

3

Santillán-Rodríguez Vinicio Estuardo

1

Postgraduate Student in Diagnostic Imaging, Universidad Católica de Cuenca, Ecuador.

Correo: anagaleas10@gmail.com. ORCID ID: https://orcid.org/0009-0007-2985-2644

2

Specialist in Radiology and Diagnostic Imaging, Cuenca, Ecuador.

Correo: franciscofaican@gmail.com. ORCID ID https://orcid.org/0000-0001-5339-7599

3

Universidad Católica de Cuenca. Ecuador.

Correo: vinicio.santillanr@ucacue.edu.ec. ORCID ID: https://orcid.org/0000-0002-4296-580X

Resumen

Antecedentes: El carcinoma papilar de tiroides (CPT) es el tipo más frecuente de cáncer de

tiroides diferenciado; su incidencia notificada ha aumentado en las últimas décadas, en gran

medida debido a una mayor detección de microcarcinomas mediante ecografía de alta resolución

y punción-aspiración con aguja fina (PAAF). Objetivo: Sintetizar la evidencia sobre la prevalencia

del CPT y su distribución por sexo y edad, así como identificar los factores de riesgo asociados

y las características de imagen relevantes para el diagnóstico y la estratificación del riesgo.

Métodos: Se realizó una revisión narrativa de la literatura en PubMed, Scopus, SciELO y Web of

Science, abarcando publicaciones en inglés y español entre 1990 y 2025. Se elaboró una matriz

de evidencia que incluyó 28 documentos en la síntesis final. Resultados: Los estudios

seleccionados mostraron una mayor incidencia de CPT en mujeres, un predominio en la edad

adulta y un aumento en la detección incidental de tumores pequeños. Los factores de riesgo más

consistentes fueron la exposición a radiación ionizante, los antecedentes familiares y las

alteraciones moleculares. En cuanto a las pruebas de imagen, la marcada hipoecogenicidad, las

microcalcificaciones, los márgenes irregulares y la morfología "más alto que ancho" fueron los

hallazgos ecográficos más sugestivos de malignidad. La evaluación de los ganglios linfáticos

cervicales y su integración con los sistemas TI-RADS/EU-TIRADS y Bethesda refuerzan la

estratificación diagnóstica. Conclusión: Esta revisión permitió vincular con mayor claridad la

epidemiología, los factores de riesgo y los hallazgos de imagen del CPT. La integración de la

ecografía estandarizada y la citología sigue siendo esencial para equilibrar la detección oportuna

con la reducción del sobrediagnóstico.

Palabras claves: cáncer de tiroides diferenciado; microcarcinoma; ecografía tiroidea; aspiración

con aguja fina; diagnóstico por imagen; metástasis ganglionar.

Abstract

Background: Papillary thyroid carcinoma (PTC) is the most common type of differentiated thyroid

cancer, and its reported incidence has increased in recent decades, largely because of greater

detection of microcarcinomas using high-resolution ultrasonography and fine-needle aspiration

(

FNA). Objective: To synthesize the evidence on the prevalence of PTC and its distribution by

sex and age, and to identify associated risk factors and imaging features relevant to diagnosis

and risk stratification. Methods: A narrative literature review was conducted in PubMed, Scopus,

SciELO, and Web of Science for publications from 1990 through 2025 in English and Spanish.

Información del manuscrito:

Fecha de recepción: 13 de mayo de 2026.

Fecha de aceptación: 20 de julio de 2026.

Fecha de publicación: 28 de agosto de 2026.

1272

Galeas-Hernández et al. (2026)

An evidence matrix was developed comprising 28 documents included in the final synthesis.

Results: The selected studies showed a higher incidence of PTC among women, predominance

in adulthood, and increasing incidental detection of small tumors. The most consistent risk factors

were ionizing radiation exposure, family history, and molecular alterations. On imaging, marked

hypoechogenicity, microcalcifications, irregular margins, and a taller-than-wide shape were the

ultrasonographic findings most suggestive of malignancy. Cervical lymph node assessment and

integration with TI-RADS/EU-TIRADS and the Bethesda System strengthen diagnostic

stratification. Conclusion: This review more clearly linked the epidemiology, risk factors, and

imaging findings of PTC. The integration of standardized ultrasonography and cytology remains

essential to balance timely detection with the reduction of overdiagnosis.

Keywords: differentiated thyroid cancer; microcarcinoma; thyroid ultrasonography; fine-needle

aspiration; diagnostic imaging; lymph node metastasis.

most regions, intensifying the debate

1. Introduction

regarding

overdiagnosis

and

Papillary thyroid carcinoma (PTC) is

the most common malignant

neoplasm of the thyroid gland and

the predominant subtype of

overtreatment

of very-low-risk

tumors (14-17). From a diagnostic

standpoint, ultrasonography is the

first-line imaging modality for

evaluating thyroid nodules and

guiding decisions regarding FNA.

differentiated thyroid cancer (1,2).

Although its overall prognosis is

favorable, PTC exhibits substantial

Standardization

through

risk-

clinicopathological

heterogeneity.

stratification systems (e.g., ACR TI-

RADS and EU-TIRADS), together

with correlation with cytology using

the Bethesda System, improves

reproducibility, prioritizes FNA of

nodules with a higher probability of

Most patients have low-risk disease,

whereas a subgroup develops local

invasion, persistent or recurrent

locoregional disease, and, less

commonly, distant metastases (1,6-

9). In recent decades, a sustained

malignancy,

and

reduces

increase in the incidence of thyroid

cancer, particularly PTC, has been

reported. This trend is largely

attributable to expanded access to

unnecessary procedures (3,11-13).

Synthesizing prevalence data and

their distribution by sex and age

provides

key

information

for

high-resolution

ultrasonography and fine-needle

aspiration (FNA), which has

increased the incidental detection of

microcarcinomas. Mortality,

however, remains relatively low in

cervical

estimating the burden of PTC,

guiding screening strategies and

resource allocation, and interpreting

the rise in reported cases in the

context of overdiagnosis. Likewise,

Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Sex differences in the prevalence of papillary thyroid carcinoma, risk factors, and imaging features: a narrative literature

review.

integrating

suspicious

findings with

and certain predisposing syndromes.

Other associations, such as thyroid

autoimmunity or variations in iodine

status, are heterogeneous across

studies and should be interpreted in

conjunction with the clinical context

ultrasonographic

standardized reporting criteria and

cytology can optimize timely

diagnosis and risk stratification,

particularly when cervical lymph

node findings that may influence

surgical planning are considered

and

ultrasonographic

On

findings

imaging,

(19,25,28).

(

5,11-13,26). In addition, identifying

risk factors and prognostic variables

age, tumor size, extrathyroidal

ultrasonography identifies suspicious

features

such

as

marked

(

hypoechogenicity,

microcalcifications,

extension,

and

lymph

node

more

and

irregular

involvement)

individualized

management,

supports

margins, and a taller-than-wide

shape; standardized reporting helps

define thresholds for FNA and follow-

up (11,12). Preoperative cervical

lymph node assessment is also

particularly relevant because of the

frequency of lymphatic metastases

and their association with a higher

risk of recurrence, which may

influence the extent of surgery and

subsequent risk stratification (5,21).

surveillance

with

potential

implications for recurrence and long-

term outcomes (6-9,10).

The epidemiology of PTC shows a

clear female predominance and a

peak occurrence in adulthood

(approximately 30-50 years), with

geographic variation influenced by

diagnostic practices and access to

imaging technologies (14-16). At the

biological level, molecular alterations

involving BRAF and RAS have been

described and contribute to PTC

heterogeneity, with associations with

distinct clinicopathological patterns

However, important knowledge gaps

remain because of methodological

variability in prevalence estimates

and the inconsistent correlation

among

histopathology, and clinical behavior

in specific hospital settings,

imaging

findings,

(

18). The best-established risk

factors include exposure to ionizing

radiation, particularly during

childhood, as well as family history

supporting the need for reviews that

integrate the available evidence

(3,5,14-17). Finally, although survival

1274

Landín-Isves et al. (2026)

in PTC is generally high, clinically

meaningful recurrence has been

reported in selected patients with

very-low-risk disease. Accordingly,

active surveillance has emerged as

an alternative strategy aimed at

reducing treatment-related morbidity

without compromising oncologic

outcomes (6-9,23,24). In this context,

the objective of this review was to

determine, based on the available

literature, the prevalence of PTC and

its differential distribution between

women and men, and to synthesize

the risk factors and imaging features

relevant to timely diagnosis and risk

stratification.

studies, pooled analyses, guidelines

or consensus documents, and

diagnostic classification systems that

provided information on prevalence

by sex and age, risk factors, imaging

findings, the clinical utility of FNA,

staging, and recurrence. General

narrative reviews were retained as

contextual

support

for

the

Discussion; however, the synthesis

of results was structured around

documents directly aligned with the

objective of this review.

A total of 50 potentially relevant

records were identified. Following

review of titles, abstracts, and full

texts, 28 documents were included in

the final synthesis and organized into

an evidence matrix according to

document type, population or

context, and main contribution. To

maintain consistency with the final

selection, references 1 and 2 were

used solely as conceptual support for

the Introduction, whereas references

2. Methods

A narrative literature review was

conducted. PubMed, Scopus,

SciELO, and Web of Science were

searched for publications in English

and Spanish from 1990 through

2025. The search strategy combined

3

through 30 comprised the

terms related to "papillary thyroid

analytical matrix (Table 1).

carcinoma,"

"thyroid

"risk

cancer,"

factors,"

"

prevalence,"

ultrasound,"

"TI-RADS,"

3. Results

Bethesda," "fine-needle aspiration,"

The evidence from the 28 included

documents clustered around four

main domains (Table 1): population

and "lymph node metastasis" using

the Boolean operators AND/OR.

Priority was given to observational

1

275

Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Sex differences in the prevalence of papillary thyroid carcinoma, risk factors, and imaging features: a narrative literature

review.

epidemiology; risk factors and tumor

biology; imaging and cytologic

while

literature

on

tumor

classification and recurrence helped

contextualize the influence of tumor

biology on clinical aggressiveness

and recurrence (18-20,25,28,30).

stratification;

and

prognosis,

including recurrence and active

surveillance. This structure provides

a direct link between the statements

made in the manuscript and the

selected literature.

Additional

associations

including

were

reported,

thyroid

autoimmunity,

population-level

variation in iodine status, and

coexistence with other

From

an

epidemiological

perspective, global studies and trend

analyses consistently showed a

female predominance in PTC and a

sustained increase in incidence,

particularly driven by small tumors

detected through ultrasonography

and FNA. Likewise, the higher

frequency among young and middle-

aged adults supports a nonuniform

distribution by sex and age and

developmental thyroid abnormalities;

however, these findings were less

consistent across studies and should

be interpreted cautiously, with

emphasis

on

their

and

clinical,

imaging

histopathological,

correlation (19,26-29).

In diagnostic imaging, the selected

evidence confirmed that high-

resolution ultrasonography is the

initial imaging modality for evaluating

thyroid nodules. Features most

strongly associated with suspicion of

indicates

that

overdiagnosis

accounts for a relevant proportion of

the contemporary increase in

reported cases (14-17).

malignancy

included

marked

With regard to risk factors, exposure

to ionizing radiation, particularly at

younger ages, family history, and

molecular determinants were the

most consistent findings in the

evidence matrix. Genomic analyses

of PTC demonstrated biological

hypoechogenicity,

microcalcifications,

irregular

margins, a taller-than-wide shape,

and selected signs of extrathyroidal

extension. In addition, ACR TI-RADS

and EU-TIRADS, together with the

Bethesda System for cytology,

provide a reproducible framework for

determining indications for FNA and

heterogeneity

associated

with

alterations involving BRAF and RAS,

1276

Landín-Isves et al. (2026)

follow-up (3,4,10-13). Cervical lymph

node assessment was central to the

4. Discussion

This evidence synthesis allowed

clearer differentiation among findings

evidence

reviewed

because

ultrasonographic identification of

suspicious lymph nodes influences

staging and surgical planning. Cystic

changes, microcalcifications, loss of

derived

from

epidemiological

studies, contributions from clinical

research, and the role of diagnostic

imaging. Across the included studies,

the female predominance of PTC

and its greater frequency in

the

fatty

hilum,

and

were

a

rounded

abnormal

repeatedly

morphology,

vascularity

adulthood

were

consistently

associated with metastasis, while

staging documents and predictive

models support their integration into

supported. However, interpretation

of this pattern should account for the

effect of differential access to

ultrasonography and FNA on

detection rates (14-17).

the

preoperative

Finally,

assessment

studies of

(5,21,22).

recurrence and follow-up showed

that extrathyroidal extension, lymph

node involvement, and certain

From

an

etiologic

and

pathophysiologic perspective, the

strongest evidence continues to

histopathological

or

molecular

profiles are associated with a higher

risk of persistent or recurrent

disease. By contrast, in carefully

selected patients with low-risk

papillary thyroid microcarcinoma,

active surveillance is a reasonable

alternative when protocol-based

support

radiation early in life and familial or

molecular susceptibility. The

exposure

to

ionizing

incorporation of genomic data,

particularly involving BRAF and RAS,

not only explains part of the

biological heterogeneity of PTC but

also helps clarify why tumors with

similar appearances may exhibit

ultrasonographic

follow-up

and

appropriate institutional expertise are

available (6-9,23,24,30).

different

clinical

behaviors.

Nevertheless, associations such as

thyroid autoimmunity or variation in

iodine exposure require critical

interpretation the

because

magnitude of these associations is

1

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Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 19 (Ed. jul – dic. 2026) ISSN: 2697-3456

Sex differences in the prevalence of papillary thyroid carcinoma, risk factors, and imaging features: a narrative literature

review.

not consistent across populations

and study designs (18-20,25,28-30).

papillary microcarcinomas supports

reconsideration of the traditional

approach of immediate treatment in

selected patients, favoring shared

decision-making tailored to the

patient's actual risk. In this regard,

the principal clinical contribution of

the present review is the integration

of the epidemiology of overdiagnosis

with concrete criteria for a more

rational diagnostic and prognostic

assessment (6-9,23,24).

From a diagnostic perspective, this

review confirms that the major

strength of current practice does not

lie in a single test, but rather in the

structured

ultrasonography, cytology, and risk-

stratification systems.

Standardization with TI-RADS and

EU-TIRADS improves

integration

of

reproducibility, while the Bethesda

System provides a structured bridge

between imaging suspicion and

Limitations

This review has limitations inherent

to its narrative design. The evidence

clinical

management.

This

combination becomes even more

valuable when cervical lymph node

matrix

studies, pooled analyses, guidelines,

and classification documents,

included

observational

assessment

is

incorporated,

because preoperative recognition of

metastatic disease can modify

staging, the extent of surgery, and

resulting in methodological and

conceptual heterogeneity across the

included sources. In addition, the

absence of formal quantitative data

extraction precluded estimation of

pooled measures of association or

diagnostic performance. Although

the group of analyzed documents

was more clearly defined, the

subsequent

3,21,22).

follow-up

(3-5,10-

1

The included studies suggest that

recurrence is determined not only by

tumor size but also by a constellation

of clinical, nodal, histopathological,

and biological variables. This finding

possibility

of

selection

and

supports

more

individualized

publication bias remains.

surveillance strategies. At the same

time, the feasibility of active

surveillance

for

very-low-risk

1278

Landín-Isves et al. (2026)

5. Conclusions

Funding

PTC continues to show a clear

female predominance and is more

frequently diagnosed in adulthood, in

a context in which overdiagnosis

associated with ultrasonography and

FNA accounts for part of the

observed increase in incidence. The

evidence matrix indicated that the

most consistent risk factors are

ionizing radiation exposure, familial

No external funding was received for

this review.

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0

Table 1. Evidence matrix of the documents included in the narrative synthesis (n = 28).

Reference Type of evidence

Population / context

Thyroid nodules /

ultrasound risk

stratification

PTC subtypes

according to the 2022

WHO classification

PTC with cervical

lymph node

Main contribution

Evaluates the performance of ultrasound risk-

stratification systems for papillary carcinoma.

3

4

5

Meta-analysis

Retrospective

comparative study

Compares ultrasonographic findings among

histological subtypes of papillary carcinoma.

Retrospective

Proposes ultrasound-based risk stratification

for cervical lymph node metastasis.

predictive model

assessment

6

7

8

9

Retrospective study Patients with PTC

Identifies prognostic factors for survival and

recurrence.

Defines clinicopathological predictors of

recurrence.

Analyzes prognostic factors associated with

recurrence.

Develops a predictive model for recurrence.

Retrospective study 4,085 patients with

PTC

Retrospective study Patients with PTC

Model development

and validation

ATA clinical

Patients with PTC

1

0

Adults with thyroid

nodules and

Summarizes recommendations for diagnosis,

staging, and management.

guideline

differentiated thyroid

cancer

1

2

3

Consensus / white

paper

European guideline

Thyroid nodules in

adults

Thyroid nodules in

adults

Establishes ACR TI-RADS criteria for risk

stratification and FNA.

Presents EU-TIRADS for ultrasonographic

stratification of malignancy risk.

Standardizes the Bethesda System and its

clinical correlation.

Cytopathology

consensus

Thyroid FNA cytology

1282

Landín-Isves et al. (2026)

1

4

5

Global

epidemiological

study

Global

epidemiological

study

Global burden of

thyroid cancer, 2022

Provides estimates of incidence and mortality.

36 cancers in 185

countries

Places the relative burden of thyroid cancer in

a global context.

1

2

6

7

8

9

0

Epidemiological

analysis

Global trend

analysis

Integrated genomic

characterization

Review / 2022

WHO update

Conceptual review

of the 2022 WHO

classification

Staging update

Global trend

Highlights the impact of overdiagnosis on the

increase in reported cases.

Reinforces the relationship between rising

incidence and overdiagnosis.

Describes molecular alterations and tumor

heterogeneity.

Summarizes classification changes relevant to

PTC.

Describes new concepts in nomenclature and

classification.

Papillary thyroid

carcinoma

Thyroid tumors

2

1

Differentiated and

anaplastic thyroid

cancer

Explains the changes introduced in the 8th

edition of the AJCC/TNM staging system.

2

3

Staging review

Clinical review

Thyroid cancer

Discusses the scope and limitations of the 8th

edition of the AJCC/TNM staging system.

Summarizes evidence supporting active

surveillance.

Low-risk papillary

thyroid

microcarcinoma

Papillary thyroid

microcarcinoma

2

3

4

5

6

7

8

9

0

Clinical review

Supports active surveillance in selected cases.

Pooled analysis of

Childhood exposure to Confirms the association between radiation

12 studies

external radiation

PTC and thyroglossal

duct cyst

exposure and thyroid cancer.

Explores their coexistence and the clinical

significance of this association.

Provides general clinical context for the

Discussion.

Descriptive clinical

article

Clinical review

Thyroid cancer

Systematic review

with meta-analysis

Narrative review

Adults with PTC

Synthesizes associated risk factors.

Papillary thyroid

carcinoma

Summarizes general clinical and imaging

features.

Observational study Patients with PTC and Describes risk factors associated with

recurrence recurrence.

1

283