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In recent years, there has been worldwide a significant (relative) increase in "small" thyroid cancer (pT1 = tumor size of ≤10 mm), which has now reached a plateau. This fact and the absence of prospective and randomized clinical trials are increasingly leading to a discussion of the so-called risk-adapted management of differentiated thyroid cancer. The available studies are partly incomplete, retrospective and difficult to compare. In addition, factors such as different iodine supply, cost-benefit considerations and regional differences in quality of surgical procedures influence the implementation of therapy concepts. Therefore, the therapy of the differentiated thyroid cancer is currently the subject of intensive discussion, especially in "low risk" situations. There is a worldwide trend to classify the risk of differentiated thyroid cancer in general lower than in the past and thus also to reduce the extent of the traditionally recommended therapy. The discussion is increasingly moving from the "one size fits all" towards personalized and thus risk-adapted therapy of the differentiated thyroid cancer.The main goal of this "paradigm shift" is to avoid an "overtreatment" which may be associated with permanent complications due to "unnecessary" surgical procedures and any negative effects of radioiodine ablation.This overview attempts to answer the following questions: When is a risk-adapted therapy for differentiated thyroid cancer justified? What are the consequences in differentiated thyroid cancer if no radioiodine therapy is performed?

Background: We aimed to study the validity of six published ultrasound criteria for risk stratification of thyroid nodules in the former severely iodine deficient population of Austria., Methods: Retrospective, single centre, observer blinded study design. All patients with a history of thyroidectomy due to nodules seen in the centre between 2004 and 2014 with preoperative in-house sonography and documented postoperative histology were analyzed ( n  = 195). A board of five experienced thyroidologists evaluated the images of 45 papillary carcinomas, 8 follicular carcinomas, and 142 benign nodules regarding the following criteria: mild hypoechogenicity, marked hypoechogenicity, microlobulated or irregular margins, microcalcifications, taller than wide shape, missing thin halo., Results: All criteria but mild hypoechogenicity were significantly more frequent in thyroid cancer than in benign nodules. The number of positive criteria was significantly higher in cancer (2.79 ± 1.35) than in benign nodules (1.73 ± 1.18; p  < 0.001). Thus, with a cut-off of two or more positive criteria, a sensitivity of 85% and a specificity of 45% were reached to predict malignancy in this sample of thyroid nodules. As expected, the findings were even more pronounced in papillary cancer only (2.98 ± 1.32 vs. 1.73 ± 1.18, p  < 0.001). The six ultrasound criteria could not identify follicular cancer., Conclusion: Our findings support the recently published EU-TIRADS score. Apart from mild hypoechogenicity, the analyzed ultrasound criteria can be applied for risk stratification of thyroid nodules in the previously severely iodine deficient population of Austria., Competing Interests: The ethic committee of the Medical University of Vienna approved this study which did not involve direct patient care. (1461/2015).All authors gave their approval for the final version to be published and agree to be accountable for this work.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.