Papillary thyroid cancers (PTCs) are generally considered to be indolent malignancies with favourable outcomes. Active surveillance (AS) has consequently been trialled as a management option for small PTCs with no evidence of regional lymph node involvement, especially papillary thyroid microcarcinomas (PTMCs - PTCs <1cm in diameter). This meta-analysis sought to determine factors predicting the progression of PTCs under AS. Nine studies with 4166 patients diagnosed with a PTC <2cm in diameter were included. Of these patients, 354 (15%) showed tumour progression during AS, with an average follow-up of nearly 3.5 years (41.58 months). Progression was most frequently due to an increase in volume >50%, then increase in diameter by >3mm, followed by development of lymph node metastasis. This last feature was responsible for evidence of progression in 13% of patients who progressed, representing 2% of all patients under AS. Patient age, sex and tumour size were found not to be associated with a higher risk of tumour progression. Although this is arguably a negative study insofar as no specific risk factors for progression were identified, useful data has nevertheless been provided in terms of an overall rate of risk of progression (15%) and chance of developing lymph node metastases (2%) with consequent possible adverse prognostic implications for patients with small PTCs undergoing AS. The authors conclude that AS may be an appropriate treatment option in a subset of appropriately counselled patients with small PTCs. In the discussion, it is suggested that minimally-invasive radiofrequency ablation (RFA) techniques should be considered as an option between AS and surgery for small PTCs – reference is made to a 2022 meta-analysis of this technique for PTMCs which reported a 93% volume reduction ratio, 64% complete disappearance rate and lymph node metastasis rate of 1%; the overall incidence of complications with RFA was 1.8%.