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The low-risk group also includes older patients with primary papillary tumors smaller than 5 cm without evidence of gross extrathyroidal invasion, and older patients with follicular cancer without major capsular invasion or blood vessel invasion.[13] Using these criteria, a retrospective study of 1,019 patients showed that the 20-year survival rate was 98% for patients with low-risk disease and 50% for patients with high-risk disease.[13] A retrospective surgical series of 931 previously untreated patients with differentiated thyroid cancer found that age older than 45 years, follicular histology, primary tumor larger than 4 cm (T2T3), extrathyroidal extension (T4), and distant metastases were adverse prognostic factors.[16,17] Favorable prognostic factors included female sex, multifocality, and regional lymph node involvement.[16] However, other studies have shown that regional lymph node involvement had no effect [18,19] or had an adverse effect on survival.[14,15,20] Another retrospective series of 1,807 patients found that the presence of distant metastases was most predictive of survival, followed by age.[21] An age cutoff of 55 years was identified as most predictive of survival