Approach to the patient: Oncocytic thyroid cancer

Oncocytic thyroid cancer (OTC), previously termed Hürthle cell carcinoma, is a rare but distinct thyroid malignancy. Although OTC arises from follicular epithelial cells and historically was classified as a subtype of follicular thyroid carcinoma, emerging molecular and clinical evidence demonstrates that OTC is distinct, leading to its reclassification by the World Health Organization (WHO) in 2022 into a separate clinical entity. OTC is characterized by a unique molecular landscape, including mitochondrial DNA mutations, increased somatic variant burden and widespread chromosomal loss of heterozygosity. Clinically, OTC presents with a spectrum of clinical behavior, with the most aggressive subtypes displaying high levels of vascular invasion and metastatic spread, mainly distant disease at the time of diagnosis. Diagnostic tools such as fine-needle aspiration can fail to reliably distinguish benign oncocytic lesions from malignant disease, complicating early evaluation and surgical decision-making, while the introduction of molecular testing has increased the accuracy of preoperative diagnostics. Poor radioiodine avidity further limits traditional postoperative management, leaving many patients with RAI-refractory disease few effective systemic treatment options. Emerging therapies, including tyrosine kinase inhibitors and mTOR pathway inhibitors, offer potential benefits but remain supported by limited evidence. As understanding of OTC continues to evolve, improving diagnostic accuracy, refining individualized treatment strategies, and expanding clinical trial data remain essential to optimizing outcomes for this distinct and often difficult to treat thyroid cancer.