Papillary thyroid carcinoma is the most common endocrine malignancy. Papillary thyroid microcarcinomas (PTMCs) are tumorswith a size of ≤1 cm. The biological behavior of these tumors differs due to the presence of their aggressive features. The prognosisof PTMCs with high-risk features, such as clinical node metastasis, distant metastasis, and significant extrathyroidal extension tothe tracheal or recurrent laryngeal nerve invasion, is poor, even if a sufficient immediate surgery is performed at diagnosis. However,PTMCs without these aggressive features are low-risk tumors because of their indolent and slow growth behaviors. The increasein thyroid cancer incidence is mostly a result of overdiagnosis of small low-risk PTMCs with indolent clinical course. Despitethe sudden increase in thyroid cancer incidence worldwide, cancer mortality did not increase. Although the traditional treatmentstrategy for PTMC is immediate surgery at diagnosis, because of the rather low disease-specific mortality rate, low recurrence rate,and potential risk for postoperative complications, active surveillance has been proposed recently as an alternative option forPTMCs without invasion, metastasis, or cytological or molecular characteristics. The recent data support that active surveillanceof low-risk PTMC should be the initial treatment modality, because only a small percentage of low-risk PTMCs show signs of progression,and delayed surgery has not caused significant recurrence. However, recent management guidelines are shifting towardmore conservative treatments, such as active surveillance. Although there is an increase in the number of studies related to activesurveillance, prospective studies have been mostly from academic referral centers in Japan. The world still needs class 1 evidenceextended prospective studies originating from different geographic regions. Active surveillance may be a good alternative to immediatesurgery for appropriately selected patients with PTMC.