Liquid Biopsy Biomarkers in Thyroid Cancer: Current Evidence and Future Directions
Keywords:
hyroid Cancer, Liquid Biopsy, Circulating Tumor DNA (ctDNA), MicroRNAs, Extracellular Vesicles, Molecular Biomarkers, Precision Oncology, FragmentomicsAbstract
Background: Thyroid cancer (TC) incidence has risen globally, yet the diagnostic and management paradigms remain heavily reliant on invasive tissue biopsies and ultrasonography, plagued by high rates of indeterminate cytology and overtreatment. Liquid biopsy, the analysis of tumor-derived material from bodily fluids, has emerged as a transformative tool in oncology, offering a minimally invasive window into tumor biology. This systematic review synthesizes the evidence from 2020 to 2026 on liquid biopsy biomarkers in TC, including circulating tumor cells (CTCs), cell-free DNA (cfDNA), circulating tumor DNA (ctDNA), microRNAs (miRNAs), and extracellular vesicles (EVs).
Methods: A systematic search of PubMed, Scopus, and Web of Science was conducted for articles published between January 1, 2020, and January 1, 2026, using PRISMA guidelines. Studies investigating the diagnostic, prognostic, or predictive utility of blood-based liquid biopsy biomarkers in differentiated thyroid cancer (DTC), medullary thyroid cancer (MTC), and anaplastic thyroid cancer (ATC) were included. A total of 50 studies were selected for final synthesis after critical appraisal.
Results: The evidence demonstrates a paradigm shift from single-analyte assays to multi-analyte and multi-omics platforms. ctDNA analysis, particularly for BRAF V600E and TERT promoter mutations, shows high specificity but variable sensitivity for DTC, proving most valuable in advanced and metastatic settings. For MTC, ctDNA-based RET mutational profiling and minimal residual disease (MRD) monitoring have become clinically actionable. The landscape for miRNAs and EVs has matured, with panels like miR-221, miR-222, and miR-146b showing robust diagnostic performance in discriminating benign from malignant indeterminate thyroid nodules, with some achieving validation in large, prospective multi-center cohorts. Strikingly, the integration of long-read sequencing and methylation-based cfDNA fragmentomics has opened new frontiers for early-stage detection.
Conclusion: Liquid biopsy is poised to transition from a research tool to an integral component of precision thyroid cancer care. The most impactful advances between 2020 and 2026 are in three areas: (1) the clinical validation of miRNA panels for indeterminate nodule triage, (2) the establishment of ctDNA for real-time therapeutic monitoring and resistance detection in advanced TC, and (3) the emergence of fragmentomics and AI-driven multi-analyte signatures. While challenges in standardization and early-stage sensitivity persist, the trajectory points toward integrating liquid biopsy into diagnostic algorithms, active surveillance protocols, and dynamic therapeutic strategies.
References
Sung H., et al., Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians, Vol. 71 No. 3 (2021): Volume 71 Issue 3, 209-249
Vaccarella S., et al, The Impact of Diagnostic Changes on the Rise in Thyroid Cancer Incidence, A Population-Based Study in Selected High-Resource Countries. Thyroid: Vol. 26 No. 8 (2021): Volume 26 Issue 8, 1127-1135
Cibas E. S., & Ali S. Z., The 2017 Bethesda System for Reporting Thyroid, Cytopathology Thyroid: Vol. 27 No. 11(2017): Volume 27 Issue 11, 1341-1346
Haugen B. R., et al., 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer, Thyroid: Vol. 26 No. 1, Volume 26 Issue 1 (2016): 1-133
Luca Giovanella, Thyroglobulin measurement in differentiated thyroid carcinoma management, Expert Review of Endocrinology & Metabolism; Vol 3 No 2 (2008): Volume 3 Issue 2, 117-125
Siravegna G., et al., Integrating liquid biopsies into the management of cancer, Nature Reviews Clinical Oncolog: Vol. 14 No. 9 (2017): 531-548
Ignatiadis M., et al., Liquid biopsy enters the clinic — implementation issues and future challenges, Nature Reviews Clinical Oncology: Vol. 18 No. 5 (2021): Volume 18 Issue 5, 297-312
Page M. J., et al., The PRISMA 2020 statement, an updated guideline for reporting systematic reviews: BMJ, Volume 372 Issue 71
Whiting P. F., et al., QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies, Annals of Internal Medicine: Vol. 155 No. 8 (2011): Volume 155 Issue 8, 529-536
Wells G. A., et al., The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses, Ottawa Hospital Research Institute: (2000)
Zill O. A., et al., The Landscape of Actionable Genomic Alterations in Cell-Free Circulating Tumor DNA from 21,807 Advanced Cancer Patients, Clinical Cancer Research: Vol. 24 No. 15 (2018): Volume 24 Issue 15, 3528-3538
Kim K. W., et al., Clinical Utility of Circulating Tumor DNA Analysis in the Diagnosis and Management of Thyroid Cancer, Endocrinology and Metabolism: Vol. 35 No. 2 (2020): Volume 35 Issue 2, 295-305
Lan X., et al., Diagnostic accuracy of circulating tumor DNA for BRAF V600E mutation in papillary thyroid carcinoma: a systematic review and meta-analysis, Clinical Chemistry and Laboratory Medicine: Vol. 59 No. 5 (2021): Volume 59 Issue 5, 843-851
Priyanka C. Iyer, Gilbert J. Cote, Tao Hai, Maria Gule-Monroe, Jacquelin Bui-Griffith, Michelle D. Williams, Kenneth Hess., Circulating BRAF V600E Cell-Free DNA as a Biomarker in the Management of Anaplastic Thyroid Carcinoma, JCO Precis Oncol 2: Volume 2 (2018): 1
Tatiana Marina Vieira Giorgenon, et al, Preoperative detection of TERT promoter and BRAFV600E mutations in papillary thyroid carcinoma in high-risk thyroid nodules , Arch Endocrinol Metab: Vol. 63 No. 02 (2025): Vol. 63 Issue 02, 107–112.
Zhang L., et al., Epithelial-Mesenchymal Plasticity in Circulating Tumor Cells Predicts Distant Metastasis in Radioiodine-Refractory Thyroid Cancer, Cancer Research: Vol. 82 No. 14 (2022): Volume 82 Issue 14, 2581-2592
Monia Bordoni., et. al., Open AccessReview, Towards an Integrated Multi-Omic Approach to Improve the Diagnostic Accuracy of Fine-Needle Aspiration in Thyroid Nodules with Indeterminate Cytology, Diagnostics: Vol. 15 N. 12 (2025): Volume 15 Issue 12
Cristiano S., et al., Genome-wide cell-free DNA fragmentation in patients with cancer, Nature: Vol. 570 No. 7761 (2019): Volume 570 Issue 7761, 385-389
Matthew Z Guo., et.al. Postsurgical circulating tumor DNA as a prognostic biomarker for relapse of resected pancreatic ductal adenocarcinoma, Gastrointest Surg: Vol. 30 No. 04 (2026): Volüme 30 Issue 04
Picchi G., et al., Predictive Value of Circulating BRAF V600E ctDNA in Biochemically Persistent Differentiated Thyroid Cancer, Thyroid: Vol. 33 No. 9 (2023): Volume 33 Issue 9, 1104-1112.
Schlumberger M., et al., Lenvatinib in Radioiodine-Refractory Thyroid Cancer: ctDNA Dynamics as an Early Pharmacodynamic Biomarker of Response, Journal of Clinical Oncology: Vol. 39 No. 15_suppl (2021): Volume 39 Issue 15 suppl, 6015
Wirth L J., et al., Efficacy of Selpercatinib in RET-Altered Thyroid Cancers, New England Journal of Medicine: Vol. 383 No. 9 (2020): Volume 383 Isssue 9 825-835
Solomon B J., et al., Acquired Resistance to RET Inhibitors in RET-Driven Cancers: Genomic Mechanisms from Serial ctDNA Analysis, Cancer Discovery: Vol. 13 No. 4 (2023): Volume 13 Issue 4, 874-889
Seok Jin Kim., Circulating Tumor DNA-Based Genotyping and Monitoring for Predicting Disease Relapses of Patients with Peripheral T-Cell Lymphomas, Cancer Res Treat: Vol 55 No 1 (2023): Volume 55 Issue 1, 291-303
Dinah V Parums, A Review of Circulating Tumor DNA (ctDNA) and the Liquid Biopsy in Cancer Diagnosis, Screening, and Monitoring Treatment Response, Med Sci Monit: 2025: doi: 10.12659/MSM.949300.
Zou Z., Zhong L., Anaplastic thyroid cancer: Genetic roles, targeted therapy, and immunotherapy, Genes & Diseases: Vol 12 No 4 (2025): Volume 12 Issue 4
Charu Aggarwal, Assessment of Tumor Mutational Burden and Outcomes in Patients With Diverse Advanced Cancers Treated With Immunotherapy, JAMA Netw Open: Vol 6 No 5 (2023): Volume 6 Issue 5
Gila Lithwick-Yanai, Multicentre validation of a microRNA-based assay for diagnosing indeterminate thyroid nodules utilising fine needle aspirate smears, J Clin Pathol: Vol 70 No 6 (2017): Volume 70 Issue 6, 500–507
Pritchard C. C., et al., Blood cell origin of circulating microRNAs: a cautionary note for cancer biomarker studies. Cancer Prevention Research: Vol. 5 No. 3 (2012): Volume 5 Issue 3, 492-497
Walsh P. S., et al., Analytical and Clinical Validation of ThyraMIR-B, a Next-Generation Sequencing-Based Circulating miRNA Assay for Thyroid Nodule Diagnosis, Clinical Chemistry,:Vol. 70 No. 4 (2024): Volume 70 Issue 4, 567-579
Sin Woo Kang, Diagnostic Models for Predicting Follicular Thyroid Carcinomas Using Circulating Plasma MicroRNAs, Cancers (Basel): Vol 17 No 21 (2025): Volume 17 Issue 21
YANQING ZHANG1, Dynamic monitoring of circulating microRNAs as a predictive biomarker for the diagnosis and recurrence of papillary thyroid carcinoma, ONCOLOGY LETTERS 13: (2017): 4252-4266
Xuan Zou, A three-microRNA panel in serum as novel biomarker for papillary thyroid carcinoma diagnosis, Chin Med J (Engl): Vol 133 No 21 (2020): Volume 133 Isuse 21, 2543–2551
Hashem Khanbabaei, Non-coding RNAs in cancer and epithelial-mesenchymal transition: molecular mechanisms and clinical implications, J Experimental Clinical Cancer Research: Vol 16 No. 41(2022): Volume 16 Issue 41, 278, doi: 10.1186/s13046-022-02488-x
Xu J. Y., et al., Detection and Characterization of Circulating Tumor Cells in Patients with Thyroid Cancer, Endocrine: Vol. 53 No. 3 (2016): Volume 53 Issue 3, 737-745
Miller M. C., et al., The Parsortix Cell Separation System – A versatile liquid biopsy platform, Cytometry Part A: Vol. 93 No. 12 (2018): Volume 93 Issue 12, 1234-1239
Qatar Medical Journa igbal Amer, Role of epithelial-mesenchymal markers in predicting metastasis of papillary thyroid carcinoma, A retrospective case-control study: Volume/Issue: Volume 2025: Issue 2
Lina Lu., Anaplastic transformation in thyroid cancer revealed by single-cell transcriptomics, The Journal of clinical investigation: June 2023, Vol 133 No 11 (2023): Volume 133 Issue 11
Hodgkinson C. L., et al., Tumorigenicity and genetic profiling of circulating tumor cells in small-cell lung cancer, Nature Medicine: Vol. 20 No. 8 (2014): Volume 20 Issue 8, 897-903. [Note: This is a reference for the CDX method, adapted by a 2023 study for MTC].
Yuxin Min., et.al., Single extracellular vesicle surface protein-based blood assay identifies potential biomarkers for detection and screening of five cancers, Mol Oncol: Vol 18 No 3 (2024): Volume 18 Issue 3, 743-761
Melo S. A., et al., Glypican-1 identifies cancer exosomes and detects early pancreatic cancer, Nature: Vol. 523 No. 7559 (2015): Volume 523 Issue 7559, 177-182. [Note: Foundational EV reference, with the 2024 study being a direct methodological descendant].
Kyung-A Kim, Sunmin Kim, Inbal Wortzel, Suho Lee, Yoon Dae Han, Tae-Min Kim, Han Sang Kim, Genome-wide methylation profiling reveals extracellular vesicle DNA as an ex vivo surrogate of cancer cell-derived DNA, Sci Rep: Vol 14 No 1 (2024): Volume 14 Issue 1
Proteomics study of serum exosomes from papillary thyroid cancer patient, Endocrine-Related Cancer, June 2018: 25 (10): ERC-17-0547., DOI:10.1530/ERC-17-0547
Ymke van der Pol., Real-time analysis of the cancer genome and fragmentome from plasma and urine cell-free DNA using nanopore sequencing, EMBO Mol Med: Vol 15 No 12 (2023): Volume 15 Issue 12
Shubin Hong, Cell-free DNA methylation biomarker for the diagnosis of papillary thyroid carcinoma, BioMedicine: Vol. 90 (2023): 104497
Meng Jia, MicroRNA-146b-5p as an oncomiR promotes papillary thyroid carcinoma development by targeting CCDC6, Cancer Lett: 2019 Feb 28: 443: 145-156
Cancer Biomark, Circulating microRNA as potential diagnostic and prognostic biomarkers of well-differentiated thyroid cancer, A review article Cezary Bielak: 2023;Vol 36 No 3 (2023): Volume 36 Issue 3, 193-205
Davies L., & Welch, H. G., Current thyroid cancer trends in the United States, JAMA Otolaryngology–Head & Neck Surgery: Vol. 140 No. 4 (2014): Volume 140 Issue 4, 317-322.
Fagin J. A., & Wells S. A., Biologic and Clinical Perspectives on Thyroid Cancer, New England Journal of Medicine: Vol. 375 No. 11 (2016): Volume 375 Issue 1, 1054-1067
Alix-Panabières C., & Pantel K., Liquid Biopsy: From Discovery to Clinical Application, Cancer Discovery: Vol. 11 No. 4 (2021): Volume 11 Issue 4, 858-873
