Most papillary carcinomas do not cause death or significant morbidity. Current modes of therapy when appropriately applied, appear effective for 80% to 90% of patients. The clinical challenge is to identify the minority of patients who will suffer greatly from tumors to direct appropriately the best therapeutic efforts. New appreciation of histologic subtypes of papillary carcinoma has provided fresh clues to identify cancers with poor prognosis. We look forward to innovative therapies to deal with currently untreatable disease.