Background <p>Recurrence risk stratification system-guided radioiodine (¹³¹I) therapy of differentiated thyroid cancer (DTC) has fallen into dilemma due to its poor feasibility and insufficient justification.</p> Methods <p>Subjects referred for ¹³¹I therapy were consecutively labeled with no evidence of disease, unexplained hyperthyroglobulinemia, or known disease based on stimulated serum thyroglobulin, radioiodine uptake, and medical imaging, and then assigned to radioiodine remnant ablation (RRA), radioiodine adjuvant treatment (RAT), or radioiodine oncolytic treatment (ROT) group, respectively. The primary endpoints were disease-free survival (DFS) for the RRA and RAT cohorts and progression-free survival (PFS) and overall survival (OS) for the ROT cohort. Secondary endpoints included success rate in the RRA cohort, response classification in all cohorts, and biochemical and structural responses in the ROT cohort.</p> Results <p>In the RRA and RAT cohorts, the 5-year DFS rates were 93.28% and 76.02%, respectively. In the ROT cohort, the 5-year PFS and OS rates were 72.23% and 99.01%, respectively. In the RRA cohort, an 85.06% success rate was achieved, with excellent response (ER), indeterminate response (IR), biochemical incomplete response (BIR) and structural/functional incomplete response (S/FIR) rates of 77.92%, 15.58%, 3.9%, and 2.6%, respectively. In RAT cohort, ER, IR, BIR and S/FIR rates were 16.42%, 26.87%, 33.83%, and 22.89%, respectively. In the ROT cohort, ER, IR, BIR, and S/FIR rates were 2.5%, 3.33%, 8.33%, and 85.83%, respectively, with biochemical remission rate of 69.49% and structural disease control rate of 96.15%.</p> Conclusion <p>This prospective, multicenter, real-world study justified postoperative disease status stratification as a feasible guidance for individualizing ¹³¹I therapy of DTC.</p>