Abstract: Objective:The clinicopathological features, diagnosis, and prognosis of follicular thyroid carcinoma (FTC) with distant me-tastasis as the first manifestation were evaluated in this study. Methods:A total of 129 FTC cases with clinical data were retrospective -ly analyzed in the Department of Pathology, Tianjin Medical University Cancer Institute and Hospital (January 2001to January 2016). Survival analysis and conjoint analysis on FTC with clinical data, diagnosis, and morphological characteristics with distant metastasis as the first manifestation were performed. Results:Among the 129 FTC cases,24cases demonstrated distant metastasis as the first mani -festation (18. 6%). Bone metastasis was the most common (13. 2%). The presence of mass and pain at the metastatic sites were the usu -al clinical complaints. The morphological characteristics of FTC with distant metastasis can be classified into four subtypes: microfollicu -lar ( 10cases), solid (4 cases), normofollicular ( 9 cases), and macrofollicular (1 case). Immunostaining tests on thyroglobulin and thyroid transcription factor-1 showed positive results in FTC with metastasis. Survival analysis showed that the five-year survival rates in the 24cases were 87. 1%. The prognosis of patients with solitary metastasis was better than that of patients with multiple metastasis ( P=0. 022 ). A higher survival rate was found in the normofollicular and macrofollicular subtypes than that detected in the microfollicular and solid subtypes (P=0. 012 ). Conclusion: FTC is susceptible to distant metastasis. Some patients with FTC demonstrated distant metastasis as the first manifestation, and their diagnosis can be confirmed by pathological feature analysis and immunostaining. The prog -nostic significance is possibly related to the number of lesions of FTC with distant metastasis and histopathological subtypes.