Thyroid carcinoma in Graves’ disease: A meta-analysis

Incidental thyroid carcinoma in an endemic goiter area in Italy: histopathological features and predictors of a common finding

PURPOSE

The occurrence and histopathological features of incidental thyroid carcinoma (ITC) vary considerably among populations from different geographical regions. The aim of this study is to assess the prevalence and histopathological characteristics of ITC in patients who underwent thyroid surgery for apparently benign thyroid diseases in an endemic goiter area in Italy.

METHODS

A total of 649 consecutive patients (531 females and 118 males; mean age, 52.9 ± 11.0 years), who underwent thyroid surgery at the Endocrine Surgery Unit of the tertiary care "Renato Dulbecco" University Hospital (Catanzaro, Italy) in the period between years 2017 and 2022, were included in this retrospective study. A comprehensive histopathological examination was performed on surgically excised thyroid tissue. Logistic regression analysis was employed to identify potential predictors of ITC.

RESULTS

The histopathological examination revealed the presence of ITC in 81 patients, accounting for 12.5% of the total study population. The female to male ratio was found to be 6.4 to 1. Among the patients with ITC, 72 had papillary carcinoma (PTC), with 53 of these tumors being microcarcinomas (microPTC). Additionally, 5 patients had follicular thyroid carcinoma, 2 patients had low-risk follicular cell-derived thyroid neoplasms, 1 patient had an oncocytic carcinoma, and 1 patient had a medullary thyroid carcinoma. Logistic regression analysis demonstrated a significant association between female sex and incidental microPTC.

CONCLUSIONS

These findings provide further evidence of the common occurrence of ITC, typically in the form of microPTC, among individuals who undergo thyroid surgery for apparently benign thyroid diseases.

Incidental but Not Insignificant: Thyroid Cancer in Patients with Graves Disease

BACKGROUND

Graves disease is the most common cause of hyperthyroidism in the US. Treatment with antithyroid drugs and radioactive iodine is more commonly used than surgical management with total thyroidectomy (TTx). However, incidentally discovered thyroid cancer (TC) has been described on surgical pathology from patients who underwent surgical treatment of Graves disease, which would be missed with these other treatment strategies. We sought to determine the incidence rate of TC among patients with surgically treated Graves disease.

STUDY DESIGN

We retrospectively reviewed patients with Graves disease who underwent TTx at a single institution from 2011 to 2023. Pathology reports were reviewed for TC. Patient demographics, preoperative laboratory and radiological evaluations, preoperative medical management, and surgical outcomes were compared between patients with and without incidental TC.

RESULTS

There were 934 patients, of whom 60 (6.4%) patients had incidentally discovered TC on pathology. The majority (58.3%) of patients had papillary thyroid carcinoma, followed by 33.3% with papillary microcarcinoma. Preoperative ultrasound (US) was obtained in 564 (60.4%) of patients, with 44.3% with nodules, but only 34 (13.7%) of those with nodules had TC on final pathology. Preoperative fine needle aspiration was obtained in 15 patients with TC, and 8 patients (53.3%) were reported as benign lesions, which ultimately had TC on final pathology. There was no difference in sex, race or ethnicity, preoperative medical management, and postoperative outcomes between the 2 groups.

CONCLUSIONS

Incidental TC was found on surgical pathology in 6.4% of patients undergoing TTx for Graves disease. Preoperative imaging with US and fine needle aspiration were often unreliable at predicting TC. The incidence of TC should not be underestimated when counseling patients on definitive management for Graves disease.

Risk of Thyroid Cancer in People With Type 1 Diabetes by Autoimmune Thyroid Diseases and Tumor Histology

Context

Thyroid cancer is the most common endocrine cancer, but little is known about it in type 1 diabetes (T1D) and its potential association with autoimmune diseases.

Objective

This study aims to assess the risk of thyroid cancer in adults with long-term T1D compared to individuals without diabetes and the proposed association of thyroid autoimmune diseases with thyroid cancer.

Methods

The study included 4758 individuals with T1D participating in the Finnish Diabetic Nephropathy Study and 12 710 controls. Thyroid cancers were obtained from the Finnish Care Registers for Health Care.

Results

27 (0.57%) individuals with T1D had thyroid cancer compared to 27 (0.21%) in the controls (standardized incidence ratio 2.43; 95% confidence interval 1.59-3.56). The absolute increase in incidence was modest, with a 0.36%-unit rise. This translates to 17 additional cases among 4710 individuals with T1D. Cancer type was papillary in 81.5% of individuals with T1D and 88.9% of the controls; the rest were follicular. In T1D the distribution of hypothyreosis was similar between those with (n = 5, 18.5%) and without (18.1%) cancer, but hyperthyreosis was diagnosed more often with thyroid cancer (n = 3, 11.1%) than without (2.3%, P = .003). None of the thyroid cancers were invasive or had metastatic characteristics.

Conclusion

Although there is an excess risk of thyroid cancer, it is only marginally increased (0.36%-unit) in individuals with T1D compared to control individuals and was not associated with increased morbidity or mortality. An overdiagnosis effect due to regular health care contacts is the most likely explanation for the higher risk.

Autoimmune Thyroid Disease and Differentiated Thyroid Carcinoma: A Review of the Mechanisms That Explain an Intriguing and Exciting Relationship

Autoimmune thyroid disease is a complex and highly frequent disease, where a wide variety of genetic, epigenetic and environmental factors (among others) come together and interact, and is characterized by the presence of two clinical outcomes: hypothyroidism (in Hashimoto's thyroiditis) and hyperthyroidism (in Graves-Basedow disease). For its part, differentiated thyroid carcinoma (mainly papillary carcinoma) is the most common type of cancer affecting the thyroid (and one of the most prevalent worldwide). An important co-occurrence between autoimmune thyroid disease and differentiated thyroid carcinoma has been documented. In this article, studies that have evaluated possible associations and relationships between autoimmune thyroid disease and differentiated thyroid cancer are systematically described and summarized. To date, the underlying mechanism that explains this association is inflammation; however, the characteristics and designs of the studies evaluated do not yet allow a causal relationship between the two entities to be established. These aspects have made it difficult to establish "causality" in the continuum of the pathogenesis between both conditions.

Association Between Antibiotic Exposure and Thyroid Cancer: A Nationwide Cohort Study in South Korea

Background: Although recent studies have introduced antibiotics as a potential risk factor for thyroid cancer, further studies are necessary. We examined the association between long-term antibiotic usage and thyroid cancer risk. Methods: This nationwide cohort study investigated 9,804,481 individuals aged 20 years or older who participated in health screening (2005-2006) with follow-up ending on December 31, 2019, using the Korean National Health Insurance Service database. Multivariable Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for thyroid cancer risk according to the cumulative days of antibiotic prescription and the number of antibiotic classes, respectively. A 1:1 propensity score (PS) matching was also performed for analysis. Results: Compared with nonusers of antibiotics, participants prescribed ≥365 days of antibiotics showed an increased risk of thyroid cancer (aHR, 1.71; CI, 1.66-1.78) after adjusting for covariates including age, smoking status, comorbidities including thyroid-related diseases, and the number of head and neck computed tomography scans. Participants prescribed ≥365 days of antibiotics also had a significantly increased risk of thyroid cancer (aHR, 1.37; CI, 1.34-1.40) compared with participants prescribed 1-14 days of antibiotics. Association remained significant in the 1:1 PS-matched cohort. Moreover, compared with nonusers of antibiotics, the 5 or more antibiotic class user group had a higher thyroid cancer risk (aHR, 1.71; CI, 1.65-1.78). Conclusions: Long-term antibiotic prescriptions and an increasing number of antibiotic classes may be associated with a higher risk of thyroid cancer in a duration-dependent manner. The effects of long-term antibiotic exposure on thyroid cancer should be further investigated.

Multifocal papillary thyroid cancer in Graves' disease: A case report

BACKGROUND

Thyroid cancer is not commonly observed in patients with Graves' disease (GD). The presence of thyroid nodules in GD is not uncommon. However, a link between these two entities has been reported. Herein, we report the case of a patient with GD and thyroid cancer in Saudi Arabia, which has not been reported previously in our region.

CASE SUMMARY

A 26-year-old male patient with GD, receiving carbimazole for 2 years, presented to our hospital. His hyperthyroidism was controlled clinically and biochemically. On clinical examination, he was found to have a left-sided thyroid nodule. Ultrasound revealed a 2.6 cm hypoechoic nodule with high vascularity. He was then referred for fine needle aspiration which showed that the nodule was highly suspicious for malignancy. The patient underwent total thyroidectomy and was diagnosed with multifocal classical micropapillary thyroid cancer. Post thyroidectomy he received radioactive iodine ablation along with levothyroxine replacement therapy.

CONCLUSION

Careful preoperative assessment and thyroid gland ultrasound might assist in screening and diagnosing thyroid cancer in patients with GD.

Stratifying High-Risk Thyroid Nodules Using a Novel Deep Learning System

INTRODUCTION

The current ultrasound scan classification system for thyroid nodules is time-consuming, labor-intensive, and subjective. Artificial intelligence (AI) has been shown to increase the accuracy of predicting the malignancy rate of thyroid nodules. This study aims to demonstrate the state-of-the-art Swin Transformer to classify thyroid nodules.

MATERIALS AND METHODS

Ultrasound images were collected prospectively from patients who received fine needle aspiration biopsy for thyroid nodules from January 2016 to June 2021. One hundred thirty-nine patients with malignant thyroid nodules were enrolled, while 235 patients with benign nodules served as controls. Images were fed to Swin-T and ResNeSt50 models to classify the thyroid nodules.

RESULTS

Patients with malignant nodules were younger and more likely male compared to those with benign nodules. The average sensitivity and specificity of Swin-T were 82.46% and 84.29%, respectively. The average sensitivity and specificity of ResNeSt50 were 72.51% and 77.14%, respectively. Receiver operating characteristics analysis revealed that the area under the curve of Swin-T was higher (AUC=0.91) than that of ResNeSt50 (AUC=0.82). The McNemar test evaluating the performance of these models showed that Swin-T had significantly better performance than ResNeSt50.Swin-T classifier can be a useful tool in helping shared decision-making between physicians and patients with thyroid nodules, particularly in those with high-risk characteristics of sonographic patterns.

A Collision Tumor of Pit-1/SF-1-positive Double Pituitary Adenoma and a Craniopharyngioma Coexisting with Graves' Disease

Double or multiple pituitary adenomas expressing different types of transcription factors and collision tumors of pituitary adenomas and craniopharyngiomas are rare. In this report, we present a case of pituitary adenoma of two different cell populations, Pit-1 and SF-1, and an adenoma and craniopharyngioma collision tumor with coexisting Graves' disease. The patient had a 16-mm pituitary tumor with pituitary stalk calcification and optic chiasm compression but no visual dysfunction. Based on hormonal profile results, the tumor in the sella was considered a nonfunctioning pituitary adenoma; nevertheless, the pituitary stalk was invaded by a different lesion, which was later confirmed to be a craniopharyngioma. Using an endoscopic endonasal approach, the pituitary adenoma was removed; however, a small remnant remained medial to the right cavernous sinus. Because the pituitary stalk lesion was isolated from the pituitary adenoma, it was preserved to maintain pituitary function. Three years after the initial surgery, the patient suffered from Graves' disease and was treated with antithyroid medications. However, the intrasellar residual and pituitary stalk lesions gradually increased in size. A second surgery was performed, and the residual intrasellar and stalk lesions were completely removed. As per the initial and second histopathologies, the pituitary adenoma comprised different cell groups positive for thyroid-(TSH) and follicle-stimulating hormones, and each cell group was positive for Pit-1 and SF-1. The pituitary stalk lesion was an adamantinomatous craniopharyngioma. We believe that TSH-producing adenoma was involved in the development of Graves' disease or that treatment for Graves' disease increased TSH-producing adenoma.

Risk and Prognosis of Thyroid Cancer in Patients with Graves' Disease: An Umbrella Review

Graves' disease (GD) is an autoimmune disease considered the most common cause of hyperthyroidism. Some studies have investigated its relationship with the risk and prognosis of developing thyroid cancer. Considering that there is no consensus on the relationship between GD and thyroid cancer risk, this umbrella review aimed to summarize the epidemiologic evidence and evaluate its strength and validity on the associations of GD with thyroid cancer risk and its prognosis. This umbrella review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We systematically searched PubMed and Scopus from January 2012 to December 2022. The strength of the epidemiological evidence was graded as high, moderate, or weak by the Measurement Tool to Assess Systematic Reviews (AMSTAR-2). "Strong" evidence was found for the risk of thyroid cancer in GD patients with thyroid nodular disease (OR: 5.30; 95% CI 2.43-12) and for the risk of mortality from thyroid cancer in these patients (OR 2.93, 95% CI 1.17-7.37, p = 0.02), particularly in Europe (OR 4.89; 95% CI 1.52-16). The results of this umbrella review should be interpreted with caution; as the evidence comes mostly from retrospective studies, potential concerns are selection and recall bias, and whether the empirically observed association reflects a causal relationship remains an open question.

Stress, Thyroid Dysregulation, and Thyroid Cancer in Children and Adolescents: Proposed Impending Mechanisms

Stress is a potential catalyst for thyroid dysregulation through cross-communication of the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid (HPT) axes. Stress and stressors exposure motivates molecular mechanisms affecting compound feedback loops of the HPT axis. While there is evidence of connection between stress and thyroid dysregulation, the question whether this connection is implicated in the development of thyroid cancer (TC) remains unanswered. In view of the rising incidence of TC in both adults and children alongside the increasing stress in our modern society, there is a need to understand possible interrelations between stress, thyroid dysregulation, and TC. Prolonged glucocorticoid secretion due to stress interferes with immune system response by altering the cytokines, inducing low-grade chronic inflammation, and suppressing function of immune-protective cells. Chronic inflammation is a risk factor linked to TC. The role of autoimmunity has been a matter of controversy. However, there is epidemiological connection between autoimmune thyroid disease (AITD) and TC; patients with AITD show increased incidence in papillary thyroid carcinoma (PTC), and those with TC show a high prevalence of intrathyroidal lymphocyte infiltration and thyroid autoantibodies. Timing and duration-dependent exposure to specific endocrine disrupting chemicals (EDCs) has an impact on thyroid development, function, and proliferation, leading to thyroid disease and potentially cancer. Thyroid hormone imbalance, chronic inflammation, and EDCs are potential risk factors for oxidative stress. Oxygen free radicals are capable of causing DNA damage via stimulation of the mitogen-activating protein kinase or phosphatidylinositol-3-kinase and/or nuclear factor kB pathways, resulting in TC-associated gene mutations such as RET/PTC, AKAP9-BRAF, NTRK1, RAASF, PIK3CA, and PTEN. Stressful events during the critical periods of prenatal and early life can influence neuroendocrine regulation and induce epigenetic changes. Aberrant methylation of tumor suppressor genes such as P16INK4A, RASSF, and PTEN is associated with PTC; histone H3 acetylation is shown to be higher in TC, and thyroid-specific noncoding RNAs are downregulated in PTC. This review focuses on the above proposed mechanisms that potentially lead to thyroid tumorigenesis with the aim to help in the development of novel prognostic and therapeutic strategies for TC.

Outcomes of Surgical Treatment for Graves' Disease: A Single-Center Experience of 216 Cases

BACKGROUND

The role of surgery in the treatment of Graves' disease (GD) needs to be revisited. The aims of the present retrospective study were to evaluate the outcomes of the current surgical strategy as a definitive treatment of GD at our center and to explore the clinical association between GD and thyroid cancer.

METHODS

A patient cohort of 216 cases from 2013 to 2020 was involved in this retrospective study. The data of the clinical characteristics and follow-up results were collected and analyzed.

RESULTS

There were 182 female and 34 male patients. The mean age was 43.9 ± 15.0 years old. The mean duration of GD reached 72.2 ± 92.7 months. Of the 216 cases, 211 had been treated with antithyroid drugs (ATDs) and hyperthyroidism had been completely controlled in 198 cases. A total (75%) or near-total (23.6%) thyroidectomy was performed. Intraoperative neural monitoring (IONM) was applied to 37 patients. The failure of ATD therapy (52.3%) was the most common surgical indication, followed by suspicion of a malignant nodule (45.8%). A total of 24 (11.1%) patients had hoarseness after the operation and 15 (6.9%) patients had transient vocal cord paralysis; 3 (1.4%) had this problem permanently. No bilateral RLN paralysis occurred. A total of 45 patients had hypoparathyroidism and 42 of them recovered within 6 months. Sex showed a correlation with hypoparathyroidism through a univariate analysis. A total of 2 (0.9%) patients underwent a reoperation because of hematomas. A total of 104 (48.1%) cases were diagnosed as thyroid cancer. In most cases (72.1%), the malignant nodules were microcarcinomas. A total of 38 patients had a central compartment node metastasis. A lateral lymph node metastasis occurred in 10 patients. Thyroid carcinomas were incidentally discovered in the specimens of 7 cases. The patients with concomitant thyroid cancer had a significant difference in body mass index, duration of GD, gland size, thyrotropin receptor antibodies and nodule(s) detected.

CONCLUSION

Surgical treatments for GD were effective, with a relatively low incidence of complications at this high-volume center. Concomitant thyroid cancer is one of the most important surgical indications for GD patients. Careful ultrasonic screening is necessary to exclude the presence of malignancies and to determine the therapeutic plan.

Cancer and Mortality Risks of Graves' Disease in South Korea Based on National Data from 2010 to 2019

Purpose

This study aimed to investigate Graves' disease (GD) associated cancer and mortality risk using a Korean population-based study.

Patients and Methods

We included 6435 patients with GD using the Korean National Health Insurance Service-National Sample Cohort database from 2010 to 2019. Data concerning such patients were compared in a 1:5 ratio with age- and sex-matched non-GD group (n=32,175). Eighteen subdivided types of cancer and cancers-in-total were analyzed. In addition to the mortality analysis, subgroup analyses were performed according to age and sex.

Results

After adjustment, the hazard ratio (HR) of the GD group for cancer-in-total was 1.07 (95% confidence interval [CI], 0.91-1.27), showing no difference when compared to the non-GD group. However, among different types of cancer, the thyroid cancer risk of the GD group was higher than that of the non-GD group (HR=1.70; 95% CI, 1.20-2.39). When subdivided by age and sex, the thyroid cancer risk of the GD group in males aged 20-39 years was higher than that of the non-GD group (HR=7.00; 95% CI, 1.48-33.12). The mortality risk of the GD group was not different from that of the non-GD group (HR=0.86; 95% CI, 0.70-1.05).

Conclusion

In South Korea, patients with GD had a higher risk of thyroid cancer than the non-GD group. In particular, males aged 20-39 years with GD were more likely to have thyroid cancer than the non-GD group.

Long-term management of Graves disease: a narrative review

Graves disease (GD) is the most common cause of hyperthyroidism, accounting for more than 90% of cases in Korea. Patients with GD are treated with any of the following: antithyroid drugs (ATDs), radioactive iodine (RAI) therapy, or thyroidectomy. Most patients begin treatment with ATDs, and clinical guidelines suggest that the appropriate treatment period is 12 to 18 months. While RAI treatment and surgery manage thyrotoxicosis by destroying or removing thyroid tissue, ATDs control thyrotoxicosis by inhibiting thyroid hormone synthesis and preserving the thyroid gland. Although ATDs efficiently control thyrotoxicosis symptoms, they do not correct the main etiology of GD; therefore, frequent relapses can follow. Recently, a large amount of data has been collected on long-term ATDs for GD, and low-dose methimazole (MMZ) is expected to be a good option for remission. For the long-term management of recurrent GD, it is important to induce remission by evaluating the patient's drug response, stopping ATDs at an appropriate time, and actively switching to surgery or RAI therapy, if indicated. Continuing drug treatment for an extended time is now encouraged in patients with a high possibility of remission with low-dose MMZ. It is also important to pay attention to the quality of life of the patients. This review aimed to summarize the appropriate treatment methods and timing of treatment transition in patients who relapsed several times while receiving treatment for GD.

A multi-channel deep convolutional neural network for multi-classifying thyroid diseases

BACKGROUND AND OBJECTIVE

Thyroid disease instances have been continuously increasing since the 1990s, and thyroid cancer has become the most rapidly rising disease among all the malignancies in recent years. Most existing studies focused on applying deep convolutional neural networks for detecting thyroid cancer. Despite their satisfactory performance on binary classification tasks, limited studies have explored multi-class classification of thyroid disease types; much less is known of the diagnosis of co-existence situation for different types of thyroid diseases.

METHOD

This study proposed a novel multi-channel convolutional neural network (CNN) architecture to address the multi-class classification task of thyroid disease. The multi-channel CNN merits from computed tomography characteristics to drive a comprehensive diagnostic decision for the overall thyroid gland, emphasizing the disease co-existence circumstance. Moreover, this study also examined alternative strategies to enhance the diagnostic accuracy of CNN models through concatenation of different scales of feature maps.

RESULTS

Benchmarking experiments demonstrate the improved performance of the proposed multi-channel CNN architecture compared with the standard single-channel CNN architecture. More specifically, the multi-channel CNN achieved an accuracy of 0.909±0.048, precision of 0.944±0.062, recall of 0.896±0.047, specificity of 0.994±0.001, and F1 of 0.917±0.057, in contrast to the single-channel CNN, which obtained 0.902±0.004, 0.892±0.005, 0.909±0.002, 0.993±0.001, 0.898±0.003, respectively. In addition, the proposed model was evaluated in different gender groups; it reached a diagnostic accuracy of 0.908 for the female group and 0.901 for the male group.

CONCLUSION

Collectively, the results highlight that the proposed multi-channel CNN has excellent generalization and has the potential to be deployed to provide computational decision support in clinical settings.

Paediatric thyroidectomy: When and why? A 25-year institutional experience

OBJECTIVE

Thyroidectomy in paediatric patients is relatively uncommon. In this study, we reviewed our experience of thyroidectomy in children and identified risk factors associated with postoperative complications.

METHODS

We performed a retrospective analysis of paediatric patients who had thyroidectomy in our institution between April 1995 and January 2021. Demographic data, preoperative cytological findings, indications of surgery, surgical complications and histological results were analysed.

RESULTS

A total of 87 paediatric patients with 92 thyroidectomy were identified. The indications for surgery were Graves' disease refractory to medical treatments (40.2%), benign thyroid nodules or multinodular goitre (26.4%), thyroid carcinoma (23.0%) and multiple endocrine neoplasm type 2A syndrome (10.3%). Patients presented with thyroid nodules or cervical lymph nodes had a 43.9% risk of malignancy. 66 total thyroidectomy were done with median operation time of 134 min(102-170), while 26 hemi-thyroidectomy were performed (Right side 12/92, Left side 14/92) with median operation time of 65 min(49-102). The median postoperative hospital stay was 2 days(1-4). Intraoperative neck dissection (p = 0.003), drain insertion (p = 0.001) and hypocalcaemia requiring medical treatment (p = 0.004) were associated with longer hospital stay. The median follow-up was 11.3 years (3.0-16.8). 32% patients had immediate postoperative hypocalcaemia and 8% patients had permanent hypoparathyroidism. Transient vocal cord palsy was found in 3 patients(3%) and all resolved within 5-month time upon reassessment direct laryngoscopy. The use of intraoperative recurrent laryngeal nerve monitoring was associated with less vocal cord palsy (p = 0.022). The median disease-free survival was 13.7 years(7.4-17.7) for patients operated for well-differentiated thyroid carcinoma(WDTC). amongst the 9 patients who had prophylactic total thyroidectomy for MEN2A syndrome, 44% were found to have medullary thyroid microcarcinomas on pathology.

CONCLUSIONS

Surgical management of paediatric thyroid disease can be complex. Postoperative hypocalcaemia and vocal cord palsy were usually transient after total thyroidectomy. The use of intraoperative recurrent laryngeal nerve monitoring had resulted in less vocal cord palsy. Long-term disease-free survival of patients with thyroid cancer had been achieved with multi-disciplinary management in our centre.

LEVEL OF EVIDENCE

Retrospective Comparative Study; Level III.

Coexistence of tuberculosis and extranodal marginal zone lymphoma of the thyroid gland: Case report and literature review

Introduction

Primary thyroid tuberculosis (TB) is rare even in countries where TB disease is endemic, with the prevalence ranging from 0.1 to 1.15%. Primary thyroid lymphoma is uncommon, and the majority of lymphomas arising in the thyroid gland are non-Hodgkin's lymphomas of B-cell origin, of which about 25% is extranodal marginal zone B cell lymphoma (MALToma).

Case presentation

An 86-year- old Turkish female patient with thyroid nodules and cervical lymphadenopathies presented with large multinodular goiter and compressive symptoms. Total thyroidectomy and central lymph node dissection were performed. The revised histological and immunohistochemical revealed the coexistence of thyroid TB and MALToma. The patient received an anti-TB treatment for six months before a revised histopathological examination. About seven months after anti-TB treatment, the patient died due to an unknown cause.

Clinical discussion

Although six cases of thyroid TB and papillary thyroid cancer have been documented in the medical literature, no cases of TB and MALToma coexistence have been published so far, to our knowledge. Another essential feature of this study is that the initial pathological examination was reported as thyroid TB. A subsequent re-examination revealed that the patient had both TB and MALT lymphoma.

Conclusion

We discuss this rare association and the dilemma encountered in the diagnosis and management of this patient with a review of the literature.

•

Primary thyroid tuberculosis (TB) is rare even in countries where TB disease is endemic, ranging from 0.1 to 1.15%.

•

Primary thyroid lymphoma is distinctly uncommon, accounting for only 0.5%–5% of all thyroid malignancies.

•

To the best of our knowledge, only six cases of thyroid TB and papillary thyroid cancer have been reported in the literature.

•

No cases of coexistence of TB and Marginal zone B-cell lymphoma have been reported so far.

Occurrence of sporadic medullary thyroid carcinoma in Graves' disease in association with a RET proto-oncogene mutation

BACKGROUND

Graves' disease may be associated with thyroid cancer, particularly differentiated thyroid cancer. Medullary thyroid cancer (MTC) is less common. The occurrence of sporadic MTC in Graves' disease in the presence of a RET proto-oncogene has never been reported.

CLINICAL PRESENTATION

A 63-year-old woman was referred for Graves' disease. A thyroid ultrasound disclosed five nodules, one of which was classified as Eu-Tirads 5 with a size of 6.7 × 6.5× 11 mm. Fine needle aspiration was reported as Bethesda class IV follicular neoplasm of a Hürthle cell subtype. Calcitonin level was found to be elevated. A total thyroidectomy confirmed the diagnosis of MTC and a bilateral cervical lymphadenectomy was performed, with four lymph nodes being infiltrated by MTC. Genetic testing revealed a M918T mutation in the RET proto-oncogene.

CONCLUSION

MTC may occur in Graves' disease, especially if a nodule is present. In this case, genetic testing should always be performed even if MTC is sporadic. Increased incidence of thyroid cancer in autoimmune thyroid diseases, as well as the link existing between autoimmunity, inflammation and carcinogenesis, leads us to hypothesize that the association here reported is not coincidental.

GATA binding protein 1 recruits histone deacetylase 2 to the promoter region of nuclear receptor binding protein 2 to affect the tumor microenvironment and malignancy of thyroid carcinoma

The tumor microenvironment (TME) and activated angiogenesis in thyroid carcinoma (TC) are critical for tumor growth and metastasis. Nuclear receptor binding protein 2 (NRBP2) has been suggested as a tumor suppressor. This study examines the function of NRBP2 in the progression of TC and the regulatory mechanism. By analyzing bioinformatic tools including GSE165724 dataset and the Cancer Genome Atlas system, we predicted NRBP2 as a poorly expressed gene in TC. Decreased NRBP2 expression was detected in TC tumor tissues and cells. Poor expression of NRBP2 was linked to unfavorable prognosis of patients. GATA binding protein 1 (GATA1) was found as a negative regulator of NRBP2. It recruited histone deacetylase2 (HDAC2) to the NRBP2 promoter to trigger histone deacetylation. NRBP2 overexpression suppressed growth of TC cells, and it reduced expression of TME markers, M2 polarization of macrophages, and angiogenesis in TC. Similar results were reproduced in vivo in nude mice. However, the anti-oncogenic roles of NRBP2 were blocked after further overexpression of GATA1 or HDAC2. In summary, this study demonstrates that GATA1 recruits HDAC2 to the NRBP2 promoter and enhances the TME and angiogenesis in TC cells.

Graves’ disease diagnosed in remnant thyroid after lobectomy for thyroid cancer

Background

The coexistence of Graves’ disease with thyroid cancer is well-known and total thyroidectomy is recommended in such cases. However, Graves’ disease might be dormant at the time of surgery and diagnosed after lobectomy for thyroid cancer.

Methods

We assessed the incidence and clinicopathological characteristic of newly developed Graves’ disease after lobectomy for thyroid cancer between 2010 and 2019.

Results

In all, 11043 patients underwent lobectomy for thyroid cancer during the study period, and 26 (0.2%) were diagnosed with Graves’ disease during follow-up. The median age was 43.8 years, 88.5% were female, and all were euthyroid before surgery. The median time from lobectomy to the diagnosis of Graves’ disease was 3.3 years. Half of the patients were diagnosed based on thyroid function tests during routine follow-up, and others were diagnosed due to symptoms of thyrotoxicosis. Among patients who had checked preoperative thyroid autoantibodies, 61.1% showed positivity. Twenty-one (80.8%), and 2 (7.7%) patients received antithyroid drugs and radioactive iodine therapy, respectively, and 3 (11.5%) underwent completion thyroidectomy.

Conclusion

Although rare, Graves’ disease can occur in the remnant thyroid after lobectomy. Such patients are more likely to have autoantibodies. An appropriate workup is required when hyperthyroidism is found during the follow-up of patients after lobectomy.

METTL3-Induced miR-222-3p Upregulation Inhibits STK4 and Promotes the Malignant Behaviors of Thyroid Carcinoma Cells

CONTEXT

Abnormally high expression of N6-methyladenosine (m6A) methyltransferase-like 3 (METTL3) has been implied to accompany thyroid carcinoma (TC) development.

OBJECTIVE

This study aimed to explore the protumorigenic role and downstream signaling axis of METTL3 in TC.

METHODS

This study was conducted at the Sun Yat-Sen Memorial Hospital Sun Yat-Sen University. METTL3 and miR-222-3p were overexpressed or downregulated in TC cells. Tumor and adjacent normal tissues were collected from 80 patients (19 men and 60 women, aged 30-70 years) with a pathological diagnosis of TC from January 2012 to January 2015. Cells were classified and subjected to different treatments. The expression of METTL3 was validated in TC tissues and cell lines. In functional studies, METTL3 and miR-222-3p were overexpressed or downregulated in TC cells to evaluate their effects on malignant behaviors, which were subsequently verified by xenografts in nude mice.

RESULTS

The expression of METTL3 was elevated in TC, correlating with poor prognosis of TC patients. Heightened METTL3 expression accelerated malignant behaviors of TC cells. Mechanistically, METTL3 stimulated miR-222-3p expression by mediating the m6A modification of pri-miR-222-3p. miR-222-3p targeted and inversely regulated serine/threonine stress kinase 4 (STK4). Knockdown of METTL3 augmented STK4 expression by downregulating miR-222-3p, thereby suppressing the malignant behaviors of TC cells as well as tumor growth and lung metastasis in nude mice.

CONCLUSION

Silencing METTL3 suppresses miR-222-3p expression and thus stimulates STK4 expression, thereby repressing the malignancy and metastasis of TC.

Clinical Characteristics and Prognosis of Coexisting Thyroid Cancer in Patients with Graves' Disease: A Retrospective Multicenter Study

BACKGROUND

The association between Graves' disease (GD) and co-existing thyroid cancer is still controversial and most of the previously reported data have been based on surgically treated GD patients. This study investigated the clinicopathological findings and prognosis of concomitant thyroid cancer in GD patients in the era of widespread application of ultrasonography.

METHODS

Data of GD patients who underwent thyroidectomy for thyroid cancer between 2010 and 2019 in three tertiary hospitals in South Korea (Asan Medical Center, Chonnam National University Hwasun Hospital, and Pusan National University Hospital) were collected and analyzed retrospectively. In the subgroup analysis, aggressiveness and clinical outcomes of thyroid cancer were compared nodular GD and non-nodular GD groups according to the presence or absence of the thyroid nodules other than thyroid cancer (index nodules).

RESULTS

Of the 15,159 GD patients treated at the hospitals during the study period, 262 (1.7%) underwent thyroidectomy for coexisting thyroid cancer. Eleven patients (4.2%) were diagnosed with occult thyroid cancer and 182 patients (69.5%) had microcarcinomas. No differences in thyroid cancer aggressiveness, ultrasonographic findings, or prognosis were observed between the nodular GD and non-nodular GD groups except the cancer subtype. In the multivariate analysis, only lymph node (LN) metastasis was an independent prognostic factor for recurrent/persistent disease of thyroid cancer arising in GD (P=0.020).

CONCLUSION

The prevalence of concomitant thyroid cancer in GD patients was considerably lower than in previous reports. The clinical outcomes of thyroid cancer in GD patients were also excellent but, more cautious follow-up is necessary for patients with LN metastasis in the same way as for thyroid cancer in non-GD patients.

Screening Leads to Overestimated Associations of Thyroid Dysfunction and Thyroiditis with Thyroid Cancer Risk

Simple Summary

The association of thyroid dysfunction and thyroiditis with the risk of thyroid cancer is an important issue in clinical practice, and is controversial due to various confounders, including screening effects. In this large-sample, population-based, nationwide study, we demonstrated that the screening effect likely significantly contributed to the positive associations of thyroid dysfunction and thyroiditis with thyroid cancer. After adjustment for this confounder, thyroid cancer risk was positively associated with hypothyroidism and thyroiditis but negatively associated with hyperthyroidism and Graves’ disease. Multiple subgroup analyses showed consistent results. Given these overestimated associations, we suggest that unnecessary and excessive concerns or screening tests for thyroid cancer could be reduced in patients with thyroid dysfunction or thyroiditis.

Abstract

We aimed to assess the relationships of functional thyroid disease and thyroiditis with subsequent thyroid cancer, which is controversial due to various confounders, and the effect of thyroid disease workup on this association. We used the cohort data from 2002 to 2015 (Study I, n = 28,330) and the entire data from 2002 to 2019 (Study II, n = 883,074) of the Korean National Health Insurance Service database, and performed logistic regression and subgroup analyses with various covariates. In Study I, hypothyroidism, thyroiditis, autoimmune thyroiditis, hyperthyroidism, and Graves’ disease showed positive associations with thyroid cancer. In Study II, after adjustment for covariates including the number of thyroid function tests, the ORs for thyroid cancer were significantly reduced in all thyroid diseases. Hypothyroidism, thyroiditis, and autoimmune thyroiditis were positively associated (adjusted odds ratio, OR (95% confidence interval, CI) 1.28 (1.25–1.32), 1.36 (1.31–1.42), and 1.17 (1.11–1.24), respectively), whereas hyperthyroidism and Graves’ disease were negatively associated with thyroid cancer (adjusted OR (95% CI) 0.80 (0.77–0.83) and 0.69 (0.65–0.74), respectively). Multiple subgroup analyses in both studies showed consistent results. In this large population-based, nationwide study, we confirmed that thyroid disease workup leads to overestimation of associations of thyroid dysfunction and thyroiditis with thyroid cancer risk.

Can we still consider thyroid hyperfunction a protective condition for the onset of thyroid cancer?

Background

Thyroid cancer is the ninth most commonly diagnosed cancer in the world, and the most common endocrine carcinoma. It was originally believed to be a rare event in patients with thyroid hyperfunction and it was reported that hyperthyroidism had a protective role against thyroid neoplasms. However, in recent years, several studies have hypothesized that differentiated thyroid carcinomas and hyperthyroidism may coexist. Our study aims therefore to evaluate the incidence of differentiated thyroid carcinomas on definitive histological examination, in patients undergoing total thyroidectomy or hemithyroidectomy with coexisting hyperfunctioning thyroid disease, to understand whether hyperthyroidism can be considered a protective condition against the onset of thyroid neoplasms.

Methods

The study involved 1,449 patients underwent to thyroid surgery from 2010 to 2018 at the General Surgery Unit, Department of Surgery, University Hospital of Parma, Parma, Italy, presenting thyroid cancer at postoperative histological exam. Patients were divided in two groups based on the presence (Group A) or absence (Group B) of hyperfunction. All data were collected in a dedicated database and include demographic data, such as age and sex, preoperative cytology, date and type of surgery, postoperative diagnosis, characteristics of aggressiveness of the neoplasm and postoperative complications. For data analysis, a P value of less than 0.05 was considered statistically significant.

Results

The incidence of thyroid carcinomas was lower in patients suffering from hyperfunction compared to the incidence found in non-hyperthyroid patients, both in preoperative cytological examination and in postoperative diagnosis through histological examination. Furthermore, the tumors that have developed in patients with hyperfunction had a comparable degree of aggression and invasiveness in the two groups studied. However, we have found an equal incidence of microcarcinomas and occult carcinomas on postoperative histological examination. Postoperative complications in patients with cancer were similar, regardless of the presence or absence of hyperfunctioning thyroid disease.

Conclusions

Our study confirms that hyperthyroidism is a protective condition against thyroid carcinoma, but the finding of an equivalent incidence of occult carcinomas in the two groups stresses the need to perform a cytological examination in case of a nodular pathology in a hyperthyroid patient before performing a treatment.

Prognosis of papillary thyroid cancer in patients with Graves' disease: a propensity score-matched analysis

Background

Patients with Graves’ disease (GD) are at a 2.5 times higher risk of developing thyroid cancer than the general population. Previous studies reported conflicting results about the prognosis of thyroid cancer concomitant with GD. This study aimed to investigate the effect of GD to the recurrence rates of papillary thyroid carcinoma (PTC).

Methods

We reviewed 3628 patients who underwent total thyroidectomy for PTC at the Ewha Womans University Medical Center from January 2006 to June 2014. Of those, 114 patients had non-occult PTC with concomitant GD. To reduce potential confounding effects and selection bias, we conducted 1:5 propensity score matching and analyzed the recurrence-free survival.

Results

Thyroid cancer in patients with GD showed lower rate of lymphatic invasion (1.8% vs. 6.7%; p = 0.037), microscopic resection margin involvement (0.9% vs. 5.8%; p = 0.024), and lymph node metastasis (29.8% vs. 37.3%; p = 0.001) than in patients without GD, respectively. During the median follow-up of 94.1 months, recurrence occurred in one patient (0.9%) with GD. After propensity score matching for adjusting clinicopathological features, 5-year recurrence-free survival was comparable between patients with GD and euthyroid patients (100% vs. 98.4%, p = 0.572). Both tumor size [hazard ratio (HR) 1.585, p < 0.001] and lymph node metastasis (HR for N1a 3.067, p = 0.024; HR for N1b 15.65, p < 0.001) were predictive factors for recurrence-free survival, while GD was not associated with the recurrence.

Conclusions

Our data suggest that GD does not affect the prognosis of PTC. Thyroid cancer in patients with GD is not more aggressive than in euthyroid patients.

Association between various thyroid gland diseases, TSH values and thyroid cancer: a case-control study

BACKGROUND

The goal of this retrospective cohort study was to analyze the association between benign thyroid alteration and thyroid cancer in patients followed in general practices in Germany.

METHODS

Patients aged 18-80 who had received an initial diagnosis of thyroid cancer in one of 1261 general practices in Germany between January 2009 and December 2018 were included in this study (index date). These patients were matched (1:1) to non-cancer patients by age, sex, physician and index year. The main outcome of the study was the association between various benign thyroid alterations and thyroid cancer.

RESULTS

The study included 2787 patients with thyroid cancer and 2787 individuals without cancer (mean age: 52.8 years, 73.5% women). The main finding was that all benign changes in the thyroid with the exception of thyroiditis were associated with thyroid cancer. The strongest association was observed by the nontoxic goiter. Half of the patients with thyroid cancer had nontoxic goiter compared to just one-sixth of the control group. Thyrotoxicosis was found in 12.9% of the cancer group and in 3.9% of the controls. By analyzing TSH in groups, we found an association between suppressed TSH and elevated TSH levels and thyroid cancer.

CONCLUSION

In accordance with the literature, we confirmed that any kind of benign thyroid alteration was associated with an elevated risk of thyroid cancer. The odds ratio was greatest for nontoxic goiter, followed by benign neoplasms of the thyroid, other disorders of the thyroid such as Hashimoto and thyrotoxicosis. We also found an elevated risk of cancer in patients with either a suppressed or elevated TSH.

Effect of Graves' disease on the prognosis of differentiated thyroid carcinoma: a meta-analysis

PURPOSE

Several studies have reported different findings on the prognosis of differentiated thyroid carcinoma combined with Graves' disease. To assess the effect of Graves' disease on differentiated thyroid carcinoma, a meta-analysis was undertaken.

METHODS

PubMed, OVID and the Cochrane Library were systematically searched for trials published prior to Oct. 2018. Studies containing data on the outcomes of Graves' disease with differentiated thyroid carcinoma were included. Summary estimates of the prevalence of recurrence/disease progression/persistence and mortality as well as odds ratios and weighted mean differences were calculated with a random-effects model.

RESULTS

Of the 916 related articles found, 13 fulfilled the inclusion criteria. The recurrence/disease progression/persistent rate was not significantly different between the Graves' disease group and the non-Graves' disease group (P = 0.86). However, the analysis of three studies with K-M curves or HRs showed that there was a significant difference between the two groups (P = 0.04). Subgroup analysis showed that the contradictory results could be due to the location/race assessed in the studies. Graves' disease almost acted as a risk factor (OR = 1.77, 95%C.I. = 0.99-3.16) for differentiated thyroid carcinoma in European studies. When heterogeneous studies were excluded, the analyses show that GD was a risk factor for recurrence/disease progression/persistence (P = 0.03, OR = 1.75, 95%C.I. = 1.04-2.95). The overall mortality rate was significantly higher in the Graves' disease group than in the non-Graves' disease group (P = 0.02, OR = 2.93, 95%C.I. = 1.17-7.37).

CONCLUSIONS

Graves' disease acts as a risk factor for the prognosis of differentiated thyroid carcinoma. The recurrence/disease progression/persistent rate may be affected by TSAbs in a specific location/race and with a genetic immunization background. However, the histotypes and subtypes may play an important role in mortality rate.

Hyperthyroidism

Hyperthyroidism is a condition where the thyroid gland produces and secretes inappropriately high amounts of thyroid hormone which can lead to thyrotoxicosis. The prevalence of hyperthyroidism in the United States is approximately 1.2%. There are many different causes of hyperthyroidism, and the most common causes include Graves' disease (GD), toxic multinodular goiter and toxic adenoma. The diagnosis can be made based on clinical findings and confirmed with biochemical tests and imaging techniques including ultrasound and radioactive iodine uptake scans. This condition impacts many different systems of the body including the integument, musculoskeletal, immune, ophthalmic, reproductive, gastrointestinal and cardiovascular systems. It is important to recognize common cardiovascular manifestations such as hypertension and tachycardia and to treat these patients with beta blockers. Early treatment of cardiovascular manifestations along with treatment of the hyperthyroidism can prevent significant cardiovascular events. Management options for hyperthyroidism include anti-thyroid medications, radioactive iodine, and surgery. Anti-thyroid medications are often used temporarily to treat thyrotoxicosis in preparation for more definitive treatment with radioactive iodine or surgery, but in select cases, patients can remain on antithyroid medications long-term. Radioactive iodine is a successful treatment for hyperthyroidism but should not be used in GD with ophthalmic manifestations. Recent studies have shown an increased concern for the development of secondary cancers as a result of radioactive iodine treatment. In the small percentage of patients who are not successfully treated with radioactive iodine, they can undergo re-treatment or surgery. Surgery includes a total thyroidectomy for GD and toxic multinodular goiters and a thyroid lobectomy for toxic adenomas. Surgery should be considered for those who have a concurrent cancer, in pregnancy, for compressive symptoms and in GD with ophthalmic manifestations. Surgery is cost effective with a high-volume surgeon. Preoperatively, patients should be on anti-thyroid medications to establish a euthyroid state and on beta blockers for any cardiovascular manifestations. Thyroid storm is a rare but life-threatening condition that can occur with thyrotoxicosis that must be treated with a multidisciplinary approach and ultimately, definitive treatment of the hyperthyroidism.

Frequency of thyroid nodules and thyroid cancer in thyroidectomized patients with Graves' disease

INTRODUCTION

Incidental thyroid cancers are frequently detected in patients operated on for Graves' disease (GD). There are no clear data about the incidence and risk factors of incidental thyroid cancer in operated GD patients. The aim of this study is to evaluate the risk of thyroid carcinoma in surgically treated GD patients.

MATERIAL AND METHODS

The data of 121 GD patients who underwent total thyroidectomy in a single center between 2005 and 2015 were retrospectively evaluated. The diagnosis of thyroid cancer was based on pathological examination.

RESULTS

Thyroid cancer was demonstrated in postoperative pathology specimens of 34 patients who were surgically treated for GD (28.1%). Preoperative thyroid ultrasonography (USG) revealed a nodular goiter in 62 (51.2%) patients. Nodules were not detected in the other 59 (48.8%) patients with GD. The frequency of thyroid cancer was significantly higher in patients with nodules (38% vs. 16%; p = 0.009). Thirty-two of the 34 cancer cases had papillary thyroid cancer (PTC), and the remaining 2 had follicular thyroid cancer (FTC). Of the 32 PTC patients, 28 were classical type, 2 patients had the follicular variant, 1 was the oncocytic variant, and 1 was a tall cell variant.

CONCLUSIONS

The incidence of thyroid cancer was higher in patients who underwent surgery for GD. In addition to a careful physical examination in the follow-up of the patients with GD, ultrasonographic evaluation should be performed. Surgical treatment should not be delayed in patients with GD when indicated.

Incidental versus clinical diagnosis of papillary thyroid microcarcinoma. Long-term prognosis

INTRODUCTION

The incidence of papillary thyroid microcarcinoma (PTMC) has increased in recent years, especially in patients operated on for presumably benign thyroid disease. The aim of this study was to analyze the differences between PTMC incidentally diagnosed and PTMC clinically diagnosed, as well as its long-term prognosis.

MATERIAL AND METHODS

The study population consisted of patients with a histological diagnosis of PTMC. Patients with previous thyroid surgery, other synchronous thyroid or extrathyroid malignancies and an ectopic location of PTMC were excluded. Two groups were compared: patients with PTMC incidentally diagnosed (group 1) and patients with PTMC clinically diagnosed (group 2). A multivariate analysis of differentiating factors was performed.

RESULTS

PTMC clinically diagnosed had a high frequency of hypothyroidism (4.6% vs. 18.9%; P=.004), extrathyroidal extension (5.7% vs. 17.6%; P=.018), metastatic lymph nodes (1.1% vs. 18.9%; P<.001) and lymphocytic thyroiditis (5.7% vs. 27%; P<.001). In the multivariate analysis, metastatic lymph nodes (OR: 22.011, IC 95%: 2.621-184.829; P=.004) and lymphocytic thyroiditis (OR: 4.949; IC 95%: 1.602-15.288; P=.005) were associated with the clinical diagnosis of PTMC. During a mean follow-up of 119.8±65.1 months, one recurrence was detected in group 2 (0% vs. 1,4%; P=.460). No patient died due to the disease.

CONCLUSIONS

PTMC clinically diagnosed, although it has more aggressive histopathological characteristics (extrathyroidal extension and metastatic lymph nodes), presents a long-term prognosis similar to the PTMC incidentally diagnosed. The presence of metastatic lymph nodes and lymphocytic thyroiditis were independent factors associated with PTMC clinically diagnosed.

Thyroid nodules as a risk factor for thyroid cancer in patients with Graves' disease: A systematic review and meta-analysis of observational studies in surgically treated patients

OBJECTIVE

Graves' disease (GD) is an autoimmune thyroid disorder characterized by hyperthyroidism. The incidence of thyroid cancer in patients with GD varies from 0.15% to 15%. There is conflicting evidence on the role of thyroid nodules as a risk factor for thyroid cancer in patients with GD.

DESIGN

Three electronic databases (PubMed, Cochrane Library, Scopus) as well as grey literature sources were searched, from inception until 25 February 2019, for observational studies about the prevalence of thyroid cancer in patients with GD.

PATIENTS

Clinical and ultrasonographic examination was necessary preoperatively for all patients to be classified depending on the presence/absence of thyroid nodules.

MEASUREMENTS

Primary outcome was the incidence of thyroid cancer. The latter was determined after total or near-total thyroidectomy by the histopathologic report. Statistical analysis was performed with revman 5.3 software.

RESULTS

The systematic review and meta-analysis included 7 studies with 2582 patients overall. The prevalence of any thyroid cancer was 11.5%. The presence of at least one thyroid nodule in patients with GD was associated with higher risk for thyroid cancer (odds ratio [OR] 5.3, 95% confidence interval [CI] 2.4-11.6, I² 83%). A subgroup analysis showed no difference in thyroid cancer risk in patients with GD according to the number of nodules (solitary versus multiple) (OR 1.4, 95% CI 0.9-2.3, I² 0%).

CONCLUSIONS

The presence of thyroid nodules is positively associated with the prevalence of thyroid cancer in surgically treated patients with GD. However, further prospective research is needed as the heterogeneity among the studies is high.

The Incidence of Childhood Thyrotoxicosis Is Increasing in Both Girls and Boys in Sweden

BACKGROUND

We found an increase in the incidence rate (IR) of childhood thyrotoxicosis (CT) during the 1990s in central Sweden. The optimal treatment method for CT is a subject that is still debated upon.

OBJECTIVES

To investigate whether the increase in IR of CT in Sweden persists and to study the treatment outcome.

METHOD

Children <16 years of age diagnosed with CT during 2000-2009 and living in 1 of 5 counties in central Sweden were identified retrospectively using hospital registers. Data on clinical and biochemical characteristics and outcomes of treatment were collected from medical records. The corresponding data from 1990 to 1999 were pooled with the new data.

RESULTS

In total, 113 children were diagnosed with CT during 1990-2009 in the study area. The overall IR was 2.2/100,000 person-years (95% CI 1.2-2.5/100,000 person-years). The IR was significantly higher during 2000-2009 than during 1990-1999 (2.8/100,000 [2.2-3.6] vs. 1.6/100,000 person-years [1.2-2.2], p = 0.006). The increase was significant for both sexes. Seventy percent of the patients who completed the planned initial treatment with antithyroid drugs (ATDs) and were not lost to follow-up relapsed within 3 years. Boys tended to relapse earlier than girls (6.0 months after drug withdrawal [95% CI 1.9-10.0] vs. 12.0 months [95% CI 6.8-17.3], p = 0.074).

CONCLUSIONS

The IR of CT is increasing in both girls and boys. Relapse rate after withdrawal of ATD treatment is 70%. Boys tend to relapse earlier than girls, and this needs to be further investigated.

Association of benign thyroid diseases with thyroid cancer risk: a meta-analysis of prospective observational studies

PURPOSE

Evidence showed that benign thyroid disease was one of the risk factors for thyroid cancer. However, the results of some studies were inconsistent and were previously meta-analyses of case-control studies. Therefore, we performed a meta-analysis of prospective studies to investigate the relationship between benign thyroid diseases and thyroid cancer risk.

METHODS

All eligible studies were identified via systematic searches of multiple literature databases. The combined RR (relative risk)/HR (hazard ratio) or SIR (standardized incidence ratio) with 95% confidence interval was calculated. Heterogeneity was assessed with the I² test. Publication bias and subgroup analyses were also performed.

RESULTS

Twelve studies were eligible for inclusion in the meta-analysis. The pooled RR/HR of thyroid carcinoma in benign thyroid diseases was 4.39 (95% CI 3.22-5.55). The pooled SIR of thyroid carcinoma in benign thyroid diseases was 5.98 (95% CI 4.09-7.86). Subgroup analysis was performed using the type of benign thyroid diseases. Effect value was RR/HR: hyperthyroidism (RR/HR = 3.89, 95% CI = 1.69-6.08), hypothyroidism (RR/HR = 2.72, 95% CI = 1.04-4.41), and goiter (RR/HR = 22.18, 95% CI = 12.09-32.28). Effect value was SIR: hyperthyroidism (RR/HR = 5.96, 95% CI = 1.88-10.03), goiter (RR/HR = 7.65, 95% CI = 6.94-8.37), and thyroiditis (RR/HR = 3.25, 95% CI = 1.62-4.89).

CONCLUSIONS

Our study has shown that benign thyroid diseases might be associated with increased risk of thyroid cancer, especially in hyperthyroidism, hypothyroidism, and goiter. However, further investigation is needed to better understand the underlying biological mechanisms.

Targeting EZH2 as a novel therapeutic strategy for sorafenib-resistant thyroid carcinoma

Thyroid carcinoma is the most common endocrine malignancy. Surgery, post‐operative selective iodine‐131 and thyroid hormone suppression were the most common methods for the therapy of thyroid carcinoma. Although most patients with differentiated thyroid carcinoma (DTC) showed positive response for these therapeutic methods, some patients still have to face the radioactive iodine (RAI)‐refractory problems. Sorafenib is an oral multikinase inhibitor for patients with advanced RAI refractory DTC. However, the side effects and drug resistance of sorafenib suggest us to develop novel drugs and strategies for the therapy of thyroid carcinoma. In this study, we firstly found that patients with sorafenib resistance showed no significant change in rapidly accelerated fibrosarcoma and VEGFR expression levels compared with sorafenib sensitive patients. Moreover, a further miRNAs screen by qRT‐PCR indicated that miR‐124‐3p and miR‐506‐3p (miR‐124/506) were remarkably reduced in sorafenib insensitive patients. With a bioinformatics prediction and functional assay validation, we revealed that enhancer of zeste homolog 2 (EZH2) was the direct target for miR‐124/506. Interestingly, we finally proved that the sorafenib resistant cells regained sensitivity for sorafenib by EZH2 intervention with miR‐124/506 overexpression or EZH2 inhibitor treatment in vitro and in vivo, which will lead to the decreased tri‐methylation at lysine 27 of histone H3 (H3K27me3) and increased acetylated lysine 27 of histone H3 (H3K27ac) levels. Therefore, we conclude that the suppression of EZH2 represents a potential target for thyroid carcinoma therapy.

Suppression of long non-coding RNA TNRC6C-AS1 protects against thyroid carcinoma through DNA demethylation of STK4 via the Hippo signalling pathway

Objectives

Thyroid carcinoma (TC) represents a malignant neoplasm affecting the thyroid. Current treatment strategies include the removal of part of the thyroid; however, this approach is associated with a significant risk of developing hypothyroidism. In order to adequately understand the expression profiles of TNRC6C‐AS1 and STK4 and their potential functions in TC, an investigation into their involvement with Hippo signalling pathway and the mechanism by which they influence TC apoptosis and autophagy were conducted.

Methods

A microarray analysis was performed to screen differentially expressed lncRNAs associated with TC. TC cells were employed to evaluate the role of TNRC6C‐AS1 by over‐expression or silencing means. The interaction of TNRC6C‐AS1 with methylation of STK4 promoter was evaluated to elucidate its ability to elicit autophagy, proliferation and apoptosis.

Results

TNRC6C‐AS1 was up‐regulated while STK4 was down‐regulated, where methylation level was elevated. STK4 was verified as a target gene of TNRC6C‐AS1, which was enriched by methyltransferase. Methyltransferase’s binding to STK4 increased expression of its promoter. Over‐expressed TNRC6C‐AS1 inhibited STK4 by promoting STK4 methylation and reducing the total protein levels of MST1 and LATS1/2. The phosphorylation of YAP1 phosphorylation was decreased, which resulted in the promotion of SW579 cell proliferation and tumorigenicity.

Conclusion

Based on our observations, we subsequently confirmed the anti‐proliferative, pro‐apoptotic and pro‐autophagy capabilities of TNRC6C‐AS1 through STK4 methylation via the Hippo signalling pathway in TC.

The risk of extra-ovarian malignancies among women with endometriosis: A systematic literature review and meta-analysis

We conducted a meta-analysis of studies reporting on the risk of extra-ovarian malignancies among women with endometriosis. Summary relative risk (SRR) and 95% confidence intervals (CI) were calculated through random effect models. We explored causes of between-studies heterogeneity and assessed the presence of publication bias. We included 32 studies published between 1989 and 2018. We found an increased risk of endometrial (SRR 1.38, 95%CI 1.10-1.74) and thyroid cancer (SRR 1.38, 95%CI 1.17-1.63), and inverse association with cervical cancer (SRR 0.78, 95%CI 0.60-0.95). No association emerged for breast cancer (SRR 1.04, 95%CI 0.99-1.09) and melanoma (SRR 1.31, 95%CI 0.86-1.96). Between-study heterogeneity was large for breast and endometrial cancer and melanoma. Associations were generally stronger in case-control, cross-sectional, and cohort studies with internal control group, compared to cohort studies with external control group. No indication for publication bias was found. Our conclusions need to be confirmed in properly designed cohort studies with clinical confirmation of endometriosis.

Increased risk of postoperative complications after total thyroidectomy with Graves' disease

BACKGROUND

The effect of Graves' disease on the risk of postoperative complications in patients undergoing total thyroidectomy is unclear.

METHODS

The incidence of recurrent laryngeal nerve (RLN) injury and hypoparathyroidism were analyzed between 165 patients with Graves' disease (GD group) and 1:1 matched patients with euthyroid states (control group).

RESULTS

The matched cohorts did not differ in age, sex, body mass index, pathologic diagnosis, and extent of operation. Excised thyroid weight was higher in the Graves' disease than in the control group (60.1 g vs 22.6 g; P < .001). Multivariate analysis showed that Graves' disease significantly increased risks of transient RLN injury (odds ratio [OR] = 4.7, 95% confidence interval [CI] = 1.5-15.5; P = .010) and transient hypoparathyroidism (OR = 2.8, 95% CI = 1.3-5.8; P = .007). Rates of permanent complications were comparable in the Graves' disease and control groups.

CONCLUSIONS

Graves' disease can be a predictive factor for postoperative RLN injury and hypoparathyroidism after total thyroidectomy.

Therapeutic plasmapheresis in thyrotoxic patients

PURPOSE

For the treatment of thyrotoxicosis, alternative treatment modalities may be necessary if anti-thyroid drugs cannot be used due to side effects, inefficiencies, or there is a need to start a rapid action such as thyroid storm. By using therapeutic plasma exchange (TPE), it is possible to effectively and rapidly remove the increased thyroid hormones. We evaluated our results and experience on a rapid, effective, and reliable alternative treatment modality in thyrotoxic patients.

METHODS

TPE was performed in 46 thyrotoxic patients at the Adult Therapeutic Apheresis Center.

RESULTS

Forty six patients with a median age of 30 years (interquartile range [IQR] 30-50) were assessed. In 40 (87%) of the cases, the diagnosis was Graves' disease. The other causes of thyrotoxicosis were amiodarone-induced thyrotoxicosis (n = 4) and toxic nodular goiter (n = 2). The median and IQR of fT3 values in patients before TPE were 9.9 (6.5-16.8) pg/mL (N: 2.3-4.2) and the median and IQR of fT4 values were 2.9 (2.3-4.1) ng/dL (N: 0.74-1.52). When the procedure was terminated, the median and IQR of fT3 values in patients were 4.0 (3.1-5.2) pg/mL and the median and IQR fT4 values were 1.6 (1.4-2.0) ng/dL. The decrease in both free thyroid hormones was found to be statistically significant (p < 0.000).

CONCLUSION

Our study is the largest series of TPE in the literature used for thyrotoxicosis. In the light of the literature and our results, we conclude that TPE is an effective alternative treatment option to prepare for ablative treatment for cases that have side effects or ineffectiveness of anti-thyroid drugs.

Treatment of adult Graves' disease

Treatment strategy in Graves' disease firstly requires recovery of euthyroid status by antithyroid therapy. Treatment modalities, precautions, advantages and side-effects are to be discussed with the patient. No particular treatment modality has demonstrated superiority. Pregnancy or pregnancy project affects choice of treatment and monitoring. Graves' orbitopathy is liable to be aggravated by iodine-131 treatment and requires pre-treatment assessment. Iodine-131 treatment aims at achieving hypothyroidism. Thyroid surgery for Graves' disease should preferably be performed by an expert team. In case of recurrence of hyperthyroidism, the various treatment options should be discussed with the patient. Empiric treatment of thyroid dermopathy uses local corticosteroids in occlusive dressing.

Coexistent thyroid nodules in patients with graves' disease: What is the frequency and the risk of malignancy?

BACKGROUND

The purpose of this study was to determine the frequency of coexistent thyroid nodules and the rate of malignancy in patients with surgically treated Graves' disease (GD).

METHODS

A retrospective review of all patients with GD who underwent thyroidectomy from 1990 to 2017 was completed. Pathology reports were reviewed for coexistent nodules. Demographics, nodule size, and results of ultrasound, ¹²³I scintigraphy, fine needle aspiration biopsy and pathology were analyzed.

RESULTS

There were 233 patients with GD who underwent thyroidectomy, 103 (44%) had one or more thyroid nodules, which were incidentally discovered on pathologic exam in 54(52%) patients. 14 (6%) patients had cancer, 9 (4%) papillary microcarcinoma and 5 (2%) papillary cancer ≥ 1 cm that occurred within a nodule diagnosed preoperatively.

CONCLUSIONS

Most thyroid nodules in patients with GD were incidentally discovered on pathologic exam. A higher rate of malignancy was found in patients with GD and clinically identifiable nodular disease.

Incidental thyroid carcinoma in surgery-treated hyperthyroid patients with Graves' disease: a systematic review and meta-analysis of cohort studies

Background

The association between Graves’ disease (GD) and thyroid carcinoma remains controversial. This study aimed to investigate incidental thyroid carcinoma (ITC) in surgery-treated hyperthyroid patients with and without GD.

Materials and methods

We searched PubMed and EMBASE for cohort studies investigating ITC in surgery-treated hyperthyroid patients without prediagnosed thyroid carcinoma in accordance with the Meta-Analysis of Observational Studies in Epidemiology guidelines. The last search was updated to January 23, 2018. All statistical tests were performed using Review Manager 5.3 and STATA version 12.0.

Results

Eleven cohort studies involving 10,743 GD and 3,336 non-GD patients were included. The pooled prevalence of ITC was 7.0% (95% confidence interval [CI] 4.5–9.6), and was comparable in surgery-treated GD and non-GD hyperthyroid patients (GD vs non-GD: pooled odds ratio [OR], 1.0; 95% CI: 0.68–1.46; P=0.98). In the subgroup analysis, toxic adenoma and toxic nodular goiter showed no difference when comparing with GD (pooled OR, 0.53; 95% CI: 0.21–1.36; P=0.18 and pooled OR, 1.01; 95% CI: 0.65–1.57; P=0.95, respectively).

Conclusion

Our study demonstrated that GD was not associated with increased risk of ITC in surgery-treated hyperthyroid patients.

The Outcome of Papillary Thyroid Cancer Associated with Graves' Disease: A Case Control Study

Introduction

Thyroidectomy is now a less popular therapeutic option for Graves' disease. The frequency of thyroid nodule and the cancer risk of these nodules accompanying Graves' disease are controversial. The outcome of thyroid cancers coexisting with Graves' disease is debated.

Study Design

Designed as retrospective case control study of papillary thyroid cancers associated with Graves' disease and those with euthyroid background. Pathological characteristics and outcome of papillary thyroid cancers in the two groups were compared.

Results

The tumour characteristics did not differ significantly in the groups. The patients were followed for a mean period of 77.32 months and found significant incidences of disease progression in patients with papillary thyroid cancer associated with Graves' disease (p = 0.034; OR 2.747, CI 1.078-7.004). Disease progression as new distant metastases mostly in skeletal locations was high in this group compared to euthyroid group (p = 0.027; OR 4.121, CI 1.008-15.600). There was higher incidence of cumulative metastatic diseases in papillary thyroid cancer associated with Graves' disease.

Conclusion

Papillary thyroid cancers associated with Graves' disease show aggressive biological behaviour and favoured site of distant metastases was osseous locations. Early diagnosis by routine screening of Graves' disease patients with ultrasound imaging and aspiration studies is recommended.