Prognostic value of preoperative anti-thyroglobulin antibody in differentiated thyroid cancer

Nomogram model of serum thymidine kinase 1 combined with ultrasonography for prediction of central lymph node metastasis risk in patients with papillary thyroid carcinoma pre-surgery

Objective

The aim of this study was to develop a nomogram, using serum thymidine kinase 1 protein (STK1p) combined with ultrasonography parameters, to early predict central lymph node metastasis (CLNM) in patients with papillary thyroid carcinoma (PTC) pre-surgery.

Methods

Patients with PTC pre-surgery in January 2021 to February 2023 were divided into three cohorts: the observation cohort (CLNM, n = 140), the control cohort (NCLNM, n = 128), and the external verification cohort (CLNM, n = 50; NCLNM, n = 50). STK1p was detected by an enzyme immunodot-blot chemiluminescence analyzer and clinical parameters were evaluated by ultrasonography.

Results

A suitable risk threshold value for STK1p of 1.7 pmol/L was selected for predicting CLNM risk by receiver operating characteristic (ROC) curve analysis. Multivariate analysis identified the following six independent risk factors for CLNM: maximum tumor size >1 cm [odds ratio (OR) = 2.406, 95% confidence interval (CI) (1.279-4.526), p = 0.006]; capsule invasion [OR = 2.664, 95% CI (1.324-5.360), p = 0.006]; irregular margin [OR = 2.922; 95% CI (1.397-6.111), p = 0.004]; CLN flow signal [OR = 3.618, 95% CI (1.631-8.027), p = 0.002]; tumor-foci number ≥2 [OR = 4.064, 95% CI (2.102-7.859), p < 0.001]; and STK1p ≥1.7 pmol/L [OR = 7.514, 95% CI (3.852-14.660), p < 0.001]. The constructed nomogram showed that the area under the ROC curve for the main dataset was 0.867 and that for the validation dataset was 0.830, exhibiting effectivity, and was recalculated to a total score of approximately 383. Through monitoring the response post-surgery, all patients were assessed as tumor-free at 12 months post-surgery, which was significantly associated with a reduction in STK1p to disease-free levels.

Conclusion

We demonstrate for the first time that a novel nomogram including STK1p combined with ultrasonography can assist in the clinical prevention of CLNM, by facilitating timely, individualized prophylactic CLNM dissection, thereby reducing the risk of secondary surgery and the probability of recurrence.

Prognostic value of preoperative thyroid autoantibodies for post-thyroidectomy patient pathology: A retrospective cohort study

OBJECTIVE

The aim of this study was to evaluate the clinical value of preoperative thyroid autoantibodies with reference to the post-thyroidectomy patient pathology.

DESIGN

A retrospective cohort study.

SETTING

Two tertiary care academic hospitals.

MATERIALS AND METHODS

A total of (n = 473) subjects who underwent thyroidectomy from 2009 to 2019 were included. Preoperative serum thyroid autoantibodies (anti-thyroglobulin [anti-Tg] and anti-thyroperoxidase [anti-TPO]) were measured, and the potential predictors of postoperative pathological diagnosis (age, gender, and thyroid autoantibodies) were assessed using multivariable regression models.

RESULTS

Patients with positive thyroid autoantibodies were more likely to have malignant disease than benign disease; adjusted odds ratio (AOR) = 1.6 (1.3-2.7, p = 0.002) for anti-Tg, and AOR = 1.6 (1.1-2.5, p = 0.027) for anti-TPO. A subset analysis of the same predictors performed on patients with cancer (malignant vs. microcarcinoma) showed that patients with ages ≥40 were more likely to develop microcarcinoma as opposed to malignant disease; AOR = 1.8 (1.1-3.1, p = 0.03) for anti-TPO, and AOR = 1.7 (1.0-2.9, p = 0.04) for anti-Tg.

CONCLUSION

Preoperative thyroid autoantibodies could be used clinically to predict the risk of malignancy in thyroid nodules, thus helping guide treatment decisions in patients with thyroid nodules and speeding up the decision to undergo surgical intervention.

Thyroid autoantibodies

Thyroid-stimulating hormone (TSH) receptor antibody (TSH-R-Ab or TRAb) testing plays a pivotal role in arriving at the aetiological diagnosis in patients with thyrotoxicosis. A positive test establishes the diagnosis of Graves' disease (GD) while a negative result in conjunction with imaging studies supports other possible aetiologies. In patients with GD, TRAb levels at diagnosis and at the time of withdrawal of antithyroid drugs can identify patients who are unlikely to achieve remission and guide clinical management decisions. We provide an algorithm that incorporates TRAb in the decision-making process for the management of thyrotoxicosis. The utility of TRAb in predicting the risk of fetal and neonatal thyroid dysfunction is established and widely accepted in guidelines. TRAb may also help in the diagnosis of Graves' orbitopathy, especially in euthyroid or hypothyroid patients and its role in guiding its management is evolving as a useful adjunct to the clinical parameters used in making therapeutic decisions.Anti-thyroid peroxidase antibodies (TPOAb) and anti-thyroglobulin antibodies (TgAb) indicate thyroid autoimmunity. The most common use of TPOAb is to identify patients at a higher risk of progression to treatment-requiring hypothyroidism. They also aid the diagnosis of immune thyroiditis and Hashimoto's encephalopathy. Thyroglobulin measurement is used to help guide differentiated thyroid cancer treatment. TgAb is used as an accompanying test with thyroglobulin measurement as its presence can interfere with the thyroglobulin assay. A negative TgAb result reduces the likelihood of, but does not exclude, interference with thyroglobulin assay.

Relationship Between Thyroid Autoantibodies and Recurrence of Papillary Thyroid Carcinoma in Children and Adolescents

Background

Numerous studies reported connection between papillary thyroid carcinoma (PTC) and thyroid autoantibody in adults, but few of them have investigated whether there is a similar link in children and adolescents. The purpose of this research was to explore the relationship between clinicopathological features, prognosis and preoperative thyroid peroxidase antibody (TPOAb) as well as thyroglobulin antibody (TgAb) status in children and adolescents with PTC.

Methods

This study retrospectively reviewed 179 patients of PTC who underwent a thyroidectomy from January 2000 to June 2021 at Tianjin Medical University Cancer Hospital. We compared preoperative TgAb and TPOAb status with the clinicopathological features and prognosis of children and adolescents with PTC in different age groups.

Results

Patients with positive preoperative TPOAb and TgAb had lower recurrence rate in the younger group (P = 0.006, 0.047, respectively). Patients with positive TPOAb preoperatively had normal level of preoperative Tg and less cervical LNM than patients with negative TPOAb in children and adolescents (P < 0.05). Positive TPOAb preoperatively of PTC patients had a longer median DFS (113.4 months) than negative TPOAb (64.9 months) (P = 0.009, log-rank). Univariate analyses showed age, maximal tumor size, T stage, multifocality, lateral LNM and N staging were predictors for cancer recurrence in children and adolescents (P<0.05). Cox regression analysis found younger age (HR 0.224, P < 0.001), lateral LNM (HR 0.137, P = 0.010), N stage (HR 30.356, P < 0.001) were independent risk factors for recurrence.

Conclusions

Our study found that presence of preoperative TPOAb and TgAb could serve as novel prognostic factors for predicting recurrence of PTC in children.

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.

Histology is more ιmportant than persistent anti-Tg antibodies for progression of differentiated thyroid cancer

CONTEXT

Anti-thyroglobulin antibodies (anti-Tg), present in 20%-25% of differentiated thyroid cancer (DTC) patients, interfere with thyroglobulin measurements posing a challenge in the follow-up.

OBJECTIVES

The aim of this study was to identify clinical-histological factors that may affect anti-Tg persistence and disease outcome in DTC with positive anti-Tg.

METHODS

We retrospectively studied 234 DTC patients, with positive anti-Tg at diagnosis (females: 82.1%, age at diagnosis: 46.0 ± 14.4 yrs, median follow-up: 5 yrs (1.5-32 yrs). 221/234 (94.4%) received radioiodine (RAI) ablation. Patients were divided into two subgroups: those whose anti-Tg became undetectable (anti-Tg-NEG) and those whose anti-Tg remained positive (anti-Tg-POS) at the end of the follow-up period.

RESULTS

Anti-Tg-POS patients (n = 80, 34.2%) compared to anti-Tg-NEG (n = 154, 65.8%) had more frequently lymph node infiltration (36.3% vs 20.1%, P = .01), extrathyroidal extension (ETE, 35.0% vs 22.1%, P = .04), poorly differentiated DTC and increased tumour size (P ≤ .004). They received higher total RAI dose (P < .001). In most cases, additional RAI administration and/or additional surgeries did not lead to anti-Tg elimination. These had more frequently structural disease persistence/progression compared to anti-Tg-NEG (remission: 78.8% vs 95.5%, persistence: 13.8% vs 3.9%, progression: 7.5% vs 0.6%, P < .001). In Kaplan-Meier analysis, the probability of disease progression was higher in anti-Tg-POS. In Cox proportional hazard analysis, the predictors of disease progression were size (P = .002) and ETE (P = .006).

CONCLUSIONS

Worse histological features are more frequent in patients with anti-Tg persistence during follow-up. Further additional RAI administration and/or surgeries do not affect anti-Tg elimination in most cases. Anti-Tg persistence correlates with structural persistence although tumour size and extrathyroidal extension are the main predictors of disease progression.

Influence Factors for Lymph Node Metastasis in Papillary Thyroid Carcinoma: Hashimoto's Thyroiditis Has a Weak Effect on Central or Lateral Lymph Node Metastasis

Purpose

To analyze the effect of Hashimoto’s thyroiditis (HT) concurrent with papillary thyroid cancer (PTC) on cervical lymph node metastasis (LNM).

Methods

Two thousand nine hundred twenty-six patients who underwent thyroidectomy and lymph node dissection between January 2015 and December 2018 were enrolled in this study. Patient demographics and clinicopathologic features were analyzed.

Results

Of the total enrolled patients, 598 (20.4%) had concurrent HT. There were 1482 PTC cases with N0, 1033 cases with N1a, and 411 cases with N1b. Patients with HT had lower frequency of extrathyroidal extension (ETE), lymphatic vascular (LV) invasion, high pathological T stage (III+IV) and central LNM rate. Stratifying central LNM by non-ETE or without intrathyroidal spreading, it was further found that central LNM rate in patients with HT was lower than that of patients without HT. However, there was no significant difference in the central LNM rate in patients with PTC stratified by ETE or intrathyroidal spreading. HT with PTC played a weak protective role in N1a, reducing the risk of N1a by 16.4%. Conversely, HT is a risk factor for N1b, increasing the risk by 1.336 times compared to patients without HT. TgAb is an independent risk factor for N1b, which appears related to the promotion of N1b by HT.

Conclusion

In PTC, HT has a protective effect on central LNM and a risk effect on lateral LNM, although the difference was not significant. This weak protective effect on N1a is more obvious in PTC with less aggressive clinicopathologic characteristics. The risk effect of HT on N1b may be associated with TgAb.

Management of Sonographically Suspicious Thyroid Nodules 1 cm or Smaller and Candidacy for Active Surveillance: Experience of a Tertiary Center in China

OBJECTIVE

Our objective was to investigate the management of patients with asymptomatic suspicious thyroid nodules ≤1 cm.

METHODS

We retrospectively reviewed medical records of patients with sonographically suspicious thyroid nodules ≤1 cm and without distant metastases, suspicious lymph node metastasis (LNM), or extrathyroidal extension (ETE).

RESULTS

Of the 386 enrolled patients, 174 (45.1%) had immediate surgery (IS), while 212 (54.9%) underwent active surveillance (AS). In the IS group, 166 (95.4%) patients were confirmed as having papillary thyroid microcarcinoma. LNM and ETE were observed in 24.7% and 2.4% cases, respectively. In the AS group, nodule size increased by ≥3 mm in 11 (5.2%) patients and 39 (18.4%) had a >50% increase in nodule volume after a median follow-up of 12 months. Nodules with smaller volume at diagnosis were more likely to increase in volume later. Newly suspicious LNM was detected in 23 (10.8%) patients. Delayed surgery (DS) was performed in 101 patients, with 27 showing disease progression. ETE and LNM were detected in 3% and 36%, respectively, of patients with papillary thyroid microcarcinoma. Compared with IS, tumors in the DS group more frequently showed lateral LNM and capsular invasion (P < .05). No patient had recurrence or died of thyroid cancer during postoperative follow-up (median 26 [4-60] months).

CONCLUSIONS

IS or DS of patients with asymptomatic suspicious thyroid nodules ≤1 cm was relatively high in China. The inertia of low-risk nodules and the effectiveness of DS for those that progressed make AS a feasible strategy.

Positive Thyroid Peroxidase Antibody and Thyroglobulin Antibody are Associated With Better Clinicopathologic Features of Papillary Thyroid Cancer

OBJECTIVE

To compare the thyroid autoantibody status of patients with papillary thyroid cancer (PTC) and benign nodular goiter as well as possible associations between thyroid autoantibodies and clinicopathologic features of PTC.

METHODS

A total of 3934 participants who underwent thyroidectomy were enrolled in this retrospective study. Patients were divided into PTC and benign nodule groups according to pathological diagnosis. Based on the preoperative serum antibody results, PTC patients were divided into thyroid peroxidase antibody (TPOAb)-positive, thyroglobulin antibody (TgAb)-positive, dual TPOAb- and TgAb-positive, or antibody-negative groups.

RESULTS

Of the 3934 enrolled patients, 2926 (74.4%) were diagnosed with PTC. Multivariate regression analyses suggested that high thyroid-stimulating hormone levels (adjusted odds ratio [OR] = 1.732, 95% CI [1.485-2.021], P < .001), positive TgAb (adjusted OR = 1.768, 95% CI [1.436-2.178], P < .001), and positive TPOAb (adjusted OR = 1.452, 95% CI [1.148-1.836], P = .002) were independent risk factors for predicting malignancy of thyroid nodules. Multinomial multiple logistic regression analyses indicated that positive TPOAb alone was an independent predictor of less central lymph node metastasis in PTC patients (adjusted OR = 0.643, 95% CI [0.448-0.923], P = .017), whereas positive TgAb alone was significantly associated with less extrathyroidal extension (adjusted OR = 0.778, 95% CI [0.622-0.974], P = .028). PTC patients with dual-positive TPOAb and TgAb displayed a decreased incidence of extrathyroidal extension (adjusted OR = 0.767, 95% CI [0.623-0.944], P = .012) and central lymph node metastasis (adjusted OR = 0.784, 95% CI [0.624-0.986], P = .037).

CONCLUSION

Although preoperative positive TPOAb and TgAb are independent predictive markers for PTC, they are also associated with better clinicopathologic features of PTC.

Investigating Antithyroglobulin Antibody As a Prognostic Marker for Differentiated Thyroid Cancer: A Meta-Analysis and Systematic Review

Background: Serum thyroglobulin (Tg) is used in the follow-up of patients with differentiated thyroid cancers (DTC), but the presence of antithyroglobulin antibodies (TgAbs) makes Tg measurements unreliable. TgAb decline after total thyroidectomy and persistent/increasing levels may indicate cancer persistence/recurrence. Hence, we aimed to determine whether TgAb might be a reliable prognostic marker for DTC. Methods: We conducted a meta-analysis and systematic review. A comprehensive literature search was performed to identify studies of patients with DTC with known TgAb status and prognostic outcomes in five databases (Medline, Embase, PubMed, Google Scholar, and Scopus). We used a random-effects model to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs) for TgAb status and its association with DTC prognosis. Results: After analysis of 34 studies, we found that TgAb+ patients have a higher risk of lymph node metastasis (OR = 1.18 [CI 1.47-2.25]) and cancer persistence/recurrence (OR = 2.78 [CI 1.55-4.98]) than TgAb- patients. However, no significant differences in mean/median tumor size, risk of extrathyroidal extension, tumor multifocality, and cancer mortality were found between the two groups. In a comparison of TgAb trends, patients with persistent/increasing TgAb levels were found to have a higher risk of cancer persistence/recurrence (OR = 9.90 [CI 4.36-22.50]) and cancer mortality (OR = 15.18 [CI 2.99-77]) than patients with decreasing TgAb levels. Conclusions: TgAb positivity and persistent/increasing trends were associated with compromised DTC prognosis. These results suggest that TgAb may be used as a prognostic marker in the follow-up of patients with DTC.

KCNN4 is a diagnostic and prognostic biomarker that promotes papillary thyroid cancer progression

The incidence of thyroid cancer remains high worldwide, and papillary thyroid cancer (PTC) is the most common type. Potassium Calcium-Activated Channel Subfamily N Member 4 (KCNN4) has been reported as an oncogene in various cancers. We examined expression of KCNN4 in public databases and discovered that it is upregulated in PTC. We verified this finding using our own validated cohort and RNA sequencing data. We also found that KCNN4 is a diagnostic and prognostic biomarker that is associated with disease-free survival, immune infiltration, and several other clinicopathological features of PTC. Gene Set Enrichment Analysis indicated that apoptotic and epithelial-mesenchymal transition gene sets are both upregulated in PTC patients with higher KCNN4 levels. In PTC cell lines, silencing KCNN4 inhibited cell proliferation, migration and invasion. Moreover, quantitative real-time PCR and Western blotting indicated that silencing KCNN4 increased expression of apoptotic genes in PTC cells and reduced the expression of genes involved in their epithelial-mesenchymal transition. These results suggest that KCNN4 promotes PTC progression by inducing epithelial-mesenchymal transition and suppressing apoptosis, which suggests KCNN4 may be a useful diagnostic and prognostic biomarker of PTC.

The value of preoperative antithyroidperoxidase antibody as a novel predictor of recurrence in papillary thyroid carcinoma

The link between chronic lymphocytic thyroiditis (CLT) and papillary thyroid carcinoma (PTC) is widely recognized. Considering the strong association between raised antithyroidperoxidase antibody (TPOAb) and CLT, we postulated that the preoperative TPOAb can predict the prognosis of PTC, particularly for recurrence. A total of 2,070 patients who underwent total thyroidectomy for classical type PTC with tumor size ≥1 cm and with available data on preoperative TPOAb and TgAb were enrolled to compare disease-free survival (DFS) according to the presence of preoperative TPOAb, TgAb, and coexistent CLT. Patients with positive preoperative TPOAb had a significantly better DFS compared to patients without positive preoperative TPOAb (hazard ratio (HR) 0.53; 95% confidence interval (CI) 0.30-0.94, p = 0.028) while no difference in DFS was found according to preoperative TgAb status. Positive preoperative TPOAb was an independent prognostic factor for structural persistent/recurrent disease after adjustment for major preoperative risk factors such as age, sex, and tumor size (HR 0.52, 95% CI 0.28-0.99, p = 0.048). Although the coexistence of CLT lowered the risk for structural persistence/recurrence in univariate analysis (HR 0.52, 95% CI 0.31-0.86, p = 0.012), it was not an independent favorable prognostic factor by multivariate analysis (HR 0.65, 95% CI 0.38-1.10, p = 0.106). However, when coexistent CLT was combined with positive preoperative TPOAb, it indicated an independent protective role in structural persistent/recurrent disease (HR 0.39, 95% CI 0.16-0.98, p = 0.045). Our study clearly showed that presence of preoperative TPOAb can be a novel prognostic factor in predicting structural persistence/recurrence of PTC.

Active Surveillance of Low-Risk Papillary Thyroid Microcarcinoma: A Multi-Center Cohort Study in Korea

BACKGROUND

Active surveillance has been introduced as a management option for low-risk papillary thyroid microcarcinoma (PTMC) due to its mostly indolent course.

METHODS

This was a multicenter study of 370 PTMC patients who underwent active surveillance more than one year. The changes in volume and maximum diameter between initial and last ultrasonography were evaluated to identify the natural course of PTMC during active surveillance.

RESULTS

Patients' age at diagnosis was 51 ± 12 years, and 110 (30%) patients were <45 years of age. The initial maximum diameter and volume of PTMCs were 5.9 ± 1.7 mm and 81.0 ± 77.7 mm³, respectively. During the median 32.5 months of follow-up, 86 (23.2%) patients were found to have an increase in tumor volume, and 13 (3.5%) patients showed an increase in the maximal diameter of the tumor. The cumulative incidence of volume increase gradually rose with time (6.9%, 17.3%, 28.2%, and 36.2% after two, three, four, and five years, respectively). The risk of volume increase in patients <45 years of age was twice as high as in older patients (p = 0.002). There was no significant difference in tumor size change according to sex, levothyroxine treatment, or presence of Hashimoto's thyroiditis. During the period, 58 (15.7%) patients underwent delayed thyroid surgery due to anxiety (37.9%), tumor size increase (32.8%), or appearance of cervical lymph node metastasis (8.6%). Lymph node metastasis was found in 29.3% of patients on pathological examination.

CONCLUSIONS

A significant number of PTMCs grow during active surveillance, and tumor volume change is a more sensitive means of evaluating tumor growth. Active surveillance can be carefully applied for selected patients. Although it is not contraindicated, it should be applied more cautiously for younger patients.

Clinical implications of anti-thyroglobulin antibody measurement before surgery in thyroid cancer

Thyroglobulin antibody (TgAb) is a class G immunoglobulin and a conventional marker for thyroid autoimmunity. From a clinical perspective, TgAb is less useful than thyroid peroxidase antibodies for predicting thyroid dysfunction. However, TgAb is found more frequently in differentiated thyroid cancer (DTC) and can interfere with thyroglobulin (Tg) measurements, which are used to monitor the recurrence or persistence of DTC. Recent studies suggested a small but consistent role for preoperative TgAb in predicting DTC in thyroid nodules, and in reflecting adverse tumor characteristics or prognosis, including lymph node metastasis, but this is still controversial. Postoperative TgAb can serve as a biomarker for remnant thyroid tissue, so follow-up measures of TgAb are useful for predicting cancer recurrence in DTC patients. Since high serum TgAb levels may also affect the fine needle aspiration washout Tg levels from suspicious lymph nodes of DTC patients, it is important to use caution when interpreting the washout Tg levels in patients who are positive for TgAb.

High Urinary Iodine, Thyroid Autoantibodies, and Thyroid-Stimulating Hormone for Papillary Thyroid Cancer Risk

Thyroid nodules have become a common clinical problem, and the clinical importance of thyroid nodules lies in the determination of thyroid cancer. This study aims to evaluate the risk factors for papillary thyroid cancer (PTC) with regard to urinary iodine concentration (UIC), thyroid-stimulating hormone (TSH), thyroid peroxidase antibody (TPOAb), and thyroglobulin antibody (TGAb) in comparison to thyroid nodular goiter (NG). Among the 2041 patients, 43.8% of which showed more than adequate (UIC 200-299 μg/L) and excessive iodine (UIC ≥ 300.0 μg/L) status. Compared with adequate iodine intake, iodine deficiency (UIC < 100 μg/L) was inversely associated with multifocality (OR 0.59, P = 0.040), while more than adequate iodine intake was independently associated with an increased risk of larger tumor size (OR 1.33, P = 0.002) in female PTC patients but not in males. No significant difference in UIC was observed between patients with PTC and NG, suggesting that high iodine intake may be related with the growth of PTC, but not with its oncogenesis. Besides, positive for TPOAb and TGAb were individually associated with papillary thyroid microcarcinoma (PTMC) risk (OR 2.05 and 1.71, respectively, both P < 0.05) in female patients with tumor foci < 1 cm but not in males. Furthermore, younger age (< 46 years), TGAb positivity and small thyroid nodules in both sexes, higher TSH, TPOAb positivity, and multifocality in females could all predict PTC risk (all P < 0.05). These results might have clinical significance for managing patients with thyroid nodules and those with thyroidectomy.