1
|
Xu D, Lai Y, Liu H, Li H, Feng N, Liu Y, Gong C, Zhang Y, Zhou J, Shen Y. A diagnostic model based on DNA methylation haplotype block characteristics for identifying papillary thyroid carcinoma from thyroid adenoma. Transl Res 2024; 264:76-84. [PMID: 37863284 DOI: 10.1016/j.trsl.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/28/2023] [Accepted: 10/16/2023] [Indexed: 10/22/2023]
Abstract
Papillary thyroid carcinoma (PTC) is the most prevalent form of thyroid cancer. Methylation of some genes plays a crucial role in the tendency to malignancy as well as poor prognosis of thyroid cancer, suggesting that methylation features can serve as complementary markers for molecular diagnosis. In this study, we aimed to develop and validate a diagnostic model for PTC based on DNA methylation markers. A total of 142 thyroid nodule tissue samples containing 84 cases of PTC and 58 cases of thyroid adenoma (TA) were collected for reduced representation bisulfite sequencing (RRBS) and subsequent analysis. The diagnostic model was constructed by the logistic regression (LR) method followed by 5-cross validation and based on 94 tissue methylation haplotype block (MHB) markers. The model achieved an area under the receiver operating characteristic curve (AUROC) of 0.974 (95% CI, 0.964-0.981) on 108 training samples and 0.917 (95% CI, 0.864-0.973) on 27 independent testing samples. The diagnostic model scores showed significantly high in males (P = 0.0016), age ≤ 45 years (P = 0.026), high body mass index (BMI) (P = 0.040), lymph node metastasis (P = 0.00052) and larger nodules (P = 0.0017) in the PTC group, and the risk score of this diagnostic model showed significantly high in recurrent PTC group (P = 0.0005). These results suggest that the diagnostic model can be expected to be a powerful tool for PTC diagnosis and there are more potential clinical applications of methylation markers to be excavated.
Collapse
Affiliation(s)
- Dong Xu
- Department of Head and Neck Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai, 200127, China
| | - Yi Lai
- Department of Head and Neck Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai, 200127, China; Department of Traditional Chinese Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai, 200127, China
| | - Hongmei Liu
- Singlera Genomics (Shanghai) Ltd., 8th Floor, Building 1, Lane 500, Furonghua Road, Pudong, Shanghai 201328, China
| | - He Li
- Department of Traditional Chinese Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai, 200127, China
| | - Ningning Feng
- Singlera Genomics (Shanghai) Ltd., 8th Floor, Building 1, Lane 500, Furonghua Road, Pudong, Shanghai 201328, China
| | - Yiying Liu
- Singlera Genomics (Shanghai) Ltd., 8th Floor, Building 1, Lane 500, Furonghua Road, Pudong, Shanghai 201328, China
| | - Chengxiang Gong
- Singlera Genomics (Shanghai) Ltd., 8th Floor, Building 1, Lane 500, Furonghua Road, Pudong, Shanghai 201328, China
| | - Yunzhi Zhang
- Singlera Genomics (Shanghai) Ltd., 8th Floor, Building 1, Lane 500, Furonghua Road, Pudong, Shanghai 201328, China
| | - Jiaqing Zhou
- Department of Head and Neck Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai, 200127, China.
| | - Yuling Shen
- Department of Head and Neck Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai, 200127, China.
| |
Collapse
|
2
|
Impact of moderate-to-severe obstructive sleep apnea on aggressive clinicopathological features of papillary thyroid carcinoma. Sleep Med 2022; 96:99-104. [DOI: 10.1016/j.sleep.2022.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 03/05/2022] [Accepted: 04/18/2022] [Indexed: 12/31/2022]
|
3
|
Cao J, Zhu X, Sun Y, Li X, Yun C, Zhang W. Potential Impact of Body Mass Index on the Clinical Outcome of Papillary Thyroid Cancer After High-Dose Radioactive Iodine Therapy. Front Endocrinol (Lausanne) 2022; 13:870530. [PMID: 35721759 PMCID: PMC9205627 DOI: 10.3389/fendo.2022.870530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
CONTEXT Obesity has been reported as a potential risk factor for the aggressiveness of papillary thyroid cancer (PTC), but the data gathered so far are conflicting. OBJECTIVE The aim of our study was to evaluate the relationship between body mass index (BMI) and aggressiveness of PTC at the diagnosis and clinical outcome. METHODS A total of 337 patients who underwent radioactive iodine (RAI) therapy between March 2017 and May 2020 were recruited. Patients were divided into four groups: underweight (BMI<18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), and obese (BMI≥ 30 kg/m2). Treatment and follow-up were defined according to criteria used in the 2015 ATA guidelines. RESULTS This study included 337 patients with PTC (71.5% women, median age 45.21 ± 13.04 years). The mean BMI was 24.2 ± 3.1 kg/m2. Obese groups had a higher age than the other groups (P = 0.001). Moreover, obese patients had larger tumor sizes and higher T stage, compared to overweight, normal weight, and underweight patients (P = 0.007). After a median follow-up of 32 months, 279 patients (82.7%) had achieved an excellent response (ER) to therapy. The overall ER rates were compared between groups, and they did not differ significantly. CONCLUSIONS We demonstrated that BMI may have an additive effect on the aggressiveness of PTC, but did not have an effect on the response to therapy after high-dose RAI therapy.
Collapse
|
4
|
Li C, Dionigi G, Liang N, Guan H, Sun H. The Relationship Between Body Mass Index and Different Regional Patterns of Lymph Node Involvement in Papillary Thyroid Cancers. Front Oncol 2021; 11:767245. [PMID: 35004287 PMCID: PMC8727595 DOI: 10.3389/fonc.2021.767245] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/03/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Lymph node (LN) metastasis is the first site of metastasis of papillary thyroid cancer (PTC). LN status influences clinical management and the prognosis of patients. We explored the relationship between patient obesity and regional patterns of LN involvement in PTC. Materials and Methods This study retrospectively analyzed the data from 12,772 PTC patients. The rate of LN metastasis, number of LN metastasis, maximum diameter of positive LN, number of dissected LN, and LN ratios (LNR) were compared between normal-weight and obese patients. Statistical methods have been adjusted for the confounders in hypothesis testing. Results Overweight and obesity were independent risk factor for metastatic LNs (OR1 = 1.125, 95% CI 1.042-1.214, P1 = 0.003; OR2 = 1.554, 95% CI 1.339-1.802, P2<0.001). Obesity was an independent risk factor for the number of metastatic CLNs (OR=1.159, 95% CI 0.975-1.377, P=0.045), however not for number of metastatic lateral LNs (P=0.907). Furthermore, obesity was not an independent risk factor for number of CLNs when dissected more than five (P=0.653), still an independent risk factors for number of metastatic lateral LNs when more than six (OR=1.185, 95% CI 1.010-1.391, P=0.037). As for LNR, obesity was an independent risk factor for the central LNR when more than 0.12 (OR adjusted 1 = 1.099, 95% CI 1.011-1.194, P1 = 0.027; OR adjusted 2 = 1.177, 95% CI 1.003-1.381, P2 = 0.045), for the lateral LNR more than 0.05 (P2 = 0.283). Conclusions Obesity was associated with poor prognoses with PTC respecting LNs. Surgeons should be extreme caution when performing central neck dissection in obese patients.
Collapse
Affiliation(s)
- Changlin Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun City, China
| | - Gianlorenzo Dionigi
- Division of Surgery, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Nan Liang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun City, China
| | - Haixia Guan
- Department of Endocrinology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- *Correspondence: Hui Sun, ; Haixia Guan,
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun City, China
- *Correspondence: Hui Sun, ; Haixia Guan,
| |
Collapse
|
5
|
Li C, Guan H, He Q, Zhao Y, Liang N, Zhang J, Dionigi G, Sun H. The relationship between lipotoxicity and risk of extrathyroidal extension in papillary thyroid microcarcinoma. Endocrine 2021; 74:646-657. [PMID: 34189681 DOI: 10.1007/s12020-021-02809-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/20/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To explore the relationship between triglyceride (TG) levels and aggressive pathological characteristics in papillary thyroid microcarcinoma (PTMC) patients, especially the relationship between TG, BMI, age, and extrathyroidal extension (ETE). METHODS A retrospective analysis of 9663 patients with PTMC in a single center from 2010 to 2017 was included in this study. Binary logistic regression was used to analyze the relationship between serum TG and aggressive pathological characteristics of PTMC in different genders. Further analyzing the risk of high TG in different ages and BMI groups. RESULTS Even after adjustment for confounding factors, high TG is still a risk factor for ETE in women with PTMC, but not a risk factor for men. Compared with the group with lower than 0.90 mmol/L, when the TG level is higher than 1.93 mmol/L, the risk of ETE in women increased by about 1.35-fold. The remaining two variables (BMI, age) as risk factors for ETE are analyzed. In the normal BMI group, high TG is still a risk factor for ETE. The risk of ETE in women more than 55 years old is significantly increased by 1.96-fold (1.34-fold in less than 55 years). CONCLUSION High TG in women is positively correlated with the risk of ETE in PTMC. PTMC with high TG in elderly women (more than 55 years) has a higher risk of ETE. TG is a potential serological index for predicting the risk of ETE in women with normal BMI.
Collapse
Affiliation(s)
- Changlin Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun, Jilin Province, China
| | - Haixia Guan
- Department of Endocrinology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, Guangdong, P. R. China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Qiao He
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Yishen Zhao
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun, Jilin Province, China
| | - Nan Liang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun, Jilin Province, China
| | - Jiao Zhang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun, Jilin Province, China
| | - Gianlorenzo Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi,", University Hospital G. Martino, University of Messina, Via C. Valeria 1, Messina, Italy.
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun, Jilin Province, China.
| |
Collapse
|
6
|
Yin Y, Xu X, Shen L, Zhao W, Diao H, Li C. Influencing Factors and Cumulative Risk Analysis of Cervical Lymph Node Metastasis of Papillary Thyroid Microcarcinoma. Front Oncol 2021; 11:644645. [PMID: 34660255 PMCID: PMC8514816 DOI: 10.3389/fonc.2021.644645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 09/13/2021] [Indexed: 12/20/2022] Open
Abstract
Objective To explore the influencing factors and cumulative risk of lymph node metastasis (LNM) in papillary thyroid microcarcinoma (PTMC) patients. Methods 607 patients confirmed PTMC pathologically after thyroidectomy were enrolled in this retrospective study. The rate of LNM was calculated. Different clinicopathological characteristics were compared in PTMC patients with and without LNM and in different subgroups of LNM, respectively. Correlation between clinicopathological characteristics and LNM was analyzed and the cumulative risk of LNM according to different clinicopathological characteristics was calculated. Results (1) There were 228 cases (37.56%) of PTMC combined with LNM. Compared with the non-lymph node metastasis group, the proportion of age <55 years, male, multiple foci, bilateral foci, diameter>0.5cm, extracapsular invasion, HT and intermediate-to-high risk stratification for recurrence of the LNM group was significantly increased (all p<0.05);(2) Multivariate logistic regression analysis showed that age <55years, male, multiple foci, diameter>0.5cm,HT were independently positively correlated with LNM (all p <0.05); (3) Subgroup analysis showed that women aged <55 years combined with HT and aged≥55 years combined with BMI≥25 kg/m2 were independently positively associated with LNM; (4) With the increase of the tumor diameter, the cumulative risk of LNM in group of age <55 years, males, and multiple foci increased gradually, and was higher than those of age≥55 years, females and single foci, respectively. (5) Among the 228 cases of LNM, the proportion of lymph nodes (LN) >5 and the positive rate of LN were both higher in male group than that in the female group. The proportion of multiple foci and HT in LLNM group was higher than that in CLNM group (all P<0.05). Conclusion Age <55 years, males, multiple foci, diameter >0.5cm and HT were independent risk factors of LNM; HT was an independent risk factor for LNM in female <55 years old, and BMI≥25 kg/m2 was an independent risk factor for LNM in female ≥55 years old; The increase of tumor diameter in age <55 years, males, multiple foci, and bilateral foci increased the cumulative risk of LNM, respectively; The number of LNM and the positive rate of LNM were both higher in male, and patients with multiple foci or HT were more likely to develop into LLNM.
Collapse
Affiliation(s)
- Yirong Yin
- Department of Endocrine and Metabolic Diseases, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiang Xu
- International Medical Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Liyan Shen
- Department of Endocrine and Metabolic Diseases, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Wenjuan Zhao
- Department of Endocrine and Metabolic Diseases, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hongcui Diao
- Department of Endocrine and Metabolic Diseases, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chengqian Li
- Department of Endocrine and Metabolic Diseases, The Affiliated Hospital of Qingdao University, Qingdao, China
| |
Collapse
|
7
|
Cui N, Sun Q, Chen L. A meta-analysis of the influence of body mass index on the clinicopathologic progression of papillary thyroid carcinoma. Medicine (Baltimore) 2021; 100:e26882. [PMID: 34397906 PMCID: PMC8360437 DOI: 10.1097/md.0000000000026882] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 07/22/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Papillary thyroid carcinoma (PTC) incidence has been increasing worldwide. Obesity, that is, having a high body mass index, is associated with the incidence of several cancers including colon, breast, esophageal, and kidney cancer. However, the association between obesity and the clinical features of PTC is still unknown. This study aimed to determine the impact of obesity on the clinical features of PTC. METHOD A database search was conducted for articles published up to 2020 on obesity and clinical features of PTC. Data were extracted from articles that met the meta-analysis inclusion criteria. RESULTS A total of 11 retrospective cohorts and 11,729 patients were included. Obesity was associated with the following variables in PTC patients: older age (difference in means = 1.95, 95% confidence interval [CI] 0.16-3.74, P = .03), male sex (odds ratio [OR] = 3.13, 95%CI 2.24-4.38, P < .00001), tumor size ≥1 cm (OR = 1.34, 95%CI 1.11-1.61, P < .002), multifocality (OR = 1.54, 95%CI 1.27-1.88, P < .0001), extrathyroidal extension (OR = 1.78, 95%CI 1.22-2.59, P = .003) and advanced tumor, node, metastasis stage (OR = 1.68, 95%CI 1.44-1.96, P < .00001). Preoperative serum thyroid-stimulating hormone level (difference in means = 0.09, 95%CI 0.35-0.52, P = .70), Vascular invasion (OR = 0.84, 95%CI 0.56-1.26, P = .41), lymph node metastasis (OR = 1.07, 95%CI 0.87-1.32, P = .50), distant metastasis (OR = 1.14, 95%CI 0.64-2.04, P = .66), and recurrence (OR = 1.45, 95%CI 0.97-2.15, P = .07) were not associated with obesity. CONCLUSION Obesity was associated with several poor clinicopathologic prognostic features: older age, male gender, tumor size ≥1 cm, extrathyroidal extension, multifocality, and advanced tumor/node/metastasis stage. However, thyroid-stimulating hormone level, vascular invasion, lymph node metastasis, distant metastasis, and recurrence were not associated with obesity in PTC.
Collapse
Affiliation(s)
- Ningning Cui
- Department of Trauma Center and Burns, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Qian Sun
- Department of Anorectal, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Li Chen
- Department of Geriatric ward, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| |
Collapse
|
8
|
Association of BMI with Clinicopathological Features of Papillary Thyroid Cancer: A Systematic Review and Meta-Analysis. World J Surg 2021; 45:2805-2815. [PMID: 34136926 DOI: 10.1007/s00268-021-06193-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Papillary thyroid cancer (PTC) is the most common subtype of thyroid cancer. The incidence of PTC is rising in tandem with an obesity epidemic. Associations have been demonstrated between increased body mass index (BMI) and worse oncological outcomes in a number of malignancies. However, research on this topic in PTC to date has been inconsistent, often due to limited data. This study aimed to measure the association between BMI and potentially adverse clinicopathological features of PTC. METHODS A meta-analysis of studies reporting outcomes after surgical treatment of PTC was performed. PubMed, Embase and the Cochrane Library were searched systematically to identify studies which provided data on BMI and clinicopathologic features of PTC. Relevant data were extracted and synthesis performed using adjusted odds ratios where available and crude values when not. Data were analysed by inverse variance using random and fixed effects models. RESULTS Data on 35,237 patients from 15 studies met the criteria for inclusion. Obesity was associated with larger tumour size (MD = 0.17 cm [0.05, 0.29]), increased rates of multifocality (OR = 1.41 [1.16, 1.70]), extrathyroidal extension (OR = 1.70 [1.39, 2.07]) and nodal spread (OR = 1.18 [1.07, 1.30]). Associations were more pronounced as BMI increased. There was no association between BMI and bilaterality, vascular invasion or metastatic spread. CONCLUSION Increased BMI is significantly associated with multiple potentially adverse features of PTC. The effect on long-term oncological outcomes requires further evaluation.
Collapse
|
9
|
Zhang X, Jiang L, Liu L, Liu B. Influence of body mass index at diagnosis on outcome of thyroid cancer in children and adolescents. Surgery 2021; 169:1373-1378. [PMID: 33612290 DOI: 10.1016/j.surg.2020.12.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/20/2020] [Accepted: 12/30/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE To systemically examine the relationship between body mass index, the extent of thyroid cancer and metastatic burden at diagnosis, and overall outcomes in children and adolescents with thyroid cancer. METHODS A retrospective series of children and adolescents with differentiated thyroid cancer who underwent total thyroidectomy and 131I therapy was analyzed. Body mass index (BMI) at the time of surgery was assessed. The Chinese age- and sex-specific BMI percentile criteria for screening overweight and obesity in children and adolescents were used to define the overweight and obesity among patients. The relationship between BMI and clinicopathological features and clinical outcomes of the disease was evaluated by logistic regression modeling, incorporating the eighth edition of the American Joint Committee on Cancer TNM staging system and the 2015 American Thyroid Association guidelines. RESULTS This study included 181 children and adolescents with differentiated thyroid cancer (82.9% females, median age 17 years). The mean BMI was 21.0 ± 3.9 kg/m2; 77.9% of the patients (N = 141) were normal weight, 13.2% (N = 24) were overweight, and 8.8% (N = 16) were obese. No positive associations were noted between BMI and T, N, or M stage on logistic regression analyses. The absence of an association was also demonstrated on analysis by BMI categories. After a median follow-up of 51 months, 114 children and adolescents (63.0%) had achieved excellent response to therapy. No associations were noted for persistent/recurrent disease among BMI groups. CONCLUSION Our study highlights the absence of increased disease burden at the time of thyroid cancer diagnosis in pediatric patients with high BMI along with the same prognosis compared with normal-weight pediatric patients.
Collapse
Affiliation(s)
- Xinyue Zhang
- Department of Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lisha Jiang
- Department of Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lina Liu
- Department of Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Liu
- Department of Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, China.
| |
Collapse
|
10
|
Economides A, Giannakou K, Mamais I, Economides PA, Papageorgis P. Association Between Aggressive Clinicopathologic Features of Papillary Thyroid Carcinoma and Body Mass Index: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2021; 12:692879. [PMID: 34276564 PMCID: PMC8279812 DOI: 10.3389/fendo.2021.692879] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/07/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The association between adiposity and papillary thyroid carcinoma (PTC) has been reported in several studies, but its association with aggressive clinicopathologic features is not well-recognized. Our aim is to systematically review the literature to identify whether adiposity, expressed through Body Mass Index (BMI), is related to aggressive clinicopathologic features such as tumor-node-metastasis (TNM) stage, extrathyroidal extension (ETE), lymph node (LN) metastasis and multifocality in patients with PTC. METHODS A systematic search for articles was performed using the PubMed, EBSCO, and Cochrane Library for all articles published in English until December 2020. Specific keywords such as "papillary thyroid carcinoma", "Body Mass Index", "clinicopathologic features" were used in the search strategy. Two independent reviewers screened all retrieved articles based on predefined inclusion and exclusion criteria. Meta-analysis was performed in the studies that reported crude and adjusted odds ratios (OR). The methodological quality was assessed using the Newcastle-Ottawa Scale. RESULTS A total of 11 retrospective cohort studies involving 26,196 participants included. Our findings showed that elevated BMI was significantly associated with ETE in both overweight (OR 1.26, 95% CI: 1.09-1.44) and obesity group (OR 1.45, 95% CI:1.26-1.64). Elevated BMI was also significantly associated with multifocality in overweight patients (OR 1.17, 95% CI:1.10-1.24) and obese patients (OR 1.45, 95% CI:1.29-1.62). Also, obesity was significantly associated with increased tumor size (OR 1.77, 95% CI:1.52-2.03) and with LN metastasis (OR 1.28, 95% CI: 1.12-1.44), whereas being overweight was significantly associated with advanced TNM stage (OR 1.55, 95% CI:1.27-1.83). CONCLUSION Our results provide strong evidence for the association between higher BMI and ETE, multifocality, and tumor size. Further studies with a larger number of participants are required to elucidate further the association of increased BMI with advanced TNM stage and LN metastasis.
Collapse
Affiliation(s)
- Aliki Economides
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
- Thyroid & Endocrinology Center, Nicosia, Cyprus
| | - Konstantinos Giannakou
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
| | - Ioannis Mamais
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
| | - Panayiotis A. Economides
- Thyroid & Endocrinology Center, Nicosia, Cyprus
- School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - Panagiotis Papageorgis
- Department of Life Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
- *Correspondence: Panagiotis Papageorgis,
| |
Collapse
|
11
|
Li CL, Dionigi G, Zhao YS, Liang N, Sun H. Influence of body mass index on the clinicopathological features of 13,995 papillary thyroid tumors. J Endocrinol Invest 2020; 43:1283-1299. [PMID: 32166701 DOI: 10.1007/s40618-020-01216-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/04/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE This retrospective study aimed to assess the association between obesity, gender, and specific clinicopathological features in patients with papillary thyroid cancer (PTC) and whether diagnostic ultrasonography (US) is adversely affected by obesity in these patients. MATERIALS AND METHODS This study retrospectively analyzed 13,995 adult patients with PTC from a single medical center in China. Data stratification was performed to assess the association of obesity with US features and aggressive clinicopathological features in different models according to the World Health Organization Body Mass Index (WHO-BMI) and Chinese BMI classification (CN-BMI). The odds ratio (OR) of malignant US features and aggressive clinicopathological features was calculated from binary logistic regression models. RESULTS The BMI, obesity ratio, malignant US features, and aggressive pathological characteristics of males were significantly higher than those of females. After adjusting for confounding factors, the association of obesity with malignant US features and aggressive pathological characteristics was found to be sex-dependent. Next, obesity (WHO-BMI) was found to have an "interfering effect" on the US assessment of PTC (OR = 0.754, 95% CI 0.609-0.932, P = 0.009) in women. Among both sexes, obesity (WHO-BMI) increased the risk of tumor size (ORmale = 1.539 and ORfemale = 1.521) and multifocality (ORmale = 1.659 and ORfemale = 1.449). However, obesity did not increase the risk of capsular invasion or tumor staging in males. The above results are consistent with the CN-BMI. In addition, age was found to have an "interfering effect" on the US evaluation of malignant nodules in both sexes. CONCLUSION The results of our study confirm that higher BMI is significantly associated with aggressive clinicopathological features of PTC. Gender differences were present with obesity ratios and aggressive clinicopathological features being significantly higher in men.
Collapse
Affiliation(s)
- C L Li
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun, Jilin, China
| | - G Dionigi
- Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Via C. Valeria 1, 98125, Messina, Italy
| | - Y S Zhao
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun, Jilin, China
| | - N Liang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun, Jilin, China
| | - H Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Engineering Laboratory of Thyroid Disease Prevention and Control, Changchun, Jilin, China.
| |
Collapse
|
12
|
Matrone A, Ceccarini G, Beghini M, Ferrari F, Gambale C, D'Aqui M, Piaggi P, Torregrossa L, Molinaro E, Basolo F, Vitti P, Santini F, Elisei R. Potential Impact of BMI on the Aggressiveness of Presentation and Clinical Outcome of Differentiated Thyroid Cancer. J Clin Endocrinol Metab 2020; 105:5687038. [PMID: 31875910 DOI: 10.1210/clinem/dgz312] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 12/23/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Obesity is a risk factor for several cancers, including differentiated thyroid cancer (DTC). Moreover, it has also been investigated as a potential risk factor for aggressiveness of DTC, but the data gathered so far are conflicting. The aim of our study was to evaluate the relationship between body mass index (BMI), aggressiveness of DTC at diagnosis, and clinical outcome. METHODS We evaluated 1058 consecutive DTC patients treated with total thyroidectomy and enrolled at the time of first radioactive iodine (131I) treatment. Patients were divided into 4 groups based on their BMI: underweight (< 18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), and obese (≥ 30 kg/m2). Histological aggressiveness of DTC at the time of diagnosis and clinical outcome according to 2015 American Thyroid Association (ATA) guidelines were evaluated. RESULTS No differences in histological features, ATA risk of recurrence, activity of 131I administered and prevalence of 131I avid metastatic disease after first131I treatment, have been demonstrated among the groups. Furthermore, at the end of follow up (median = 5.7 years), no differences were evident in the number of further treatments performed as well as in the clinical response. CONCLUSIONS In our study group of Caucasian subjects, we could not demonstrate any association between BMI and aggressiveness of DTC, neither at the time of diagnosis nor during follow-up. These data indicate that postsurgical assessment and therapeutic attitude for treatment and follow-up of DTC should be based on the class of risk applied to the general population, with no concern for BMI.
Collapse
Affiliation(s)
- Antonio Matrone
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| | - Giovanni Ceccarini
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| | - Marianna Beghini
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| | - Federica Ferrari
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| | - Carla Gambale
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| | - Mariaida D'Aqui
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| | - Paolo Piaggi
- Phoenix Epidemiology and Clinical Research Branch National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health-Phoenix, Arizona US
| | - Liborio Torregrossa
- Department of Surgical, Medical, Molecular Pathology and Critical Area, Anatomic Pathology Section, University of Pisa, Pisa, Italy
| | - Eleonora Molinaro
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| | - Fulvio Basolo
- Department of Surgical, Medical, Molecular Pathology and Critical Area, Anatomic Pathology Section, University of Pisa, Pisa, Italy
| | - Paolo Vitti
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| | - Ferruccio Santini
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| | - Rossella Elisei
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Pisa, Italy
| |
Collapse
|
13
|
Barrea L, Gallo M, Ruggeri RM, Giacinto PD, Sesti F, Prinzi N, Adinolfi V, Barucca V, Renzelli V, Muscogiuri G, Colao A, Baldelli R. Nutritional status and follicular-derived thyroid cancer: An update. Crit Rev Food Sci Nutr 2020; 61:25-59. [PMID: 31997660 DOI: 10.1080/10408398.2020.1714542] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The incidence of differentiated thyroid cancer has been increasing in the last decades all over the world. Such a steady growth cannot be entirely attributable to more intensive thyroid nodule screening and more sensitive diagnostic procedures. Several environmental factors have changed with sufficient rapidity in the same time frame and may represent credible candidates for this increase. They include modified iodine intake, lifestyle-associated risk factors, exposure to various toxic compounds, pollutants and xenobiotics, nutritional deficiencies, eating habits and comorbidities. Foremost, nutritional patterns have gained high interest as possible promoters and modifiable risk factors for thyroid cancer in recent years. The aim of this narrative review is to focus on the relationship between thyroid cancer and nutritional factors, dietary habits and obesity. Low iodine intake has been associated to increased risk of thyroid cancer, favoring the development of more aggressive histotypes. Moreover, correction of iodine deficiency can shift thyroid cancer subtypes toward less aggressive forms, without affecting the overall risk for cancer. Actually, evidence regarding the association between selenium and vitamin D deficiency and thyroid cancer is very limited, despite their well-known anti-cancer potentials, and the clinical usefulness of their supplementation is still uncertain in this setting. Albeit the relationship between single foods and thyroid cancer is difficult to examine, fish and iodine-rich foods, vegetables, and fruits might exert protective effects on thyroid cancer risk. Conversely, no clear association has been found for other foods to date. Lastly, a clear association between obesity and the risk of thyroid cancer, with more aggressive behavior, seems to emerge from most studies, likely involving variations in thyroid function and chronic inflammation mediated by cytokines, insulin, leptin and adiponectins. Although no definite association between dietary factors and thyroid cancer has been firmly established so far, some nutritional patterns, together with excessive weight, seem to play a relevant role in thyroid cancer carcinogenesis as well as in its severity and aggressiveness. These effects may play an additive role to the well-established one exerted by environmental carcinogens, such as pollutants and radiation exposure.
Collapse
Affiliation(s)
- Luigi Barrea
- Unit of Endocrinology, Dipartimento di Medicina Clinica e Chirurgia, Federico II University Medical School of Naples, Naples, Italy
| | - Marco Gallo
- Oncological Endocrinology Unit, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Rosaria Maddalena Ruggeri
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Paola Di Giacinto
- Endocrinology Unit, Department of Oncology and Medical Specialities, A.O. San Camillo-Forlanini, Rome, Italy
| | - Franz Sesti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Natalie Prinzi
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori Milano, ENETS Center of Excellence, Milan, Italy
| | - Valerio Adinolfi
- Endocrinology and Diabetology Unit, ASL Verbano Cusio Ossola, Domodossola, Italy
| | - Viola Barucca
- Digestive and Liver Disease Unit, S. Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Valerio Renzelli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Giovanna Muscogiuri
- Unit of Endocrinology, Dipartimento di Medicina Clinica e Chirurgia, Federico II University Medical School of Naples, Naples, Italy
| | - Annamaria Colao
- Unit of Endocrinology, Dipartimento di Medicina Clinica e Chirurgia, Federico II University Medical School of Naples, Naples, Italy
| | - Roberto Baldelli
- Endocrinology Unit, Department of Oncology and Medical Specialities, A.O. San Camillo-Forlanini, Rome, Italy
| | | |
Collapse
|
14
|
Grani G, Lamartina L, Montesano T, Ronga G, Maggisano V, Falcone R, Ramundo V, Giacomelli L, Durante C, Russo D, Maranghi M. Lack of association between obesity and aggressiveness of differentiated thyroid cancer. J Endocrinol Invest 2019; 42:85-90. [PMID: 29667113 DOI: 10.1007/s40618-018-0889-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 04/10/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Aim of this study was to evaluate the association between body mass index (BMI) and aggressive features of differentiated thyroid cancer (DTC) in a prospective cohort. METHODS Patients with DTC were prospectively enrolled at a tertiary referral center and grouped according to their BMI. Aggressive clinic-pathological features were analyzed following the American Thyroid Association Initial Risk Stratification System score. RESULTS The cohort was composed of 432 patients: 5 (1.2%) were underweight, 187 (43.3%) normal weight, 154 (35.6%) overweight, 68 (15.7%) grade 1 obese, 11 (2.5%) grade 2 obese and 7 (1.6%) grade 3 obese. No single feature of advanced thyroid cancer was more frequent in obese patients than in others. No significant correlation was found between BMI, primary tumor size (Spearman's ρ - 0.02; p = 0.71) and ATA Initial Risk Stratification System score (ρ 0.03; p = 0.49), after adjustment for age. According to the multivariate logistic regression analysis, male gender and pre-surgical diagnosis of cancer were significant predictors of cancer with high or intermediate-high recurrence risk according to the ATA system (OR 2.06 and 2.51, respectively), while older age at diagnosis was a protective factor (OR 0.98), and BMI was not a predictor. BMI was a predictor of microscopic extrathyroidal extension only (OR 1.06). CONCLUSIONS Obesity was not associated with aggressive features in this prospective, European cohort of patients with DTC.
Collapse
Affiliation(s)
- G Grani
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Viale del Policlinico, 155, 00161, Rome, RM, Italy
| | - L Lamartina
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Viale del Policlinico, 155, 00161, Rome, RM, Italy
| | - T Montesano
- Unità di Medicina Nucleare, Sapienza Università di Roma, Rome, Italy
| | - G Ronga
- Unità di Medicina Nucleare, Sapienza Università di Roma, Rome, Italy
| | - V Maggisano
- Dipartimento di Scienze della Salute, Università di Catanzaro "Magna Graecia", Catanzaro, Italy
| | - R Falcone
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Viale del Policlinico, 155, 00161, Rome, RM, Italy
| | - V Ramundo
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Viale del Policlinico, 155, 00161, Rome, RM, Italy
| | - L Giacomelli
- Dipartimento di Scienze Chirurgiche, Sapienza Università di Roma, Rome, Italy
| | - C Durante
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Viale del Policlinico, 155, 00161, Rome, RM, Italy.
| | - D Russo
- Dipartimento di Scienze della Salute, Università di Catanzaro "Magna Graecia", Catanzaro, Italy
| | - M Maranghi
- Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Viale del Policlinico, 155, 00161, Rome, RM, Italy
| |
Collapse
|
15
|
Gąsior-Perczak D, Pałyga I, Szymonek M, Kowalik A, Walczyk A, Kopczyński J, Lizis-Kolus K, Trybek T, Mikina E, Szyska-Skrobot D, Gadawska-Juszczyk K, Hurej S, Szczodry A, Słuszniak A, Słuszniak J, Mężyk R, Góźdź S, Kowalska A. The impact of BMI on clinical progress, response to treatment, and disease course in patients with differentiated thyroid cancer. PLoS One 2018; 13:e0204668. [PMID: 30273371 PMCID: PMC6166948 DOI: 10.1371/journal.pone.0204668] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 09/12/2018] [Indexed: 12/21/2022] Open
Abstract
Introduction Obesity is a serious health problem worldwide, particularly in developed countries. It is a risk factor for many diseases, including thyroid cancer. The relationship between obesity and prognostic factors of thyroid cancer is unclear. Aims We sought to ascertain the relationship between body mass index (BMI) and clinicopathological features increasing the risk of poor clinical course, treatment response, and clinical outcome in patients with differentiated thyroid cancer (DTC). Subjects & methods The study included 1181 patients with DTC (88% women and 12% men) treated at a single center from 2000 to 2016. BMI before surgery and aggressive clinicopathological features, according to the American Thyroid Initial Risk stratification system, were analyzed. The relationship between BMI and initial risk, treatment response, and final status of the disease was evaluated, incorporating the revised 2015 American Thyroid Association guidelines and the 8th edition of the American Joint Committee on Cancer/Tumor-Node-Metastasis (AJCC/TNM) staging system. Patients were stratified according to the World Health Organization classification of BMI. Statistical analysis was performed using univariate and multivariate logistic regression analysis. Results Median follow-up was 7.7 years (1–16 years). There were no significant associations between BMI and extrathyroidal extension (microscopic and gross), cervical lymph node metastasis, or distant metastasis in univariate and multivariate analyses. BMI did not affect initial risk, treatment response or disease outcome. Obesity was more prevalent in men (p = 0.035) and in patients ≥55 years old (p = 0.001). There was no statistically significant relationship between BMI and more advanced TNM stage in patients ≤55 years old (stage I vs. stage II) (p = 0.266) or in patients >55 years old (stage I–II vs. III–IV) (p = 0.877). Conclusions Obesity is not associated with more aggressive clinicopathological features of thyroid cancer. Obesity is not a risk factor for progression to more advanced stages of disease, nor is it a prognostic factor for poorer treatment response and clinical outcome.
Collapse
Affiliation(s)
| | - Iwona Pałyga
- Endocrinology Clinic, Holycross Cancer Centre, Kielce, Poland
| | - Monika Szymonek
- Endocrinology Clinic, Holycross Cancer Centre, Kielce, Poland
| | - Artur Kowalik
- Department of Molecular Diagnostics, Holycross Cancer Centre, Kielce, Poland
| | | | - Janusz Kopczyński
- Department of Surgical Pathology, Holycross Cancer Centre, Kielce, Poland
| | | | - Tomasz Trybek
- Endocrinology Clinic, Holycross Cancer Centre, Kielce, Poland
| | - Estera Mikina
- Endocrinology Clinic, Holycross Cancer Centre, Kielce, Poland
| | | | | | - Stefan Hurej
- Endocrinology Clinic, Holycross Cancer Centre, Kielce, Poland
| | - Artur Szczodry
- Endocrinology Clinic, Holycross Cancer Centre, Kielce, Poland
| | - Anna Słuszniak
- Laboratory of Tumor Markers, Holycross Cancer Centre, Kielce, Poland
| | - Janusz Słuszniak
- Department of Surgical Oncology, Holycross Cancer Centre, Kielce, Poland
| | - Ryszard Mężyk
- Cancer Epidemiology, Holycross Cancer Centre, Kielce, Poland
| | - Stanisław Góźdź
- Oncology Clinic, Holycross Cancer Centre, Kielce, Poland
- Faculty of Health Sciences, Jan Kochanowski University, Kielce, Poland
| | - Aldona Kowalska
- Endocrinology Clinic, Holycross Cancer Centre, Kielce, Poland
- Faculty of Health Sciences, Jan Kochanowski University, Kielce, Poland
| |
Collapse
|