Clinical outcome and prognosis of differentiated thyroid carcinoma with distant metastasis

OBJECTIVE

The objective of this study is to investigate the risk and prognostic factors for radioactive iodine (RAI)-refractory (RAIR) differentiated thyroid cancer (DTC) with distant metastasis.

METHODS

A total of 128 patients with distant metastasis-DTC who underwent iodine-131 radiotherapy were included in this cohort study. After exclusion, 75 DTC patients who were resistant to radioiodine therapy and 53 patients in whom the treatment was successful were finally included. Clinical data as well as BRAF V600E and telomerase reverse transcriptase (TERT) promoter mutations were compared between these two groups to predict the risk of RAIR. Patients with RAIR-distant metastasis-DTC were followed up to further investigate the risk factors for disease progression after the cancer became iodine-refractory.

RESULTS

Univariate analysis showed that TERTp mutation, age at diagnosis, mean maximum tumor diameter, lymph node metastasis, synchronous metastasis or heterochronous metastasis, mean cumulative dose of RAI, and preoperative Tg were statistically different between the RAIR and RAIE (radioiodine efficient) groups. Logistic regression analysis further found that the TERTp mutation may be risk factor for iodine refractory occurrence. During the follow-up of RAIR-distant metastasis-DTC patients, 41 patients developed disease progression, and 24 patients had good disease control.

CONCLUSION

We found that TERTp mutation is correlated with the poor curative effect of RAI therapy in distant metastasis-DTC. Once iodine refractory occurs, patients aged 55 years or older are more likely to develop disease progression.

Ultrasound‑guided Percutaneous Radiofrequency and Microwave Ablation for Cervical Lymph Node Metastasis from Papillary Thyroid Carcinoma: A Systematic Review and Meta‑analysis of Clinical Efficacy and Safety

AIM

To evaluate the efficacy and safety of radiofrequency ablation (RFA) and microwave ablation (MWA) for treating cervical lymph node metastasis (CLNM) from papillary thyroid carcinoma (PTC).

METHODS

Medline, EMBASE, Web of Science, and Cochrane Library were searched for studies on the efficacy and safety of thermal ablations for treating CLNM from PTC until July 2024. Among 544 papers, 11 articles were reviewed involving 233 patients and 432 CLNM cases. Random- or fixed-effects models assessed pooled proportions of volume reduction rate (VRR), complete disappearance, recurrence, major and minor or other complications. Similarly, pooled estimates of changes in the largest diameter, volume, and serum thyroglobulin (Tg) were evaluated post-ablation. Subgroup analysis by treatment modality was performed. Study heterogeneity was analyzed using Q statistics and inconsistency index (I2). The quality of the studies was assessed using the MINORS scale.

RESULTS

Eleven studies with 233 patients and 432 CLNM were analyzed. The pooled VRR was 95.24% [95% Confidence Interval (CI): 91.97- 98.51%], complete disappearance was 63.1%, and recurrence was 1.6%. Changes in largest diameter, volume, and serum Tg were 8.36 mm (95%CI: 6.46-10.26mm), 216.09mm³, and 6.12ng/ml, respectively. Major complications occurred at 3.0%, while minor complications were 25.6%. Significant heterogeneity was found for diameter, volume, VRR, Tg, and minor complications. Subgroup analysis showed that MWA had a higher VRR (97.18%) than RFA (93.84%) (P < 0.001).

CONCLUSION

Both RFA and MWA were effective and safe for treating CLNM from PTC. However, RFA showed lower volume reduction than MWA with significant heterogeneity in VRR.

DATA AVAILABILITY STATEMENT

The original contributions revealed in the study are included in the article/Supplemental Material. Further inquiries can be made to the corresponding author.

High-Grade Papillary Thyroid Carcinoma, Diffuse Sclerosing Subtype: A Series of 18 Cases Detailing the Pathologic Features, Potential for Misdiagnosis, and Aggressive Clinical Behavior

High-grade differentiated thyroid carcinoma is a novel classification defined by elevated mitotic count (MC) of ≥5/2 mm 2 and/or tumor necrosis. It may assume a phenotype of papillary thyroid carcinoma, diffuse sclerosing subtype (PTC-DS), and can be termed HGPTC-DS. A detailed clinicopathologic review was conducted on a large series of 18 cases of HGPTC-DS. A control group of 41 PTC-DSs with genomic data was also included. Histologically, HGPTC-DS showed typical features of PTC-DS and HG areas, often exhibiting solid architecture of uniform squamoid cells admixed with tumor necrosis, frequently the comedo type. All HGDTC-DSs had tumor necrosis. The MC was often low (median 1/2 mm 2 ). PTC nuclear features were retained and no nuclear pleomorphism was seen. HGPTC-DS was often subjected to misdiagnosis. Among the 7 external cases, the initial diagnosis was anaplastic carcinoma in 1 and PTC in 5. Compared with PTC-DS, HGPTC-DS was associated with positive resection margin, AJCC eighth edition pT3b and pT4a/4b disease, gross extrathyroidal extension (ETE), a higher number of regional lymph nodes metastasis, a larger size of nodal metastasis, decreased recurrence-free survival (RFS) and regional recurrence-free survival ( P <0.05). Among the 9 HGPTC-DSs sequenced, 5 harbored RET fusions, 2 had STRN::ALK fusion, and 1 had BRAF p.V600E mutation. In conclusion, HGPTC-DS is a rare high-grade carcinoma characterized by uniform squamoid area with comedo-type tumor necrosis, high pT stage, gross ETE, large volume nodal metastasis, poor RFS, and RRFS. Given its rarity, it may be subjected to misdiagnosis as PTC and anaplastic carcinoma.

Incremental yield of exome sequencing over standard prenatal testing in structurally normal fetuses: systematic review and meta-analysis

OBJECTIVE

To critically review the literature and synthesize evidence on the incremental yield of prenatal exome sequencing (PES) in fetuses with an apparently normal phenotype with a normal G-banded karyotype or chromosomal microarray (CMA).

METHODS

This systematic review and meta-analysis was conducted using a predetermined protocol and registered with PROSPERO (ID: CRD42024593349). We included observational cohort studies reporting on the incremental yield of PES in fetuses with an apparently normal phenotype and a previously normal G-banded karyotype/CMA. The risk of bias of the included studies was assessed using the Newcastle-Ottawa Scale. The pooled proportion of events was calculated using generalized linear mixed models, using the metaprop function in R version 2.15.1.

RESULTS

Four studies (1916 fetuses) were included in this systematic review and meta-analysis, of which 32 cases had a pathogenic or likely pathogenic variant. The pooled incremental yield of PES in fetuses with an apparently normal phenotype was 1.6% (95% CI, 1.0-2.6%); the majority of variants were de novo within genes associated with autosomal dominant inherited conditions (pooled incremental yield, 0.9% (95% CI, 0.5-1.7%)). Based on the expected severity of the associated disease, the pooled incremental yield was 0.5% (95% CI, 0.1-1.5%) for severe disease and 0.5% (95% CI, 0.2-1.5%) for moderate disease. There were insufficient data to conduct the predefined secondary analyses according to normality of phenotype at birth, variants of uncertain significance and expected age of disease onset.

CONCLUSION

Pooling data from four studies, we found that 1.6% of phenotypically normal fetuses with a normal G-banded karyotype or CMA may have a pathogenic or likely pathogenic variant identified on PES, most of which occur de novo. The likelihood of a variant being associated with severe disease in such fetuses is 0.5%. However, more research is needed regarding the development of a universal classification of disease severity and the utilization of this evidence in clinical practice. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Cytopathology of follicular and oncocytic follicular thyroid neoplasms: A Bethesda System perspective

The third edition of The Bethesda System for Reporting Thyroid Cytopathology includes category IV, follicular neoplasm (FN), which is used to classify fine-needle aspirates of thyroid nodules that may correspond to invasive follicular-derived neoplasia other than papillary thyroid carcinoma. This diagnosis is infrequently rendered, and may represent a challenge for pathologists. This review presents a practical approach to FN and its subtype oncocytic follicular neoplasm (OFN). First, minimal criteria for the diagnosis must be achieved, namely sufficient cellularity, architectural features consistent with neoplasia, and follicular cell or oncocytic cytomorphology. Second, select diagnoses that are common or important differential diagnoses for FN or OFN must be ruled out, via a combination of morphological findings and limited ancillary tests, when available. These include follicular nodular disease, parathyroid sampling, metastatic carcinoma, noninvasive follicular thyroid neoplasm with papillary-like nuclear features, medullary thyroid carcinoma, certain subtypes of papillary thyroid carcinoma, and lymphocytic thyroiditis. This approach should allow for a careful selection of cases where diagnostic thyroid lobectomy is an appropriate therapeutic modality.

Machine Learning Model for Risk Stratification of Papillary Thyroid Carcinoma Based on Radiopathomics

RATIONALE AND OBJECTIVES

This study aims to develop a radiopathomics model based on preoperative ultrasound and fine-needle aspiration cytology (FNAC) images to enable accurate, non-invasive preoperative risk stratification for patients with papillary thyroid carcinoma (PTC). The model seeks to enhance clinical decision-making by optimizing preoperative treatment strategies.

METHODS

A retrospective analysis was conducted on data from PTC patients who underwent thyroidectomy between October 2022 and May 2024 across six centers. Based on lymph node dissection outcomes, patients were categorized into high-risk and low-risk groups. Initially, a clinical predictive model was established based on the maximum diameter of the thyroid nodules. Radiomics features were extracted from preoperative two-dimensional ultrasound images, and pathomics features were extracted from 400x magnification H&E-stained tumor cell images from FNAC. The most predictive radiomics and pathomics features were identified through univariate analysis, Pearson correlation analysis and LASSO algorithm. The most valuable radiopathomics features were then selected by combining these predictive features. Finally, machine learning with the XGBoost algorithm was employed to construct radiomics, pathomics, and radiopathomics models. The performance of the models was evaluated using the area under the curve (AUC), decision curve analysis, accuracy, specificity, sensitivity, positive predictive value, and negative predictive value.

RESULTS

A total of 688 PTC patients were included, with 344 classified as intermediate/high-risk and 344 as low-risk. The multimodal radiopathomics model demonstrated excellent predictive performance, with AUCs of 0.886 (95% CI: 0.829-0.924) and 0.828 (95% CI: 0.751-0.879) in two external validation cohorts, significantly outperforming the clinical model (AUCs of 0.662 and 0.601), radiomics model (AUCs of 0.702 and 0.697), and pathomics model (AUCs of 0.741 and 0.712).

CONCLUSION

The radiopathomics model exhibits significant advantages in accurately predicting preoperative risk stratification in PTC patients. Its application is expected to reduce unnecessary lymph node dissection surgeries, optimize treatment strategies, and improve therapeutic outcomes.

Utility of prophylactic central dissection in papillary thyroid carcinoma with clinically apparent lymph node metastases isolated to the lateral neck

BACKGROUND

The utility of prophylactic ipsilateral central neck dissection in papillary thyroid carcinoma presenting with clinically/sonographically apparent lymph node metastases isolated to the lateral neck is unclear. The study assessed whether prophylactic central neck dissection was associated with improved recurrence-free survival.

METHODS

Single-center retrospective cohort study of patients undergoing thyroidectomy and lateral neck dissection for initial treatment of papillary thyroid carcinoma with clinically/sonographically apparent lymph node metastases isolated to the lateral neck from 2006 to 2022. We compared patients who underwent prophylactic central neck dissection with those who did not. Primary outcome was estimated recurrence-free probability, calculated using the Kaplan-Meier method and log-rank test.

RESULTS

The study cohort comprised 65 patients, 53 (81.5%) of whom received prophylactic central neck dissection in addition to total thyroidectomy and lateral neck dissection. Clinicopathologic features in the 2 groups were similar. Median follow-up was 50.2 months. The estimated 10-year recurrence-free probability was 92.5% for patients who received prophylactic central neck dissection and 66.7% for those who did not receive prophylactic central neck dissection (P = .013). Two of the 6 structural recurrences in the non-prophylactic central neck dissection group were found in the central neck and could potentially have been prevented by prophylactic central neck dissection. Patients who received prophylactic central neck dissection had a higher likelihood of achieving excellent response to therapy compared to patients who did not (59% vs 25%, P = .05). The rate of permanent hypoparathyroidism was comparable among patients who underwent prophylactic central neck dissection versus those who did not (P = .3), and no vocal cord palsy was observed in either group.

CONCLUSIONS

In patients initially presenting with clinically apparent nodal metastases of papillary thyroid carcinoma isolated to the lateral neck, prophylactic central neck dissection performed concurrently with total thyroidectomy and lateral neck dissection is associated with improved recurrence-free survival and greater likelihood of excellent response to therapy.

A Comparison of the Predictive Value of International Medullary Thyroid Carcinoma Grading System (IMTCGS) With That of Other Risk Factors in a Chinese Medullary Thyroid Carcinoma Cohort

BACKGROUND

The International Medullary Thyroid Carcinoma Grading System (IMTCGS) was recently introduced in medullary thyroid carcinoma (MTC). This study aimed to assess the predictive value of the IMTCGS for disease response and survival, and compare its predictive ability with that of other traditional risk factors in a Chinese MTC cohort.

METHODS

The data of 137 MTC patients undergoing initial surgery between January 2004 and June 2023 were included for analysis. Histologic features were reviewed by two pathologists. Kaplan-Meier survival analysis and Cox proportional hazard model were performed to analyse the association between risk factors (including IMTCGS high vs low grade) and progression-free survival (PFS) and disease-specific survival (DSS). ROC analysis and Delong's test were used to compare the predictive ability of IMTCGS with that of other risk factors.

RESULTS

Local recurrence, distant metastasis, and disease-specific death were observed in 14/134 (10.45%), 3/134 (2.24%), and 6/137 (4.38%) MTC patients, respectively. IMTCGS, TNM stage, postoperative calcitonin, postoperative CEA, and vascular invasion were associated with PFS in Kaplan-Meier survival analysis (all p < 0.05). Postoperative calcitonin was the only independent predictor for PFS in multivariate analysis (HR = 1.002, p = 0.002). ROC analysis and Delong's test showed that postoperative calcitonin had superior predictive value for structural recurrence than IMTCGS (AUC 0.90 vs. 0.64, p = 0.002). IMTCGS, TNM stage, and vascular invasion were associated with DSS in Kaplan-Meier survival analysis (both p < 0.05). In multivariate analysis, IMTCGS was the only independent predictor for DSS (HR = 11.23, p = 0.05). The AUC of IMTCGS was 0.81 (p = 0.01) for disease-specific death.

CONCLUSION

In this Chinese MTC cohort, IMTCGS was a powerful predictor of disease-specific death, while postoperative calcitonin was a powerful predictor of structural recurrence.

The Effect of a Surgeon Communication Strategy on Treatment Preference for Thyroid Cancer: A Randomized Trial

BackgroundCancer diagnosis causes emotional distress, which can influence patients' treatment choice. This study aimed to investigate the effect of increased emotionally supportive surgeon communication in a virtual setting on treatment preference for thyroid cancer.DesignThis randomized trial (NCT05132478), conducted from November 2021 to February 2023, enrolled adults with ≤4-cm thyroid nodules not requiring surgery. Participants were randomized 1:1 to watch a virtual clinic visit depicting a patient-surgeon treatment discussion for low-risk thyroid cancer. Control and intervention videos were identical except for added emotionally supportive communication in the intervention. The primary outcome was treatment preference for total thyroidectomy or lobectomy. Secondary outcomes were perceived physician empathy, physician trust, decisional confidence, and disease-specific knowledge. An intention-to-treat analysis was performed using conditional regression to account for stratification by sex. Qualitative content analysis evaluated participants' open-ended responses about treatment choice and surgeon communication.ResultsOf 208 eligible patients, 118 (56.7%) participated. Participants were 85.6% female and 88.1% White. Overall, 89.0% (n = 105) of participants preferred lobectomy, which was similar between the intervention and control groups (90.0% v. 87.9%, respectively, P = 0.72). Compared with control, participants who viewed the consultation with enhanced communication perceived higher levels of physician empathy (34.5 ± 5.8 v. 25.9 ± 9.1, P < 0.001) and reported increased trust in the physician (12.0 ± 2.6 v. 10.4 ± 3.1, P < 0.001). The groups were similar in decisional confidence (7.6 ± 2.1 v. 7.7 ± 1.9, P = 0.74) and disease-specific knowledge. Prominent qualitative themes among participants choosing thyroid lobectomy included desire to avoid daily thyroid hormone (n = 53) and concerns about surgical complications (n = 25).ConclusionsIn this randomized controlled study, a significant proportion of participants preferred thyroid lobectomy if diagnosed with low-risk thyroid cancer. Participants perceived increased empathy when provided even in the virtual setting, which was associated with increased trust in the physician.HighlightsIn this single-site, randomized controlled trial, enhanced emotionally supportive surgeon communication had no effect on hypothetical treatment preference for low-risk thyroid cancer.Participants who experienced enhanced emotionally supportive surgeon communication perceived higher physician empathy and reported greater trust in the physician.The incorporation of empathetic communication during surgical consultation for low-risk thyroid cancer promotes patient trust and perception of empathy.

Outcomes and effectiveness of active surveillance for low-risk papillary thyroid carcinoma: a systematic review and meta-analysis

PURPOSE

This study aimed to evaluate the outcomes and effectiveness of active surveillance (AS) in patients with low-risk papillary thyroid carcinoma (PTC) and compare them to those of immediate surgery (IS).

METHODS

A systematic review and meta-analysis, including 14 comparative studies and 7 noncomparative studies, was conducted, encompassing a total of 9,397 patients.

RESULTS

AS was associated with lower rates of familial history of thyroid cancer, multiplicity, and overall mortality compared to IS. The disease progression rate during AS was 14.53% (95% CI, 9.59-21.43%), and the delayed surgery rate was 14.91% (95% CI, 8.35-25.21%). No thyroid cancer-related mortality was observed in either the AS and IS groups. Clinicopathological characteristics showed no significant differences between delayed surgery and IS, except for higher rates of extrathyroidal extension and multiplicity in the delayed surgery group. Overall complication and recurrence rates were higher in the delayed surgery group than in the IS group. Quality of life and anxiety levels were similar between AS and IS, except for interest in sex, where AS was more beneficial.

CONCLUSION

AS is a feasible and reliable option for managing low-risk PTC, with a relatively low rate of disease progression and no thyroid cancer-related mortality. However, AS should be undertaken with caution, given the higher rates of overall complications and recurrence in the delayed surgery group compared to the IS group. Further studies with larger sample sizes and long-term follow-up are needed to clarify the role and effectiveness of AS.

[Pharmacotherapy of obesity in Germany]

Pharmacotherapy is part of a comprehensive guideline-conform treatment concept for people with obesity. The foundation of obesity treatment is initially a conservative multimodal basic treatment and consists of a low-energy diet, increased physical activity and behavioral changes. If the individual treatment goals are not achieved with this approach, medications can support the basic treatment. The concept is that drugs should not only achieve weight reduction and stabilization of the reduced body weight but also provide better long-term treatment for the chronic multisystem disease obesity. The incretin-based pharmacotherapy with liraglutide, semaglutide and tirzepatide, which have been introduced in recent years, have not only pronounced weight-reducing but also beneficial cardiometabolic effects. These include improvements in obesity-related comorbidities, such as type 2 diabetes, hypertension, fatty liver disease, obstructive sleep apnea, cardiovascular risk factors, chronic kidney disease and others. In contrast, incretin-based pharmacotherapy is typically associated with mild to moderate gastrointestinal side effects. With the marketing launch of setmelanotide, a medication became available for the treatment of rare monogenic forms of obesity. In addition, numerous incretin-based active agents and new substance classes are in advanced phases of clinical development. Due to their favorable efficacy and side effect profiles and also with respect to the positive cardiometabolic effects, the new drugs have the potential to significantly increase the importance of pharmacotherapy of obesity in Germany.

Natural history and long-term follow-up of incidental thyroid nodules on CT imaging

OBJECTIVES

Incidental thyroid nodules (ITNs) are found in up to 25% of CT scans. Increased use of cross-sectional imaging has contributed to the increased incidence of thyroid cancer worldwide. ITNs pose a management dilemma since nodule malignancy rate is 5%-15% but most cancers are indolent and prognosis in differentiated thyroid cancer is excellent. Study aims are to determine prevalence of ITNs ≥1 cm on CT scans, evaluate reporting practices, assess for emergence of clinically evident thyroid cancer during 13-year follow-up and assess interim nodule growth and clinical outcomes in nodules that were further investigated.

METHODS

Direct image review of 1499 consecutive CT scans that included the thyroid, performed during January 2009 in a large NHS health board was performed. Clinical data up to January 2022 was analysed in 150 patients with at least 1 ITN ≥1 cm.

RESULTS

ITN prevalence was 11% with mean patient age 70 years and mean nodule diameter 17.5 mm. 30% of ITNs were mentioned in the CT report. During the follow-up period 11% proceeded to thyroid ultrasound, 5% fine needle aspiration, and 2% diagnostic hemithyroidectomy with no thyroid malignancy found. One hundred twenty patients (80%) were deceased by the study endpoint, none from thyroid malignancy. No patients presented with clinically evident thyroid malignancy during follow-up.

CONCLUSIONS

None of 150 ITN cases developed clinically evident thyroid malignancy in a 13-year follow-up period with 80% of patients deceased by the study endpoint from non-thyroid causes.

ADVANCES IN KNOWLEDGE

This would suggest that ITNs detected on CT do not require further investigation unless malignant appearances or significant clinical concern for thyroid malignancy.

Screening for autoimmune atrophic gastritis by serum gastrin measurement in subjects with type 1 diabetes

INTRODUCTION

Despite associated risk of anemia and gastric cancer, screening for autoimmune atrophic gastritis (AAG) is underperformed in subjects with type 1 diabetes mellitus (T1DM). We measured the predictive value of serum gastrin as a biomarker of gastric atrophy in subjects with T1DM and parietal cell autoantibodies (PCA).

SUBJECTS AND METHODS

PCA measurements were retrospectively retrieved in 1,425 consecutive subjects with T1DM between 2014 and 2018. Screening for AAG was conducted in PCA+ subjects by measuring blood counts, serum ferritin, vitamin B12 and gastrin; and by performing gastroduodenal fibroscopy, with fundic biopsies for histology and Helicobacter pylori. The performance of blood biomarkers of gastric atrophy was analyzed in comparison with the histopathological gold standard.

RESULTS

PCA were found in 185/1,425 subjects (13 %). PCA positivity was associated with female sex, older age, longer T1DM duration, and co-occurrence of anti-GAD and anti-thyroperoxydase autoantibodies. Of the 185 PCA+ subjects, 122 (66 %) participated in screening. AAG was found in 69/122 (57 %) subjects and Helicobacter pylori infection in 20/122 (16 %). Compared to PCA+ subjects without gastric atrophy, those with gastric atrophy had more frequently iron deficiency (65 % vs. 18 %, P < 0.0001), and/or vitamin B12 deficiency (57 % vs. 7 %, P < 0.0001); 44/69 (64 %) presented a pre-tumoral lesion and 6 % a tumor. Using a cut-off of 1.2-fold above the upper normal limit, serum gastrin concentration displayed 91 % sensitivity and 82 % specificity at predicting gastric atrophy.

CONCLUSION

In subjects with T1DM and PCA, serum gastrin is a reliable biomarker of gastric atrophy that can be used to select subjects requiring gastroduodenal fibroscopy.

Adolescents and young adults with germline CDH1 variants and the risk of overtreatment

BACKGROUND

Adolescents and young adults (AYA) with germline CDH1 variants are at risk of overtreatment when precancer lesions are detected with endoscopic screening. We characterize diffuse-type gastric cancer prevalence and survival in AYA managed with prophylactic total gastrectomy (PTG) or endoscopic surveillance.

METHODS

Prospective cohort study of 188 individuals aged 39 and younger enrolled from January 27, 2017, to May 1, 2023. Clinicopathological data, prevalence of early gastric signet ring cell (SRC) lesions, advanced gastric cancer diagnoses, and cancer-specific survival were measured.

RESULTS

Among 188 AYA patients, 104 chose surveillance and 67 pursued PTG for management of elevated gastric cancer risk. AYA who enrolled early in the study period and had SRC lesions detected on preoperative endoscopy were more likely to elect for PTG compared with surveillance. SRC lesions were detected on preoperative endoscopy in 48% of patients who subsequently had PTG, and yet nearly all (93%, 62/67) had multifocal SRC (pT1aN0) on final pathology. Median age at enrollment (30 vs 31 years, P = .21), biological sex (P = .17), and median number of family members with gastric cancer (3 vs 4, P = .14) were not different between groups. No patients under surveillance developed advanced cancer or developed cancer recurrence after PTG with a median follow-up of 2.5 years (IQR = 1.6-4.0) from initial endoscopy.

CONCLUSIONS

Cancer-specific outcomes were not different in AYA who harbored SRC and were managed with surveillance or PTG. Lack of cancer-specific deaths and low prevalence of advanced gastric cancer underscore the risk of overtreatment of SRC lesions and suggest that active surveillance is warranted.

Associations of clinicopathologic features and mutation status with lateral lymph node metastasis as a predictor of disease-free survival in papillary thyroid carcinoma

BACKGROUND

Lateral lymph node metastasis (LLNM) is a significant risk factor for poor prognosis in papillary thyroid carcinoma (PTC). Data on the association between LLNM and genetic alterations in PTC remains limited. This study investigated clinicopathological and molecular predictive factors for LLNM in patients with PTC.

METHODS

We conducted a single-center retrospective analysis of 603 patients who underwent thyroid surgery between January 2018 and December 2023. Clinicopathological features and genetic mutations, including BRAFV600E and telomerase reverse transcriptase (TERT) promoter mutations, were assessed to identify predictors of LLNM. The impact of these features on disease-free survival (DFS) was analyzed using multivariable Cox regression.

RESULTS

LLNM was found in 154 (25.5 %) patients. Independent predictors of LLNM included age < 55 years (odds ratio [OR] = 2.491, 95 % confidence interval [CI]: 1.411-4.398), multifocality (OR = 2.056, 95 % CI: 1.254-3.370), lymphatic invasion (OR = 1.811, 95 % CI: 1.094-2.997), gross extrathyroidal extension (ETE) (OR = 2.611, 95 % CI: 1.333-5.115), central lymph node metastasis (CLNM) without extranodal extension (ENE) (OR = 12.060, 95 % CI: 4.205-34.595) or with ENE (OR = 68.060, 95 % CI: 23.224-199.453), and TERT promoter mutation (OR = 2.272, 95 % CI: 1.078-4.786). CLNM with ENE, LLNM with ENE and TERT promoter mutation were significantly correlated with shorter DFS.

CONCLUSIONS

LLNM is not rare in PTC and represents an adverse prognostic factor significantly associated with age, gross ETE, multifocality, lymphatic invasion, CLNM, and TERT promoter mutation.

Limited Utility of Routine Surveillance Ultrasound in Differentiated Thyroid Cancer Patients With Undetectable Postoperative Thyroglobulin Levels

BACKGROUND

Neck ultrasound (US) and serum thyroglobulin (Tg) measurements are mainstays of long-term differentiated thyroid cancer (DTC) surveillance. Given the high sensitivity of serum Tg, we aimed to assess the utility of neck US in DTC patients who underwent total thyroidectomy and have undetectable serum Tg.

METHODS

We performed a retrospective cohort analysis of DTC patients who underwent a total thyroidectomy at our institution (2010-2023) and received US-guided fine needle aspiration (FNA) during their surveillance. Patients were categorised into three lab categories based on serum Tg and Tg antibody (Tg Ab) status before the biopsy: (1) 'Negative Tg' if undetectable Tg ( < 0.2 ng/dL) and Tg Ab, (2) 'Positive Tg' if detectable Tg and undetectable Tg Ab, and (3) 'Positive Tg Ab' if detectable Tg Ab. To calculate the positive predictive value (PPV) of neck US, we defined the 'true positive' of US as findings that prompted an FNA biopsy resulting with DTC, and 'false positive' findings prompting an FNA biopsy that did not result as DTC.

RESULTS

A total of 118 patients were included, encompassing 146 FNA biopsies: 33 (23%) had Negative Tg, 84 (57%) had Positive Tg, and 29 (20%) had Positive Tg Ab lab results before their biopsies. The PPV of neck US in the setting of Negative Tg was 3% (one true positive, 32 false positives), while the PPV was 50% (42 true positives, 42 false positives) for Positive Tg, and 52% (15 true positives, 14 false positives) for Positive Tg Ab cohorts. Sub-analysis of the Positive Tg cohort using different serum Tg level cutoffs revealed a PPV of 29% at just detectable serum Tg of 0.2 ng/dL, and PPV of 38% for Tg < 1.0 ng/dL. The PPV stabilised at 58% for Tg levels ≥ 1 ng/dL.

CONCLUSION

With the low PPV of neck US, high cost of surveillance, and the advent of ultra-sensitive serum Tg measurements, future guidelines should consider reducing routine neck US surveillance in patients with undetectable serum Tg and only performing it when there is a rise in serum Tg levels.

Intranodal thyroid inclusions revisited: a morphological analysis and application of BRAF VE1 immunohistochemistry

AIMS

The diagnosis of intranodal thyroid inclusions (ITIs) is controversial. We aim to investigate their clinicopathologic features and utilize immunohistochemistry (IHC) to support the diagnosis.

METHODS AND RESULTS

Forty-one cases of incidentally found ITIs between 2019 and 2023 were categorized into three groups, namely, Group A: thyroidectomy due to papillary thyroid carcinoma (PTC) with regional lymph node dissection (n = 33), Group B: thyroidectomy due to benign thyroid disease with incidental perithyroid lymph node sampling (n = 4), and Group C: surgery due to other head and neck cancers with lateral neck lymph node dissection (n = 4). The overall incidence of ITIs was 4.17% (33/792) in Group A and 0.76% (4/524) in Group C. All ITIs sufficient for study were negative for BRAF VE1 IHC. HBME-1 and galectin-3 IHC were also negative in all analysed cases. Although various degrees of nuclear changes were present in ITIs, classical PTC nuclear features, i.e. pseudoinclusions, nuclear grooves, and chromatin alterations, were less commonly seen (0%, 29.3%, and 51.2%, respectively) than in metastatic PTC (90%, 95%, and 95%, respectively) (all P < 0.001). Interestingly, 77.3% (17/22) of cases with lymph node metastasis in Group A had coexistence of ITIs and metastasis in the same lymph node. During follow-up, two cases in Group A had PTC recurrence without accompanying ITIs, while none in Group B or C had recurrent thyroid lesions.

CONCLUSION

We propose key diagnostic features for ITIs incorporating morphology and BRAF VE1, HBME-1, and galectin-3 IHC. The distinction between ITIs and metastatic PTC can be clinically relevant.

Targeting VEGF signaling for tumor microenvironment remodeling and metastasis inhibition: Therapeutic strategies and insights

The tumor microenvironment (TME) plays a pivotal role in cancer progression and metastasis, with vascular endothelial growth factor (VEGF) signaling serving as a key regulator of tumor angiogenesis and immune evasion. VEGF induces abnormal blood vessel formation, promoting tumor growth, immune suppression, and metastasis through epithelialmesenchymal transition (EMT). As a result, VEGF signaling has become a critical therapeutic target in cancer treatment. This review examines the molecular mechanisms driving VEGF-mediated tumor growth and angiogenesis, with a focus on the interaction between tumor and endothelial cells and the dual role of VEGF in fostering vascularization and immune suppression. Current anti-VEGF therapies, including monoclonal antibodies (e.g., bevacizumab) and tyrosine kinase inhibitors (TKIs), have demonstrated efficacy and have received FDA approval for various cancers; however, therapeutic resistance remains a significant challenge. Strategies to overcome resistance, such as novel VEGF inhibitors, vascular normalization approaches, and combination therapies with immune checkpoint inhibitors, have been explored. Additionally, future directions emphasize the need for personalized approaches to improve treatment efficacy and reduce metastasis. A comprehensive understanding of VEGF signaling in the TME may pave the way for more effective cancer therapies.

Genomic testing for RET in the clinic: UK and global perspective

Graphical abstract

Abstract

RET is a key oncogene in neuroendocrine cancer. Pathogenic germline variants lead to multiple different phenotypes, including multiple endocrine neoplasia type 2, medullary thyroid cancer (MTC), Hirschsprung disease and kidney malformations. Pathogenic somatic variants are also associated with MTC, and RET rearrangements are observed in papillary thyroid cancer, non-small cell lung cancer and pan-cancer syndromes. Testing for both germline and somatic variants is now feasible in everyday clinical practice, and their identification has important clinical consequences, both for affected individuals and their families. This mini-review will discuss current germline and somatic testing strategies in the UK and worldwide, as well as reporting and test outcomes (including variants of uncertain significance or incidental findings). It will explore actions following identification of a pathogenic germline variant, including predictive, reproductive and childhood testing, and somatic testing of RET variants in solid tumours informing personalised cancer treatment. Finally, it will discuss the challenge of delivering rapid and equitable access to genomic testing to ensure that all individuals can benefit promptly and appropriately to improve clinical outcomes.

Clinical Role of Pre-ablation Stimulated Thyroglobulin and Thyroid-Stimulating Hormone Ratio for Radioactive Iodine Treatment in Adults with Papillary Thyroid Cancer

OBJECTIVE

This investigation assesses the predictive utility of the pre-ablation stimulated thyroglobulin to thyroid-stimulating hormone ratio (sTg/TSH) and examines the other factors affecting the efficacy of radioactive iodine (RAI) therapy in adult patients with papillary thyroid cancer (PTC).

METHODS

We performed a retrospective review of clinical and pathological data from 1071 patients who received a total thyroidectomy followed by RAI therapy. The study included 576 of these patients. Participants were separated into two groups according to their reaction to RAI therapy: excellent response (ER) and non-ER (NER). The factors that contribute to NER were found using univariate and multivariate binary logistic regression analyses. The predictive importance of the sTg and sTg/TSH ratio was discovered by analyzing receiver operating characteristic (ROC) curves and setting diagnostic criteria. Decision curve analysis (DCA) was used to assess the practical implications of these findings.

RESULTS

Among the 576 patients assessed, 60.07% (346 individuals) demonstrated an ER to RAI treatment. Independent predictors of a NER identified through both univariate and multivariate logistic regression analyses included multifocality (odds ratio [OR] = 2.16, 95% confidence interval [CI]: 1.28-3.67, P = 0.004), having more than ten positive lymph nodes (PLN) (OR = 3.78, 95% CI: 1.68-8.54, P = 0.001), presence of distant metastases (OR = 19.22, 95% CI: 2.09-176.93, P = 0.009), elevated stimulated thyroglobulin (sTg) levels (OR = 1.04, 95% CI: 1.00-1.07, P = 0.025), and a higher sTg/TSH ratio (OR = 2.48, 95% CI: 1.80-3.41, P < 0.001). Receiver operating characteristic (ROC) curve analysis established diagnostic thresholds for predicting NER at an sTg level of 7.255 ng/ml (area under the curve [AUC] = 0.893) and an sTg/TSH ratio of 0.127 (AUC = 0.889), both demonstrating robust sensitivity and specificity. Smooth curve fitting illustrated a progressive increase in the risk of NER with rising levels of the sTg/TSH ratio. DCA confirmed the substantial clinical net benefit of these predictors in forecasting NER outcomes.

CONCLUSIONS

The sTg/TSH ratio is confirmed as a reliable diagnostic marker for predicting the response to primary RAI treatment in PTC. Moreover, active postoperative follow-up and surveillance are essential for patients with multifocality, PLN >10, sTg >7.255 ng/ml, and sTg/TSH ratio >0.127.

Molecular oncology of iodine refractory thyroid cancer current therapies and perspective

Thyroid cancer (TC) is the most common endocrine malignancy. Most patients will be treated and cured by surgery but a low percentage will develop advanced disease. The treatment of advanced disease is at first the use of radioiodine treatment in differentiated cancer then at progression will rely on molecular alterations and consequently in targeted treatments. In this review, we will explore the most frequent molecular alterations of each histological subtype: differentiated thyroid cancer (DTC), anaplastic thyroid cancer (ATC), medullary thyroid cancers (MTC) and clinically tested and approved treatment. We will also report the clinical and preclinical perspective in this field.

Breaking barriers: noninvasive AI model for BRAFV600E mutation identification

OBJECTIVE

BRAFV600E is the most common mutation found in thyroid cancer and is particularly associated with papillary thyroid carcinoma (PTC). Currently, genetic mutation detection relies on invasive procedures. This study aimed to extract radiomic features and utilize deep transfer learning (DTL) from ultrasound images to develop a noninvasive artificial intelligence model for identifying BRAFV600E mutations.

MATERIALS AND METHODS

Regions of interest (ROI) were manually annotated in the ultrasound images, and radiomic and DTL features were extracted. These were used in a joint DTL-radiomics (DTLR) model. Fourteen DTL models were employed, and feature selection was performed using the LASSO regression. Eight machine learning methods were used to construct predictive models. Model performance was primarily evaluated using area under the curve (AUC), accuracy, sensitivity and specificity. The interpretability of the model was visualized using gradient-weighted class activation maps (Grad-CAM).

RESULTS

Sole reliance on radiomics for identification of BRAFV600E mutations had limited capability, but the optimal DTLR model, combined with ResNet152, effectively identified BRAFV600E mutations. In the validation set, the AUC, accuracy, sensitivity and specificity were 0.833, 80.6%, 76.2% and 81.7%, respectively. The AUC of the DTLR model was higher than that of the DTL and radiomics models. Visualization using the ResNet152-based DTLR model revealed its ability to capture and learn ultrasound image features related to BRAFV600E mutations.

CONCLUSION

The ResNet152-based DTLR model demonstrated significant value in identifying BRAFV600E mutations in patients with PTC using ultrasound images. Grad-CAM has the potential to objectively stratify BRAF mutations visually. The findings of this study require further collaboration among more centers and the inclusion of additional data for validation.

Comparison of core-needle biopsy and repeat fine-needle aspiration biopsy for thyroid nodules with initially inconclusive findings: a systematic review, diagnostic accuracy meta-analysis, and meta-regression

INTRODUCTION

The rate of nondiagnostic and indeterminate cytology findings from fine-needle aspiration biopsy (FNAB) is quite high, resulting in repeated puncture and unnecessary surgery. The primary objective of this investigation is to compare diagnostic accuracy of core-needle biopsy (CNB) with repeat FNAB for thyroid nodules with initially inconclusive (nondiagnostic and/or atypia of undetermined significance) FNAB results.

MATERIALS AND METHODS

A thorough search was performed on the Cochrane Library, Scopus, Europe PMC, and Medline databases until October 20th, 2024, employing a combination of pertinent keywords. This review incorporates literature that examines the comparison between CNB and repeat FNAB for thyroid nodule. Pooled odds ratio (OR) of nondiagnostic and inconclusive findings of CNB and repeat FNAB were calculated. A meta-analysis was conducted to assess the diagnostic accuracy of both biopsy methods for malignancy diagnosis utilizing a bivariate random-effects model.

RESULTS

A total of 9 studies were incorporated. The results of our meta-analysis indicated lower rate of nondiagnostic (OR 0.12; 95% confidence interval [CI]: 0.06-0.23, P < 0.00001), atypia of undetermined significance (OR 0.34; 95%CI: 0.21-0.56, P < 0.0001), and inconclusive (OR 0.12; 95%CI: 0.07-0.22, P < 0.00001) findings from CNB compared to repeat FNAB. CNB also exhibited markedly superior cumulative sensitivity estimates (75.1%) compared to repeat FNAB (56.5%), however cumulative specificity did not show a significant difference between CNB (99.9%) and repeat FNAB (99.7%). No patients who received CNB or repeat FNAB encountered any major complications.

CONCLUSIONS

Our study suggests that CNB can be employed to diagnose thyroid nodules that were previously inconclusive on FNAB, rather than repeating the FNAB procedure.

Feasibility, efficacy, and safety of core needle biopsy as a first-line method for cervical lymphadenopathy

OBJECTIVES

This study aimed to determine the feasibility, diagnostic efficacy, and safety of ultrasound-guided core needle biopsy (CNB) as a first-line biopsy method for cervical lymphadenopathy of non-thyroid origin.

MATERIALS AND METHODS

This retrospective cohort study included consecutive patients with cervical lymphadenopathy in whom US-guided CNB was used as the first-line biopsy method for cervical lymph nodes (LNs) of presumed non-thyroid origin. The coaxial CNB technique was routinely used, while the tilting and hydrodissection CNB techniques were selectively employed for small high-risk LNs. The primary endpoint of this study was the diagnostic efficacy of CNB, evaluated by the rate of inconclusive results (nondiagnostic and indeterminate) and diagnostic accuracy (criterion 1: malignant results; criterion 2: malignant or indeterminate result). The secondary outcomes included the feasibility and safety of CNB, assessed based on the technical success rate and complication rate, respectively.

RESULTS

The rates of nondiagnostic, indeterminate, and inconclusive results were 0.7%, 3.4%, and 4.1%, respectively. The sensitivity, specificity, and accuracy of CNB for malignant LNs were 96.2%, 100%, and 97.8%, respectively, with criterion 1, and these values were all 99.8% with criterion 2. The technical success rate of CNB was 99.3%. There were no major complications and 7 cases (0.6%) of minor complications (asymptomatic hematomas).

CONCLUSION

CNB was technically feasible, effective, and safe as a first-line biopsy method for cervical lymphadenopathy of non-thyroid origin with high diagnostic accuracy for malignant nodal disease.

KEY POINTS

Question The role of US-guided CNB as a first-line biopsy method for cervical LNs has not yet been verified and established. Findings US-guided CNB, as a first-line method, demonstrated a high technical success rate and diagnostic accuracy for malignant nodes, with few minor complications. Clinical relevance US-guided CNB can be used as an effective first-line biopsy method for cervical lymphadenopathy and will enable accurate diagnosis of malignant LNs.

Management, biomarkers and prognosis in people developing endocrinopathies associated with immune checkpoint inhibitors

Immune-related adverse events (irAEs), including endocrine irAEs, can occur in response to cancer immunotherapy using immune checkpoint inhibitors (ICIs). Of the endocrine irAEs, pituitary and thyroid irAEs are most frequently observed, followed by primary adrenal insufficiency, type 1 diabetes mellitus and hypoparathyroidism. Notably, pituitary irAEs and type 1 diabetes mellitus can be lethal if overlooked, potentially leading to adrenal crisis and diabetic ketoacidosis, respectively. On the other hand, pituitary and thyroid irAEs are reported to be associated with more favourable prognoses in some cancers if treated appropriately with hormone-replacement therapies. It would be useful to identify those people who are likely to develop endocrine irAEs before initiating therapy with ICIs. Anti-pituitary antibodies and thyroid autoantibodies have been identified as potential biomarkers for the development of pituitary and thyroid irAEs, respectively. This Review elaborates on the clinical characteristics and management strategies of several endocrine irAEs, using the latest research findings and guidelines published by several academic societies.

Optimizing the screening process for TIRADS could reduce the number of unnecessary thyroid biopsies

Objective

Current Thyroid Imaging Reporting and Data Systems (TIRADS) exhibit considerable variability in size thresholds for fine-needle aspiration biopsy. This study harnesses the systematic variations among dissimilar TIRADS optimization strategies for biopsy selection.

Methods

The analysis focused on the discrepancies observed among the four widely utilized TIRADS systems: ACR-TIRADS, Kwak-TIRADS, C-TIRADS and EU-TIRADS. Subsequently, several methods derived from the combination of two TIRADS were constructed via serial testing. Last but not least, diagnostic performance was assessed through unnecessary biopsy rate (UBR), missed malignancy rate and the frequency of clinically significant missed diagnoses.

Results

A total of 699 nodules were included in the study. The accuracy for nodules consistently recommended for biopsy by the four TIRADS was merely 50.8%. Without elevating the risk of missed diagnoses, which could potentially influence prognosis as per the current literature, for eligible nodules recommended for biopsy by original TIRADS, incorporating another TIRADS in serial could further reduce the number of biopsies by 7.8-19.2%.

Conclusions

Conspicuous disparities exist in biopsy guidelines among TIRADS systems, urging increased caution among healthcare providers, particularly when they are extensively applied in patient evaluations. As evidently demonstrated by our research findings, combining recommendations from two TIRADS systems could effectively and safely lessen UBRs. These findings also advocate for the integration of prognostic-impact assessment in developing novel biopsy optimization strategies.

Interpretable machine learning for thyroid cancer recurrence predicton: Leveraging XGBoost and SHAP analysis

PURPOSE

For patients suffering from differentiated thyroid cancer (DTC), several clinical, laboratory, and pathological features (including patient age, tumor size, extrathyroidal extension, or serum thyroglobulin levels) are currently used to identify recurrence risk. Validation and potential adjustment of their individual and combined prognostic values using a large patient cohort with several years of follow-up might improve the correct identification of patients at risk.

METHODS

In this retrospective study, we developed an XGBoost model using clinical and biomarker features for accurate DTC recurrence prediction using a cohort of 1228 consecutive patients (965 papillary, and 263 follicular) that were treated at the Department of Nuclear Medicine at University Hospital Augsburg between 1976 and 2010. The dataset was split into 982 patients for model training, and 246 for independent testing. From the 982 patients, 200 different random combinations of 785 training and 197 validation patients were conducted. To identify critical risk factors and understand the model's decision-making process, we conducted Shapely Additive exPlanations (SHAP) analysis.

RESULTS

The XGBoost model achieved an AUROC of 0.84 (95 % CI: 0.84-0.86; SD: 0.08), sensitivity of 0.79 (95 % CI: 0.77-0.81; SD: 0.17), and specificity of 0.78 (95 % CI: 0.77-0.79; SD: 0.04) on the validation datasets, and an AUROC of 0.88 (sensitivity 0.83, specificity 0.80) on the independent test set. Tumor size, maximal thyroglobulin values within six months after thyroidectomy, and maximal thyroglobulin antibody levels within 12 to 24 months after thyroidectomy were the most important factors. SHAP dependence plots suggested new recurrence risk thresholds for a tumor size of 25 mm, maximal serum thyroglobulin levels of 3 and 10 ng/mL, respectively, and maximal thyroglobulin antibody levels of 120 IU/mL.

CONCLUSION

Our XGBoost model, supported by SHAP analysis empowers clinicians with interpretable insights and defined risk thresholds and could facilitate informed decision-making and patient-centric care.

Recent Advances in Diagnostics and Therapeutics for Paediatric Thyroid Cancer

PURPOSE OF REVIEW

Paediatric thyroid cancer management traditionally relied on extrapolation from adult data and, despite good survival outcomes, often involved extensive surgical approaches and radioactive iodine (RAI) therapy with potentially life-long complications. Increasing understanding of paediatric diagnostic techniques, molecular tumour drivers and targeted therapies will allow a more nuanced, disease-specific comprehensive model of care. This review summarises recent developments in paediatric thyroid cancer biology, diagnosis and models of care.

METHODS

Review of relevant literature from the last 5 years to inform a narrative summary by a multidisciplinary team of clinician experts in paediatric thyroid cancer management.

FINDINGS

Standardised risk scoring systems will likely improve the objectivity and accuracy of paediatric thyroid nodule risk stratification on ultrasound, but further studies are needed to validate these. Identification of somatic and germline gene variants is playing a rapidly increasing role in paediatric thyroid cancer diagnosis and planning of surgical approaches and neoadjuvant and adjuvant therapies. There is growing recognition that lobectomy may achieve comparable outcomes, with reduced risk of complications, to total thyroidectomy in patients with low-risk disease. Molecularly targeted therapies are now available for the management of advanced disease as an adjuvant, and likely neo-adjuvant, therapy for medical debulking of large tumours and resensitisation of RAI-resistant disease.

CONCLUSIONS

The management pathways for paediatric thyroid cancer are rapidly evolving due to the increasing availability of paediatric-specific data. As management options become more complex, interdisciplinary collaboration and shared decision-making are ever more important.

The Landmark Series: Extent of Surgery for Low-Risk Differentiated Thyroid Cancer

The management of patients with differentiated thyroid cancers (DTCs) at low risk for disease progression or relapse after treatment remains controversial. These patients have excellent disease-specific survival. Therefore, minimizing the impact of treatments on patients' quality of life is particularly important. For these reasons, the pendulum has swung in recent years to favor less extensive surgery toward lobectomy instead of total thyroidectomy, away from prophylactic (central compartment) lymphadenectomy, and even in some cases, omitting surgery altogether. This review discusses several of the influential studies from the past two decades that have had an impact on the management for these patients, including a shift toward more personalized care.

High Sensitivity of Fine-Needle Aspiration Calcitonin in Detecting Medullary Thyroid Carcinoma Is Independent of Predefined Decisional Thresholds

The measurement of Calcitonin (Ctn) in fine-needle aspiration (FNA) washout fluids (FNA-Ctn) has demonstrated excellent sensitivity, significantly higher than FNA cytology, in detecting medullary thyroid carcinoma (MTC). However, the absence of a fixed cutoff value for FNA-Ctn poses a limitation. This study aimed to investigate whether the sensitivity of FNA-Ctn in detecting MTC varies with different cutoffs reported in the literature. A single-centre series of MTCs was retrospectively reviewed. The preoperative FNA-Ctn levels were re-evaluated using various thresholds previously reported in the literature, and the corresponding FNA-Ctn sensitivities were compared. Twenty-one MTCs were included (69% women; median age 59 years; median serum Ctn value 86 pg/mL; median MTC major diameter 10 mm). The median FNA-Ctn value was 2000 pg/mL (interquartile range 49-250). MTCs nodules were assessed at high risk (ACR TI-RADS 5) in 50% of cases, while 47.6% were cytologically malignant. Additionally, 42.9% of cases were assessed as stage III according to Union for International Cancer Control staging system (UICC). Serum Ctn was significantly lower in stage I (p = 0.04). FNA-Ctn was positively correlated with serum Ctn (Rho = 0.45; p = 0.04), while ACR TI-RADS assessment with MTC stage (Rho = 0.69; p = 0.003). FNA-Ctn sensitivity ranged from 95% to 100% based on the previously proposed FNA-Ctn cutoffs. The high sensitivity of FNA-Ctn in detecting MTC did not significantly differ when applying the previously proposed cutoffs. Given the absence of a universally applicable FNA-Ctn decisional threshold, institutions should establish their own diagnostic cutoffs. Future guidelines should incorporate these concepts to enhance clinical decision-making and patient outcomes.

Precision treatment guided by patient-derived organoids-based drug testing for locally advanced thyroid cancer: a single arm, phase 2 study

PURPOSE

Locally advanced thyroid cancer (LATC) presents significant surgical challenges, with a high risk of incomplete resection and poor prognosis. Patient-derived organoids (PDOs) are a powerful tool to assess drug sensitivity at an individual level and to suggest new treatment options or re-challenge. This study aimed to evaluate the method's feasibility and efficacy as applied to patients with LATC.

METHODS

In this single arm, phase 2 study, we enrolled 75 patients with LATC. Biopsies from the primary tumor or metastatic site were cultured using organoid models. Sensitivity testing was performed by using PDOs with a panel of drugs with proven activity in phase II or III trials. At the discretion of the investigator considering toxicity, the drug with the highest relative activity was offered. The primary endpoint was the objective response rate (ORR).

RESULTS

Fifty-five patients received at least one dose of recommended drug and the primary endpoint, objective response was met in 18 patients with an overall ORR as 32.7% (95% CI 20.7-46.7). Based on the pre-defined subgroups of different histological subtypes, the ORR for patients with differentiated thyroid cancer, medullary thyroid cancer, anaplastic thyroid cancer were 32.6%, (95% CI 19.1-48.5), 16.7% (95% CI 0.4-64.1) and 50% (95% CI 11.8-88.2), respectively. The R0/R1 resection rate was 34.5% (19/55).

CONCLUSIONS

This study is the first to validate the feasibility of PDOs and in vitro sensitivity testing for LATC. PDO-based neoadjuvant therapy holds promise in improving prognosis and providing surgical opportunities for these patients.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (NCT06482086) on 06/25/2024.

Redifferentiation therapy in unresectable or metastatic radioactive iodine refractory thyroid cancer: an International Thyroid Oncology Group statement

In patients with follicular cell-derived thyroid cancer that have distant metastases and no iodine uptake, redifferentiation-ie, the restoration of tumoural 131I uptake with systemic therapy-is now possible. The use of mitogen-activated protein kinase (MAPK) inhibitors for a short period of time before the administration of high activity 131I shows promising results with iodine uptake restoration and tumour response. Redifferentiation has been used in patients with BRAF-mutated and RAS-mutated tumours in prospective trials and in the case of patients with RET or NTRK fusions. The iodine uptake restoration ranges from 33% to 95%, and tumour response rates from 11% to 80%. There is substantial variability between trials with regards to inclusion criteria, duration of redifferentiation drug therapy, activity of radioactive iodine, and use of dosimetry. Randomised studies are missing to clearly establish the effectiveness and applicability of redifferentiation. Thus, long-term studies are needed to establish the most effective redifferentiation protocols. The objectives of this Review are to: (1) provide a comprehensive review of the available results from prospective trials and case reports, including results regarding the restoration of radioiodine uptake and treatment efficacy (morphological and biological); (2) describe the differences in redifferentiation trial design between studies and discuss their potential impact on treatment efficacy; (3) describe the implications and limitations of dosimetry; and (4) outline the key questions to be addressed in future redifferentiation trials.

Gastrointestinal adverse events associated with Lenvatinib versus Lenvatinib plus Pembrolizumab: A pharmacovigilance study in FDA adverse event reporting system

This study aimed to empirically analyze gastrointestinal adverse events associated with Lenvatinib monotherapy and its combination with Pembrolizumab using FDA FAERS data (January 2015-December 2023), focusing on risk profiles, temporal patterns, and influencing factors. Proportional disproportionality analysis (ROR, PRR, BCPNN, EBGM) evaluated drug-AE associations. Kaplan-Meier curves characterized temporal distributions, while Wilcoxon rank-sum test compared median time-to-onset between regimens. Univariate logistic regression identified independent risk factors. A total of 291 severe gastrointestinal AEs reports were included. The gastrointestinal system had the most positive AE signals in both treatment groups. Perforation events showed strong positive signals in both regimens, while haemorrhage and fistula events were unique positive signals in the lenvatinib monotherapy group. In contrast, colitis and pancreatitis positive signals were more common in the combination therapy group. Most gastrointestinal AEs in both groups occurred within the first month of treatment. The monotherapy group had a significantly shorter median onset time than the combination therapy group (27 days vs. 38 days, P = 0.003). Logistic regression indicated that female sex (OR = 0.195, P = 0.022) and low-dose medication (OR = 0.240, P = 0.049) were independent protective factors for gastrointestinal AEs in the monotherapy group. This first comprehensive comparison reveals distinct gastrointestinal toxicity profiles: monotherapy predisposes to acute bleeding/fistulas, while combination therapy increases delayed tumor-related complications. Intensive monitoring during the first treatment month and gender/dosage-adjusted prevention strategies are recommended. These findings provide evidence-based insights for optimizing safety management of targeted-immunotherapy combinations.

The diagnostic role of FNA based on clinicopathological features in thyroid malignancy

BACKGROUND

Thyroid nodules are mostly benign lesions within the thyroid, with a small percentage being malignant. The decision for surgery is mainly based on the fine needle aspiration (FNA) cytology report, which is categorized into six categories from non-diagnostic to malignant. The accuracy of FNA is of utmost importance to minimize the complications due to misdiagnosis.

METHODS

In a retrospective study, we analyzed 310 patients who underwent thyroidectomy due to suspicious thyroid nodules with both FNA and histopathological results. We reviewed patient files, extracting demographic data, FNA results, and final histopathology reports and grouped them based on the size of the nodules. Sensitivity, specificity, and predictive values were calculated.

RESULTS

The average age of the patients was 42.9 ± 13.2 years, and the average size of the largest nodule diameter was 2.1 ± 1.89 cm. Histopathological evaluation of specimens obtained during surgery showed that 184 (59.4%) samples were malignant and 126 (40.6%) were non-malignant. The overall specificity was 96.8%, and the sensitivity was 89.6%, and the accuracy of FNA in diagnosing malignancy was 92.2%. Logistic regression analysis revealed that Bethesda classification (OR: 2.34; 95%CI: 1.73-3.16; P < 0.001), and also tumor size (OR: 2.02; 95%CI: 1.32-3.10; P = 0.001) exhibited a significant direct correlation with the capability of FNA in accurately diagnosing malignancy. The highest FNA accuracy of malignancy detection was among nodules above 3 cm (97.1%) while in nodules smaller than 1 cm the accuracy was 73.2%.

CONCLUSION

FNA is a suitable diagnostic tool for detecting malignant nodules, while diagnostic capability varies with approaches to indeterminate FNA results. False positive and negative rates are crucial, with challenges in diagnosing malignancy in the context of multinodular goiter cases and smaller nodules.

Preoperative prediction of Ki-67 expression in medullary thyroid carcinoma based on ultrasonographic features: a 10-year retrospective study

PURPOSE

To identify ultrasonographic features that help distinguish Ki-67 expression levels in patients with medullary thyroid carcinoma (MTC).

MATERIALS AND METHODS

A total of 210 patients (245 nodules) with pathological diagnosis of MTC were included in this retrospective study between January 2013 and April 2024. Based on preoperative clinical and ultrasonographic features, univariate analysis and multivariate logistic regression analysis were performed to determine the risk factors associated with Ki-67 ≥ 5 %. A prediction model was subsequently established to evaluate the differential diagnostic performance of Ki-67 by the area under the curve (AUC).

RESULTS

Among the 210 MTC patients (245 nodules), 35 patients (41 nodules) exhibited high Ki-67 expression (Ki-67 ≥ 5 %), while 175 patients (204 nodules) had low Ki-67 expression (Ki-67 < 5 %). There were no significant differences in age, sex, body mass index (BMI), preoperative calcitonin and preoperative CEA levels between the two groups (P > 0.05). Multivariate analysis of the nodules in the two groups revealed that the ultrasound features, including location in the upper or middle region, tumor size > 2.15 cm, and markedly hypoechoic were independent risk factors for high Ki-67 expression. A prediction model was established with the AUC of 0.812 (95 % CI 0.743-0.882).

CONCLUSIONS

Compared to the low Ki-67 expression group, Ki-67 ≥ 5 % group were more likely to exhibit the ultrasound characteristics of location in the upper or middle region, tumor size > 2.15 cm, and markedly hypoechoic. The prediction model demonstrated preferable diagnostic value.

Diagnostic yield of thyroid CT in differentiated thyroid carcinoma according to treatment response

OBJECTIVES

To evaluate the diagnostic yield of thyroid CT in patients with post-treatment differentiated thyroid carcinoma (DTC) stratified by treatment response.

MATERIALS AND METHODS

This retrospective study included DTC patients who underwent total thyroidectomy and radioactive iodine ablation, followed by thyroid CT. Patients were categorized into response assessment groups according to the American Thyroid Association guidelines: excellent response (ER), biochemical incomplete response (BIR), indeterminate response (IR), and structural incomplete response (SIR). Diagnostic yield was defined as the proportion of patients with recurrent tumors among all patients. The yields of ER, BIR, and IR were compared. For IR, subgroup analyses were performed based on the presence of indeterminate lesions on ultrasound (US). Chi-squared tests with Bonferroni correction were used to compare the diagnostic yields between groups.

RESULTS

A total of 450 patients (mean age, 44.9 ± 13.4 years; 164 men) were included. The overall diagnostic yield of thyroid CT was 15.3% (69/450; 95% confidence interval [CI]: 12.3-19%). Yields for the ER, BIR, and IR groups were 2% (4/201; 95% CI: 0.6-5.2%), 23.1% (12/52; 95% CI: 13.6-36.3%), and 26.9% (53/197; 95% CI: 21.2-33.5%), respectively. Among IR patients, the yield was significantly lower in US-negative patients (7.5%, 7/93; 95% CI: 3.5-15%) compared to those with indeterminate US lesions (44.2%, 46/104; 95% CI: 35.1-53.8%) (p < 0.001).

CONCLUSION

The diagnostic yield of thyroid CT varies according to the treatment response; it was low in ER and US-negative IR but higher in BIR and IR with indeterminate US lesions.

KEY POINTS

Question Guidelines recommend considering CT for follow-up in DTC based on treatment response, but the diagnostic yield of CT remains underexplored. Findings The diagnostic yield of CT was low in an ER and US-negative IR but higher in BIR and US-positive IR. Clinical relevance The diagnostic yield of thyroid CT varies according to treatment response. Utilizing CT based on treatment response may enhance the detection of recurrent tumors or clarify unclear findings on US.

5G remote robotic-assisted transcervical thyroidectomy: the first case report in the world

BACKGROUND

The incidence of thyroid malignancies is increasing due to the development of detection techniques. The demand for aesthetics and precision has led surgeons to innovate in surgery, and with the development of 5G technology, telesurgery has become a reality.

CASE PRESENTATION

We present the case of a 37-year-old woman with a physical examination that revealed a nodule of about 0.5*0.5 cm in size in the left lobe of the thyroid gland, with preoperative puncture pathology suggestive of papillary carcinoma. A 5G remote robotic thyroidectomy was performed from Shanghai to Shenzhen.

CONCLUSIONS

We believe this paper reports the world's first 5G tele-robotic-assisted transthoracic breast approach thyroidectomy.

Analysis of risk factors for distant metastasis of column cell subtypes of thyroid papillary carcinoma

OBJECTIVE

To analyze independent risk factors for distant metastasis of columnar cell subtype of papillary thyroid carcinoma (CCS-PTC) and to construct and validate a nomogram to help clinicians make more individualized clinical decisions.

STUDY DESIGN

Retrospective population-based cohort study.

SETTING

Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

Patient data were downloaded from the SEER database. Chi-square test and Logistic regression analysis were used to determine independent risk factors for distant metastasis of CCS-PTC. A nomogram based on significant independent risk factors was established using the rms package of R software (version 4.3.3). The performance of the nomograms was evaluated using subject work characteristic curves (ROC), calibration curves, and decision curve analysis (DCA).

RESULTS

A total of 1712 patients with CCS-PTC were included, of which 79 patients developed distant metastasis, accounting for 4.61% of the entire cohort. The results of chi-square test showed that age, gender, race, tumor size, and lymph node metastasis were significantly associated with distant metastasis of CCS-PTC. Multifactorial logistic regression analysis showed that age, race, tumor size, and lymph node metastasis were independent risk factors for distant metastasis of CCS-PTC, and this was used to draw the nomogram. the results of ROC, calibration curves, and DCA showed that the predictive performance of the nomogram was good.

CONCLUSION

We successfully constructed and validated a nomogram for CCS-PTC distant metastases, which is important for clinicians to identify patients at high risk of distant metastases in a timely manner and make more individualized clinical decisions.

Establish a Nomogram Based on Ultrasound Novel Vascularity Characteristics to Differentiate Follicular Thyroid Carcinoma From Follicular Benign Neoplasms

PURPOSE

This study aimed to construct a nomogram based on novel ultrasound vascularity features to differentiate follicular thyroid carcinoma (FTC) from follicular benign neoplasms (FBN).

METHODS

A total of 153 patients were included. We evaluated various sonographic features of all nodules and analyzed the diagnostic efficiency of different vascularity patterns for FTC. Furthermore, independent predictors for FTC were screened using multivariable logistic regression. A nomogram was established to predict FTC, and various methods were used to evaluate the performance of the nomogram.

RESULTS

The firework-like pattern and central-grasp pattern were more likely to appear in the FTC (p < 0.001, p = 0.007), while the ring-like pattern was more likely to appear in the FBN (p < 0.001). The firework-like pattern showed the best performance in accuracy (71.2%) and NPV (73.4%) among other vascularity patterns. Besides, thick hypo-halo, ring-like pattern, central-grasp pattern, and firework-like pattern were four predictors used to construct the nomogram. The bootstrap AUC was 0.814 (95% CI: 0.743-0.884) which revealed the nomogram had accurate prediction accuracy.

CONCLUSION

The firework-like pattern and central-grasp pattern were vascularity characteristics for FTC, while the ring-like pattern was for FBN. Besides, our nomogram based on novel vascularity characteristics can help distinguish FTC and FBN before operation.

Thyroid cancer

In recent decades, the diagnosis of thyroid cancer, especially the papillary type, has increased significantly due to the use of imaging techniques such as ultrasound. For this reason, it is essential to rationalize diagnosis and treatment, since the behavior of thyroid cancer varies from slow-progressing tumors to highly aggressive ones. The application of risk assessment systems for ultrasound images and the optimization of cytology incorporating molecular studies allows cases to be stratified in order to select therapy on an individual basis. Currently, attempts are being made to avoid overtreatment in low-risk tumors, with active surveillance or minimally invasive techniques. The administration of radioiodine is indicated according to risk, with lower doses, and in advanced cases, oncospecific systemic treatments are being incorporated. The management of thyroid cancer requires a multidisciplinary team and population studies and quality clinical trials are necessary to update treatment guidelines.

Micronucleus and Nuclear Budding Help to Identify Malignancy in Thyroid Fine Needle Aspiration Cytology

OBJECTIVE

Micronucleus (MN) and Nuclear Budding (NB) Have Been Used as an Important Stimulus for Nuclear Atypia in Revealing Chromosomal Damage and Cancer Risk. This Study Aims to Assess MN and NB as Nuclear Parameters and Explore Their Role in Differential Diagnosis of Thyroid FNA and "Bethesda System for Reporting Thyroid Cytology" (BSRTC).

METHODS

The Study Included 350 Thyroid FNA Samples Categorised According to BSRTC. NB And MN Were Evaluated in 1000 Thyrocytes on FNA Slides. The Thyroidectomy Sections Were Divided Into Three Categories as 'Malignant', 'Low-Risk' and 'Benign'.

RESULTS

A Total of 350 Cases Were Classified as follows: 55 (15.71%) Benign, 159 (45.43%) Atypia of Undetermined Significance (AUS), 20 (5.71%) Follicular Neoplasm (FN), 48 (13.71%) Suspicious for Malignancy (SFM) and 68 (19.43%) Malignant. In comparison to all other cytopathologic diagnostic groups, the benign group had significantly lower levels of MN and NB (p < 0.001). The AUS group's MN and NB counts were significantly lower than those of the FN, SFM and malignant groups (MN for AUS-FN/SFM/M p < 0.001, NB for AUS-FN p = 0.01, NB for AUS-SFM/M p < 0.001, respectively). MN and NB counts were greater in the AUS group for cases with a malignant histopathologic diagnosis than for those with a benign histopathologic diagnosis (p < 0.001). MN and NB cut-off values > 5.50 and > 14.50, respectively, suggest high sensitivity and specificity of malignancy.

CONCLUSIONS

Increased Frequency of MN and NB closely associated with an increased risk of malignancy in thyroid FNA. Assessing MN and NB in thyroid FNA may help better stratify the risk in the AUS category.

Protocol and Progress of a Thyroid Study in the Epidemiological Study of Health Effects in Fukushima Emergency Workers

OBJECTIVE

To describe the protocol and progress of a thyroid study using thyroid ultrasonography in emergency workers who responded to the Fukushima nuclear accident.

METHODS

Thyroid ultrasonography was performed on Fukushima emergency workers at over 60 health examination institutions. The accuracy of ultrasonography is controlled by standard procedural protocols, examiner training, and a central review system. Thyroid findings are classified into 4 categories: Category A1 (no nodule or cyst), Category A2 (nodules ≤ 5.0 mm and/or cysts ≤ 20.0 mm), Category B (nodules ≥ 5.1 mm and/or cysts ≥ 20.1 mm), and Category C (requires immediate further examination). Participants classified as Categories B or C are recommended for secondary examination.

RESULTS

Among 3398 participants with available ultrasound images obtained at the first health examination between January 2016 and October 2023, 45.2 % were classified as Category A1, 39.2 % as Category A2, 15.5 % as Category B, and 0 % as Category C. Of the 207 participants for whom secondary examination results were available, seven were diagnosed with cancer or suspected cancer.

CONCLUSIONS

An accuracy control system of thyroid ultrasonography has been established which will continue to carefully investigate the thyroids of Fukushima emergency workers.

Anlotinib inhibits c-MET and ITGA2 in the treatment of anaplastic thyroid carcinoma

OBJECTIVE

This study explored the therapeutic effects of anlotinib in anaplastic thyroid carcinoma (ATC) models and the underlying molecular mechanisms.

METHODS

Human C643 and CAL-62 anaplastic thyroid carcinoma cell lines were cultured in vitro and treated with anlotinib. The effects of anlotinib on the proliferation, apoptosis, cell cycle progression, migration, and invasion of C643 and CAL-62 cells were observed. The tumour volumes and body weights of BALB/c-nu mice bearing subcutaneous tumours were recorded within 14 days of anlotinib treatment. HE staining and immunohistochemical staining for Ki67 and CD31 were performed on the tumour tissues from the mice. We collected anlotinib-treated and untreated C643 cell samples for subsequent transcriptome sequencing and analysis. Western blotting was conducted to measure the protein expression of c-MET, p-MET, LAMC2, COL5A1, and ITGA2 in mouse tumour tissues and C643 cell samples.

RESULTS

Anlotinib inhibited the growth of C643 and CAL-62 cells in a dose-dependent manner. Anlotinib also induced apoptosis and caused cell cycle arrest at the G2/M phase in C643 and CAL-62 cells (p < 0.05). Anlotinib significantly reduced the migration and invasion of C643 and CAL-62 cells (p < 0.001). Moreover, anlotinib effectively suppressed the growth of subcutaneously transplanted tumours in mice (p < 0.05). Immunohistochemical staining for Ki67 and CD31 demonstrated that anlotinib significantly inhibited tumour cell proliferation and angiogenesis. Furthermore, anlotinib downregulated the protein expression of p-MET, LAMC2, COL5A1, and ITGA2 in mouse tumour tissues and C643 cells (p < 0.05).

CONCLUSION

This study confirmed the therapeutic effect of anlotinib on ATC via in vivo and in vitro experiments. In addition, preliminary studies suggest that the mechanism of anlotinib in treating ATC may be to alter the high invasiveness of ATC cells by inhibiting c-MET signaling pathway.

Cancer-Associated Retinopathy Presenting as Panuveitis Secondary to Minimally Invasive Follicular Thyroid Carcinoma

Purpose: To describe a case of cancer-associated retinopathy (CAR) secondary to follicular thyroid carcinoma. Methods: A single retrospective case was evaluated. Results: A 68-year-old woman presented with floaters and decreased vision in the right eye and was found to have panuveitis. The left eye subsequently developed panuveitis 6 months later, ultimately resulting in retinal atrophy. Extensive investigations, including vitreous biopsies, imaging, and positron emission tomography, led to a diagnosis of CAR secondary to minimally invasive follicular thyroid carcinoma with serology positive for anti-enolase, anti-HSP60, and anti-glyceraldehyde-3-phosphate dehydrogenase. Conclusions: Cases of CAR secondary to minimally invasive follicular thyroid carcinoma are rare. Ensuring an early diagnosis and promptly initiating treatment, with a goal of preserving sight, are imperative.

Malignancy Risk, Molecular Mutations, and Surgical Outcomes of Thyroid Nodules Classified as Atypia of Undetermined Significance in the Bethesda System: A Comprehensive Analysis

OBJECTIVES

Thyroid nodules classified as atypia of undetermined significance (AUS) within the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) present a diagnostic challenge, with a risk of malignancy (ROM) of 5% to 50%. In 2017, TBSRTC introduced AUS subcategories to enhance ROM assessment. This study explores the correlation between AUS subclassification, molecular mutations, and surgical outcomes.

METHODS

Retrospective analysis was performed of 114 AUS cases with molecular profiling by ThyroSeqV3 and surgical follow-up. AUS subcategories as defined by TBSRTC included: AUS-Architectural, AUS-Nuclear, AUS-Nuclear and Architectural, and AUS-Hürthle cell. Pathology diagnoses were categorised as benign, malignant, or borderline, including noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP).

RESULTS

Of the 114 nodules, 32.5% were AUS-Architectural, 28.9% AUS-Nuclear and Architectural, 18.4% AUS-Nuclear, 19.3% AUS-Hürthle cell, and 0.9% AUS-Not Otherwise Specified. Papillary carcinoma, predominantly follicular variant, was the most common diagnosis (47.4%), followed by benign lesions (34.2%) and NIFTP (9.6%). RAS family mutations were the most prevalent molecular alteration (34.2%) followed by DICER1, EIF1AX, EXH1 mutations, CNA and GEP (29.8%). THADA fusions, PTEN, TSHR and BRAFK601E mutations were identified in 10.5% of cases, while high-risk mutations such as BRAF V600E, TERT, and TP53 were found in 8.8% of cases. AUS subcategories demonstrated distinct molecular profiles and were linked to varying surgical outcomes.

CONCLUSIONS

AUS subcategorization is associated with specific molecular profiles and surgical outcomes, supporting the subclassification of AUS cases per TBSRTC guidelines for improved risk stratification and clinical management. Further prospective studies with larger cohorts are necessary for validation.

Urinary iodine levels and thyroid disorder prevalence in the adult population of China: a large-scale population-based cross-sectional study

In the past decade, the incidence of thyroid disorders has been steadily increasing, emerging as a prominent public health concern. Consequently, there is a growing interest in understanding the association between iodine nutritional status and thyroid disorders. We selected 13,487 adults (aged 18-69 years) from the baseline population of Zhejiang Environmental Health Cohort (ZEHC) research. Serum thyroid function indicators, urinary iodine concentration (UIC), and urinary creatinine were measured and an ultrasonography of the thyroid were systematically assessed. Urinary iodine/creatinine ratio (UI/Cr) was calculated to mitigate hydration bias. The median of UIC and UI/Cr were 158.2 (IQR: 97.0-250.5) µg/L and 113.4 (IQR: 69.5-178.4) µg/g, respectively. Excessive iodine intake (UIC ≥ 300 µg/L) increased the risk of subclinical hypothyroidism (adjusted OR 1.451, 95% CI 1.252-1.681), while insufficient iodine intake (UIC < 100 µg/L) reduced this risk (adjusted OR 0.831, 95% CI 0.716-0.965). Conversely, insufficient iodine intake (UIC < 100 µg/L) was associated with elevated thyroid nodule incidence (adjusted OR 1.196, 95% CI 1.099-1.301). After creatinine adjustment, the risk of subclinical hypothyroidism was higher in high (quartile 4) UI/Cr level (adjusted OR 1.520, 95% CI 1.334-1.732), and participants with low (quartile 1) UI/Cr level exhibit a lower risk of subclinical hypothyroidism (adjusted OR 0.624, 95% CI 0.523-0.744). Participants with low (quartile 1) UI/Cr level had a significant increase in the incidence of thyroid nodule (adjusted OR 1.315, 95% CI 1.203-1.437). This large-scale population-based study found that higher iodine level was associated with an increased risk of subclinical hypothyroidism, while lower iodine level was associated with an increased incidence of thyroid nodules.