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Ho J, Han M, Jung I, Jo YS, Lee J. Impact of thyroid hormone replacement on the risk of second cancer after thyroidectomy: a Korean National Cohort Study. Sci Rep 2023; 13:16280. [PMID: 37770542 PMCID: PMC10539343 DOI: 10.1038/s41598-023-43461-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 09/24/2023] [Indexed: 09/30/2023] Open
Abstract
We aimed to investigate the effect of thyroid hormone administration on the risk of second primary cancer in patients who underwent thyroidectomy for differentiated thyroid cancer. Data were extracted from the medical billing data of the Health Insurance Review and Assessment Service in South Korea. Patients between 19 and 80 years old who underwent thyroid surgery at least once between January 2009 and June 2020 were included. Data of patients with second primary cancer and control patients with matched age, sex, operation date, and follow-up duration were extracted at a ratio of 1:4. A nested case-control analysis was performed to exclude length bias to confirm the correlation between the duration of thyroid hormone administration, dose, and incidence of second primary cancer. Of the 261,598 patients who underwent surgery for thyroid cancer included in the study, 11,790 with second primary cancer and 47,160 without second primary cancer were matched. The average dose of thyroid hormone increased the adjusted odds ratio (OR) for both low (≤ 50 μg, OR 1.29, confidence interval (CI) 1.12-1.48) and high (< 100 μg, OR 1.24, CI 1.12-1.37) doses. Analyzing over time, the adjusted OR of second primary cancer increased, especially in short (≤ 1 year) (OR 1.19; CI 1.06-1.34) and long (> 5 years) duration (OR 1.25; CI 1.10-1.41). In conclusion, insufficient and excessive thyroid hormone replacement might be linked to increased second primary cancer in patients who underwent thyroidectomy for differentiated thyroid cancer.
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Affiliation(s)
- Joon Ho
- Department of Surgery, Open NBI Convergence Technology Research Laboratory, Yonsei University College of Medicine, Seoul, South Korea
| | - Minkyung Han
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Inkyung Jung
- Division of Biostatistics, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, South Korea.
| | - Young Suk Jo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea.
| | - Jandee Lee
- Department of Surgery, Open NBI Convergence Technology Research Laboratory, Yonsei University College of Medicine, Seoul, South Korea.
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Demircan K, Bengtsson Y, Chillon TS, Vallon-Christersson J, Sun Q, Larsson C, Malmberg M, Saal LH, Rydén L, Borg Å, Manjer J, Schomburg L. Matched analysis of circulating selenium with the breast cancer selenotranscriptome: a multicentre prospective study. J Transl Med 2023; 21:658. [PMID: 37741974 PMCID: PMC10517476 DOI: 10.1186/s12967-023-04502-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/03/2023] [Indexed: 09/25/2023] Open
Abstract
INTRODUCTION Low serum selenium and altered tumour RNA expression of certain selenoproteins are associated with a poor breast cancer prognosis. Selenoprotein expression stringently depends on selenium availability, hence circulating selenium may interact with tumour selenoprotein expression. However, there is no matched analysis to date. METHODS This study included 1453 patients with newly diagnosed breast cancer from the multicentric prospective Sweden Cancerome Analysis Network - Breast study. Total serum selenium, selenoprotein P and glutathione peroxidase 3 were analysed at time of diagnosis. Bulk RNA-sequencing was conducted in matched tumour tissues. Fully adjusted Cox regression models with an interaction term were employed to detect dose-dependent interactions of circulating selenium with the associations of tumour selenoprotein mRNA expression and mortality. RESULTS 237 deaths were recorded within ~ 9 years follow-up. All three serum selenium biomarkers correlated positively (p < 0.001). All selenoproteins except for GPX6 were expressed in tumour tissues. Single cell RNA-sequencing revealed a heterogeneous expression pattern in the tumour microenvironment. Circulating selenium correlated positively with tumour SELENOW and SELENON expression (p < 0.001). In fully adjusted models, the associations of DIO1, DIO3 and SELENOM with mortality were dose-dependently modified by serum selenium (p < 0.001, p = 0.020, p = 0.038, respectively). With increasing selenium, DIO1 and SELENOM associated with lower, whereas DIO3 expression associated with higher mortality. Association of DIO1 with lower mortality was only apparent in patients with high selenium [above median (70.36 µg/L)], and the HR (95%CI) for one-unit increase in log(FPKM + 1) was 0.70 (0.50-0.98). CONCLUSIONS This first unbiased analysis of serum selenium with the breast cancer selenotranscriptome identified an effect-modification of selenium on the associations of DIO1, SELENOM, and DIO3 with prognosis. Selenium substitution in patients with DIO1-expressing tumours merits consideration to improve survival.
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Affiliation(s)
- Kamil Demircan
- Institute for Experimental Endocrinology, Cardiovascular-Metabolic-Renal (CMR)-Research Center, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health (BIH), Biomedical Innovation Academy (BIA), Berlin, Germany
| | - Ylva Bengtsson
- Department of Surgery, Skåne University Hospital Malmö, Lund University, Malmö, Sweden
| | - Thilo Samson Chillon
- Institute for Experimental Endocrinology, Cardiovascular-Metabolic-Renal (CMR)-Research Center, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | | | - Qian Sun
- Institute for Experimental Endocrinology, Cardiovascular-Metabolic-Renal (CMR)-Research Center, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christer Larsson
- Division of Translational Cancer Research, Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Martin Malmberg
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Lao H Saal
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Lisa Rydén
- Department of Surgery, Skåne University Hospital Malmö, Lund University, Malmö, Sweden
| | - Åke Borg
- Division of Oncology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Jonas Manjer
- Department of Surgery, Skåne University Hospital Malmö, Lund University, Malmö, Sweden.
| | - Lutz Schomburg
- Institute for Experimental Endocrinology, Cardiovascular-Metabolic-Renal (CMR)-Research Center, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
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Lu M, Liu H, Zheng B, Sun S, Chen C. Links between Breast and Thyroid Cancer: Hormones, Genetic Susceptibility and Medical Interventions. Cancers (Basel) 2022; 14:5117. [PMID: 36291901 PMCID: PMC9600751 DOI: 10.3390/cancers14205117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/07/2022] [Accepted: 10/12/2022] [Indexed: 08/27/2023] Open
Abstract
Breast and thyroid glands are two common sites of female malignancies. Since the late 19th century, physicians have found that the cancers in either thyroid or mammary gland might increase the risk of second primary cancers in the other site. From then on, many observational clinical studies have confirmed the hypothesis and more than one theory has been developed to explain the phenomenon. Since the two glands both have secretory functions and are regulated by the hypothalamic-pituitary axis, they may share some common oncogenic molecular pathways. However, other risks factors, including medical interventions and hormones, are also observed to play a role. This article aims to provide a comprehensive review of the associations between the two cancers. The putative mechanisms, such as hormone alteration, autoimmune attack, genetic predisposition and other life-related factors are reviewed and discussed. Medical interventions, such as chemotherapy and radiotherapy, can also increase the risk of second primary cancers. This review will provide novel insights into the research designs, clinical managements and treatments of thyroid and breast cancer patients.
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Affiliation(s)
| | | | | | - Shengrong Sun
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Chuang Chen
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan 430060, China
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Yuan K, Song W, Liu Z, Lin GN, Yu S. Mendelian Randomization and GWAS Meta Analysis Revealed the Risk-Increasing Effect of Schizophrenia on Cancers. BIOLOGY 2022; 11:1345. [PMID: 36138824 PMCID: PMC9495962 DOI: 10.3390/biology11091345] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/02/2022] [Accepted: 09/06/2022] [Indexed: 11/17/2022]
Abstract
The causal relationship between cancer and Schizophrenia (SCZ) remains controversial. Some researchers have found that SCZ is a cancer-preventive factor in cohort studies or meta-analyses, whereas others have found the opposite. To understand more about this issue, we used two-sample Mendelian randomization (2SMR) on available GWAS summary results to evaluate potential genetic connections between SCZ and 13 cancers. We discovered that the genetic susceptibility to schizophrenia lead to an increasing risk of breast cancer (odds ratio [OR] per log-odds increase in schizophrenia risk: 1.049, 95% confidence interval [CI]:1.023-1.075; p = 0.00012; FDR = 0.0017), ovarian cancer (OR, 1.326; 95% CI, 1.267-1.387; p = 0.0007; FDR = 0.0045), and thyroid cancer (OR, 1.575; 95% CI, 1.048-2.365; p = 0.0285; FDR = 0.123). Secondly, we performed a meta-analysis based on the GWAS summary statistics of SCZ and the three significant cancers. Next, we associated genetic variants to genes using two gene mapping strategies: (a) positional mapping based on genomic proximity and (b) expression quantitative trait loci (eQTL) mapping based on gene expression linkage across multiple tissues. As a result, we identified 114 shared loci and 437 shared genes in three groups, respectively. Functional enrichment analysis shows that the most enriched biological pathways are related to epigenetic modification. In addition, we noticed that SCZ would affect the level of thyroid-stimulating hormone (OR, 1.095; 95% CI, 1.006-1.191; p = 0.0354; FDR = 0.177), which may further affect the level of estrogen and the risk of the above three cancers. In conclusion, our findings under the 2SMR assumption provide crucial insights into the risk-increasing effect of SCZ on three cancers' risk. Furthermore, these results may provide insights into understanding the genetic predisposition and underlying biological pathways of comorbid SCZ and cancers.
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Affiliation(s)
- Kai Yuan
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai 200030, China
| | - Weichen Song
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai 200030, China
| | - Zhe Liu
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Guan Ning Lin
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai 200030, China
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Shunying Yu
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai 200030, China
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McVicker L, Cardwell CR, McIntosh SA, McMenamin ÚC. Cancer-specific mortality in breast cancer patients with hypothyroidism: a UK population-based study. Breast Cancer Res Treat 2022; 195:209-221. [PMID: 35908274 PMCID: PMC9374643 DOI: 10.1007/s10549-022-06674-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 07/04/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Epidemiological studies have indicated a higher prevalence of hypothyroidism in breast cancer patients, possibly related to shared risk factors and breast cancer treatments. However, few studies have evaluated how hypothyroidism impacts survival outcomes in breast cancer patients. We aimed to determine the association between hypothyroidism and breast cancer-specific and all-cause mortality. METHODS We conducted a population-based study using the Scottish Cancer Registry to identify women diagnosed with breast cancer between 2010 and 2017. A matched comparison cohort of breast cancer-free women was also identified. Using hospital diagnoses and dispensed prescriptions for levothyroxine, we identified hypothyroidism diagnosed before and after breast cancer diagnosis and determined associations with breast cancer-specific and all-cause mortality. Cox proportional hazards regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CI) adjusted for potential confounders. RESULTS A total of 33,500 breast cancer patients were identified, of which 3,802 had hypothyroidism before breast cancer diagnosis and 565 patients went on to develop hypothyroidism after. Breast cancer patients had higher rates of hypothyroidism compared with cancer-free controls (HR 1.14, 95% CI 1.01-1.30). Among breast cancer patients, we found no association between hypothyroidism (diagnosed before or after) and cancer-specific mortality (before: HR 0.99, 95% CI 0.88-1.12, after: HR 0.97, 95% CI 0.63-1.49). Similar associations were seen for all-cause mortality. CONCLUSION In a large contemporary breast cancer cohort, there was little evidence that hypothyroidism, either at diagnosis or diagnosed after breast cancer, was associated with cancer-specific or all-cause mortality.
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Affiliation(s)
- Lauren McVicker
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK.
| | | | - Stuart A McIntosh
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, Northern Ireland, UK
- Breast Surgery Department, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - Úna C McMenamin
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
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He X, Zhong M, Zhang Q, Aierken N, Cui L, Xing Z, Lei K. Thyrotropin suppression therapy using levothyroxine does not negatively affect breast cancer prognosis. Cancer Treat Res Commun 2022; 31:100525. [PMID: 35114502 DOI: 10.1016/j.ctarc.2022.100525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/15/2022] [Accepted: 01/24/2022] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Breast cancer (BC) and thyroid dysfunction are common in females, yet the relationship between thyroid hormone and BC is unclear. To search for the connection between thyrotropin and BC, we contradistinguished BC patients with or without synchronous second primary thyroid cancer (TC) with surgery using data from the Surveillance, Epidemiology, and End Results (SEER) database. Theoretically, according to the ATA (American Thyroid Association) guidelines, all TC patients were treated with thyrotropin suppressive therapy only from 2010 to 2015. MATERIALS AND METHODS Data from BC patients with a synchronous second TC with surgery (BC2TC) and only BC patients (1BC) during 2010-2015 were extracted from the SEER database. Differences in the clinicopathological characteristics between BC2TC and 1BC patients were analyzed by chi-square tests. Comparisons of the disease-specific survival (DSS) and overall survival (OS) curves between these two groups were performed with the log-rank (Mantel-Cox) test. RESULTS Within this dataset, we identified 134 BC2TC patients during the period from 2010 to 2015. Significant differences between the BC2TC and 1BC groups were found only for different ages and TNM (tumor-node-metastasis status) stages. There were no significant differences in DSS between the two cohorts (P = 0.060). The same tendencies in OS or DSS were observed for the different age groups and different TNM groups, even the stage I, N0 (without metastases to lymph nodes), and ER (+) (estrogen receptor (ER)-positive) groups. CONCLUSIONS There were no remarkable differences in survival between the BC2TC and 1BC groups, and thyrotropin suppression therapy using levothyroxine did not negatively affect BC prognosis.
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Affiliation(s)
- Xianghong He
- Public Basic Courses Department, Guangdong University of Science and Technology, Dongguan, Guangdong, China
| | - Miaochun Zhong
- Department of General Surgery, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Qian Zhang
- Department of General Surgery, The 7th Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong, China; Institute of Medicine and Nursing, Hubei University of Medicine China
| | - Nijiati Aierken
- Department of General Surgery, The 7th Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong, China
| | - Lingfei Cui
- Department of General Surgery, The 7th Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong, China
| | - Zhaomin Xing
- Department of General Surgery, The 7th Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong, China
| | - Kefeng Lei
- Department of General Surgery, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China; Department of General Surgery, The 7th Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong, China.
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Voutsadakis IA. The TSH/Thyroid Hormones Axis and Breast Cancer. J Clin Med 2022; 11:687. [PMID: 35160139 PMCID: PMC8836919 DOI: 10.3390/jcm11030687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/22/2022] [Accepted: 01/27/2022] [Indexed: 12/20/2022] Open
Abstract
Breast cancer, the most prevalent female carcinoma, is characterized by the expression of steroid nuclear receptors in a subset of cases. The most important nuclear receptor with prognostic and therapeutic implications is the Estrogen Receptor (ER), which is expressed in about three out of four breast cancers. The Progesterone Receptor (PR) and the Androgen Receptor (AR) are also commonly expressed. Moreover, non-steroid nuclear receptors, including the vitamin D receptor (VDR) and the thyroid receptors (TRs), are also present in breast cancers and have pathophysiologic implications. Circulating thyroid hormones may influence breast cancer risk and breast cancer cell survival, through ligating their canonical receptors TRα and TRβ but also through additional membrane receptors that are expressed in breast cancer. The expression of TR subtypes and their respective isotypes have diverse effects in breast cancers through co-operation with ER and influence on other cancer-associated pathways. Other components of the TSH/thyroid hormone axis, such as TSH and selenoiodinase enzymes, have putative effects in breast cancer pathophysiology. This paper reviews the pathophysiologic and prognostic implications of the thyroid axis in breast cancer and provides a brief therapeutic perspective.
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Affiliation(s)
- Ioannis A. Voutsadakis
- Algoma District Cancer Program, Sault Area Hospital, Sault Ste. Marie, ON P6B 0A8, Canada; or
- Section of Internal Medicine, Division of Clinical Sciences, Northern Ontario School of Medicine, Sudbury, ON P6B 0A8, Canada
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Low thyroid hormone receptor alpha-2 (THRα-2) tumor expression is associated with unfavorable tumor characteristics and high breast cancer mortality. Breast Cancer Res 2021; 23:117. [PMID: 34930399 PMCID: PMC8691018 DOI: 10.1186/s13058-021-01496-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 12/13/2021] [Indexed: 11/10/2022] Open
Abstract
Background The active thyroid hormone triiodothyronine (T3) has been found to have an estrogen-like effect on breast cancer cells. Thyroid hormone receptor alpha-2 (THRα-2) acts as an antagonist for triiodothyronine (T3) signaling, and a low expression has been associated with unfavorable tumor characteristics and a higher mortality in breast cancer. However, the evidence are not conclusive. The present study evaluates tumor-specific THRα-2 expression in invasive breast cancers and its association with tumor characteristics and long-term mortality in a large population. Method The Malmö Diet and Cancer Study (MDCS), a population-based cohort in Sweden that included 17,035 women from 1991 to 1996, was used. Women diagnosed with breast cancer during 1991–2010 were eligible for inclusion. A tissue micro array was constructed from stored tumor material and stained for THRα-2 using immunohistochemistry. Tumors from 654 patients were scored regarding the intensity and the fraction of cells stained, then dichotomized into low or high expression. Date and cause of death were collected up until 2018-12-31. Tumor- and patient characteristics were available from the MDCS. Missing data was imputed using chained equations. Logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for low vs high expression of THRα-2 related to specific tumor factors. Mortality was evaluated with Kaplan–Meier curves and Cox regression, rendering hazard ratios (HRs). Analyses were also stratified for estrogen receptor (ER) status. Results We found strong evidence of an association between low THRα-2 and unfavorable tumor characteristics, including estrogen receptor negativity: OR 4.04 (95% CI 2.28–7.15) and tumor size > 20–50 mm: OR 2.20 (95% CI 1.39–3.49). We found evidence of increased breast cancer-specific mortality for women with low THRα-2, HR 1.38 (95% CI 0.96–1.99), which remained after adjusting for age at diagnosis, HR 1.48 (95% CI 1.03–2.14), but not after adjusting for relevant prognostic factors, HR 0.98 (95% CI 0.66–1.45). THRα-2 expression in ER-negative tumors had an inverse correlation with overall mortality, HR 0.27 (95% CI 0.11–0.65). Conclusion Low tumor-specific THRα-2 expression was in this study associated with prognostically unfavorable tumor characteristics and a higher mortality in breast cancer, but not independent from other prognostic factors. Supplementary Information The online version contains supplementary material available at 10.1186/s13058-021-01496-7.
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Expression of Thyroid Peroxidase Antibody, Thyroglobulin Antibody, and Thyrotropin Receptor Antibody in Breast Cancer and Their Associations with Clinical Characteristics of Breast Cancer. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02887-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Yuan S, Kar S, Vithayathil M, Carter P, Mason AM, Burgess S, Larsson SC. Causal associations of thyroid function and dysfunction with overall, breast and thyroid cancer: A two-sample Mendelian randomization study. Int J Cancer 2020; 147:1895-1903. [PMID: 32215913 PMCID: PMC7611568 DOI: 10.1002/ijc.32988] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 02/11/2020] [Accepted: 03/12/2020] [Indexed: 12/13/2022]
Abstract
Whether thyroid dysfunction plays a causal role in the development of cancer remains inconclusive. We conducted a two-sample Mendelian randomization study to investigate the associations between genetic predisposition to thyroid dysfunction and 22 site-specific cancers. Single-nucleotide polymorphisms associated with four traits of thyroid function were selected from a genome-wide association meta-analysis with up to 72,167 European-descent individuals. Summary-level data for breast cancer and 21 other cancers were extracted from the Breast Cancer Association Consortium (122,977 breast cancer cases and 105,974 controls) and UK Biobank (367,643 individuals). For breast cancer, a meta-analysis was performed using data from both sources. Genetically predicted thyroid dysfunction was associated with breast cancer, with similar patterns of associations in the Breast Cancer Association Consortium and UK Biobank. The combined odds ratios of breast cancer were 0.94 (0.91-0.98; p = 0.007) per genetically predicted one standard deviation increase in TSH levels, 0.96 (0.91-1.00; p = 0.053) for genetic predisposition to hypothyroidism, 1.04 (1.01-1.07; p = 0.005) for genetic predisposition to hyperthyroidism and 1.07 (1.02-1.12; p = 0.003) per genetically predicted one standard deviation increase in free thyroxine levels. Genetically predicted TSH levels and hypothyroidism were inversely with thyroid cancer; the odds ratios were 0.47 (0.30-0.73; p = 0.001) and 0.70 (0.51-0.98; p = 0.038), respectively. Our study provides evidence of a causal association between thyroid dysfunction and breast cancer (mainly ER-positive tumors) risk. The role of TSH and hypothyroidism for thyroid cancer and the associations between thyroid dysfunction and other cancers need further exploration.
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Affiliation(s)
- Shuai Yuan
- Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Siddhartha Kar
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- MRC Integrative Epidemiology Unit, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | - Paul Carter
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Amy M. Mason
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Stephen Burgess
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- MRC Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
| | - Susanna C. Larsson
- Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Wändell P, Carlsson AC, Li X, Sundquist J, Sundquist K. Levothyroxine treatment is associated with an increased relative risk of overall and organ specific incident cancers - a cohort study of the Swedish population. Cancer Epidemiol 2020; 66:101707. [PMID: 32222650 DOI: 10.1016/j.canep.2020.101707] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 03/09/2020] [Accepted: 03/15/2020] [Indexed: 12/24/2022]
Abstract
High thyroid hormone values have been associated with an increased risk of incident cancers, especially breast cancer but also lung cancer and any solid cancers. We explored whether there is an increased risk of overall and cause-specific cancers in those receiving levothyroxine treatment. We included all individuals ≥ 18 years in Sweden (N = 8,573,313) on January 1 2009, and identified patients with two or more dispensed prescriptions of levothyroxine 2005-2006 (n = 253,193, 3.0 %). A cancer diagnosis in the Swedish Cancer Register 2009-2015 was used as outcome. We excluded patients with a cancer diagnosis before 2005. Cox regression was used (hazard ratios, HRs, and 95 % confidence intervals, CI) with adjustments for age, socioeconomic/neighborhood factors and co-morbidities. Totally 399,751 cases of incident cancer were identified, with a slight increased overall risk associated with levothyroxine treatment for both men, adjusted HR 1.06 (95 % CI 1.03-1.10), and women, adjusted HR 1.08 (95 % CI 1.07-1.10). For men, increased risks were found for cancers of the thyroid gland and other endocrine glands. For women, increased risks were found for cancers of the breast, endometrium, other female genitals (ovaries not included), stomach, colon, liver, pancreas, urinary bladder, skin, leukemia, and unspecified primary tumor. Unlike men, for women, no increased risk was found for cancer of the thyroid gland. In conclusions, levothyroxine treatment was associated with an excess cancer risk, including many different types of cancer, especially among women. Our results need confirmation by other studies, but levothyroxine is recommended to be prescribed only on approved indications.
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Affiliation(s)
- Per Wändell
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.
| | - Axel C Carlsson
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; Academic Primary Health Care Centre, Stockholm Region, Stockholm, Sweden
| | - Xinjun Li
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden; Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA; Center for Community-Based Healthcare Research and Education (CoHRE), Department of Functional Pathology, School of Medicine, Shimane University, Japan
| | - Kristina Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden; Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA; Center for Community-Based Healthcare Research and Education (CoHRE), Department of Functional Pathology, School of Medicine, Shimane University, Japan
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Schmohl KA, Nelson PJ, Spitzweg C. Tetrac as an anti-angiogenic agent in cancer. Endocr Relat Cancer 2019; 26:R287-R304. [PMID: 31063970 DOI: 10.1530/erc-19-0058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 04/04/2019] [Indexed: 12/24/2022]
Abstract
The thyroid hormones T3 and T4 have emerged as pro-angiogenic hormones with important implications for cancer management. Endogenous circulating hormone levels may help stimulate cancer progression and limit the effectiveness of anticancer therapy, though clinical data remain inconclusive. The capacity of thyroid hormones to modulate angiogenesis is mediated through non-canonical mechanisms initiated at the cell surface receptor integrin αvβ3. This integrin is predominantly expressed on tumour cells, proliferating endothelial cells and tumour stroma-associated cells, emphasising its potential relevance in angiogenesis and tumour biology. Thyroid hormone/integrin αvβ3 signalling results in the activation of intracellular pathways that are commonly associated with angiogenesis and are mediated through classical pro-angiogenic molecules such as vascular endothelial growth factor. The naturally occurring T4 analogue tetrac blocks the pro-angiogenic actions of thyroid hormones at the integrin receptor, in addition to agonist-independent anti-angiogenic effects. Tetrac reduces endothelial cell proliferation, migration and tube formation through a reduction in the transcription of vascular growth factors/growth factor receptors, hypoxia-inducible factor-1α, pro-angiogenic cytokines and a number of other pro-angiogenic genes, while at the same time stimulating the expression of endogenous angiogenesis inhibitors. It further modulates vascular growth factor activity by disrupting the crosstalk between integrin αvβ3 and adjacent growth factor receptors. Moreover, tetrac disrupts thyroid hormone-stimulated tumour recruitment, differentiation and the pro-angiogenic signalling of tumour stroma-associated mesenchymal stem cells. Tetrac affects tumour-associated angiogenesis via multiple mechanisms and interferes with other cancer cell survival pathways. In conjunction with its low toxicity and high tissue selectivity, tetrac is a promising candidate for clinical application.
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Affiliation(s)
- Kathrin A Schmohl
- Department of Internal Medicine IV, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Peter J Nelson
- Department of Internal Medicine IV, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Christine Spitzweg
- Department of Internal Medicine IV, University Hospital of Munich, LMU Munich, Munich, Germany
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13
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Breast cancer prognosis is better in patients who develop subsequent metachronous thyroid cancer. PLoS One 2019; 14:e0215948. [PMID: 31042767 PMCID: PMC6493754 DOI: 10.1371/journal.pone.0215948] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 03/30/2019] [Indexed: 12/11/2022] Open
Abstract
Breast cancer (BC) and thyroid cancer (TC) are common malignancies among females. However, the connection between TC and BC is not well understood. To explore the relationship between these two cancers and to determine the effect of second metachronous TC on BC survival, we compared BC patients with or without second primary TC using data from the Surveillance, Epidemiology, and End Results (SEER) database. We extracted data from patients with only BC or TC and from BC patients with a second metachronous cancer from 2000–2014. Differences in the clinicopathological and treatment characteristics between BC patients with or without second metachronous TC were analyzed by chi-square tests. Multivariate analyses of BC survival were performed by using Cox regression models. Comparison of disease-specific survival (DSS) curves between these cohorts was performed with the log-rank (Mantel-Cox) test. Survival analyses were also performed using data from 1980–1994. Within this dataset, we found 1,262 BC cases in which a second metachronous TC (BC2TC) developed, accounting for 3.1% of all metachronous cancers following BC from 2000–2014. No significant differences were found in molecular markers. In addition, the mean age at BC diagnosis was younger in the BC2TC group than in the BC group (55.418 y vs 60.273 y). Half of the BC2TC patients developed TC in the first three years following BC diagnosis. Patients with BC2TC showed better DSS than those with BC alone from 2000–2014 (P<0.001). However, this superiority was not significant from 1980–1994 (P = 0.579) or for TNM stage I BC (P = 0.927) and grade I BC (P = 0.431) from 2000–2014. In conclusion, the incidence of BC2TC has increased dramatically during the past 15 years. In addition, patients with BC2TC showed better DSS than patients with BC alone, especially in cases from 2000–2014.
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14
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Falstie-Jensen AM, Kjærsgaard A, Lorenzen EL, Jensen JD, Reinertsen KV, Dekkers OM, Ewertz M, Cronin-Fenton DP. Hypothyroidism and the risk of breast cancer recurrence and all-cause mortality - a Danish population-based study. Breast Cancer Res 2019; 21:44. [PMID: 30902106 PMCID: PMC6431068 DOI: 10.1186/s13058-019-1122-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 02/14/2019] [Indexed: 12/13/2022] Open
Abstract
Background Hypothyroidism may occur as a late effect of breast cancer-directed treatment, particularly after radiotherapy, but little is known whether hypothyroidism affects the prognosis after breast cancer. We investigated the association between hypothyroidism and breast cancer recurrence, and all-cause mortality. Methods In this population-based cohort study, we used national medical registries to identify all Danish women 35 years or older diagnosed with stage I–III, operable breast cancer between 1996 and 2009. Hypothyroidism was defined as hospital diagnoses ascertained via diagnostic codes, or as prescriptions for levothyroxine. Two analytic models were used: (i) hypothyroidism present at the time of the breast cancer diagnosis (prevalent) and (ii) hypothyroidism diagnosed during follow-up as a time-varying exposure lagged by 1 year (incident). Breast cancer recurrence was defined as any local, regional, or distant recurrence or contralateral breast cancer. All-cause mortality included death from any cause in any setting. We used Cox regression models accounting for competing risks to compute adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of breast cancer recurrence and all-cause mortality. Results The study cohort included 35,463 women with breast cancer with 212,641 person-years of follow-up. At diagnosis, 1272 women had hypothyroidism and 859 women developed hypothyroidism during follow-up. In total, 5810 patients developed recurrent breast cancer. Neither prevalent nor incident hypothyroidism was associated with breast cancer recurrence (adjusted HRprevalent 1.01, 95% CI 0.87–1.19; adjusted HRincident 0.93, 95% CI 0.75–1.16, respectively). Furthermore, no differences were seen for all-cause mortality for prevalent or incident hypothyroidism (adjusted HRprevalent 1.02, 95% CI 0.92–1.14, and HRincident 1.08, 95% CI 0.95–1.23, respectively). Stratification by menopausal status, oestrogen receptor status, chemotherapy, or radiotherapy did not alter the estimates. Conclusions Hypothyroidism present at diagnosis or during follow-up was not associated with breast cancer recurrence or all-cause mortality in women with breast cancer. Our findings provide reassurance to patients and their physicians that hypothyroidism is unlikely to impact on the clinical course of breast cancer or survival. Electronic supplementary material The online version of this article (10.1186/s13058-019-1122-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anne Mette Falstie-Jensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, DK-8200, Aarhus N, Denmark.
| | - Anders Kjærsgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, DK-8200, Aarhus N, Denmark
| | - Ebbe Laugaard Lorenzen
- Department of Oncology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jeanette Dupont Jensen
- Department of Oncology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kristin Valborg Reinertsen
- National Advisory Unit on Late Effects after Cancer Treatment, Department of Oncology, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway
| | - Olaf M Dekkers
- Department of Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marianne Ewertz
- Department of Oncology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Deirdre P Cronin-Fenton
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, DK-8200, Aarhus N, Denmark
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15
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Godlewska M, Krasuska W, Czarnocka B. Biochemical properties of thyroid peroxidase (TPO) expressed in human breast and mammary-derived cell lines. PLoS One 2018. [PMID: 29513734 PMCID: PMC5841765 DOI: 10.1371/journal.pone.0193624] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Thyroid peroxidase (TPO) is an enzyme and autoantigen expressed in thyroid and breast tissues. Thyroid TPO undergoes a complex maturation process however, nothing is known about post-translational modifications of breast-expressed TPO. In this study, we have investigated the biochemical properties of TPO expressed in normal and cancerous human breast tissues, and the maturation process and antigenicity of TPO present in a panel of human breast tissue-derived cell lines. We found that the molecular weight of breast TPO was slightly lower than that of thyroid TPO due to decreased glycosylation and as suggest results of Western blot also shorter amino acid chain. Breast TPO exhibit enzymatic activity and isoelectric point comparable to that of thyroid TPO. The biochemical properties of TPO expressed in mammary cell lines and normal thyrocytes are similar regarding glycan content, molecular weight and isoelectric point. However, no peroxidase activity and dimer formation was detected in any of these cell lines since the majority of TPO protein was localized in the cytoplasmic compartment, and the TPO expression at the cell surface was too low to detect its enzymatic activity. Lactoperoxidase, a protein highly homologous to TPO expressed also in breast tissues, does not influence the obtained data. TPO expressed in the cell lines was recognized by a broad panel of TPO-specific antibodies. Although some differences in biochemical properties between thyroid and breast TPO were observed, they do not seem to be critical for the overall three-dimensional structure. This conclusion is supported by the fact that TPO expressed in breast tissues and cell lines reacts well with conformation-sensitive antibodies. Taking into account a close resemblance between both proteins, especially high antigenicity, future studies should investigate the potential immunotherapies directed against breast-expressed TPO and its specific epitopes.
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Affiliation(s)
- Marlena Godlewska
- Department of Biochemistry and Molecular Biology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Wanda Krasuska
- Department of Biochemistry and Molecular Biology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Barbara Czarnocka
- Department of Biochemistry and Molecular Biology, Center of Postgraduate Medical Education, Warsaw, Poland
- * E-mail:
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Brandt J, Borgquist S, Almgren P, Försti A, Huss L, Melander O, Manjer J. Thyroid-associated genetic polymorphisms in relation to breast cancer risk in the Malmö Diet and Cancer Study. Int J Cancer 2017; 142:1309-1321. [PMID: 29134650 DOI: 10.1002/ijc.31156] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/13/2017] [Accepted: 10/26/2017] [Indexed: 02/06/2023]
Abstract
Previous studies have suggested that thyroid function is associated with breast cancer risk, which could have an important clinical impact, as one in eight women will develop a thyroid disorder during her lifetime. However, the underlying pathomechanism behind the association is still unknown. We used the Malmö Diet and Cancer Study (a population-based prospective study consisting of 17,035 women) to examine 17 single nucleotide polymorphisms (SNPs) previously related to levels of free thyroxine (free T4) and thyroid peroxidase antibodies (TPO-Ab) as potential genetic risk factors for breast cancer. A baseline examination including free T4 and TPO-Ab levels was conducted at the time of inclusion. Genotyping was performed on 901 breast cancer patients and 3335 controls. Odds ratios (95% confidence intervals) for high free T4, TPO-Ab positivity, and breast cancer were calculated by logistic regression and adjusted for confounders. We identified one free T4-related SNP (rs2235544, D101 gene) that was significantly associated with both free T4 level and breast cancer risk. There was a suggested association between rs11675434 (TPO gene) and TPO-Ab level, and TPO-Ab-related rs11675434 (TPO), rs3094228 (HCP5), rs1033662 (no registered gene), and rs301806 (RERE) were associated with breast cancer risk. There was an indicated interaction between rs6485050 (no registered gene) and free T4 level in regards to breast cancer risk. This is the first study to suggest an association between thyroid-related SNPs and breast cancer risk. All SNPs have a biological plausibility of being associated with breast cancer risk, and may contribute to the genetic predisposition to breast cancer.
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Affiliation(s)
- Jasmine Brandt
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Signe Borgquist
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden.,Clinical Trial Unit, Skåne University Hospital, Lund, Sweden
| | - Peter Almgren
- Department of Clinical Sciences, Skåne University Hospital Malmö Clinical Research Center, Lund University, Malmo, Sweden
| | - Asta Försti
- Division of Molecular Genetic Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 580, Heidelberg, D-69120, Germany.,Center for Primary Health Care Research, Lund University, Malmö, 205 02, Sweden
| | - Linnea Huss
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Olle Melander
- Department of Clinical Sciences, Skåne University Hospital Malmö Clinical Research Center, Lund University, Malmo, Sweden
| | - Jonas Manjer
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
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17
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Godlewska M, Arczewska KD, Rudzińska M, Łyczkowska A, Krasuska W, Hanusek K, Ruf J, Kiedrowski M, Czarnocka B. Thyroid peroxidase (TPO) expressed in thyroid and breast tissues shows similar antigenic properties. PLoS One 2017; 12:e0179066. [PMID: 28575127 PMCID: PMC5456382 DOI: 10.1371/journal.pone.0179066] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/23/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Thyroid peroxidase (TPO) is essential for physiological function of the thyroid gland. The high prevalence of thyroid peroxidase antibodies (TPOAbs) in patients with breast cancer and their protective role had previously been demonstrated, indicating a link between breast cancer and thyroid autoimmunity. Recently, TPO was shown to be present in breast cancer tissue samples but its antigenicity has not been analyzed. METHODS In this study, we investigated TPO expression levels in a series of fifty-six breast cancer samples paired with normal (peri-tumoral) tissue and its antigenic activity using a panel of well-characterized murine anti-human TPOAbs. RESULTS We have shown that TPO transcripts were present in both normal and cancer tissue samples, although the amounts in the latter were reduced. Additionally, we observed that TPO levels are lower in more advanced cancers. TPO protein expression was confirmed in all tissue samples, both normal and cancerous. We also found that the antigenicity of the immunodominant regions (IDRs) in breast TPO resembles that of thyroid TPO, which is crucial for effective interactions with human TPOAbs. CONCLUSIONS Expression of TPO in breast cancer together with its antigenic activity may have beneficial effects in TPOAb-positive breast cancer patients. However, further studies are needed to confirm the beneficial role of TPOAbs and to better understand the underlying mechanism.
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Affiliation(s)
- Marlena Godlewska
- Department of Biochemistry and Molecular Biology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Katarzyna D. Arczewska
- Department of Biochemistry and Molecular Biology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Magdalena Rudzińska
- Department of Biochemistry and Molecular Biology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Anna Łyczkowska
- Department of Biochemistry and Molecular Biology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Wanda Krasuska
- Department of Biochemistry and Molecular Biology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Karolina Hanusek
- Department of Biochemistry and Molecular Biology, Center of Postgraduate Medical Education, Warsaw, Poland
| | - Jean Ruf
- UMR-MD2, Aix-Marseille University, Marseille Medical School, Marseille, France
| | - Mirosław Kiedrowski
- Clinical Department of Oncology and Hematology, Central Clinical Hospital of the Ministry of Interior in Warsaw, Warsaw, Poland
| | - Barbara Czarnocka
- Department of Biochemistry and Molecular Biology, Center of Postgraduate Medical Education, Warsaw, Poland
- * E-mail:
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