Family history of cancer and risk of sporadic differentiated thyroid carcinoma

Molecular Landscape and Therapeutic Strategies in Pediatric Differentiated Thyroid Carcinoma

There has been significant progress in understanding the molecular landscape of pediatric differentiated thyroid carcinoma (DTC) over the past 2 decades. Classification of pediatric DFC into 3 tiers, RAS-like mutant, BRAF mutant, and kinase fusions, accurately reflects an increasing risk for invasive behavior, including regional and distant metastasis. In clinical practice, somatic oncogene testing for nodules with indeterminate cytology per the Bethesda System for Reporting Thyroid Cytopathology provides objective data to optimize surgical planning. In addition, knowledge of the somatic oncogene for widely invasive carcinomas allows for incorporation of oncogene-specific inhibitory therapy both in the adjuvant and neoadjuvant setting. In the present review, we review the risk factors, clinical presentation, and evaluation of pediatric DTC, highlighting the correlation among ultrasound features, cytology, and oncogenic driver of the tumor. We subsequently propose an integrated, multimodal approach that can be used to improve diagnostic accuracy and reliability for preoperative planning as well as identify and discuss which pediatric patients may benefit from systemic oral targeted therapy.

Enhancing patient representation learning with inferred family pedigrees improves disease risk prediction

BACKGROUND

Machine learning and deep learning are powerful tools for analyzing electronic health records (EHRs) in healthcare research. Although family health history has been recognized as a major predictor for a wide spectrum of diseases, research has so far adopted a limited view of family relations, essentially treating patients as independent samples in the analysis.

METHODS

To address this gap, we present ALIGATEHR, which models inferred family relations in a graph attention network augmented with an attention-based medical ontology representation, thus accounting for the complex influence of genetics, shared environmental exposures, and disease dependencies.

RESULTS

Taking disease risk prediction as a use case, we demonstrate that explicitly modeling family relations significantly improves predictions across the disease spectrum. We then show how ALIGATEHR's attention mechanism, which links patients' disease risk to their relatives' clinical profiles, successfully captures genetic aspects of diseases using longitudinal EHR diagnosis data. Finally, we use ALIGATEHR to successfully distinguish the 2 main inflammatory bowel disease subtypes with highly shared risk factors and symptoms (Crohn's disease and ulcerative colitis).

CONCLUSION

Overall, our results highlight that family relations should not be overlooked in EHR research and illustrate ALIGATEHR's great potential for enhancing patient representation learning for predictive and interpretable modeling of EHRs.

Polygenic Score for Clinicopathologic Features and Survival Outcomes in Papillary Thyroid Carcinoma

Importance

Genome-wide association studies have identified germline variants associated with the development of papillary thyroid carcinoma (PTC) that can be used to construct a polygenic score (PGS). It is important to determine whether patients with higher germline genetic risk, as summarized using PGS, present with more aggressive disease and/or develop worse clinical outcomes.

Objective

To assess whether germline risk defined by PGS is associated with clinicopathologic features and survival outcomes for patients with PTC.

Design, Setting, and Participants

This retrospective cohort study included patients with newly diagnosed PTC who presented to The University of Texas MD Anderson Cancer Center for treatment between 1999 and 2014, with a median follow-up of 12 years. Data were analyzed from December 2023 to April 2024.

Exposure

Germline risk, as defined by PGS.

Main Outcomes and Measures

Genomic DNA was extracted from buffy coat cells isolated from peripheral blood samples, and genotyping for germline polymorphisms was performed. Germline risk for PTC was estimated with a previously validated PGS calculated from 10 single-nucleotide variations identified through genome-wide association studies. Stage; PTC-specific survival, defined as the time from PTC diagnosis to death caused by PTC; and overall survival, defined as the time from PTC diagnosis to death by any cause, were analyzed.

Results

A total of 366 patients were included in the study (261 women [71.3%]; mean [SD] age at diagnosis, 44.3 [13.8] years). There was a statistically significant association between higher PGS and multifocality (β [SE], 0.40 [0.23]; P = .045) and cervical lymph node involvement (N stage) (β [SE], 0.62 [0.35]; P = .009) at diagnosis. PGS was associated with PTC-specific survival (hazard ratio, 2.66; 95% CI, 1.03-6.85; P = .04), but this association was not independent of age and overall stage. There was not a statistically significant association between PGS and overall survival.

Conclusions and Relevance

Findings of this cohort study suggest that patients with a higher germline risk of PTC, as estimated by PGS, present with more aggressive clinicopathologic features. These results contribute to the current understanding of inherited risk in PTC and how germline variants could potentially contribute to disease presentation and clinical outcomes.

Investigating papillary thyroid cancer risk factors among women living at the central region of Iran: a case-control study

BACKGROUND

The etiology of thyroid cancer especially in women in not well recognized in Yazd, at the center of Iran. The aim of present study was to investigate the risk factors of thyroid cancer among women living in this province.

METHODS

The present study was carried out as a case-control study, comprising women diagnosed with papillary thyroid cancer (PTC) as the case group, along with two distinct control groups sourced from different origins (i.e., relatives and non-relatives) between 2020 and 2022. Data pertaining to several risk factors including demographic characteristics, reproductive variables, medical history related to thyroid and non-thyroid ailments, exposure to head and neck radiation, as well as familial cancer history, was collected from all participants. Binary logistic regression was utilized to discover risk and protective factors.

RESULTS

In present study, 77 individuals participated in the case group, 76 in the relative control group and 72 in the non-relative control group. The history of OCP use and exposure to head and neck radiation were remained in the model as risk factors in all three case‒relative control (OR = 6.65, 95%CI: 2.53‒17.49; P-value < 0.001), case‒non-relative control (OR = 6.32, 95%CI: 2.14‒18.70; P-value = 0.001) and case‒total control comparisons (OR = 6.66, 95%CI: 2.84‒15.64; P-value < 0.001).

CONCLUSION

The OCP use as well as exposure to head and neck radiation were determined to be strong or relatively strong risk factors in both case‒relative control and case‒non-relative control comparisons. Consequently, it seems these two factors represent genuine risk factors for papillary thyroid cancer.

Narrative overview of possible preventive measures for differentiated thyroid carcinomas

There is compelling evidence that although the increased availability of sensitive imaging is the main cause of the increasing incidence of differentiated thyroid cancer, particularly the papillary type, there are other factors involved. Despite the acknowledged role of genetic and certain lifestyle factors, comprehensive studies delineating the interactions between multiple risk factors and the mechanistic pathways involved are scarce. A greater understanding of both modifiable and non-modifiable risk factors for thyroid cancer is critical to prevent and manage the disease and could provide a scientific basis for future research into more appropriate lifestyles and living environments for people at high risk. We reviewed the main endogenous factors that, although considered non-modifiable, can help identify at-risk individuals. In addition, we offer a narrative review of other putative causes and make recommendations for measures to prevent the emergence of new cases of differentiated thyroid cancer.

The impact of family cancer history on tumor metabolism and prognosis in patients with non-small cell lung cancer

Non-small cell lung cancer (NSCLC) is a leading cause of cancer-related mortality, and the role of family cancer history in disease progression and treatment response remains underexplored. This study aims to investigate the influence of family tumor history on disease-free survival, tumor metabolism, and treatment response in NSCLC patients. A retrospective, single-center study of 414 NSCLC patients was conducted, with 101 patients having a family history of cancer (FHC). Disease-free survival (DFS), tumor glucose metabolism assessed by 18F-FDG PET/CT, and treatment response to chemoradiotherapy, targeted therapy, and immunotherapy were analyzed. Multivariate modeling was performed to improve prognostic prediction. Patients with FHC exhibited higher TNM staging, increased susceptibility to lymph node invasion, and elevated tumor glucose metabolism levels. Family history of cancer, particularly colorectal and lung cancer, was a significant risk factor for disease-free survival. Targeted therapy and immunotherapy significantly improved patient prognosis, while family history of cancer affected the efficacy of chemoradiotherapy but not targeted therapy or immunotherapy. Multivariate modeling combining FHC, treatment, and tumor metabolism levels yielded improved predictive performance. Our study highlights the importance of considering a patient's family history when assessing risk profiles and formulating treatment decisions for NSCLC patients. Further research is needed to understand the molecular mechanisms underlying these observed associations and to develop more effective treatment strategies for NSCLC patients with a cancer family history.

Changes in Thyroglobulin Antibody Levels in Differentiated Thyroid Cancer Patients After Thyroidectomy: A Retrospective Study in Basrah, Iraq

INTRODUCTION

Differentiated thyroid cancer (DTC), the most common endocrine malignancy is subdivided into papillary (the most common) and follicular type. Generally, DTC has a good prognosis with standard treatments such as surgery and, in some cases, radioactive iodine (RAI). Post-treatment follow-up includes thyroglobulin (Tg) and anti-thyroglobulin antibody (TgAb) measurement and imaging to assess treatment success and detect recurrence. However, TgAb can interfere with Tg measurements, making it essential to measure TgAb at different times (months).  Aim of the study: The aim of this study was to evaluate the changes in TgAb level in DTC patients after thyroidectomy and its association with recurrence.

METHODS

This was a retrospective cohort study done at the Faiha Specialized Diabetes, Endocrine, and Metabolism Center (FDEMC), Basrah, Iraq, for individuals diagnosed with DTC between 2008 and 2023. The data collected were analyzed using IBM SPSS Statistics for Windows, Version 21.0 (Released 2012; IBM Corp., Armonk, New York, United States). The categories were classified according to the TgAb level as: (i) elevated (>115 IU/ml) and (ii) normal (<115 IU/ml), where TgAb levels measured at 0-6 months, 6-12 months, 24-36 months, 36-48 months, and beyond 48 months.

RESULTS

The mean age at diagnosis of the study population (n=108) was 40.15 years with a female-to-male ratio of 4:1. Among these individuals, 52.8% (n=57) were found to be obese. Total thyroidectomy was performed on 84.3% (n=91). Papillary thyroid cancer was diagnosed in 69.5% (n=75). TgAb levels were influenced by body mass index (BMI); higher BMI (>30kg/m2) was associated with less consistent TgAb normalization, particularly beyond 48 months (P = 0.04). The study found no significant differences in TgAb normalization based on gender, age, BMI, type of surgery, type of cancer, American Thyroid Association (ATA) risk of recurrence, or radioactive iodine (RAI) treatment.

CONCLUSION

 Factors including gender, age, type of surgery, type of cancer, ATA risk of recurrence, and RAI treatment did not significantly affect TgAb normalization in DTC individuals over the study period. However, higher BMI is associated with less consistent TgAb normalization in the long term.

A nomogram for predicting adverse pathologic features in low-risk papillary thyroid microcarcinoma

BACKGROUND

Identifying risk factors for adverse pathologic features in low-risk papillary thyroid microcarcinoma (PTMC) can provide valuable insights into the necessity of surgical or non-surgical treatment. This study aims to develop a nomogram for predicting the probability of adverse pathologic features in low-risk PTMC patients.

METHODS

A total of 662 patients with low-risk PTMC who underwent thyroid surgery were retrospectively analyzed in Qilu Hospital of Shandong University from May 2019 to December 2021. Logistic regression analysis was used to determine the risk factors for adverse pathologic features, and a nomogram was constructed based on these factors.

RESULTS

Most PTMC patients with these adverse pathologic features had tumor diameters greater than 0.6 cm (p < 0.05). Other factors (age, gender, family history of thyroid cancer, history of autoimmune thyroiditis, and BRAFV600E mutation) had no significant correlation with adverse pathologic features (p > 0.05 each). The nomogram was drawn to provide a quantitative and convenient tool for predicting the risk of adverse pathologic features based on age, gender, family history of thyroid cancer, autoimmune thyroiditis, tumor size, and BRAFV600E mutation in low-risk PTMC patients. The areas under curves (AUC) were 0.645 (95% CI 0.580-0.702). Additionally, decision curve analysis (DCA) and calibration curves were used to evaluate the clinical benefits of this nomogram, presenting a high net benefit.

CONCLUSION

Tumor size > 0.60 cm was identified as an independent risk factor for adverse pathologic features in low-risk PTMC patients. The nomogram had a high predictive value and consistency based on these factors.

Organochlorine pesticides induce thyroid tumors through oxidative stress; an in vivo and in silico study

Thyroid disease is one of the most common endocrine problems around the world. Among the numerous factors, exposure to environmental elements such as pesticides is associated with an increase in the incidence of thyroid disorders. The aim of the present study was to investigate the role of organochlorine pesticides (OCPs) in induction of oxidative stress (OS) and development of thyroid tumors. This case-control study was conducted on 61 patients with papillary thyroid carcinoma (PTC), 70 patients with benign thyroid nodules (BTN), and 73 healthy individuals as control. Seven derived OCPs residues measured by gas chromatography (GC), and enzyme activities of acetylcholinesterase (AChE), superoxide dismutase3 (SOD3), catalase (CAT), glutathione peroxidase3 (GPx3) and paraoxonase1 (PON1) and also, non-enzymatic antioxidant including; malondialdehyde (MDA), total antioxidant capacity (TAC), protein carbonyl (PC), and nitric oxide (NO) biomarkers in all participants were investigated. Furthermore, all of the above enzymes were docked against measured OCPs. The results revealed that β-HCH, γ-HCH, 2,4 DDE, 4,4 DDE, 2,4-DDT, and 4,4-DDT levels along with MDA, NO, and PC levels were elevated, while AChE, SOD3, GPx3, CAT, and PON1 activities and TAC levels were decreased in the PTC and BTN groups compared with the control group. Therefore, OCPs might play a role in the development of thyroid tumors through several mechanisms including generation of OS. Importantly, in silico analysis confirmed the in vivo findings.

Association between Obesity Indexes and Thyroid Cancer Risk in Korean Women: Nested Case-Control Study

Objective: This study aimed to identify the association between various obesity indexes, including waist circumference (WC), waist−hip ratio (WHR), waist−height ratio (WHTR), and BMI, and their combinations with body mass index (BMI) and thyroid cancer risk. Methods: Of the 65,639 participants who completed a follow-up survey of the Health Examinee Study (HEXA), a prospective cohort of the Korean Genome and Epidemiology Study, 412 female incident thyroid cancer cases, and 1648 birth year- and enrollment year-matched female controls were included. Multiple conditional logistic regression was used to estimate the association between obesity indexes and thyroid cancer risk. Results: The risk of developing thyroid cancer was increased by 1.37-fold (95% confidence interval (CI) = 1.03−1.81) higher in the obese BMI group (≥25.0 Kg/m2) compared to that in the normal BMI group (<23.0 Kg/m2). Obesity in terms of WC (≥85.0 cm) and WHTR (≥0.5) was associated with an increased risk of thyroid cancer (OR 1.55, 95% CI = 1.16−2.07; OR 1.37, 95% CI = 1.07−1.75, respectively). However, increased WHR levels did not show any significant association. Women with both obese levels of BMI (≥25.0 Kg/m2) and other obesity indexes (WC ≥ 85.0 cm, WHR ≥ 0.85, or WHTR ≥ 0.5) showed an increased risk of thyroid cancer with OR of 1.63 (95% CI = 1.14−2.31), 1.49 (95% CI = 1.05−2.12), and 1.42 (95% CI = 1.04−1.94), compared to those with normal levels of BMI and each obesity index. Conclusion: These results provide evidence of the contribution of both total and central adiposity across the lifespan of thyroid cancer incidence. Risk factor modifications must be considered to explain the current thyroid cancer epidemic.

The Immune Landscape of Papillary Thyroid Cancer in the Context of Autoimmune Thyroiditis

Simple Summary

The association between papillary thyroid cancer and Hashimoto’s thyroiditis went through a long-standing human debate recently elucidated by the establishment of a novel mouse model. Papillary thyroid carcinoma is an excellent model for studying the tumor immune microenvironment because it is naturally accompanied by immune cells, making it a good candidate for the treatment with immune checkpoint inhibitors.

Abstract

Papillary thyroid cancer (PTC) often co-occurs with Hashimoto’s thyroiditis, an association that has long been reported in clinical studies, remaining controversial. Experimental evidence has recently shown that pre-existing thyroiditis has a beneficial effect on PTC growth and progression by a distinctive expansion of effector memory CD8 T cells. Although the link between inflammation and PTC might involve different components of the immune system, a deep characterization of them which includes T cells, B cells and tertiary lymphoid structures, Mye-loid cells, Neutrophils, NK cells and dendritic cells will be desirable. The present review article considers the role of the adaptive and innate immune response surrounding PTC in the context of Hashimoto’s thyroiditis. This review will focus on the current knowledge by in vivo and in vitro studies specifically performed on animals’ models; thyroid cancer cells and human samples including (i) the dual role of tumor-infiltrating lymphocytes; (ii) the emerging role of B cells and tertiary lymphoid structures; (iii) the role of myeloid cells, dendritic cells, and natural killer cells; (iv) the current knowledge of the molecular biomarkers implicated in the complex link between thyroiditis and PTC and the potential implication of cancer immunotherapy in PTC patients in the context of thyroiditis.

Thyroid nodules in childhood-onset Hashimoto's thyroiditis: Frequency, risk factors, follow-up course and genetic alterations of thyroid cancer

OBJECTIVE

We evaluated the frequency, risk factors and the follow-up outcomes of thyroid nodules, and genetic alterations in thyroid cancer, in youth with childhood-onset Hashimoto thyroiditis (HT) residing in an iodine-sufficient country.

DESIGN

A retrospective cohort study.

PATIENTS AND MEASUREMENTS

A total of 213 patients (194 females, mean age 10.6 years at the time of HT diagnosis) were ultrasonographically evaluated. Thyroid nodules were categorized using the Korean Thyroid Imaging Reporting and Data System (K-TIRADS) and the American College of Radiology Thyroid Imaging Reporting and Data System (ACR-TI-RADS).

RESULTS

Thyroid nodules were detected in 40 (18.8%) patients over a median follow-up period of 3.4 years, usually after the onset of puberty. A family history of thyroid disease (hazard ratio 2.1, p = .031) was predictive of thyroid nodule detection. Papillary thyroid carcinoma (PTC) was diagnosed in 9 (4.2% of all and 22.5% of nodule-positive patients). The malignant nodules had a higher K-TIRADS or ACR-TI-RADS risk level compared with benign nodules (p < .01 for both). Genetic alterations were revealed in 7 (BRAF^V600E in 6 and RET-ERC1 fusion in 1) of the eight available tumour tissue samples. None showed evidence of disease over a median follow-up period of 3.4 years.

CONCLUSIONS

The nodule detection rate was 18.8%, with a 22.5% risk of malignancy among the detected nodules in childhood-onset HT patients, showing increased risk in those with a family history. Additional large-scale studies are required to evaluate the usefulness of K-TIRADS or ACR-TI-RADS risk level for the differentiation of paediatric thyroid nodules.

Thyroid cancer and its associated factors: A population-based case-control study

Considering the rising incidence and mortality of thyroid cancer (TC) worldwide, the aim of our study was to determine the risk factors for TC in a province with the highest incidence of TC in the country located at the South of Iran. A population-based case-control study was performed on 708 participants (361 new cases and 347 controls). The case participants were selected from the Iranian National Cancer Registry database. Frequency matched for gender and age, and the control participants were selected randomly from the neighborhood of the cases. Based on the results of multiple logistic regression analysis, benign thyroid diseases (eg, hyperthyroidism OR_yes/no = 14.06, 95% CI: 5.13-38.51), family history of TC (OR_yes/no = 3.54, 95% CI: 1.51-8.26), radiation exposure of the head (OR_yes/no = 1.92, 95% CI: 1.03-3.60), family history of thyroid diseases (OR_yes/no = 1.76, 95% CI: 1.19-2.62) and family history of other types of cancer (OR_yes/no = 1.67, 95% CI: 1.01-2.74), significantly increased the risk of developing TC. On the other hand, high blood pressure (OR_yes/no = 0.35, 95% CI: 0.19-0.64), higher education (OR_{college/illiterate} = 0.54, 95% CI: 0.30-0.96), consumption of unsaturated fat (OR_{unsaturated/saturated} = 0.59, 95% CI: 0.39-0.87) and being married (OR_{married/single} = 0.60, 95% CI 0.37-0.98) were found to be protective factors. Some community-based interventions, for example, reduction in radiation exposure and screening members of families with underlying thyroid diseases may help in preventing or early diagnosis of TC. More studies on the health effects of local herbs are highly recommended.

Adequacy and Effectiveness of Watson For Oncology in the Treatment of Thyroid Carcinoma

BACKGROUND

IBM's Watson for Oncology (WFO) is an artificial intelligence tool that trains by acquiring data from the Memorial Sloan Kettering Cancer Center and learns from test cases and experts. This study aimed to analyze the adequacy and effectiveness of WFO in determining the treatment method for patients with thyroid carcinoma.

MATERIALS AND METHODS

We retrospectively enrolled 50 patients with thyroid cancer who underwent surgery in 2018 and entered their clinical data into WFO. The WFO treatment recommendations were compared with the surgical procedures and recommended treatments performed according to the Korean Thyroid Endocrine Surgery Association guidelines.

RESULTS

The overall concordance rate between WFO-recommended treatments and actual surgical treatments was 48%, and for patients with stage I, II, and III disease, these rates were 52.4, 50, and 16.7%, respectively. A lower concordance rate was observed with respect to treatment for advanced thyroid cancer.

CONCLUSION

WFO is a useful clinical aid but must be used with caution. A surgeon's decision takes precedence over WFO recommendations in the treatment of advanced thyroid cancer.

Association between Family Histories of Thyroid Cancer and Thyroid Cancer Incidence: A Cross-Sectional Study Using the Korean Genome and Epidemiology Study Data

This study assessed the association between thyroid cancer and family history. This cross-sectional study used epidemiological data from the Korean Genome and Epidemiology Study from 2001 to 2013. Among 211,708 participants, 988 were in the thyroid cancer group and 199,588 were in the control group. Trained interviewers questioned the participants to obtain their thyroid cancer history and age at onset. The participants were examined according to their age, sex, monthly household income, obesity, smoking, alcohol consumption, and past medical history. The adjusted odds ratios (95% confidence intervals) for the family histories of fathers, mothers, and siblings were 6.59 (2.05–21.21), 4.76 (2.59–8.74), and 9.53 (6.92–13.11), respectively, and were significant. The results for the subgroup analyses according to sex were consistent. The rate of family histories of thyroid cancer for fathers and siblings were not different according to the thyroid cancer onset, while that of mothers were higher in participants with a younger age at onset (<50 years old group, 11/523 [2.1%], p = 0.007). This study demonstrated that thyroid cancer incidence was associated with thyroid cancer family history. This supports regular examination of individuals with a family history of thyroid cancer to prevent disease progression and ensure early management.

Nutritional status and follicular-derived thyroid cancer: An update

The incidence of differentiated thyroid cancer has been increasing in the last decades all over the world. Such a steady growth cannot be entirely attributable to more intensive thyroid nodule screening and more sensitive diagnostic procedures. Several environmental factors have changed with sufficient rapidity in the same time frame and may represent credible candidates for this increase. They include modified iodine intake, lifestyle-associated risk factors, exposure to various toxic compounds, pollutants and xenobiotics, nutritional deficiencies, eating habits and comorbidities. Foremost, nutritional patterns have gained high interest as possible promoters and modifiable risk factors for thyroid cancer in recent years. The aim of this narrative review is to focus on the relationship between thyroid cancer and nutritional factors, dietary habits and obesity. Low iodine intake has been associated to increased risk of thyroid cancer, favoring the development of more aggressive histotypes. Moreover, correction of iodine deficiency can shift thyroid cancer subtypes toward less aggressive forms, without affecting the overall risk for cancer. Actually, evidence regarding the association between selenium and vitamin D deficiency and thyroid cancer is very limited, despite their well-known anti-cancer potentials, and the clinical usefulness of their supplementation is still uncertain in this setting. Albeit the relationship between single foods and thyroid cancer is difficult to examine, fish and iodine-rich foods, vegetables, and fruits might exert protective effects on thyroid cancer risk. Conversely, no clear association has been found for other foods to date. Lastly, a clear association between obesity and the risk of thyroid cancer, with more aggressive behavior, seems to emerge from most studies, likely involving variations in thyroid function and chronic inflammation mediated by cytokines, insulin, leptin and adiponectins. Although no definite association between dietary factors and thyroid cancer has been firmly established so far, some nutritional patterns, together with excessive weight, seem to play a relevant role in thyroid cancer carcinogenesis as well as in its severity and aggressiveness. These effects may play an additive role to the well-established one exerted by environmental carcinogens, such as pollutants and radiation exposure.

Geographic influences in the global rise of thyroid cancer

The incidence of thyroid cancer is on the rise, and this disease is projected to become the fourth leading type of cancer across the globe. From 1990 to 2013, the global age-standardized incidence rate of thyroid cancer increased by 20%. This global rise in incidence has been attributed to several factors, including increased detection of early tumours, the elevated prevalence of modifiable individual risk factors (for example, obesity) and increased exposure to environmental risk factors (for example, iodine levels). In this Review, we explore proven and novel hypotheses for how modifiable risk factors and environmental exposures might be driving the worldwide increase in the incidence of thyroid cancer. Although overscreening and the increased diagnosis of possibly clinically insignificant disease might have a role in certain parts of the world, other areas could be experiencing a true increase in incidence due to elevated exposure risks. In the current era of personalized medicine, national and international registry data should be applied to identify populations who are at increased risk for the development of thyroid cancer.

Increased Incidence of Thyroid Cancer among World Trade Center First Responders: A Descriptive Epidemiological Assessment

An increased incidence of thyroid cancer among 9/11 rescue workers has been reported, the etiology of which remains unclear but which may, at least partly, be the result of the increased medical surveillance this group undergoes. This study aimed to investigate thyroid cancer in World Trade Center (WTC) responders by looking at the demographic data and questionnaire responses of thyroid cancer cases from the Mount Sinai WTC Health Program (WTCHP). WTCHP thyroid cancer tumors were of a similar size (p = 0.4), and were diagnosed at a similar age (p = 0.2) compared to a subset of thyroid cancer cases treated at Mount Sinai without WTC exposure. These results do not support the surveillance bias hypothesis, under which smaller tumors are expected to be diagnosed at earlier ages. WTCHP thyroid cancer cases also reported a past history of radiation exposure and a family history of thyroid conditions at lower rates than expected, with higher than expected rates of previous cancer diagnoses, family histories of other cancers, and high Body Mass Indexes (BMIs). Further research is needed to better understand the underlying risk factors that may play a role in the development of thyroid cancer in this group.

American Head and Neck Society Endocrine Section clinical consensus statement: North American quality statements and evidence-based multidisciplinary workflow algorithms for the evaluation and management of thyroid nodules

BACKGROUND

Care for patients with thyroid nodules is complex and multidisciplinary, and research demonstrates variation in care. The objective was to develop clinical guidelines and quality metrics to reduce unwarranted variation and improve quality.

METHODS

Multidisciplinary expert consensus and modified Delphi approach. Source documents were workflow algorithms from Kaiser Permanente Northern California and Cancer Care of Ontario based on the 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer.

RESULTS

A consensus-based, unified preoperative, perioperative, and postoperative workflow was developed for North American use. Twenty-one panelists achieved consensus on 16 statements about workflow-embedded process and outcomes metrics addressing safety, access, appropriateness, efficiency, effectiveness, and patient centeredness of care.

CONCLUSION

A panel of Canadian and United States experts achieved consensus on workflows and quality metric statements to help reduce unwarranted variation in care, improving overall quality of care for patients diagnosed with thyroid nodules.

Bethesda thyroid categories and family history of thyroid disease

OBJECTIVE

Thyroid cancer is the most common type of endocrine-related cancer worldwide. The aim of this article was to assess the relationship between thyroid diseases diagnosed by fine needle aspiration (FNA) and family history of thyroid disease.

DESIGN

The study was conducted in a tertiary high-volume thyroid cancer centre. Fine needle aspiration (FNA) of a thyroid nodule detected on neck ultrasound for any reason was performed in all included patients.

PATIENTS

A total of 10 709 patients were included in the study.

MEASUREMENTS

Correlation of cytological findings classified according to the Bethesda system and family history was calculated using Fisher's exact test.

RESULTS

There were 2580 (24.09%) patients with non-malignant thyroid diseases in the family and 198 (1.85%) patients who had a history of thyroid cancer in the family. A total of 2778 (25.94%) patients had positive family history of thyroid diseases, and 7931 (74.06%) patients had negative family history. In patients with papillary thyroid carcinoma in family history, the difference between those with benign (Bethesda 2) and malignant thyroid FNA diagnosis (Bethesda 6) was found to be statistically significant (P = .0432).

CONCLUSIONS

Family history plays a significant role in the development of thyroid cancer, and having first-degree relatives with not only medullary, but also papillary thyroid cancer strongly predicts the risk of developing the malignant thyroid disease. In contrast, benign thyroid disorders in family history do not lead to the development of thyroid cancer.

Incidental finding of papillary thyroid carcinoma on CT examination of mandibular lesion: Case report

The number of significant incidental findings identified on radiographic examinations has increased. In total, 169 patients, 87 males and 82 females, with a mean age of 67.3 years (range, 17-92 years), as well as 65 patients (38.5%), 43 (66.2%) female and 22 (33.8%) male had abnormal findings in the thyroid for one year in our institution. Thyroid nodules are the most common incidental findings on oral and maxillofacial evaluations. Computed tomography (CT) and magnetic resonance imaging (MRI) examination are frequently used to detect thyroid abnormality. The present study reported a case of papillary thyroid carcinoma (PTC) detected following CT and MRI examination of a mandibular lesion. The CT examination of the oral and maxillofacial region included the thyroid, which must be examined carefully to detect various diseases, including PTC. Collaboration between radiologists and clinicians is important to manage these incidental findings.

NYPD Cancer Incidence Rates 1995-2014 Encompassing the Entire World Trade Center Cohort

OBJECTIVE

The aim of this study was to compare cancer incidence rates (CIRs), between preexposure (1995-2000) and postexposure (2002-2014) periods in the entire New York City Police Department cohort exposed to the 2001 World Trade Center (WTC) disaster.

METHODS

CIR derived from active duty officer records, including postexposure data on retired officers.

RESULTS

We observed 870 cancer cases in 859 officers (1995-2014), including 193 active duty cases pre-WTC and 677 cases (484 active duty, 193 retired) post-WTC. Overall, median CIR increased 1.44-fold compared with pre-WTC, with brain cancer increasing 3.27-fold, and kidney cancer increasing similarly. Thyroid cancer and non-Hodgkin's lymphoma increased 2.29 and 1.68-fold, respectively.

CONCLUSIONS

Findings should be interpreted cautiously, given the small number of cancers at specific sites, and possibility of confounders. However, apparent increases in cancers overall, and in highlighted sites, remain of concern, underscoring the need for continued monitoring of this cohort.

Risk Factors for Thyroid Cancer: A Hospital-Based Case-Control Study in Korean Adults

PURPOSE

Although the incidence of thyroid cancer in Korea has rapidly increased over the past decade, few studies have investigated its risk factors. This study examined the risk factors for thyroid cancer in Korean adults.

MATERIALS AND METHODS

The study design was a hospital-based case-control study. Between August 2002 and December 2011, a total of 802 thyroid cancer cases out of 34,211 patients screened from the Cancer Screenee. Cohort of the National Cancer Center in South Korea were included in the analysis. A total of 802 control cases were selected from the same cohort, and matched individually (1:1) by age (±2 years) and area of residence for control group 1 and additionally by sex for control group 2.

RESULTS

Multivariate conditional logistic regression analysis using the control group 1 showed that females and those with a family history of thyroid cancer had an increased risk of thyroid cancer, whereas ever-smokers and those with a higher monthly household income had a decreased risk of thyroid cancer. On the other hand, the analysis using control group 2 showed that a family history of cancer and alcohol consumption were associated with a decreased risk of thyroid cancer, whereas higher body mass index (BMI) and family history of thyroid cancer were associated with an increased risk of thyroid cancer.

CONCLUSION

These findings suggest that females, those with a family history of thyroid cancer, those with a higher BMI, non-smokers, non-drinkers, and those with a lower monthly household income have an increased risk of developing thyroid cancer.

Association of rs6983267 Polymorphism and Thyroid Cancer Susceptibility: A Systematic Review and Meta-Analysis

Background

Recent genome-wide association studies have identified rs6983267 polymorphism as a key locus in the 8q24 region associated with multisite cancers. However, the information on its association with thyroid cancer is inconclusive. The aim of this study was to determine whether this locus is a risk factor for susceptibility to thyroid cancer by conducting a meta-analysis.

Material/Methods

Relevant studies were identified by searching PubMed and Embase databases. The pooled odds ratio (OR) and corresponding 95% confidence interval (95% CI) were calculated.

Results

A total of 4 studies including 2825 cases and 9684 controls were enrolled to this meta-analysis. The pooled data showed the G allele of the rs6983267 polymorphism is a risk factor for susceptibility to thyroid cancer (OR=1.08, 95%CI: 1.02–1.16, P=0.01). Significant associations were also found in homozygote comparison (GG vs. TT: OR=1.17, 95%CI: 1.03–1.33, P=0.02) and dominant model (GG+GT vs. TT: OR=1.13, 95%CI: 1.01–1.26, P=0.03). Borderline significant associations in similar directions were found in the recessive model (GG vs. GT+TT: OR=1.10, 95%CI: 0.99–1.22, P=0.07) and heterozygote comparison (GT vs. TT: OR=1.10, 95%CI: 0.99–1.24, P=0.09).

Conclusions

Our meta-analysis shows that the rs6983267 G>T polymorphism might be associated with higher risk of thyroid cancer. Further research with larger sample sizes and full investigation of confounding risk factors is needed to confirm or revise our conclusions.

Selected single-nucleotide polymorphisms in FOXE1, SERPINA5, FTO, EVPL, TICAM1 and SCARB1 are associated with papillary and follicular thyroid cancer risk: replication study in a German population

Several single-nucleotide polymorphisms (SNPs) have been associated with papillary and follicular thyroid cancer (PTC and FTC, respectively) risk, but few have replicated. After analyzing 17525 tag SNPs in 1129 candidate genes, we found associations with PTC risk in SERPINA5, FTO, HEMGN (near FOXE1) and other genes. Here, we report results from a replication effort in a large independent PTC/FTC case-control study conducted in Germany. We evaluated the best tagging SNPs from our previous PTC study and additionally included SNPs in or near FOXE1 and NKX2-1 genes, known susceptibility loci for thyroid cancer. We genotyped 422 PTC and 130 FTC cases and 752 controls recruited from three German clinical centers. We used polytomous logistic regression to simultaneously estimate PTC and FTC associations for 79 SNPs based on log-additive models. We assessed effect modification by body mass index (BMI), gender and age for all SNPs, and selected SNP by SNP interactions. We confirmed associations with PTC and SNPs in FOXE1/HEMGN, SERPINA5 (rs2069974), FTO (rs8047395), EVPL (rs2071194), TICAM1 (rs8120) and SCARB1 (rs11057820) genes. We found associations with SNPs in FOXE1, SERPINA5, FTO, TICAM1 and HSPA6 and FTC. We found two significant interactions between FTO (rs8047395) and BMI (P = 0.0321) and between TICAM1 (rs8120) and FOXE1 (rs10984377) (P = 0.0006). Besides the known associations with FOXE1 SNPs, we confirmed additional PTC SNP associations reported previously. We also found several new associations with FTC risk and noteworthy interactions. We conclude that multiple variants and host factors might interact in complex ways to increase risk of PTC and FTC.

Anthropometric Risk Factors for Differentiated Thyroid Cancer in Young Men and Women From Eastern France: A Case-Control Study

The incidence of thyroid cancer has risen over the past decade, along with a rise in obesity. We studied the role of anthropometric risk factors for differentiated thyroid cancer at the time of diagnosis and at age 20 years in a case-control study conducted in eastern France between 2005 and 2010. The study included 761 adults diagnosed with differentiated thyroid cancer before 35 years of age between 2002 and 2006. They were matched with 825 controls from the general population. Odds ratios were calculated using conditional logistic regression models and were reported for all participants, those with papillary cancer only, and women only. The risk of thyroid cancer was higher for participants with a high body surface area (BSA), great height, or excess weight and for women with a high body fat percentage. Conversely, no significant association was found between body mass index and the risk of thyroid cancer. In the present study, we provide further evidence of the role of BSA and excess weight in the risk of thyroid cancer. These epidemiologic observations should be confirmed by further exploration of the biological mechanisms responsible for the associations of obesity and BSA with thyroid cancer.

Clinical presentation of patients with a thyroid follicular neoplasm: are there preoperative predictors of malignancy?

BACKGROUND

Studies examining differences in presentation of patients with benign [follicular adenoma (FA)] and malignant follicular thyroid neoplasms [follicular thyroid carcinoma (FTC) or follicular variant papillary thyroid carcinoma (FVPTC)] include only one or two of these subtypes, and none has considered clinical, cytological, and sonographic features together. We therefore examined presenting clinical features of all benign and malignant follicular neoplasm subtypes in an attempt to identify predictors of malignancy.

METHODS

Consecutive patients with a surgically resected follicular thyroid neoplasm at a tertiary hospital from 2005 to 2013 were reviewed. Age, gender, symptoms, history, physical findings, nodule size, sonographic, cytologic, and final pathologic results were recorded. Multivariate logistic regression was used to determine variables that contributed to a diagnosis of malignant follicular neoplasm.

RESULTS

A total of 616 patients (163 males, 453 females) presented with 441 FAs, 17 FTCs, and 158 FVPTCs. On multivariate analysis, male sex [odds ratio (OR) 1.87, p = 0.008], family history of thyroid cancer (OR 5.16, p < 0.001), and history of head and neck radiation (OR 2.01, p = 0.04) were associated with an increased odds of malignancy; age >45 (OR 2.03, p = 0.001), dysphagia (OR 3.48, p = 0.001) or pressure sensation (OR 3.00, p = 003), concomitant hyperthyroidism (OR 4.76, p = 0.01), nodules ≥4 cm (OR 3.68, p < 0.001), and multinodularity on physical examination (OR 1.93, p = 0.004) were associated with an increased odds of a benign lesion.

CONCLUSIONS

Independent clinical predictors exist that might be helpful in preoperative differentiation of benign and malignant follicular neoplasms. A combination of these predictors with both FNA and molecular results may help us to improve the clinical management of patients with follicular thyroid lesions.

Association of Pre-miR-146a rs2910164 Polymorphism with Papillary Thyroid Cancer

The incidence rate of papillary thyroid cancer (PTC) has increased over the past decades, but the pathogenesis remains unclear. rs2910164, located in pre-miR-146a, has been studied in PTCs with different ethnicity, but the results were inconsistent. Here we evaluate the association between rs2910164 polymorphism and PTC and investigate the effect of this polymorphism on patients' clinicopathological characteristics. 1238 PTC patients and 1275 controls, all Han population, from Northern China, were included in our study. rs2910164 was genotyped using Matrix-Assisted Laser Desorption/Ionization Time of Flight Mass Spectrometry (MALDI-TOF-MS). Analysis of inheritance model was performed using the SNPStats program. Strength of association was assessed by odds ratio (OR) and 95% confidence interval (CI). Overall, no statistical difference in rs2910164 genotype distribution and allelic frequencies between cases and controls was found, and patients with different genotypes had similar clinicopathological characteristics in terms of stage, location, concurrent of benign thyroid tumor, and thyroiditis, while, as the number of G alleles increased, proportion of patients aged ≥45 years and those without metastasis increased (P trend < 0.001 and P trend = 0.003, resp.). However, no association remained significant after Bonferroni correction under any model of inheritance. Our results suggest no association between rs2910164 polymorphism with PTC and patients' clinicopathological characteristics.

Menstrual and reproductive factors in the risk of differentiated thyroid carcinoma in young women in France: a population-based case-control study

The incidence of thyroid cancer has increased in eastern Europe since the Chernobyl nuclear power plant accident. Although the radioactive fallout was much less severe and the thyroid radiation dose was much lower in France, a case-control study was initiated in eastern France. The present study included 633 young women who were diagnosed with differentiated thyroid cancer before 35 years of age between 2002 and 2006 and matched with 677 controls. Face-to-face interviews were conducted from 2005 to 2010. Odds ratios were calculated using conditional logistic regressions and were reported in the total group and by histopathological type of cancer ("only papillary" and "excluding microcarcinomas"). The risk of thyroid cancer was higher in women who had a higher number of pregnancies, used a lactation suppressant, or had early menarche. Conversely, breastfeeding, oral contraceptive use, and late age at first pregnancy were associated with a lower risk of thyroid cancer. No association was observed between thyroid cancer and having irregular menstrual cycle, undergoing treatment for menstrual cycle regularity shortly after menarche, having a cessation of menstruation, use of another contraceptive, history of miscarriage or abortion for the first pregnancy, or having had gestational diabetes. This study confirms the role of hormonal and reproductive factors in thyroid cancer, and our results support the fact that exposure to estrogens increases thyroid cancer risk.

Risk-based ultrasound screening for thyroid cancer in obese patients is cost-effective

BACKGROUND

A higher body mass index (BMI) is associated with more advanced stages of thyroid cancer. Screening obese patients for thyroid cancer has been proposed but has yet to be examined for cost-effectiveness. The objective of this study was to assess the cost-effectiveness of ultrasound (US) screening of obese patients for thyroid cancer.

METHODS

A decision-tree model compared cost savings for the following: (i) base case scenario of an obese patient with thyroid nodule found by palpation, (ii) universal US screening of all obese patients, and (iii) risk-based US screening in obese patients. Risk-based screening consisted of patients who had at least one of four major identified risk factors for thyroid cancer (family history of thyroid cancer, radiation exposure, Hashimoto's thyroiditis, and/or elevated thyrotropin). Patients with nodules underwent established treatment and management guidelines. The model accounted for recurrence, complications, and long-term treatment/follow-up for five years. Outcome probabilities were identified from a literature review. Costs were estimated using a third-party payer perspective. Sensitivity analyses were performed to examine the impact of risk factor prevalence and US cost on the model.

RESULTS

The resulted costs per patient were $210.73 in the base case scenario, $434.10 in the universal US screening arm, and $166.72 in the risk-based screening arm. Risk-based screening remained cost-effective until more than 14% of obese patients had risk factors and with a wide variation of US costs ($0-$1113).

CONCLUSION

Risk-based US screening in selected obese patients with risk factors for thyroid cancer is cost-effective. Recommendations for screening this subgroup will result in cost savings and a likely decreased morbidity and mortality in this subpopulation with more aggressive disease.

Association of ATM Gene Polymorphism with PTC Metastasis in Female Patients

Ataxia telangiectasia mutated (ATM) gene is critical in the process of recognizing and repairing DNA lesions and is related to invasion and metastasis of malignancy. The incidence rate of papillary thyroid cancer (PTC) has increased for several decades and is higher in females than males. In this study, we want to investigate whether ATM polymorphisms are associated with gender-specific metastasis of PTC. 358 PTC patients in Northern China, including 109 males and 249 females, were included in our study. Four ATM single nucleotide polymorphisms (SNPs) were genotyped using Matrix-Assisted Laser Desorption/Ionization Time of Flight Mass Spectrometry (MALDI-TOF-MS). Association between genotypes and the gender-specific risk of metastasis was assessed by odds ratios (OR) and 95% confidence intervals (CI) under the unconditional logistic regression analysis. Significant associations were observed between rs189037 and metastasis of PTC in females under different models of inheritance (codominant model: OR = 0.15, 95% CI 0.04-0.56, P = 0.01 for GA versus GG and OR = 0.08, 95% CI 0.01-0.74, P = 0.03 for AA versus GG, resp.; dominant model: OR = 0.49, 95% CI 0.25-0.98, P = 0.04; overdominant model: OR = 0.47, 95% CI 0.25-0.89, P = 0.02). However, no association remained significant after Bonferroni correction. Our findings suggest a possible association between ATM rs189037 polymorphisms and metastasis in female PTCs.

Ultra-rare mutation in long-range enhancer predisposes to thyroid carcinoma with high penetrance

Thyroid cancer shows high heritability but causative genes remain largely unknown. According to a common hypothesis the genetic predisposition to thyroid cancer is highly heterogeneous; being in part due to many different rare alleles. Here we used linkage analysis and targeted deep sequencing to detect a novel single-nucleotide mutation in chromosome 4q32 (4q32A>C) in a large pedigree displaying non-medullary thyroid carcinoma (NMTC). This mutation is generally ultra-rare; it was not found in 38 NMTC families, in 2676 sporadic NMTC cases or 2470 controls. The mutation is located in a long-range enhancer element whose ability to bind the transcription factors POU2F and YY1 is significantly impaired, with decreased activity in the presence of the C- allele compared with the wild type A-allele. An enhancer RNA (eRNA) is transcribed in thyroid tissue from this region and is greatly downregulated in NMTC tumors. We suggest that this is an example of an ultra-rare mutation predisposing to thyroid cancer with high penetrance.

Common single nucleotide polymorphisms in genes related to immune function and risk of papillary thyroid cancer

Accumulating evidence suggests that alterations in immune function may be important in the etiology of papillary thyroid cancer (PTC). To identify genetic markers in immune-related pathways, we evaluated 3,985 tag single nucleotide polymorphisms (SNPs) in 230 candidate gene regions (adhesion-extravasation-migration, arachidonic acid metabolism/eicosanoid signaling, complement and coagulation cascade, cytokine signaling, innate pathogen detection and antimicrobials, leukocyte signaling, TNF/NF-kB pathway or other) in a case-control study of 344 PTC cases and 452 controls. We used logistic regression models to estimate odds ratios (OR) and calculate one degree of freedom P values of linear trend (P(SNP-trend) ) for the association between genotype (common homozygous, heterozygous, variant homozygous) and risk of PTC. To correct for multiple comparisons, we applied the false discovery rate method (FDR). Gene region- and pathway-level associations (P(Region) and P(Pathway)) were assessed by combining individual P(SNP-trend) values using the adaptive rank truncated product method. Two SNPs (rs6115, rs6112) in the SERPINA5 gene were significantly associated with risk of PTC (P(SNP-FDR)/P(SNP-trend)= 0.02/6×10(-6) and P(SNP-FDR)/P(SNP-trend)= 0.04/2×10(-5), respectively). These associations were independent of a history of autoimmune thyroiditis (OR = 6.4; 95% confidence interval: 3.0-13.4). At the gene region level, SERPINA5 was suggestively associated with risk of PTC (P(Region-FDR)/P(Region)= 0.07/0.0003). Overall, the complement and coagulation cascade pathway was the most significant pathway (P(Pathway)= 0.02) associated with PTC risk largely due to the strong effect of SERPINA5. Our results require replication but suggest that the SERPINA5 gene, which codes for the protein C inhibitor involved in many biological processes including inflammation, may be a new susceptibility locus for PTC.

Ultrasonographic screening for thyroid cancer in siblings of patients with apparently sporadic papillary carcinoma

BACKGROUND

Epidemiological studies have shown a higher risk of thyroid cancer among individuals who have a relative with papillary thyroid cancer (PTC) compared to those without a family history. This study evaluated the prevalence of thyroid cancer among subjects with only one first-degree relative (sibling) with PTC who had no palpable nodules, factors predictive of this malignancy, and the characteristics of tumors discovered during ultrasonographic screening.

METHODS

A total of 757 siblings of 447 patients with apparently sporadic PTC were examined. Nodules were palpable in 34 subjects (excluded). The 723 individuals without palpable abnormalities were submitted to thyroid ultrasonography and comprised the study group. The control group, consisting of 241 volunteers without a family history of thyroid cancer matched for gender and age to the study group, was also submitted to thyroid ultrasonography. All nodules ≥ 5 mm were examined by fine-needle aspiration cytology. Subjects with benign cytology were not submitted to surgery, whereas the subjects having malignant, suspicious for a malignancy, indeterminate, or inadequate cytology were referred for thyroidectomy.

RESULTS

Ultrasonography detected nodules in 303 (41.9%) study subjects. PTC was observed in 5.94% of the 723 subjects studied (8% women and 3.75% men, p=0.017) and in 14.2% of the 303 subjects with nonpalpable nodular disease. In the control group, 80 (33.2%) of the volunteers had nodules. PTC was observed in 1.2% of them and in 3.8% of those with nodular disease. In addition, 7.17% of the 447 patients had siblings with PTC detected only by ultrasonography. Multicentricity of the tumor was the main predictor of the presence of malignancy in siblings of patients with PTC. Twenty-two subjects (3% of those screened) had tumors that were not intrathyroid microcarcinomas (whereas all three tumors detected in controls were intrathyroid microcarcinomas). Screening permitted an earlier diagnosis of the disease when compared to siblings with a spontaneous diagnosis.

CONCLUSIONS

The present results favor ultrasonographic screening of first-degree relatives of patients with apparently sporadic multicentric PTC, especially among women.