Attaining biochemical euthyroidism early after total thyroidectomy in Graves' disease may lower long-term morbidity risk.

BACKGROUND: The relationship between good early control of thyroid hormone levels after thyroidectomy for Graves' disease (GD) and subsequent risks of mortality and morbidities is not well known. The aim of this study was to examine the association between thyroid hormone levels within a short interval after surgery and long-term mortality and morbidity risks from a population-based database. METHODS: Patients with GD who underwent complete/total thyroidectomy between 2006 and 2018 were selected from the Hong Kong Hospital Authority clinical management system. All patients were classified into three groups (euthyroidism, hypothyroidism, and hyperthyroidism) according to their thyroid hormone levels at 6, 12, and 24 months after surgery. Cox proportional hazards models were performed to compare the risks of all-cause mortality, cardiovascular disease (CVD), Graves' ophthalmopathy, and cancer. RESULTS: Over a median follow-up of 68 months with 5709 person-years, 949 patients were included for analysis (euthyroidism, n = 540; hypothyroidism, n = 282; and hyperthyroidism, n = 127). The hypothyroidism group had an increased risk of CVD (HR = 4.20, 95 per cent c.i. 2.37 to 7.44, P < 0.001) and the hyperthyroidism group had an increased risk of cancer (HR = 2.14, 95 per cent c.i. 1.55 to 2.97, P < 0.001) compared with the euthyroidism group. Compared with patients obtaining euthyroidism both at 6 months and 12 months, the risk of cancer increased in patients who achieved euthyroidism at 6 months but had an abnormal thyroid status at 12 months (HR = 2.33, 95 per cent c.i. 1.51 to 3.61, P < 0.001) and in those who had abnormal thyroid status at 6 months but achieved euthyroidism at 12 months (HR = 2.52, 95 per cent c.i. 1.60 to 3.97, P < 0.001). CONCLUSIONS: This study showed a higher risk of CVD in postsurgical hypothyroidism and a higher risk of cancer in hyperthyroidism compared with achieving euthyroidism early after thyroidectomy. Patients who were euthyroid at 6 months and 12 months had better outcomes than those achieving euthyroidism only at 6 months or 12 months. Attaining biochemical euthyroidism early after thyroidectomy should become a priority.

Long-term outcome of patients treated with antithyroid drugs, radioactive iodine or surgery for persistent or relapsed Graves' disease.

BACKGROUND: The aim of this study was to compare long-term mortality, morbidity, and cumulative healthcare costs between antithyroid drugs, radioactive iodine, and surgical treatment for patients with persistent or relapsed Graves' disease. METHODS: Data on patients with persistent or relapsed Graves' disease between 2006 and 2018 were retrieved from the Hong Kong Hospital Authority. Hazard ratios (HRs) estimated by Cox proportional hazards regression models were used to compare the risks of all-cause mortality, cardiovascular disease, atrial fibrillation, psychological disease, Graves' ophthalmopathy, and cancer across treatment groups. The 10-year healthcare cost and change in co-morbidity status were also estimated. RESULTS: Over a median follow-up of 79 months (22 636 person-years), a total of 3443 patients (antithyroid drug 2294, radioactive iodine 755, surgery 394) were analysed. Compared with antithyroid drug treatment, surgery was associated with significantly lower risks of all-cause mortality (HR 0.40, 95 per cent c.i. 0.36 to 0.45), cardiovascular disease (HR 0.54, 0.48 to 0.60), atrial fibrillation (HR 0.11, 0.09 to 0.14), psychological disease (HR 0.85, 0.79 to 0.92), Graves' ophthalmopathy (HR 0.09, 0.08 to 0.10), and cancer (HR 0.56, 0.50 to 0.63). Patients who underwent surgery also had a lower risk of all outcome events than those in the radioactive iodine group. The 10-year direct cumulative healthcare cost was €14 754 for surgery compared with €17 390 for antithyroid drugs, and €17 918 for the radioactive iodine group. CONCLUSION: Patients who underwent surgery for persistent or relapsed Graves' disease had lower risks of all-cause mortality and analysed morbidities. The 10-year cumulative healthcare cost in the surgery group was lowest among the three treatment alternatives.

Diagnostic performance evaluation of different TI-RADS using ultrasound computer-aided diagnosis of thyroid nodules: An experience with adjusted settings.

BACKGROUND: Thyroid cancer diagnosis has evolved to include computer-aided diagnosis (CAD) approaches to overcome the limitations of human ultrasound feature assessment. This study aimed to evaluate the diagnostic performance of a CAD system in thyroid nodule differentiation using varied settings. METHODS: Ultrasound images of 205 thyroid nodules from 198 patients were analysed in this retrospective study. AmCAD-UT software was used at default settings and 3 adjusted settings to diagnose the nodules. Six risk-stratification systems in the software were used to classify the thyroid nodules: The American Thyroid Association (ATA), American College of Radiology Thyroid Imaging, Reporting, and Data System (ACR-TIRADS), British Thyroid Association (BTA), European Union (EU-TIRADS), Kwak (2011) and the Korean Society of Thyroid Radiology (KSThR). The diagnostic performance of CAD was determined relative to the histopathology and/or cytology diagnosis of each nodule. RESULTS: At the default setting, EU-TIRADS yielded the highest sensitivity, 82.6% and lowest specificity, 42.1% while the ATA-TIRADS yielded the highest specificity, 66.4%. Kwak had the highest AUROC (0.74) which was comparable to that of ACR, ATA, and KSThR TIRADS (0.72, 0.73, and 0.70 respectively). At a hyperechoic foci setting of 3.5 with other settings at median values; ATA had the best-balanced sensitivity, specificity and good AUROC (70.4%; 67.3% and 0.71 respectively). CONCLUSION: The default setting achieved the best diagnostic performance with all TIRADS and was best for maximizing the sensitivity of EU-TIRADS. Adjusting the settings by only reducing the sensitivity to echogenic foci may be most helpful for improving specificity with minimal change in sensitivity.

MicroRNA-125b Interacts with Foxp3 to Induce Autophagy in Thyroid Cancer.

Thyroid cancer is rapidly increasing in incidence worldwide. Although most thyroid cancer can be cured with surgery, radioactive iodine, and/or chemotherapy, thyroid cancers still recur and may become chemoresistant. Autophagy is a complex self-degradative process that plays a dual role in cancer development and progression. In this study, we found that miR-125b was downregulated in tissue samples of thyroid cancer as well as in thyroid cancer cell lines, and the expression of Foxp3 was upregulated. Further, we demonstrated that miR-125b could directly act on Foxp3 by binding to its 3' UTR and inhibit the expression of Foxp3. A negative relationship between miR-125b and Foxp3 was thus revealed. Overexpression of miR-125b markedly sensitized thyroid cancer cells to cisplatin treatment by inducing autophagy through an Atg7 pathway in vitro and in vivo. Taken together, our findings demonstrate a novel mechanism by which miR-125b has the potential to negatively regulate Foxp3 to promote autophagy and enhance the efficacy of cisplatin in thyroid cancer. miR-125 may be of therapeutic significance in thyroid cancer.

Computer-aided assessment of regional vascularity of thyroid nodules for prediction of malignancy.

Color Doppler vascular index (VI) was assessed alone and in combination with grey-scale ultrasound (GSU) in regionally subdivided thyroid nodules in diagnosing thyroid cancer. Color Doppler sonograms of 111 thyroid nodules were evaluated by a home-developed algorithm that performed "offsetting" (algorithm for changing the area of a region of interest, ROI, without distorting the ROI's contour) and assessed peripheral, central and overall VI of thyroid nodules. Results showed that the optimum offset for dividing peripheral and central regions of nodule was 22%. At the optimum offset, the mean VI of peripheral, central, and overall regions of malignant nodules were significantly higher than those of benign nodules (26.5 ± 16.2%, 21.7 ± 19.6%, 23.8 ± 4.6% v/s 18.2 ± 16.7%, 11.9 ± 15.1% and 16.6 ± 1.8% respectively, P < 0.05). The optimum cut-off of peripheral, central, and overall VI was 19.7%, 9.1% and 20.2% respectively. When compared to GSU alone, combination of VI assessment with GSU evaluation of thyroid nodules increased the diagnostic accuracy from 58.6% to 79.3% (P < 0.05). In conclusion, a novel algorithm for regional subdivision and quantification of thyroid nodular VI in ultrasound images was established, and the optimum offset and cut-off were derived. Assessment of intranodular VI in conjunction with GSU can increase the accuracy in ultrasound diagnosis of thyroid cancer.

Expression of Antioxidant Molecules and Heat Shock Protein 27 in Thyroid Tumors.

Oxidative stress-induced DNA damage is a known causing factor for many types of tumors, but information on the role of oxidants and antioxidants in thyroid tumors is limited. The aim of this study was to determine antioxidant levels in thyroid tumors. In this study, tumor and its matched non-tumor thyroid tissue samples were obtained from 53 patients with thyroid tumors. The levels of manganese superoxide dismutase (MnSOD), thioredoxin reductase 2 (TXNRD2), glutathione (GSH), glutathione peroxidase (Gpx), catalase (CAT), and 27 kd heat-shock protein (hsp27) were determined in both thyroid tissue samples and cultured thyroid cells by immunohistochemical staining and western blot. Hydrogen peroxide (H2 O2 ) was used to generate oxidant stress in the cell culture experiments. We found that the levels of MnSOD, TXNRD2, GSH, Gpx, and Hsp27 were increased in both malignant and benign tumors, while the level of CAT was decreased. To verify the results of the tissue study, we treated cultured thyroid cells with H2 O2 and found the same pattern of antioxidant changes. Hsp27 was also increased after H2 O2 treatment. The expression of hsp27 was upregulated by 8.24-, 6.96-, and 3.09-fold in thyroid cancer, follicular adenoma, multinodular goiter, respectively. Collectively, our study demonstrated that the levels of hsp27 together with MnSOD, TXNRD2, GSH, and Gpx were significantly upregulated by H2 O2 in thyroid tumors. The increase of these antioxidants is observed in both malignant and benign tumors, particularly in the former. The upregulation of antioxidants is likely a protective mechanism of tumor cells to maintain their survival and growth. J. Cell. Biochem. 117: 2473-2481, 2016. © 2016 Wiley Periodicals, Inc.

Estrogen receptor α induces prosurvival autophagy in papillary thyroid cancer via stimulating reactive oxygen species and extracellular signal regulated kinases.

CONTEXT: The incidence of papillary thyroid cancer (PTC) shows a predominance in females, with a male:female ratio of 1:3, and none of the known risk factors are associated with gender difference. Increasing evidence indicates a role of estrogen in thyroid tumorigenesis, but the mechanism involved remains largely unknown. OBJECTIVE: This study aimed to assess the contribution of autophagy to estrogen receptor α (ERα)-mediated growth of PTC. DESIGN: The expression of ERα in thyroid tissue of patients with PTC tissues was analyzed. Cell viability, proliferation, and apoptosis were evaluated after chemical and genetic inhibition of autophagy. Autophagy in PTC cell lines BCPAP and BCPAP-ERα was assessed. RESULTS: ERα expression was increased in PTC tissues compared with the adjacent nontumor tissues. Estrogen induced autophagy in an ERα-dependent manner. Autophagy induced by estrogen/ERα is associated with generation of reactive oxygen species, activation of ERK1/2, and the survival/growth of PTC cells. Chemical and genetic inhibition of autophagy dramatically decreased tumor cell survival and promoted apoptosis, confirming the positive role of autophagy in the growth of PTC. CONCLUSIONS: ERα contributes to the growth of PTC by enhancing an important prosurvival catabolic process, autophagy, in PTC cells. The inhibition of autophagy promotes apoptosis, implicating a novel strategy for the treatment of ERα-positive PTC.

Inhibition of Foxp3 in cancer cells induces apoptosis of thyroid cancer cells.

Foxp3+ regulatory T cells (Tregs) in lymphocytes facilitate the thyroid tumor growth and invasion. Very limited information is available on Foxp3 expression in thyroid cancer cells and its function is totally unknown. This study demonstrated that Foxp3 expression was increased in thyroid cancer cells. Inhibition of Foxp3 decreased cell proliferation and migration, but increased apoptosis, suggesting a positive role of Foxp3 in cancer growth. Interestingly, Foxp3 inhibition enhanced PPARγ expression and activity. In addition, Foxp3 inhibition downregulated NF-κB subunit p65 and cyclin D1 but upregulated caspase-3 levels. These molecular changes are in line with Foxp3 shRNA-mediated alteration of cell functions. Collectively, our study demonstrates that thyroid cancer cells express a high level of functional Foxp3 and that the inhibition of the Foxp3 suppresses the proliferation and migration but promotes apoptosis, suggesting that targeting Foxp3 in thyroid cancer cells may offer a novel therapeutic option for thyroid cancer.

Morphologic change in computed tomography of aldosterone-producing adenoma after radiofrequency ablation.

OBJECTIVE: To evaluate the morphologic changes of aldosterone-producing adenoma (APA) on computed tomography (CT) before and after radiofrequency ablation (RFA) and to assess the factors that are important in determining successful complete ablation of these tumours. METHOD: Between August 2004 and August 2011, 24 consecutive patients with APA undergoing CT-guided percutaneous RFA were identified from our prospective database. The pre-RFA and post-RFA CT appearances of these APAs that showed positive biochemical response were reviewed retrospectively for their 3-dimensional size, tumour volume, and CT attenuation in terms of Hounsfield units (HU). A comparison of these parameters before and after RFA was performed. RESULTS: In this study, there were 23 APAs in these 24 patients that showed biochemical cure of primary aldosteronism after RFA. When comparing post-RFA to pre-RFA CTs, there was no significant change in tumour size (14.5 mm vs 14.6 mm: P = .83) and tumour volume (1.55 cm(3) vs 1.59 cm(3); P = .41) after RFA. In nonenhanced CT images, there was no significant reduction in HU from pre-RFA to post-RFA measurements (4.4 HU vs 7.9 HU; P = .52). In contrast-enhanced CTs, there was a significant drop in HU after RFA (from 48.3 HU to 14.7 HU; P = .03). None of the included cases showed a focal region of contrast enhancement to suggest residual tumour. CONCLUSION: A change in tumour size, tumour volume, and HU in nonenhanced CT were unreliable in defining radiologic treatment success. Only changes in HU in contrast-enhanced CT was useful in confirming a positive treatment response after RFA for APA.

The cross-talk between estrogen receptor and peroxisome proliferator-activated receptor gamma in thyroid cancer.

BACKGROUND: Estrogen receptor (ER) and peroxisome proliferator-activated receptor gamma (PPARγ) are associated with thyroid tumorigenesis and treatment. However, the interaction between them has not been studied. METHODS: The impact of ER over-expression or down-expression by DNA/small interfering RNA (siRNA) transfection, ERα agonists, and the ERß agonist diarylpropiolnitrile (DPN) on PPARγ expression/activity was examined in papillary thyroid carcinoma (PTC) and anaplastic thyroid carcinoma (ATC) cells. The effects of PPARγ modulation by rosiglitazone (RTZ), a PPARγ ligand, and of PPARγ siRNA on ER expression were determined. Cellular functions reflected by cell proliferation and migration were assayed. Apoptosis was analyzed by terminal deoxynucleotidyl transferase dUTP nick-end labeling, and apoptotic-related proteins were evaluated by Western blot analysis. RESULTS: PPARγ protein and activity were reduced by the over-expression of either ERα or ERß, whereas repression of ERα or ERß increased PPARγ expression. The administration of RTZ counteracted the effects of ER and also reduced their expression, particularly in PTC cells. Moreover, knockdown of PPARγ increased ER expression and activity. Functionally, ERα activation offset the inhibitory effect of PPARγ on cellular functions, but ERß activation aggregated it and induced apoptosis, particularly in PTC cells. Finally, the interaction between ERß and PPARγ enhanced the expression of proapoptotic molecules, such as caspase-3 and apoptosis-inducing factor. CONCLUSIONS: This study provides evidence supporting a cross-talk between ER and PPARγ. The reciprocal interaction between PPARγ and ERß significantly inhibits the proliferation and migration of thyroid cancer cells, providing a new therapeutic strategy against thyroid cancer.

The learning curve for endorectal ultrasonography in rectal cancer staging.

BACKGROUND: Endorectal ultrasound (ERUS) is an emerging technique for preoperative rectal cancer staging. It is an operator-dependent examination with accuracy closely related to endosonographer experience. In this study, we prospectively analyzed our results of ERUS staging for rectal cancer, aiming to determine its accuracy and to define the learning curve of the procedure. METHODS: Between July 2007 and August 2009, consecutive patients with rectal cancer were recruited for preoperative ERUS staging performed by a single colorectal surgeon. We compared results of ERUS tumor (uT) and nodal (uN) staging with pathological staging of surgical specimens in patients who had surgery without neoadjuvant chemoradiation. To evaluate the learning-curve effect on ERUS, patients were divided into two equal halves for analysis (early group and late group). RESULTS: In the 26-month study period, 50 patients (36 males) with median age of 67 years (range 47-89 years) underwent ERUS staging. The overall accuracy rates of uT and uN staging were 86 and 66%. For uT staging, 10% of tumors were overstaged and 4% were understaged. For uN staging, 22% of patients were overstaged and 12% were understaged. With experience accumulation from early group to late group, accuracy improvement was observed in uN staging (52 vs. 80%, P = 0.037), while the accuracy rate remained consistently high in uT staging (84 vs. 88%, P = 1.0). CONCLUSIONS: ERUS was accurate in preoperative staging of rectal cancer. It was an easy-to-learn procedure for accurate tumor staging, but considerable experience was required to attain accuracy for nodal staging.

Rectal stump lavage: simple procedure resulting in life-threatening complication.

In colorectal resections, rectal stump lavage is commonly performed prior to primary anastomosis for reducing bacterial counts and minimizing the risk of anastomotic recurrence. Being a potent bactericidal and cytotoxic disinfectant, chlorhexidine is frequently chosen as the irrigation solution of choice for such purposes. Despite its widespread use, the potential for developing chlorhexidine allergy is still a major concern due to the ever-rising number of literature reports of hypersensitivity reactions to chlorhexidine in surgical patients. This report illustrates the first reported case of life-threatening chlorhexidine anaphylaxis after its use in rectal stump lavage for colorectal resection. This report serves as a reminder of the potential danger of this "hidden allergen" in clinical practice.

Critical appraisal on the role and outcome of emergency colectomy for uncomplicated right-sided colonic diverticulitis.

BACKGROUND: Emergency colectomy is well accepted for treating complicated right-sided colonic diverticulitis. However, the role of colectomy for uncomplicated diverticulitis is not well defined. The aim of this study was to evaluate the short-term and long-term surgical outcome of uncomplicated right-sided diverticulitis in our locality. PATIENTS AND METHODS: Retrospective chart review of patients operated for right-sided diverticulitis over a 20-year period was conducted. Recurrent attacks of right-sided diverticulitis, re-operation rate and re-hospitalisation rate were the long-term parameters of interest. An updated telephone interview was carried out for all surviving patients. RESULTS: Seventy-four patients (35 males and 39 females), median age 35.5 (range 16-70) years, were operated for uncomplicated diverticulitis. Thirty patients underwent colectomy, whereas the others underwent appendectomy with diverticulectomy (n = 8) or appendectomy alone (n = 36). All short-term parameters were less favourable for the colectomy group, including higher complication rate, slower return of gastrointestinal function, higher requirement of parenteral analgesic and longer hospital stay. Without colectomy, only 2 patients developed recurrent diverticulitis necessitating hospitalisation, both of whom resolved on conservative treatment. On the other hand, 1 patient required re-operation after colectomy because of intestinal obstruction. The overall re-hospitalisation rate was comparable between the colectomy and the non-colectomy group (16.7% vs. 13.6%). CONCLUSIONS: Emergency colectomy can eradicate suspicious lesions and eliminate risk of recurrent diverticulitis but at the expense of higher morbidity rates. As the natural course of uncomplicated right-sided colonic diverticulitis is usually benign, conservative treatment with minimal surgery may be a better therapeutic option.