Association of thyroglobulin antibody and thyroid peroxidase antibody status with aggressive features in papillary thyroid carcinoma with Hashimoto’s thyroiditis

Introduction

According to the Global Cancer Observatory 2020 (GLOBOCAN 2020) database from the World Health Organization (WHO) International Agency for Research on Cancer, thyroid cancer ranks as the ninth most common cancer worldwide (1), with papillary thyroid carcinoma (PTC) comprising around 80% of cases (2). Hashimoto’s thyroiditis (HT), the most prevalent autoimmune thyroid disorder, coexists with PTC in about 23% of cases (3-5). The relationship between PTC and HT has been a key research focus (6-14), as immune system dysfunction can promote tumor immune escape, potentially facilitating malignancy. However, thyroid antibodies and lymphocytes may also target both thyroid and tumor cells, possibly limiting tumor metastasis and progression (9,15). Current studies largely believe that HT can promote the carcinogenesis of thyroid nodules (6,16-18). However, in patients already diagnosed with PTC, the presence of HT is often associated with a more favorable prognosis, including smaller tumor size, reduced central and lateral lymph node metastasis ratio (LLNMR), and less extrathyroidal extension (5,17-24).

From an immunopathological perspective, the hallmark of HT is lymphocytic infiltration into the thyroid tissue (15). Beyond the action of autoreactive Th1 cells, recent studies have identified the imbalance between regulatory T cells (Tregs) and Th17 cells as another critical contributor to thyroid follicular destruction (25-27). Anti-thyroglobulin antibody (TgAb) and anti-thyroid peroxidase antibody (TPOAb), as important serological markers of thyroid autoimmunity, are most commonly used in the diagnosis of HT, with detection rates of approximately 75% and 90%, respectively (9). Beyond their diagnostic value, these antibodies may also shape the local immune microenvironment and influence tumor progression (12,28,29). Based on antibody status, HT patients can be categorized into four groups: (I) TgAb and TPOAb double-positive (TAb⁺); (II) TgAb single-positive (TgAb⁺); (III) TPOAb single-positive (TPOAb⁺); and (IV) TPOAb and TgAb double-negative (TAb⁻) (30,31).

The specific humoral immune responses induced by TgAb and TPOAb are thought to affect PTC development and prognosis (23,32). However, while research has generally explored the relationship between HT and PTC, few studies have examined how different antibody statuses and levels impact PTC progression and prognosis, with mixed findings (14,30,33-40). Therefore, this study aims to explore the invasive or protective effects of different TgAb and TPOAb statuses in PTC patients with HT. We present this article in accordance with the STROBE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-47/rc).

Methods

Study design and participants

Our study design was a cross-sectional study, in which participants were divided into different groups based on their TgAb and TPOAb statuses. The tumor’s aggressive features were compared between these groups. Patients included in this study underwent thyroid surgery at Beijing Hospital from January 2019 to March 2022 and were pathologically diagnosed with PTC and HT. To minimize confounding bias, we applied the following exclusion criteria: (I) incomplete or significantly missing clinical and pathological data; (II) long-term preoperative use of antithyroid drugs or thyroid hormone replacement therapy; (III) history of second thyroid surgery or head and neck radiotherapy; and (IV) other autoimmune diseases. Following the application of these criteria, 317 patients were included in the final analysis, which is consistent with or greater than the sample size commonly seen in similar studies. For this retrospective review, the Ethics Committee of Beijing Hospital deemed waiver of consent to participate to be ethically acceptable. All research procedures strictly adhered to the protocol approved by the Ethics Committee of Beijing Hospital (IRB approval number: 2021BJYYEC-044-03) and complied with ethical standards, including the Declaration of Helsinki and its subsequent amendments.

Data collection and variables

Clinical data recorded included gender, age, preoperative levels of free triiodothyronine (FT3), free thyroxine (FT4), thyrotropin (TSH), carcinoembryonic antigen (CEA), TPOAb, TgAb, surgical method, and so on. The normal ranges for serum FT3, FT4, TSH, TPOAb, TgAb, and CEA in our hospital were 2.3–4.2 pg/mL, 0.89–1.76 ng/dL, 0.35–5.5 IU/mL, 0–70 IU/mL, 0–70 IU/mL, and 0–5 ng/mL, respectively. Serum thyroid antibody levels above the upper limit were considered positive.

Pathologically confirmed HT was defined by the presence of diffuse lymphocyte and plasma cell infiltration, oxygen-philic cells, and the formation of lymphoid follicles or reactive germ centers in normal thyroid tissue. Notably, peritumor lymphocyte infiltration was not considered HT, as it may be an anti-tumor immune response (30,41). The pathological diagnosis is confirmed by professional pathologists. Recorded pathological parameters included tumor diameter, number of tumors, number of central and lateral lymph nodes dissected and metastases, presence of endovascular cancer thrombus, invasive envelope, extrathyroid extension (ETE), multifocality, and bilaterality. Multifocality was defined as having two or more tumor lesions within the thyroid gland, with tumor size calculated as the sum of all tumor focal diameters, as it is a more accurate predictor of lymph node status than primary tumor size (42). Bilateral involvement was defined as two or more tumor lesions located in both thyroid glands.

Additionally, we documented ultrasound findings, including boundary clarity, regularity of shape, presence of micro-calcification, aspect ratio greater than 1, presence of diffuse lesions, and suspicious lymph nodes. Experienced sonographers performed the thyroid ultrasounds.

Statistical analysis

Statistical analyses were performed using IBM SPSS Statistics, version 25 (SPSS Inc., Chicago, IL, USA). Continuous variables were summarized by median values and interquartile range (IQR), and were compared across groups using the Kruskal-Wallis H test. While categorical variables were presented as counts and percentages (%), and were analyzed using the Pearson chi-squared test or Fisher’s exact test. A P value of <0.05 was considered statistically significant.

Results

Clinical and pathological characteristics

A total of 317 cases were included in this study (Figure 1). To facilitate analysis, patients were stratified into two subgroups (<55 and ≥55 years) according to the American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) (8th edition) staging system. Clinical data showed no significant differences in sex, age, or thyroid function across groups with different TPOAb and TgAb statuses (Table 1). Pathological features indicated no association between antibody status and certain aggressive features such as multifocality (P=0.15), bilaterality (P=0.24), capsular invasion (P=0.37), intravascular infiltration (P=0.88), and extrathyroidal invasion (P=0.18) (Table 2). However, significant differences were found in the proportion of tumors larger than 4 cm (P=0.004). Pairwise comparisons showed that TAb⁻ group had a higher proportion of tumors >4 cm compared to the TAb⁺ group (P=0.008) and the TPOAb⁺ group (P=0.03) (Table S1). These findings suggest that TAb⁺ and TPOAb⁺ statuses may have a protective effect against PTC, whereas TAb⁻ antibody status may promote tumor invasiveness.

Figure 1 Flow chart of case selection and grouping method. HT, Hashimoto’s thyroiditis; PTC, papillary thyroid carcinoma; TAb⁻, TgAb and TPOAb double-negative; TAb⁺, TgAb and TPOAb double-positive; TgAb, thyroglobulin antibody; TgAb⁺, TgAb single-positive; TPOAb, thyroid peroxidase antibody; TPOAb⁺, TPOAb single-positive.

Comparison of lymph node metastasis (LNM) data

For the comparison of LNM data, our findings showed that HT types based on TPOAb and TgAb status did not significantly affect central lymph node metastasis (CLNM) (P=0.29) and LLNM (P=0.39). However, the number and proportion of CLNM and LLNM are also important aspects of our concern, given their importance in deciding postoperative I-131 therapy. Among the 317 patients, 135 had central lymph node metastasis. We compared the number of central lymph nodes dissection (NCLND), number of central lymph nodes metastasis (NCLNM), and central lymph node metastasis ratio (CLNMR) in four groups of patients with CLNM (Table 3), and the results showed that there was no significant difference in NCLND (P=0.25). However, significant differences were found in NCLNM (P=0.01) and CLNMR (P=0.03). Then we conducted post-hoc pairwise comparisons, which revealed that the TAb⁻ group had significantly higher NCLNM than the TAb⁺ (P=0.02) and TPOAb⁺ (P=0.03) groups (Table S2), as well as higher CLNMR compared to the TPOAb⁺ group (P=0.02) (Table S3). In LLNM patients (Table 4), there was no significant difference between groups in number of lateral lymph nodes dissection (NLLND) (P=0.08) and number of lateral lymph nodes metastasis (NLLNM) (P=0.20), but LLNMR differed significantly (P=0.01). Post-hoc pairwise comparisons revealed that the TAb⁻ group had a significantly higher LLNMR compared to the TPOAb⁺ group (P=0.02) (Table S4). These results suggest that the TAb⁻ group exhibits greater aggressiveness than the TAb⁺ and TPOAb⁺ groups concerning the number and rate of lymph node metastases.

Comparison of ultrasound information

In addition, we analyzed and compared complete ultrasound information from patients with four different antibody states (Table 5), which revealed significant differences in the probability of diffuse lesions (P<0.001) but no significant differences in microcalcification (P=0.09), boundary clarity (P=0.50), regularity (P=0.85), aspect ratio >1 (P=0.55), and the presence of suspicious lymph nodes (P=0.20). The likelihood of diffuse lesions was 66.17% in the TAb⁺ group, 39.68% in the TgAb⁺ group, 39.66% in the TPOAb⁺ group, and 22.22% in the TAb⁻ group. Diffuse lesions appear as flaky, diffuse hypoechoic areas in thyroid ultrasound due to antibody-induced thyroid cell necrosis and regeneration. While ultrasonography aids in diagnosing HT, its sensitivity is limited and is often combined with TPOAb and TgAb levels. Our study confirmed a higher probability of diffuse lesions in the TAb⁺ group compared to the other three groups, with similar probabilities in the TgAb⁺ and TPOAb⁺ groups, significantly higher than in the TAb⁻ group. This expected finding supports our study’s credibility.

Discussion

TgAb and TPOAb are considered to be associated with the development and prognosis of PTC combined with HT. However, existing studies on this association are scarce and yield inconsistent results, leaving the exact relationship unclear. Vasileiadis et al. (43) found positive TgAb closely associated with PTC occurrence, larger tumor sizes (>10 mm), and LNM. Wen et al. (30) reported that the TgAb-positive group had the highest CLNMR, while the TPOAb-positive group had the lowest. Min et al. (44) found high serum TgAb levels (>1,150 IU/mL) determined to be significantly associated with the CLNM in PTC patients with HT. In contrast, Dong et al. (45) observed that high TPOAb levels (>1,300 IU/mL) strongly indicate multifocal PTC in HT patients, suggesting the benefit of total thyroidectomy. Li et al. (34) believed that positive TPOAb alone was an independent predictor of less CLNM in PTC patients, whereas positive TgAb alone was significantly associated with less extrathyroidal extension. Most studies have focused on single antibody effects (TgAb or TPOAb) on specific pathologies or CLNM, with few evaluating all four antibody statuses on comprehensive clinical, pathological, and ultrasound characteristics in PTC combined with HT patients. Our retrospective analysis of 317 patients, categorized into four groups by antibody status, revealed no significant effects of different antibody statuses on thyroid function or most pathological and ultrasound features. However, significant associations were observed with tumor size ≥4 cm (P=0.004), and diffuse lesion detection in ultrasound (P<0.001). The TAb⁻ group had a significantly higher rate of tumors ≥4 cm than the TAb⁺ group and the TPOAb⁺ group, and a lower probability of diffuse lesion detection than the TAb⁺ group. These findings are consistent with the study by Zhou et al. (31), which reported no significant effect of antibody status on CLNM (P=0.29) or LLNM (P=0.39), but significant effects on NCLNM, CLNMR, and LLNMR. Elevated antibody levels in the TAb⁺ and TPOAb⁺ groups may enhance anti-tumor humoral and cellular immune responses, thereby reducing tumor aggressiveness (9,15,21,25,46). In contrast, the TAb⁻ group’s weaker anti-tumor humoral response may rely more on cellular immunity, increasing tumor aggressiveness.

There are several limitations in this study. Firstly, it primarily focused on the relationship between antibody status and PTC aggressiveness, without delving into the underlying molecular mechanisms. Secondly, due to selective screening criteria, important genetic factors such as TG and BRAF mutations were not considered, potentially limiting the scope of the findings. Lastly, the study’s small sample size and its design as a single-center retrospective study may introduce errors and selection bias. Therefore, prospective studies with larger, more diverse sample sizes are necessary to validate and support these findings.

Conclusions

This retrospective study found that TgAb and TPOAb statuses have significant correlations with NCLNM, CLNMR, and LLNMR. The TAb⁻ group had a higher risk of invasive features, while the TAb⁺ and TPOAb⁺ groups demonstrated a reduced risk, suggesting a potential protective role of humoral immunity in limiting tumor spread. Beyond the presence of autoantibodies, we also speculate that local lymphocytic infiltration may contribute to this protective effect by reshaping the tumor immune microenvironment. Further research is warranted to elucidate the underlying mechanisms.

Acknowledgments

During the preparation of this work, the authors used ChatGPT 4.0 in order to improve readability and language. After using this tool, the authors reviewed and edited the content as needed and takes full responsibility for the content of the publication.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-47/rc

Data Sharing Statement: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-47/dss

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-47/prf

Funding: This study was supported by grants from National High Level Hospital Clinical Research Funding [No. BJ-2023-093 and No. BJ-2020-169 (to G.M.)].

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-47/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.The study was approved by the Research Ethics Board of the Beijing Hospital (IRB approval number: 2021BJYYEC-044-03). For this retrospective review, the Ethics Committee of Beijing Hospital deemed waiver of consent to participate is ethically acceptable.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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