The relationship between vitamin D nutritional status and ultrasound classifications of thyroid nodules in young and middle-aged euthyroid male petroleum workers

doi:10.21203/rs.3.rs-3144302/v1

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The relationship between vitamin D nutritional status and ultrasound classifications of thyroid nodules in young and middle-aged euthyroid male petroleum workers

https://doi.org/10.21203/rs.3.rs-3144302/v1

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Background

Previous studies on the relationship between Thyroid Nodules(TNs) and Vitamin D (VD) have produced conflicting results. These discrepancies may be attributed to variations in the study populations, different methods of VD measurement, unclear thyroid function status, and the potential confounding effects of VD2 and VD3. This study was aimed to analyze the relationship between VD2 and VD3 nutritional status and the occurrence risk of TNs in young and middle-aged euthyroid male (YMAEM) petroleum workers without thyroid autoimmunity (TAI).

Methods

The health check-up database of 2037 YMAEM petroleum workers between the ages of 30 and 60 without TAI was retrospectively analyzed. Serum 25-hydroxy vitamin D [25(OH)VD], 25(OH)VD3 and 25(OH)VD2 levels were assayed by liquid chromatography-tandem mass spectrometry (LC-MS/MS). The participants were classified into different groups according to their ultrasound images of TNs based on Chinese-Thyroid Imaging Reporting and Data System (C-TRIADS). C-TRIADS consist of 6 grades, and the upper three indicate TNs with potential malignancy.

Results

No C-TRIADS 5 or 6 nodules were found in these participants. The serum 25(OH)VD level in the C-TIRADS 4 TN group was significantly lower than that in the C-TIRADS 1, C-TIRADS 2, and C-TIRADS 3 groups. The overall prevalence of TNs was similar among the VD-deficient, insufficient, and sufficient groups. However, the prevalence of patients with C-TIRADS 4 TNs was markedly higher in the VD-deficient group (18.5%) than in the insufficient (5.5%, P.adj < .05) and sufficient groups (4.1%, P.adj < .05). Identical findings were observed among the groups with low, medium, and high serum 25(OH)VD3 levels, but not among those with different serum 25(OH)VD2 levels. A binary logistic regression analysis indicated that, compared to the VD-sufficiency group, the VD-deficiency group [OR = 5.02 (95% CI: 3.08–8.17; P < .001)] significantly increased the risk of developing C-TIRADS 4 TNs.

Conclusions

VD deficiency [25(OH)VD < 20.00 ng/mL] was an independent risk factor for the development of TNs with malignant ultrasound characteristics in YMAEM petroleum workers without TAI. Low levels of VD3, rather than VD2, may increase the prevalence of C-TIRADS 4 TNs in YMAEM petroleum workers.

Thyroid nodules

Ultrasound

25(OH)VD

25 (OH)VD2

25(OH)VD3

C-TRIADS

Thyroid nodules (TNs) are a prevalent thyroid disease, with a prevalence of 4–7% in healthy populations detected by palpation [1] and up to 65.0% with high-resolution ultrasound[2]. A recent nationwide study reported a prevalence of TNs of 38.0% [3]. While most TNs are benign, they have a 7.0–15.0% chance of being malignant [4, 5]. Risk factors for thyroid cancer include iodine deficiency, age, female gender, smoking and alcohol consumption, estrogen levels, obesity, metabolic syndrome, and head and neck ionizing radiation [6–10].

Besides regulating calcium and phosphorus metabolism, Vitamin D (VD) impacts angiogenesis, cell invasion, and cell lifecycle [11]. In addition, it has been found to regulate mRNA encoding malignant cells, thus preventing the recurrence and metastasis of tumor cells [12]. Furthermore, it can also affect the biological characteristics of cancer stem cells by regulating microRNA expression [[13]. Recently, the role of VD in malignant TNs has aroused widespread interest. Several studies have suggested that a decrease in circulating 25-hydroxy vitamin D [25(OH)VD] concentrations could be linked to a higher incidence of malignant TNs [14, 15]. However, a pilot study in the United States failed to establish a link between serum VD concentrations and malignant TNs [16]. Furthermore, a recent study reported that low VD levels did not affect the invasiveness of papillary thyroid carcinoma (PTC), including multicentricity, lymphovascular invasion, and metastasis [17]. Therefore, the connection between VD concentrations and the likelihood of malignant TNs remains uncertain.

The potential impact of serum VD levels on the development of benign TNs also remains controversial. One study showed an inverse correlation between VD concentrations and the likelihood of benign TNs in subjects with normal thyroid function [18]. Another study found that VD deficiency did not increase the risk of benign TNs in centenarians, but did increase the risk of malignant TNs [19]. However, some studies suggested that a deficiency in VD could potentially increase the likelihood of developing both benign and malignant TN [20].

Existing studies have primarily investigated the connection between serum overall VD levels and the likelihood of TNs, without considering the potential distinct effects of VD3 and VD2 on TN occurrence. In this study, we selected young and middle-aged euthyroid male (YMAEM) petroleum workers without thyroid autoimmunity (TAI) as subjects to explore the potential link between their serum levels of VD, VD3, and VD2 and the incidence of TNs. Specifically, we examined the potential correlation between VD levels and the occurrence of TNs with malignant ultrasound features.

Subjects

The researchers conducted a retrospective analysis of health check-up database from young and middle-aged male workers at a petroleum factory in Dalian city. Initially, 2359 workers aged 30 to 60 who had all required examinations completed, including thyroid ultrasound, thyroid functions, thyroid autoantibodies, and VD levels were recruited into the present study. Among them, 201 workers with positive thyroid autoantibodies, 104 with thyroid dysfunction, 5 with a history of thyroidectomy, and 12 with unclear Chinese-Thyroid Imaging Reporting and Data System (C-TIRADS) ultrasound classification of TNs were excluded. Finally, 2037 YMAEM petroleum workers without TAI were included into the following analysis. The workers' TNs were categorized into six grades according to C-TIRADS [21]. Participants were grouped based on the highest C-TIRADS classification of TNs displayed in their ultrasound results. Among the participants, 935 had no TNs (C-TIRADS 1 nodules), 357 had C-TIRADS 2 nodules, 553 had C-TIRADS 3 nodules, and 192 had C-TIRADS 4 nodules, including 149 with 4A, 37 with 4B, and 6 with 4C. However, no C-TRIADS 5 or 6 nodules were found in these participants (Fig. 1).

Laboratory measurements

In this study, Serum thyroid stimulating hormone (TSH), free triiodothyronine (FT3), free thyroxine (FT4), antithyroperoxidase antibody (TPOAb), antithyroglobulin antibody (TgAb) were measured using a chemiluminescent enzyme immunoassay (Siemens, CENTAUR XP). 25(OH)VD3 and 25(OH)VD2 concentrations were determined using liquid chromatography-tandem mass spectrometry analysis (LC-MS/MS) (AB SCIEX Triple QuadTM 4500MD analyzer). The concentrations of 25(OH)VD were calculated as the sum of 25(OH)VD3 and 25(OH)VD2 concentrations. A serum TPOAb > 60.00 IU/mL and/or TgAb > 60.00 IU/mL was considered positive for thyroid autoantibodies; otherwise, it was negative. A serum 25(OH)VD concentration above 30.00 ng/mL was categorized as sufficient for the body's VD status, between 20.00 and 30.00 ng/mL was categorized as insufficient, and below 20.00 ng/mL was categorized as deficient according to international and domestic guidelines [22]. As optimal reference range values for 25(OH)VD3 and 25(OH)VD2 have not been established by international and domestic guidelines, this study used their respective tertile values for stratification.

VD levels were categorized as follows: a concentration of 25(OH)VD < 20.00 ng/mL was defined as the low VD level group (VD-L group, VD deficient), 20.00 ng/mL ≤ 25(OH)VD < 30.00 ng/mL was defined as the medium VD level group (VD-M group, VD insufficient), and 25(OH)VD ≥ 30.00 ng/mL was defined as the high VD level group (VD-H group, VD sufficient). In a similar manner, a concentration of 25(OH)VD2 < 0.49 ng/mL was defined as the low VD2 level group (VD2-L group), 0.49 ng/mL ≤ 25(OH)VD2 < 0.99 ng/mL was defined as the medium VD2 level group (VD2-M group), and 25(OH)VD2 ≥ 0.99 ng/mL was defined as the high VD2 level group (VD2-H group). Finally, a concentration of 25(OH)VD3 < 19.07 ng/mL was defined as the low VD3 level group (VD3-L group), 19.07 ng/mL ≤ 25(OH)VD3 < 26.70 ng/mL was defined as the medium VD3 level group (VD3-M group), and 25(OH)VD3 ≥ 26.70 ng/mL was defined as the high VD3 level group (VD3-H group).

Statistical analysis

The study employed SPSS Statistics 27.0 (SPSS, Inc.) for statistical analyses. Continuous variables, such as FT3 and FT4, were normally distributed and reported as mean ± standard deviation (SD), while non-normally distributed variables, such as TSH, BMI, age, 25(OH)VD, 25(OH)VD3 and 25(OH)VD2 were reported as median with interquartile range (Q25-Q75). The one-way analysis of variance (ANOVA) was used for normally distributed data with homogenous variances, including FT3 and FT4, while the non-parametric Kruskal-Wallis H test was used for non-normally distributed data or those with heterogeneous variances, such as TSH, BMI, age, 25(OH)VD, 25(OH)VD3 and 25(OH)VD2. Categorical variables were compared using the chi-square test, and multiple comparisons were performed using the Bonferroni correction method. The adjusted P-value, denoted as "P.adj," was utilized in this research, where a value less than 0.05 indicated statistical significance. Furthermore, the Cochran-Mantel-Haenszel test was used to investigate the prevalence trend of C-TIRADS 4 TNs across subjects with different levels of VD. Lastly, the study estimated the odds ratios (ORs) for the risk of C-TIRADS 4 TNs in subjects with varying levels of VD using binary logistic regression analysis.

Demographic characteristics and clinical parameters comparison

An analysis of health check-up data from 2,307 participants revealed that among YMAEM petroleum workers without TAI, 53.9% (1,102/2,037) had TNs, and 9.4% (192/2307) had C-TIRADS 4 TNs according to the ultrasound imaging system. There were significant differences in age, FT4, FT3, and TSH among participants with different C-TIRADS categories (P < .05), but there was no significant difference in body mass index (BMI) (P > .05) (Table 1). The TIRADS 3 TN group had slightly lower TSH level compared to the group with no TNs. In contrast, other groups did not show a significant change in TSH levels compared to the group with no TNs (Table 1). This finding did not support the previous hypothesis that elevated TSH levels stimulate the development of TNs [23, 24]. The serum concentrations of 25(OH)VD and 25(OH)VD3 in the C-TIRADS 4 TN group were significantly lower than those in the C-TIRADS 1, C-TIRADS 2, and C-TIRADS 3 groups (P < 0.05). However, there was no significant difference in 25(OH)VD2 concentration among these four groups (P > .05) (Table 1). Additionally, the proportion of individuals with 25(OH)VD below 30.00 ng/mL in the C-TIRADS 4 TNs group (89.1%) was significantly higher than that in the C-TIRADS 1 (74.0%, P.adj < .05), C-TIRADS 2 (75.1%, P .adj < .05), and C-TIRADS 3 groups (71.6%, P.adj < .05) (Table 1).

Table 1

**Comparison of demographic characteristics and clinical parameters in 2037 YMAEM petroleum workers**
	Total	C- TIRADS 1 TNs Group	C-TIRADS 2 TNs Group	C- TIRADS 3 TNs Group	C-TIRADS 4 TNs Group	P^#
n	2037	935	357	553	192
Age (years)	50.00 (45.00–54.00)	48.00 (43.00–52.00)	51.00^a (46.00–55.00)	51.00^a (47.00–56.00)	51.00^{a, b, c} (48.00–56.00)	< 0.001
BMI (kg/m2)	25.73 (23.78–28.03)	25.66 (23.62–27.99)	25.61 (23.74–27.73)	25.72 (23.89–28.04)	26.26 (24.22–28.74)	0.061
FT3 (pmol/L)	5.32 ± 0.43	5.34 ± 0.42	5.28 ± 0.45	5.30 ± 0.43	5.36 ± 0.433	0.019
FT4 (pmol/L)	16.43 ± 1.87	16.32 ± 1.82	16.34 ± 1.91	16.44 ± 1.84	17.07 ± 1.97^{a ,b, c}	< 0.001
TSH (mIU/L)	1.36 (1.02–1.84)	1.41 (1.07–1.91)	1.36 (1.00-1.89)	1.30^a (0.91–1.73)	1.30 (1.02–1.82)	< 0.001
25(OH)VD (ng/mL)	23.97 (18.05–30.01)	23.68 (18.04–30.19)	24.65 (19.33–29.82)	25.06^a (19.94–30.79)	17.59^{a, b, c} (12.64–23.72)	< 0.001
25(OH)VD3 (ng/mL)	22.77 (17.14–28.82)	22.67 (17.11–29.04)	23.56 (18.31–28.65)	24.41^a (18.65–30.02)	16.55^{a, b, c} (11.74–22.49)	< 0.001
25(OH)VD2 (ng/mL)	0.70 (0.40–1.29)	0.71 (0.40–1.38)	0.67 (0.40–1.25)	0.67 (0.40–1.22)	0.76 (0.48–1.25)	0.353
25(OH)VD, n(%) < 30.00 ng/mL ≥ 30.00 ng/mL	1527 (75.0) 510 (25.0)	692 (74.0) 243 (26.0)	268 (75.1) 89 (24.9)	396 (71.6) 157 (28.4)	17 (89.1)^{a, b, c} 21 (10.9)	< 0.001
TgAb, n (%) < 15.00 IU/mL (undetectable) 15.00–60.00 IU/mL	1931 (94.8) 106 (5.2)	874 (93.5) 61 (6.5)	340 (95.2) 17 (4.8)	528 (95.5) 25 (4.5)	189(98.4)^a 3 (1.6)	0.028
TPOAb, n (%) < 28.00 IU/mL (undetectable) 28.00–60.00 IU/mL	1187 (58.3) 850 (41.7)	539 (57.6) 396 (42.4)	206 (57.7) 151 (42.3)	331 (59.9) 222 (40.1)	111 (57.8) 81 (42.2)	0.853

ANOVA was used to compare the differences in FT3 and FT4 across the different C-TIRADS groups. Multiple comparisons were conducted using the Bonferroni correction method, but no significant differences were found in pairwise comparisons of FT3 levels. The non-parametric Kruskal-Wallis H test was used to analyze the differences in age, BMI, TSH, 25(OH)VD, 25(OH)VD3 and 25(OH)VD2 in different C-TIRADS groups, while Pearson's chi-squared test was used to analyze the differences in TGAb and TPOAb

^#Comparison of differences between C-TIRADS1, C-TIRADS 2, C-TIRADS 3, and C-TIRADS4 groups. ^aCompared with the group of TNs classified as C-TIRADS 1, P.adj < .05; ^bCompared with the group of TNs classified as C-TIRADS 2, P.adj < .05; ^cCompared with the group of TNs classified as C-TIRADS 3, P.adj < .05

Distribution of TNs

For a more in-depth investigation of the link between VD levels and TN risk, 25(OH)VD, 25(OH)VD3 and 25(OH)VD2 were respectively divided into three groups of L (low level), M (medium level), and H (high level) according to their different serum concentrations. No significant difference was observed in the overall prevalence of TNs among the VD-L, VD-M, and VD-H groups of 25(OH)VD (53.8%, 55.4% vs. 52.4%, P > .05) (Fig. 2a). Likewise, no significant difference was observed in the overall prevalence of TNs among the L, M, and H groups of 25(OH)VD3 and 25(OH)VD2 (P > .05) (Fig. 2b, 2c). However, when the 1102 patients with TNs were further classified by C-TIRADS, A significant variation was observed in the overall distribution of TNs (C-TIRADS 2, 3, and 4 nodules) among the L, M, and H groups of 25(OH)VD and 25(OH)VD3 (P < .05) (Fig. 3a, 3b). On the other hand, no significant difference was observed in the overall distribution of TNs among the L, M, and H groups of 25(OH)VD2 (P > .05) (Fig. 3c). Notably, the proportion of C-TIRADS 4 TNs in the low level group of 25(OH)VD (34.3%) was significantly higher than in the medium (9.9%, P.adj < .05) and high level groups (7.9%, P.adj < .05) (Table 2). However, no statistically significant difference was observed in the proportion of C-TIRADS 4 TNs between the medium and high level groups (P.adj > .05) (Table 2). Similar findings were observed in the groups of low, medium, and high levels of 25(OH)VD3 (33.2%, 10.5% vs. 8.5%, P.adj < .05) (Table 2).

Table 2

Multiple comparisons of TN distribution in YMAEM petroleum workers based on their serum VD levels
TNs	25(OH)VD (ng/mL)			25(OH)VD3 (ng/mL)
TNs	VD-L (< 20.00)	VD-M (20.00–30.0)	VD-H (≥ 30.00)	VD3-L (< 19.07)		VD3-M (19.07–26.70)	VD3-H (≥ 26.70)
C-TIRADS 2 n (%)	96^a (26.6)	172^b (36.3)	89^{a, b} (33.3)	99^a (26.9)	139^b (36.6)		119^{a, b} (33.6)
C-TIRADS 3 n (%)	141^a (39.1)	255^b (53.8)	157^b (58.8)	147^a (39.9)	20^b (52.9)		205^b (57.9)
C- TIRADS 4 n (%)	124^a (34.3)	47^b (9.9)	21^b (7.9)	122^a (33.2)	40^b (10.5)		30^b (8.5)
Total n (%)	361 (100.0)	474 (100.0)	267 (100.0)	368 (100.0)	380 (100.0)		354 (100.0)
Among all the YMAEM petroleum workers with TNs (n = 1102), the Bonferroni correction method was used to investigate the differences in the distribution of TN categories among the L, M, and H groups of 25(OH)VD and 25(OH)VD3, respectively. The same superscript letter indicates that the percentage of TN in the same category did not have statistically significant differences between the L, M, and H groups of 25(OH)VD or 25(OH)VD3

The stratification VD levels were performed as described in Fig. 2

Prevalence of C-TIRADS 4 TNs

Then the study analyzed the prevalence of C-TIRADS 4 TNs in relation to L, M, and H groups of 25(OH)VD and 25(OH)VD3. Among the 2037 petroleum workers, the VD-L group (18.5%) had a significantly higher prevalence of C-TIRADS 4 TNs compared to the VD-M (5.5%, P.adj < .05) and VD-H groups (4.1%, P.adj < .05), with no significant difference between VD-M and VD-H groups (P.adj > .05) (Fig. 4a). Similar results were observed in the VD3-L (18.0%), VD3-M (5.9%), and VD3-H (4.4%) groups of 25(OH)VD3 (Fig. 4b). A trend test showed that as the concentrations of 25(OH)VD or 25(OH)VD3 increased,the prevalence of C-TIRADS 4 TNs decreased in YAMEA petroleum workers (P for trend < .05) (Fig. 4a, 4b).

A binary logistic regression analysis was carried out to investigate the likelihood of developing C-TIRADS 4 TNs among petroleum workers with different levels of VD. The study adjusted for confounding variables, such as age, BMI, FT3, FT4, TSH, TgAb, and TPOAb, in the 25(OH)VD group. The results indicated that having low VD levels (VD-L) increased the risk of developing C-TIRADS 4 TNs with an adjusted odds ratio (OR) of 5.02 [95% confidence interval (CI): 3.08–8.17, P < .001] compared to those with high VD levels (VD-H) (Table 3). Conversely, having moderate VD levels (VD-M) did not increase the risk of developing C-TIRADS 4 TNs significantly, with an adjusted OR of 1.37 (95% CI: 0.80–2.34, P > .05) compared to VD-H (Table 3). The same trend was observed in the 25(OH)VD3 group, where the adjusted OR for VD3-L was 4.50 (95% CI: 2.94–6.87, P < .001) and for VD3-M was 1.39 (95% CI: 0.85–2.28, P > .05) compared to VD3-H (Table 3). A trend analysis revealed that the ORs for YAMEA petroleum workers to develop C-TIRADS 4 TNs increased as the serum concentrations of 25(OH)VD or 25(OH)VD3 decreased, both before and after adjusting for confounding factors (P for trend < .05) (Table 3). As there was no statistical difference in the adjusted OR values for C-TIRADS 4 TN risk between VD-M and VD-H groups, the study stratified 25(OH)VD according to 20.00 ng/mL for further analysis. After fully adjusting for confounding factors, the study found that individuals with 25(OH)VD levels below 20.00 ng/mL had a significantly higher risk of developing C-TIRADS TNs (OR = 4.07, 95% CI: 2.96–5.61, P < .001) (results not shown).

Table 3

The risk of C-TIRASD 4 TN occurrence in 2037 YMAEM petroleum workers
	25(OH)VD OR (95% CI)			25(OH)VD3 OR (95% CI)
	VD-L (< 20.00 ng/mL)	VD-M (20.00–30.00 ng/mL)	VD-H^# (≥ 30.00 ng/mL)	VD3-L (< 19.07 ng/mL)	VD3-M (19.07–26.70 ng/mL)	VD3-H^# (≥ 26.70 ng/mL)	P for trend
Unadjusted	5.28 (3.27–8.52)	1.35 (0.80–2.30)	1.00	4.74 (3.13–7.18)	1.35 (0.83–2.20)	1.00	< 0.001
Model 1	5.25 (3.25–8.51)	1.40 (0.83–2.38)	1.00	4.72 (3.01–7.18)	1.42 (0.87–2.32)	1.00	< 0.001
Model 2	5.02 (3.08–8.17)	1.37 (0.80–2.34)	1.00	4.50 (2.94–6.87)	1.39 (0.85–2.28)	1.00	< 0.001

Model 1 was adjusted for age and BMI

Model 2 was adjusted for age, BMI, FT3, FT4, TSH, TPOAb, TgAb

^#Reference group

The stratification of serum VD levels were performed as described in Fig. 2

TNs are prevalent in the general population, and their clinical significance primarily lies in excluding thyroid cancer. In 2009, Chilean scholars were the first to attempt to establish the TIRADS for TNs [25]. Subsequently, in 2017, the American College of Radiology (ACR) published the ACR-TIRADS classification system for TNs [26]. However, these two versions of TN ultrasound scoring systems do not completely fulfill the current clinical medical requirements in China. Moreover, the application of TIRADS for TNs in the domestic ultrasound field can be confusing. Therefore, the Chinese Medical Association has taken steps to develop a Chinese version of TIRADS [21]. In this study, we utilized the C-TIRADS classification system to categorize TNs and assess the correlation between different levels of VD and the risk of TNs among YAMEA petroleum workers without TAI.

VD exists in two forms, VD3 and VD2, and is converted into 25(OH)VD3 and 25(OH)VD2, which is the storage form of VD, by 25-hydroxylase in the liver [27]. As a steroid hormone, VD regulates the expression of various genes related to cell proliferation, survival, transformation, migration, and communication in cancer and stromal cells such as adipocytes, immune cells, and endothelial cells. This is achieved by activating the VD receptor (VDR) transcription factor either directly or indirectly [28, 29].

We conducted this study to test the hypothesis that VD nutritional status may be related to the prevalence of TNs, particularly malignant TNs. Health check-up data from 2037 workers in the petroleum sector formed the basis of this study. First, we analyzed the differences in serum levels of VD, VD3, and VD2 in subjects with TNs of different C-TIRADS classifications. Patients with C-TIRADS 4 TNs exhibited a significant reduction in serum levels of 25(OH)VD and 25(OH)VD3, whereas no significant alteration was observed in the serum levels of 25(OH)VD2. This was consistent with a previous study [19], which only explored the correlation between serum total VD levels and TNs, without investigating the individual roles of VD3 and VD2 in TNs. Next, we classified 25(OH)VD, 25(OH)VD3, and 25(OH)VD2 into low, medium, and high levels based on differences in serum VD concentrations in petroleum workers. We found no significant difference in the overall prevalence of TNs among the low, medium, and high-level groups of 25(OH)VD, 25(OH)VD3, and 25(OH)VD2 respectively. However, among the YMAEM petroleum workers with TNs (n = 1102), the proportion of C-TIRADS 4 TNs was higher in the low-level group of 25(OH)VD and 25(OH)VD3, while there was no significant difference in the proportion of C-TIRADS 4 TNs among the low, medium, and high-level groups of 25(OH)VD2. Therefore, future studies on the relationship between VD and the prevalence of TNs should focus only on 25(OH)VD and 25(OH)VD3, and not on 25(OH)VD2. Based on all petroleum workers (n = 2037), the prevalence of C-TIRADS 4 TNs in the low-level group of 25(OH)VD or 25(OH)VD3 was significantly higher than their respective medium-level and high-level groups. After fully adjusting for confounding factors using binary logistic regression analysis, we found that the deficiency of 25(OH)VD or the decrease in 25(OH)VD3 was an independent risk factor for the increased risk of C-TIRADS 4 TNs in YAMEA petroleum workers without TAI. Due to the significant increase in the risk of C-TIRADS 4 TNs in the low-level group of 25(OH)VD, but similar risk in the medium- and high-level groups, a stratified analysis was performed based on 20.00 ng/mL for 25(OH)VD. We found that a level of 25(OH)VD below 20.00 ng/mL was an independent risk factor for YMAEM petroleum workers to develop C-TIRADS 4 TNs. These results indicated that the decrease in VD3 not VD2 levels may not affect the overall prevalence of TNs in YMAEM petroleum workers but may increase the risk of C-TIRADS 4 TNs.

Several previous studies have shown that elevated levels of serum VD may reduce the likelihood of developing malignant TNs. Hu et al. found that a high concentration of VD might mitigate the risk of malignant TNs in their study on 276 patients [30]. Similarly, a meta-analysis of 14 studies conducted by Zhao et al. in 2019 revealed that VD deficiency increased the risk of malignant TNs by nearly 30% compared to the healthy control group [31]. Moreover, a recent case-control study conducted in China reported that 25(OH)VD and VD binding protein had an inhibitory effect on the incidence of malignant TNs [32]. Many studies have suggested that VD could have anti-tumor effects by promoting cell apoptosis, inhibiting proliferation, blocking the cell cycle, promoting differentiation, reducing inflammatory responses, and reducing invasiveness [31]. Additionally, studies have shown that the VD receptor (VDR) can inhibit the growth of differentiated thyroid cancer (DTC) cells by regulating the E-cadherin/β-catenin complex. This suggested that modulating the VDR signaling pathway could be a potential therapeutic approach to attenuate thyroid cancer progression [15, 33]. However, the specific mechanism remains unclear, and conflicting evidence exists [34, 35]. For instance, Huang et al. recently conducted a study comparing serum VD levels between PTC and benign TNs and found no reliable evidence to support serum VD levels as a risk factor or prognostic indicator for PTC [36]. Several possible reasons may account for these discrepancies. First, previous studies only measured total VD levels in serum and did not evaluate the individual effects of VD3 and VD2. Second, The inconsistent selection of study populations in existing research has led to differences in the conclusions regarding the relationship between VD and TNs. Third, different methods and units of measurement are used to measure serum VD levels. Finally, there is cross-reactivity between VD3 and VD2 forms, and measuring VD levels using immunological methods can lead to measurement errors compared to LC-MS/MS methods [37–39].

In this study, we utilized LC-MS/MS to quantify VD3 and VD2 concentrations in plasma. Our findings indicated that a reduction in plasma 25(OH)VD or 25(OH)VD3 levels increased the risk of C-TIRADS 4 TNs in petroleum workers without TAT. However, no such effect was observed for 25(OH)VD2. Interestingly, a meta-analysis from 2019 showed that supplementation with VD3 can reduce cancer mortality, while supplementation with VD2 did not have this effect [40]. Thus, different forms of VD may have different effects on human health [41]. Additionally, VD3 and VD2 have been found to have similar but different ways of affecting the body's immune system according to blood transcriptome analysis [42].

Strengths and limitations

Our study had several strengths. Firstly, all participants' TNs were categorized according to C-TIRADS, which was considered more appropriate for the Chinese population. Secondly, we analyzed the individual relationship between VD3 and VD2 and TNs. However, our study also had some limitations. Firstly, the study subjects were strictly limited, and the conclusions of the study may not necessarily apply to other populations. Secondly, it was a single-center study. Finally, there was a lack of histopathology of TNs. As this was a cross-sectional study, it could only establish a relationship between VD and TNs, but could not confirm a causal relationship. Therefore, further prospective research and related basic research are needed to confirm any causal relationship. It would be premature to blindly expand the role of VD in malignant TNs before the conclusion of the above research.

VD deficiency [25(OH)VD < 20.00 ng/mL]was an independent risk factor for developing TNs with malignant ultrasound characteristics in YMAEM petroleum workers who did not have TAI. Among these workers, low levels of VD3, not VD2, appeared to be associated with an increased prevalence of TNs with malignant ultrasound characteristics.

vitamin D

TNs

thyroid nodules

YMAEM

young and middle-aged euthyroid male

TAI

thyroid autoimmunity

25(OH)VD

25-hydroxy vitamin D

TSH

Serum thyroid stimulating hormone

FT3

free triiodothyronine

FT4

free thyroxine

TPOAb antithyroperoxidase antibody

TgAb

antithyroglobulin antibody

LC-MS/MS

liquid chromatography-tandem mass spectrometry analysis

ANOVA

one-way analysis of variance

ORs

odds ratios

C-TIRADS

Chinese-Thyroid Imaging Reporting and Data System

ACR

American College of Radiology

VDR

vitamin D receptor

DTC

Differentiated thyroid cancer

PTC

Papillary thyroid carcinoma

Acknowledgments

The authors express their sincere gratitude to the study participants.

Authors’ contributions

The study was designed by JL. Data collection was carried out by DL, SL, CZ, ZC, and BL. Statistical analysis was performed by JH, BG, and DW. The manuscript was drafted by DW and revised by WT and ZS. All authors have read and agreed to the published version of the manuscript.

Funding

This work was supported by the Distinguished Professor at Educational Department of Liaoning Province (grant number: No. [2014]187) and the Research Fund of Hongqi Hospital Affiliated to Mudanjiang Medical University (grant number: No. 2021HQ-09).

Availability of data and materials

The datasets used and/or analyzed in the current study can be obtained from the corresponding author upon reasonable request.

Ethics approval and consent to participate

All procedures used in human research were in compliance with the Constitution and/or the Helsinki Declaration of 1964 and the ethical standards of the National Research Council. This study was approved by the Medical Ethics Committee of The Second Affiliated Hospital of Dalian Medical University (protocol code: No. 2022/090). All subjects participating in the study signed the informed consent form.

Consent for publication

Not applicable.

Competing interests

The authors declare no conflict of interest.

Author details

¹Department of Endocrinology and Metabolism, The Institute of Endocrinology, NHC Key Laboratory

of Diagnosis and Treatment of Thyroid Diseases, The First Hospital of China Medical University,

Shenyang 110001, China.

²Department of Endocrinology and Metabolism, Hongqi Hospital Affiliated to Mudanjiang Medical

University, Mudanjiang 157011, China.

³Department of Endocrinology, The Second Hospital of Dalian Medical University, Dalian 116023,

China.

⁴Health Management Center, The Second Hospital of Dalian Medical University, Dalian 116023,China

⁵Liaoning University of Traditional Chinese Medicine, Shenyang 110847, China.

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No competing interests reported.

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The relationship between vitamin D nutritional status and ultrasound classifications of thyroid nodules in young and middle-aged euthyroid male petroleum workers

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Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Subjects and methods

Subjects

Laboratory measurements

Statistical analysis

Results

Demographic characteristics and clinical parameters comparison

Distribution of TNs

The stratification VD levels were performed as described in Fig. 2

Prevalence of C-TIRADS 4 TNs

Discussion

Strengths and limitations

Conclusions

Abbreviations

Declarations

References

Additional Declarations

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