Introduction
Thyroid nodules are common findings in the general population, detected in approximately 65%, with most being benign. However, differentiated thyroid carcinoma (DTC) incidence has risen steadily, partly due to improved diagnostic imaging and biopsy techniques. Beyond detection advances, metabolic factors such as insulin resistance and cardiovascular risk (CVR) profiles may contribute to the pathophysiology of thyroid malignancies. Despite clinical interest, definitive associations between insulin resistance, serum thyroid hormone levels—particularly free thyroxine (FT4)—and thyroid cancer characteristics remain underexplored.
Study Design
This observational, cross-sectional study evaluated 160 adult thyroid nodule (TN) patients from a tertiary endocrinology service in Campinas, Brazil. Inclusion criteria incorporated confirmed thyroid nodules via standardized ultrasonography performed over a decade (2007–2017). Clinical data included anthropometry, lipid profiles, glucose metabolism indices (fasting glucose, glycated hemoglobin), cardiovascular risk scores (Framingham, ASCVD), and thyroid function tests (TSH, FT4). Cytological classifications per Bethesda guidelines and histopathological diagnoses for differentiated thyroid carcinoma (papillary and follicular types) were analyzed. The study excluded patients with recent acute cardiovascular events, severe systemic illness, or interfering medications. Statistical analyses employed non-parametric tests and logistic regression to identify associations and predictors of malignant cytology and pathology.
Key Findings
- Demographics and Comorbidities: The cohort was predominantly female (85.5%), with high prevalence of obesity (41.3%), type 2 diabetes mellitus (24.1%), arterial hypertension (63.4%), and dyslipidemia (38.1%).
- Ultrasound Features and Metabolic Associations: Microcalcifications within thyroid nodules—an ultrasonographic marker with high specificity for malignancy—were significantly associated with elevated cardiovascular risk scores (Framingham, ASCVD) and worse glycemic markers (fasting glucose and HbA1c). Other ultrasound parameters (echogenicity, vascularity, margins) showed no correlation with metabolic risk factors.
- Cytological and Pathological Correlations with Metabolic Parameters: Cytology Bethesda categories indicative of benign lesions (category II) were linked to lower fasting glucose, whereas atypical or suspicious categories (III and IV) showed increasing associations with impaired glucose metabolism and higher CVR scores. Interestingly, patients with papillary thyroid carcinoma had lower Framingham scores, and those with follicular carcinoma exhibited smaller abdominal waist circumference, reflecting possibly distinct metabolic profiles according to histological subtype.
- Insulin Resistance Indicators and Thyroid Morphology: Positive correlations emerged between insulin resistance factors and gland size and multinodularity: higher relative fat mass (RFM), waist circumference, fasting glucose, and HbA1c were associated with greater thyroid gland volume and larger, more numerous nodules, consistent with insulin’s mitogenic and anti-apoptotic influences on thyroid tissue.
- Serum Free Thyroxine (FT4) as a Predictor: Elevated FT4 levels—within normal reference ranges in euthyroid patients—increased the odds of malignant cytology by 4.7-fold and were independently associated with a 7.4-fold increase in risk of differentiated thyroid carcinoma. This supports potential proliferative and pro-angiogenic roles of thyroid hormones in neoplastic thyroid tissue expansion.
- Lipid Profile and Malignancy Risk: Higher serum high-density lipoprotein (HDL) cholesterol levels were paradoxically associated with increased odds of malignant cytology (6.4% per unit increase), although no direct link between HDL and confirmed thyroid cancer diagnosis was found. Statin use correlated with a lower likelihood of malignancy, suggesting therapeutic lipid modulation might influence thyroid neoplasm biology.
- Thyroid Autoimmunity: Presence of anti-thyroglobulin (TgAb) or anti-thyroperoxidase antibodies (TPOAb) showed no significant associations with insulin resistance markers, cardiovascular risk, or thyroid nodule characteristics, indicating autoimmunity may be independent of metabolic-related thyroid cancer risk factors.
Expert Commentary
The study deepens understanding of metabolic influences on thyroid tumorigenesis, highlighting that insulin resistance and subtle variations in thyroid hormone levels might augment malignant potential in thyroid nodules. These findings resonate with prior mechanistic and animal studies suggesting that thyroid hormones enhance mitogenic pathways and angiogenesis in malignant cells. Importantly, the association of higher FT4 within euthyroid ranges with cancer risk challenges traditional clinical interpretations of thyroid hormone metrics and advocates for cautious longitudinal monitoring.
The paradoxical HDL findings invite further research into lipid metabolism interplay with thyroid neoplasia, potentially involving qualitative changes in lipoprotein particles or HDL functionality rather than quantity alone. Statin use emerging as protective reflects anti-inflammatory and possibly pleiotropic anti-cancer effects. Nonetheless, causality cannot be established from this cross-sectional design; prospective studies and mechanistic investigations are warranted.
The absence of association between thyroid autoimmunity and insulin resistance contrasts with some prior hypotheses but underscores the multifactorial nature of thyroid carcinogenesis. Clinicians should consider metabolic evaluation in patients with suspicious thyroid nodules as part of comprehensive risk stratification.
Study limitations include sample size constraints for multivariate analyses and inherent cross-sectional design limiting causal inference. The homogeneous tertiary-care cohort may limit generalizability. However, standardized ultrasonography and pathology assessment bolster internal validity.
Conclusion
Elevated serum free thyroxine within normal ranges and markers of insulin resistance including increased waist circumference, glycemic abnormalities, and cardiovascular risk scores are closely linked with malignant cytology and differentiated thyroid carcinoma. Thyroid nodules exhibiting microcalcifications and larger multinodular goiters correlate with higher metabolic risk, reinforcing the biological plausibility of insulin and thyroid hormones as contributors to tumor proliferation.
These findings suggest integrating metabolic and hormonal profiles, including FT4 and insulin resistance assessments, into the clinical evaluation of thyroid nodules may improve malignancy prediction and patient stratification. Additionally, lipid-lowering interventions such as statins could have a role in modulating thyroid malignancy risk, warranting further prospective research.
Clinicians managing patients with thyroid nodules should consider comprehensive cardiovascular and metabolic risk profiling alongside traditional ultrasound and cytological assessments to enhance early malignant nodule identification and patient outcomes.
References
1. Durante C, Grani G, Lamartina L, et al. The diagnosis and management of thyroid nodules: a review. JAMA. 2018;319(9):914–924.
2. Kent WDT, Hall SF, Isotalo PA, et al. Increased incidence of differentiated thyroid carcinoma and detection of subclinical disease. CMAJ. 2007;177(11):1357–1361.
3. Enewold L, Zhu K, Ron E, et al. Rising thyroid cancer incidence in the United States by demographic and tumor characteristics, 1980–2005. Cancer Epidemiol Biomarkers Prev. 2009;18(3):784–791.
4. Panagiotou G, Komninou D, Anagnostis P, et al. Association between lifestyle and anthropometric parameters and thyroid nodule features. Endocrine. 2017;56(3):560–567.
5. Shin J, Kim M-H, Yoon K-H, et al. Relationship between metabolic syndrome and thyroid nodules in healthy Koreans. Korean J Intern Med. 2016;31(1):98–105.
6. Lin H-Y, Tang H-Y, Shih A, et al. Thyroid hormone is a MAPK-dependent growth factor for thyroid cancer cells and is anti-apoptotic. Steroids. 2007;72(2):180–187.
7. Krashin E, Piekiełko-Witkowska A, Ellis M, et al. Thyroid Hormones and Cancer: a Comprehensive Review of Preclinical and Clinical Studies. Front Endocrinol (Lausanne). 2019;10:59.
8. Kim TH, Lee MY, Jin SM, et al. The association between serum concentration of thyroid hormones and thyroid cancer: a cohort study. Endocr Relat Cancer. 2022;29(12):635–644.
9. Zhang X, Ze Y, Sang J, et al. Risk factors and diagnostic prediction models for papillary thyroid carcinoma. Front Endocrinol (Lausanne). 2022;13:938008.
10. Ru X, Su Z, Guo Y. Assessing the influence of metabolic syndrome on thyroid cancer: insights from a Mendelian randomization approach. Discov Oncol. 2025;16(1):1048.
11. Yuan J, Chen Z, Zhang J, et al. Preoperative serum lipids as novel predictors of survival in 3575 patients with papillary thyroid cancer. J Clin Endocrinol Metab. 2025;110(3):668–676.
12. Liang W, Sun F. Do metabolic factors increase the risk of thyroid cancer? A Mendelian randomization study. Front Endocrinol (Lausanne). 2023;14:1234000.
13. Chen Y, Zhu C, Chen Y, et al. The association of thyroid nodules with metabolic status: a cross-sectional SPECT–China study. Int J Endocrinol. 2018;2018:6853617.
14. Yin D-T, He H, Yu K, et al. The association between thyroid cancer and insulin resistance, metabolic syndrome and its components: a systematic review and meta-analysis. Int J Surg. 2018;57:66–75.
15. Tsatsoulis A. The role of insulin resistance/hyperinsulinism on the rising trend of thyroid and adrenal nodular disease in the current environment. J Clin Med. 2018;7(3):37.
16. Mijović T, How J, Pakdaman M, et al. Body mass index in the evaluation of thyroid cancer risk. Thyroid. 2009;19(5):467–472.
17. Dobbins M, Decorby K, Choi BCK. The association between obesity and cancer risk: a meta-analysis of observational studies from 1985 to 2011. ISRN Prev Med. 2013;2013:680536.