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Radiation exposure, young age, and female gender are associated with high prevalence of RET/PTC1 and RET/PTC3 in papillary thyroid cancer: a meta-analysis

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Oncotarget. 2016; 7:16716-16730. https://doi.org/10.18632/oncotarget.7574

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Xuan Su, Zhaoqu Li, Caiyun He, Weichao Chen, Xiaoyan Fu and Ankui Yang _

Abstract

Xuan Su1,*, Zhaoqu Li1,*, Caiyun He2,*, Weichao Chen1, Xiaoyan Fu1, Ankui Yang1

1Department of Head and Neck, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China

2Department of Molecular Diagnostics, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China

*These authors have contributed equally to this article and thus are regarded as the co-first author

Correspondence to:

Ankui Yang, e-mail: yangak@sysucc.org.cn

Keywords: RET/PTC, papillary thyroid cancer, radiation, biomarker

Received: October 12, 2015    Accepted: February 02, 2016    Published: February 23, 2016

ABSTRACT

Background: RET/PTC rearrangements have been identified as a specific genetic event in papillary thyroid cancer (PTC). We conducted this meta-analysis to identify an enriched population who were more likely to occur RET/PTC fusion genes.

Methods: All relevant studies in the PubMed, Web of Science, and Embase databases were searched up to June 2015. The studies found were screened according to our inclusion and exclusion criteria. All analyses were performed using STATA software.

Results: Eventually, 38 eligible studies comprising 2395 participants were included. Overall analysis indicated that radiation exposure contributed to increased RET/PTC risk (OR = 2.82; 95%CI: 1.38–5.78, P = 0.005). Stratified analysis according to RET/PTC subtype and geographical area showed that this association was restricted to the RET/PTC3 subtype (OR = 8.30, 95%CI: 4.32–15.96, P < 0.001) in the Western population. In addition, age < 18 years, i.e., young age, was associated with higher prevalence of RET/PTC3 (OR = 2.03, 95%CI: 1.14–3.62, P = 0.017), especially in the radiation-exposure subpopulation (OR = 2.35, 95%CI: 1.01–5.49, P = 0.048). The association between female gender and RET/PTC1 risk was more significant in the PTC patients without radiation exposure (OR = 1.69, 95%CI: 1.04–2.74, P = 0.034).

Conclusion: Both radiation exposure and young age are associated with increased risk of RET/PTC3 and that female gender is associated with higher prevalence of RET/PTC1 in the subpopulation without radiation exposure. The RET/PTC status in combination with radiation exposure, age, and sex should be considered in the differential diagnosis of suspicious PTC.


INTRODUCTION

Rearrangement involving the RET proto-oncogene, referred to RET/PTC (the rearranged during transfection/papillary thyroid carcinoma tyrosine kinase) fusion genes, is one of the best-known mutations in papillary thyroid carcinoma (PTC) [1]. RET/PTC is identified as a specific genetic event in patients with PTC, which forms the basis of differential diagnosis and novel therapeutic approaches to this disease [2]. However, the prevalence rate of the major RET/PTC subtypes in different ethnicities and their correlation with the clinicopathologic features of PTC remains controversial and as yet are not routinely investigated in clinical practice.

The receptor tyrosine kinase RET plays a critical role in cell differentiation and proliferation, which is required for normal development of several tissues, especially in early embryogenesis [3]. In 1985, Takahashi and colleagues initially reported RET as a proto-oncogene that can be activated by interchromosomal rearrangement [4]. Subsequent studies demonstrated more than a dozen different forms of RET rearrangement, of which RET/PTC1 and RET/PTC3 are the most common, resulting from the fusion of RET with H4 and of RET with RFG/ELE1 respectively [5]. However, their prevalence rates in PTC exhibit significant geographic variation, ranging from 0% to 86.7% among studies [6, 7]. As risk factors such as sex, age, and radiation exposure are related to PTC pathogenesis, scientists have focused on searching for the factors that increase RET/PTCrearrangement risk. Accordingly, several studies have detected RET/PTC rearrangements more frequently in PTC in children than in adults [8, 9]. A relatively high prevalence of RET/PTC rearrangements was reported in radiation-induced PTC [10]. In addition, ethnicity and demographic characteristics may also influence the frequency of RET/PTC rearrangement [11-13]. To date, numerous relevant studies have been published but with divergent results.

In this study, we aimed to identify an enriched population who were more likely to occur RET/PTC1 and RET/PTC3 fusion genes and to provide more useful information on candidate selection for PTC prevention, diagnosis, and treatment. Therefore, we performed this meta-analysis to investigate the association between the presence/absence of RET/PTC1 or RET/PTC3 and radiation exposure, sex, age, and ethnicity.

RESULTS

Basic characteristics of enrolled studies

The article selection flowchart is depicted in Figure 1. A total 2014 records were obtained by searching the PubMed, Web of Science, and Embase databases. After removing duplicates, we found 1206 potentially relevant records. By reviewing titles, abstracts, and full texts according to the inclusion and exclusion criteria, 1168 articles were excluded because they were not relevant, involved in vitro or animal experiments, were reviews or meeting abstracts, contained data covered by other studies, had no raw data, etc. Eventually, 38 full-text articles, which consisted of 2395 PTC cases, met our inclusion criteria and were included in the final meta-analysis [6-10, 14-47].

Flowchart of literature search and selection of studies.

Figure 1: Flowchart of literature search and selection of studies.

The main characteristics of the studies included in this meta-analysis are summarized in Table 1. The status of the RET/PTC fusion gene in the original studies were detected by PCR combined with reverse transcription (RT), Southern Blot or fluorescence in situ hybridization (FISH). The included studies involved populations from different geographical regions, namely Asia, Europe, and America; therefore, we divided the studies into Asian and Western subgroups.

Table 1: Characteristics of studies included in the meta-analysis

First author

Year of publication

Ethnicity

Region

Method of detection

Radiation

No.of patients

Nikiforov et al

1997

Belarussian, Los Angeles, Cincinnati

Western

RT-PCR

Mixed

55

Bounacer et al

1997

French

Western

RT-PCR

Mixed

39

Motomura et al

1998

Japanese

Asian

RT-PCR

Non-radiation

21

Smida et al

1999

Belarussian, German

Western

RT-PCR

Mixed

83

Rabes et al

2000

Belarus, Russia, Ukrainian

Western

PCR

Radiation

191

Elisei et al

2001

Belarus, Itaian

Western

PCR

Mixed

89

Puxeddu et al

2003

Italian

Western

RT-PCR, Southern Blot

Non-radiation

48

Rhoden et al

2004

American

Western

RT-PCR

NM

25

Nakazawa et al

2005

Japanese

Asian

RT-PCR

Non-radiation

169

Brzezianska et al

2006

Polish

Western

RT-PCR

NM

33

Hamatani et al

2008

Japanese

Asian

RT-PCR

Mixed

71

Tuttle et al

2008

Russian

Western

RT-PCR

Radiation

76

Lam et al

2002

China, Hong Kong

Asian

RT-PCR

Non-radiation

21

Detours et al

2005

Ukrainian

Western

RT-PCR

Mixed

20

Lima et al

2004

Ukrainian

Western

RT-PCR

Mixed

34

Penko et al

2005

American

Western

PCR

Mixed

13

Romei et al

2008

Italian

Western

RT-PCR

Non-radiation

70

Hieber et al

2011

Ukrainian

Western

FISH

Radiation

22

Guerra et al

2014

Italian

Western

RT-PCR

NM

72

Zou et al

2014

Saudi Arabian

Asian

RT-PCR

NM

88

Chung et al

1999

Korean

Asian

RT-PCR

Non-radiation

31

Powell et al

2005

Ukrainian

Western

PCR

Mixed

35

Unger et al

2004

Ukrainian

Western

FISH

Radiation

29

Wang et al

2008

Chinese

Asian

RT-PCR

Non-radiation

126

Nikiforova et al

2004

Belorussian, Ukrainian

Western

PCR

Mixed

137

Basolo et al

2002

Italian

Western

RT-PCR

NM

91

Rao et al

2014

Indian

Asian

RT-PCR

Non-radiation

30

Collins et al

2002

American

Western

IHC

Mixed

64

Chung et al

2004

Korean

Asian

RT-PCR+IHC

Non-radiation

22

Unger et al

2006

Ukrainian

Western

FISH

Radiation

13

Sadetzki et al

2004

Israelis

Asian

RT-PCR

Mixed

49

Smyth et al

2005

Irish

Western

Taqman

NM

34

Learoyd et al

1998

Australian, Swedish

Western

RT-PCR

Mixed

50

Nakazawa et al

2009

Japanese

Asian

FISH+RT-PCR

Non-radiation

14

Di Cristofaro et al

2005

Ukrainian, French

Western

RT-PCR

Mixed

50

Erdogan

2008

Turkish

Asian

RT-PCR

Non-radiation

101

Fenton et al

2000

American

Western

PCR

Non-radiation

33

Guerra et al

2011

Italian

Western

RT-PCR

NM

50

Stanojevic et al

2011

Serbian

Western

PCR

Non-radiation

266

We also summarized the positive rates of RET/PTC from each original study (Table 2). The overall prevalence of RET/PTC was relatively higher in the Western populations (42.19%) than in the Asian populations (36.73%). A similar tendency was observed for the RET/PTC1 subtype, whereas the Asian populations demonstrated a higher positive rate for the RET/PTC3 subtype (Asian vs. Western populations: 26.50% vs. 17.05%). In the Asian studies, the positive rates of RET/PTC3 in the studies by Lam et al. [16] and Rao et al. [7] were up to 85.71% and 86.67%, respectively, while another six studies reported a much lower incidence of RET/PTC3 that ranged from 0% to 20.79% [9, 14, 20-23].

Table 2: Positive rates of RET/PTC1 and RET/PTC3 in each original study

First author

Year of publication

No. of PTC cases

Freq. of RET/PTC1 and 3

RET/PTC1 and 3(%)

Freq. of RET/PTC1

RET/PTC1(%)

Freq. of RET/PTC3

RET/PTC3(%)

For Asian studies

36.73%

21.06%

26.50%

Motomura et al

1998

21

7

33.33%

5

23.81%

2

9.52%

Nakazawa et al

2005

169

48

28.40%

43

25.44%

8

4.73%

Hamatani et al

2008

71

12

16.90%

Lam et al

2002

21

18

85.71%

18

85.71%

Zou et al

2014

88

12

13.64%

12

13.64%

Chung et al

1999

31

4

12.90%

Wang et al

2008

126

18

14.29%

Rao et al

2014

30

26

86.67%

0

0.00%

26

86.67%

Chung et al

2004

22

2

9.09%

1

4.55%

1

4.55%

Sadetzki et al

2004

49

22

44.90%

20

40.82%

0

0.00%

Nakazawa et al

2009

14

4

28.57%

4

28.57%

0

0.00%

Erdogan

2008

101

67

66.34%

32

31.68%

21

20.79%

For Western studies

42.19%

25.25%

17.05%

Nikiforov et al

1997

55

40

72.73%

14

25.45%

25

45.45%

Bounacer et al

1997

39

18

46.15%

15

38.46%

5

12.82%

Smida et al

1999

83

39

46.99%

26

31.33%

13

15.66%

Rabes et al

2000

191

86

45.03%

48

25.13%

38

19.90%

Elisei et al

2001

89

40

44.94%

18

20.22%

26

29.21%

Puxeddu et al

2003

48

13

27.08%

8

16.67%

5

10.42%

Rhoden et al

2004

25

18

72.00%

18

72.00%

5

20.00%

Brzezianska et al

2006

33

7

21.21%

Tuttle et al

2008

76

13

17.11%

11

14.47%

5

6.58%

Detours et al

2005

20

7

35.00%

1

5.00%

2

10.00%

Lima et al

2004

34

14

41.18%

Penko et al

2005

13

7

53.85%

5

38.46%

2

15.38%

Romei et al

2008

13

18.57%

12

17.14%

Hieber et al

2011

22

17

77.27%

Guerra et al

2014

72

12

16.67%

Powell et al

2005

35

16

45.71%

Unger et al

2004

29

5

17.24%

2

6.90%

3

10.34%

Nikiforova et al

2004

137

48

35.04%

16

11.68%

32

23.36%

Basolo et al

2002

91

28

30.77%

6

6.59%

22

24.18%

Collins et al

2002

64

44

68.75%

Unger et al

2006

13

10

76.92%

Smyth et al

2005

34

13

38.24%

10

29.41%

3

8.82%

Learoyd et al

1998

50

4

8.00%

4

8.00%

0

0.00%

Di Cristofaro et al

2005

50

30

60.00%

26

52.00%

13

26.00%

Fenton et al

2000

33

14

42.42%

11

33.33%

3

9.09%

Guerra et al

2011

50

18

36.00%

Stanojevic et al

2011

266

55

20.68%

42

15.79%

13

4.89%

Association between radiation exposure and RET/PTC fusion genes

As radiation exposure is the best-known risk factor for PTC, we initially investigated the effect of radiation on RET/PTC rearrangement (Table 3). Fourteen studies investigated the distribution difference of radiation exposure between RET/PTC-positive and -negative patients with PTC. When the RET/PTC1 and RET/PTC3 subtypes were combined, radiation exposure conferred increased overall risk for RET/PTC development (OR = 2.82, 95%CI: 1.38–5.78; P = 0.005, Figure 2) and there was moderate heterogeneity (I2 = 74%, Phet < 0.001). Stratified analysis according to geographical region decreased the heterogeneity slightly, and increased risk for RET/PTC rearrangement persisted in the Western subpopulation, demonstrating an increased OR of 3.97 (95%CI: 2.03–7.75; P < 0.001).

Table 3: Meta-analysis results for association between RET/ PTC fusion genes and radiation exposure in patients with PTC

Radiation exposure vs. non-radiation exposure

No. of studies

No. of cases/controls

OR(95%CI)

P value

Model

I2

Pheta

For RET/PTC1 and 3

 All

14

537/388

2.82(1.38,5.78)

0.005

Random

74%

<0.001

 Region

 Asian

4

232/71

0.88(0.26,2.93)

0.833

Random

56%

0.077

 Western

10

305/317

3.97(2.03,7.75)

<0.001

Random

59%

<0.001

For RET/PTC1

 All

9

285/287

1.86(0.66, 5.28)

0.243

Random

76.00%

<0.001

 Region

 Asian

1

37/12

0.24(0.06,0.96)

0.043

Random

/

/

 Western

8

248/275

2.46(0.83,7.27)

0.104

Random

74.10%

<0.001

For RET/PTC3

 Allb

8

243/240

8.30(4.32,15.96)

<0.001

Fixed

0.00%

0.980

 Region

 Asian

/

/

/

/

/

/

/

 Western

8

243/240

8.30(4.32,15.96)

<0.001

Fixed

0.00%

0.980

a, P-value for heterogeneity test;

b, Data from Sadetzki et al. [21] and Learoyd et al. [6] showed that the RET/PTC3 gene prevalence was 100% in both the groups with and without radiation exposure and that the OR and standard error could not be estimated; therefore, these studies were excluded. The statistically significant results are highlighted in bold.

Results of the association between RET/PTC1 and RET/PTC3 fusion genes and radiation exposure in patients with PTC.

Figure 2: Results of the association between RET/PTC1 and RET/PTC3 fusion genes and radiation exposure in patients with PTC.

When the RET/PTC1 and RET/PTC3 subtypes were considered separately, radiation exposure conferred significantly higher risk for RET/PTC3 rearrangement (OR = 8.30, 95%CI: 4.32–15.96; P < 0.001, Figure 3) but not for RET/PTC1 rearrangement. This association was only evident in the Western subpopulation. Separate pooled analysis for the RET/PTC1 and RET/PTC3 subtypes was not performed for the Asian subpopulation because three original studies involving this population investigated the combined status of RET/PTC1 and RET/PTC3, and the data could not be extracted separately [9, 15, 22]. Only one study with a small sample in an Asian country reported the RET/PTC1 and RET/PTC3 fusion gene data separately [21]. There was significant inter-study heterogeneity in the RET/PTC1 analysis but not in the RET/PTC3 analysis.

Results of the association between RET/PTC3 fusion gene and radiation exposure in patients with PTC.

Figure 3: Results of the association between RET/PTC3 fusion gene and radiation exposure in patients with PTC.

Association between RET/PTC fusion genes and age

Different age effects have been observed in the development of PTC, and we therefore explored whether young age affected the penetrance of theRET/PTC fusion genes in children and adolescents (Table 4). In this meta-analysis, age < 18 years was considered young, i.e., children and adolescents. In the combined analysis of the RET/PTC1 and RET/PTC3 subtypes, no association was observed between age and RET/PTC rearrangement. In the separate analysis of the RET/PTC1 and RET/PTC3 subtypes, young people had nearly two-fold greater risk for RET/PTC3 rearrangement (Figure 4) but penetrance of the RET/PTC1 fusion gene was not affected. When radiation exposure was also considered, young people in the subpopulation with radiation exposure had higher risk for developing RET/PTC3 rearrangement as compared to adults with radiation exposure. These positive associations were performed in a fixed-effects model and had slight inter-study heterogeneity (all Phet > 0.10).

Table 4: Meta-analysis results for association between RET/PTC fusion genes and age in patients with PTC

Young people vs. adult

No. of studies

No. of cases/controls

OR(95%CI)

P value

Model

I2

Pheta

For RET/PTC1 and 3

 All

8

187/332

1.10(0.56,2.16)

0.783

Random

51.50%

0.044

 Region

 Asian

2

41/149

1.76(0.84,3.69)

0.133

Fixed

4.30%

0.307

 Western

6

146/183

0.98(0.41,2.31)

0.956

Random

54.50%

0.052

 Radiation

 Radiation exposure

6

116/122

0.88(0.48,1.62)

0.682

Fixed

41.50%

0.129

 Non-radiation exposure

5

71/200

1.46(0.81,2.65)

0.212

Fixed

33.90%

0.195

For RET/PTC1

 All

6

172/286

0.98(0.60,1.58)

0.921

Fixed

7.20%

0.370

 Region

 Asian

2

41/149

1.33(0.61,2.91)

0.476

Fixed

0.00%

0.466

 Western

4

131/137

0.81(0.44,1.50)

0.507

Fixed

21.40%

0.282

 Radiation

 Radiation exposure

5

107/109

0.52(0.26,1.05)

0.070

Fixed

49.30%

0.096

 Non-radiation exposure

5

71/200

1.47(0.76,2.86)

0.250

Fixed

0.00%

0.574

For RET/PTC3

 All

7

179/318

2.03(1.14,3.62)

0.017

Fixed

46.70%

0.081

 Region

 Asian

2

42/148

3.23(0.87,12.00)

0.080

Fixed

7.20%

0.299

 Western

5

137/170

1.84(0.97,3.50)

0.206

Random

50.1%%

0.091

 Radiation

 Radiation exposure

5

107/109

2.35(1.01,5.49)

0.048

Fixed

0.00%

0.574

 Non-radiation exposure

5

72/199

1.68(0.28,10.01)

0.570

Random

67.00%

0.028

a, P-value for heterogeneity test. The statistically significant results are highlighted in bold.

Results of the association between RET/PTC3 fusion gene and young age in patients with PTC.

Figure 4: Results of the association between RET/PTC3 fusion gene and young age in patients with PTC.

Association between RET/PTC fusion genes and sex

Females are more likely to develop PTC, therefore we investigated whether female gender increases the chance of RET/PTC rearrangement in patients with PTC. As suggested by the findings in Table 5, sex was not statistically associated with RET/PTC status in the combined analysis. In subgroup analysis, a pooled analysis of 13 studies showed that female gender was associated with RET/PTC1 development in the subpopulation without radiation exposure. Female patients had 1.69-fold greater risk for RET/PTC1 rearrangement than male patients did (95%CI: 1.04–2.74; P = 0.034, Figure 5). However, female gender did not appear to play a role in RET/PTC3 rearrangement (all, P > 0.05). Only slight inter-study heterogeneity was observed in all of the above analyses (all Phet > 0.10).

Table 5: Meta-analysis results for association between RET/ PTC fusion genes and sex in patients with PTC

Female vs. male

No. of studies

No. of cases/controls

OR(95%CI)

P value

Model

I2

Pheta

For RET/PTC1 and 3

  All

27

1211/474

1.04(0.81,1.33)

0.775

Fixed

0.00%

0.938

  Region

  Asian

9

373/138

1.42(0.81,2.49)

0.216

Fixed

0.00%

0.754

  Western

18

838/336

0.95(0.72,1.27)

0.747

Fixed

0.00%

0.934

  Radiation

  Radiation exposure

11

369/174

0.94(0.63,1.41)

0.760

Fixed

0.00%

0.941

  Non-radiation exposure

17

721/258

1.28(0.90,1.82)

0.171

Fixed

7.20%

0.370

For RET/PTC1

  All a

16

832/324

1.21(0.87,1.69)

0.256

Fixed

0.00%

0.857

  Region

  Asian

5

213/62

0.98(0.48,2.01)

0.962

Fixed

0.00%

0.604

  Western

11

619/261

1.28(0.88,1.87)

0.193

Fixed

0.00%

0.796

  Radiation

  Radiation exposure

4

185/104

1.22(0.70,2.11)

0.482

Fixed

0.00%

0.892

  Non-radiation exposure

13

581/192

1.69(1.04,2.74)

0.034

Fixed

0.00%

0.768

For RET/PTC3

  All,b

17

785/304

0.87(0.60,1.27)

0.466

Fixed

0.00%

0.625

  Region

  Asian

5

155/40

1.54(0.59,3.99)

0.378

Fixed

0.00%

0.763

  Western

11

619/261

0.77(0.51,1.17)

0.223

Fixed

0.00%

0.527

  Radiation

  Radiation exposure

4

185/104

0.82(0.45,1.48)

0.504

Fixed

0.00%

0.903

  Non-radiation exposure

11

570/186

1.06(0.60,1.87)

0.847

Fixed

0.00%

0.696

a, P-value for heterogeneity test;

b, Data from Rao et al. [7] and Detours et al. [31] showed that RET/PTC1 gene prevalence was 100% in both female and male groups and that the OR and standard error could not be estimated; therefore, these studies were excluded. The statistically significant results are highlighted in bold.

Results of the association between RET/PTC1 fusion gene and female gender in PTC patients without radiation exposure.

Figure 5: Results of the association between RET/PTC1 fusion gene and female gender in PTC patients without radiation exposure.

Heterogeneity testing and sensitivity analysis

The inter-study heterogeneities in each comparison are presented in Tables 35. Pooled analyses for assessing the effect of radiation exposure and young age on the combined status of the RET/PTC1 and RET/PTC3 fusion genes demonstrated moderate heterogeneity. To explore the source of heterogeneity, subgroup analyses based on ethnicity and RET/PTC subtype were performed. Heterogeneity was decreased in the subgroup analysis and may be partly explained by the different ethnicities and RET/PTC subtypes (Tables 3 and 5).

Sensitivity analysis was also conducted to assess the influence of individual studies on the overall risk of RET/PTC rearrangement by excluding any single study in turn and recalculating the pooled ORs and 95%CI. For the effect of radiation on RET/PTC rearrangement, Sadetzki et al. [21], Nakazawa et al. [22], and Bounacer et al. [24] reported greater differences in the risk estimates compared with other studies in the sensitivity analysis. Sensitivity analysis excluding the three studies generated a similar pooled OR of 3.30 (95%CI: 1.96–5.54, P < 0.001; I2= 32.1%, Phet = 0.142) among homogeneous studies. For the effect of young age on RET/PTC rearrangement, the outlier studies appeared to be the studies of Smida et al. (1999)[8] and Hieber et al. (2011)[35]. After removing the two studies, the heterogeneity was no longer significant (I2= 34.0%, Phet = 0.181), and similar estimates (OR = 1.10 vs. 1.53) were generated before and after these data were removed, indicating the relatively high stability of the results.

Publication bias

Begg’s test and Egger’s test were performed to quantitatively evaluate the publication bias of the studies; the results are listed in Table 6. No significant publication bias was observed in all comparisons (all, P > 0.10).

Table 6: Analysis for publication bias

Variable

Begg’s test

Egger’s test

z value

P valuea

t value

P valuea

For RET/PTC1 and 3

  Radiation exposure vs. non-radiation exposure

0.93

0.352

1.34

0.205

  Female vs. male

1.02

0.307

0.24

0.811

  Children and adolecent vs. adult

-0.25

0.805

0.16

0.882

For RET/PTC1

  Radiation exposure vs. non-radiation exposure

1.25

0.211

1.71

0.132

  Female vs. male

0.27

0.787

0.15

0.879

  Children and adolecent vs. adult

-0.19

0.851

0.39

0.715

For RET/PTC3

  Radiation exposure vs. non-radiation exposure

-0.56

0.573

-1.75

0.156

  Female vs. male

0.27

0.787

0.59

0.567

  Children and adolecent vs. adult

0.45

0.652

1.92

0.113

a, P value>0.1 was considered as no publication bias.

DISCUSSION

Previous study results on the relationship between PTC-related risk factors and RET/PTC rearrangement were controversial. To our knowledge, this is the first meta-analysis evaluating the effect of radiation exposure, female gender, and young age on RET/PTC rearrangement. By performing the present meta-analysis, we found that radiation exposure contributed to increased risk of RET/PTC rearrangement, especially for the RET/PTC3 subtype. Young age was also associated with higher prevalence of RET/PTC3, and this association was more significant in the subpopulation exposed to radiation. Our pooled estimate also demonstrated an association between female gender and higher prevalence of the RET/PTC1 subtype in the subpopulation that had not been exposed to radiation. These results identify an enriched population of RET/PTC fusion genes in patients with PTC and provide novel insights into the utility of RET/PTC rearrangement in the differential diagnosis of suspicious PTC.

Exposure to ionizing radiation is a well-known risk factor for thyroid cancer, particularly for papillary carcinoma [48, 49]. Therefore, it is likely that radiation exposure may also be a causative factor for RET/PTC rearrangement. Our pooled estimates provide clear evidence that radiation exposure could be responsible for the difference in RET/PTC3 prevalence between sporadic and radiation-associated tumors, whereas the rate of RET/PTC1 prevalence was similar between the two groups. The corresponding pooled OR for RET/PTC3 was up to 8.30, and this association was evident in the Western populations. However, we could not derive a negative or null association in the Asian population because of a lack of original studies from the Asian region. There are valid reasons to believe that there is a causative link between radiation exposure and RET/PTC rearrangements. For example, Nikiforov et al. reported much higher RET/PTC3 prevalence in post-Chernobyl PTC than in subjects without radiation exposure [10]. In addition, RET/PTC rearrangement, predominantly RET/PTC3, in thyroid cells, can be induced by ionizing radiation [50]. This may be linked to the particular effectiveness of radiation in causing double-strand breaks, which would be the direct cause of RET rearrangement [50, 51]. This mechanism may partially explain the association between radiation exposure and RET/PTC rearrangement in thyroid cancer.

The data synthesis in the present meta-analysis also demonstrated increased risk of RET/PTC3 in PTC in young people. Our observations further indicate that young patients who exposed to radiation have higher RET/PTC3 risk than young patients who have not been exposed to radiation. Original studies have shown that RET/PTC3 is more common in children and adolescents compared to adults [8, 9]. When the radiation exposure effect was considered in young people, RET/PTC3 was indicated as the most common form of rearrangement in radiation-associated childhood PTC [8, 10, 25, 52]. As the thyroid is very sensitive to radiation, the thyroid of young people might be more vulnerable to radiation than that of adults, which may result in higher RET/PTC prevalence in young people [53]. Nevertheless, it is important to consider that the statistical power in each original study may be partly determined by the cutoff value of age, such as age at diagnosis and age at exposure to radiation. When the cutoff age varies, the issue of the impact of patient age on RET/PTC rearrangement remains inconclusive, which would require further validation. By setting a cutoff age of 18 years in this meta-analysis, the corresponding results may indicate the relatively low defense ability of children against pathogenic factors.

Concerning the impact of sex, we observed that the association between female gender and increased RET/PTC1 risk was more significant in patients who had not been exposed to radiation. For unknown reasons, thyroid cancer is three times more prevalent in women than in men [54]. One possible explanation for this gender disparity is the hormonal differences between men and women. It has been documented that chromosome breaks and sister chromatid exchanges are elevated in women who are pregnant or taking oral contraceptives [55]. There is also evidence supporting the premise that RET/PTC is an estrogen-dependent gene required for breast cancer cell growth [56]. The above evidence suggests that some inherent differences render females more susceptible to RET rearrangements.

Nevertheless, this study has some limitations. First, although we included all available relevant articles in this meta-analysis, the sample sizes remain insufficiently large. Second, most studies in relation to the association between radiation exposure and RET/PTC3 were from the Western countries, thus the generalizability of our conclusions is limited. In the future, more studies are needed to confirm this association in Asian regions. Third, only two common RET/PTC subtypes, RET/PTC1 and RET/PTC3, were considered in this study, mainly due to the limitation of current laboratory techniques for simultaneously detecting all RET/PTC subtypes.

In conclusion, both radiation exposure and young age, i.e., age < 18 years, are associated with increased risk of RET/PTC3 rearrangement. In addition, female gender is associated with higher prevalence of the RET/PTC1 subtype in the subpopulation not exposed to radiation. We suggest that RET/PTC status in combination with radiation exposure, age, and sex should be considered when differential diagnoses are suggested for suspicious patients. Further large-scale studies concerning the relationship between radiation exposure and RET/PTC in the Asian population are required to confirm our meta-analysis results.

MATERIALS AND METHODS

Search strategy

We searched the PubMed, Web of Science, and Embase databases for all articles on the association between the RET/PTC fusion gene and PTC up to June 2015. The published date of available articles in this study was from 1959 to 2015. The keywords used for the search were “RET/PTC”, “RET/PTC fusion gene”, or “RET/PTC fusion oncoproteins” in combination with “Thyroid Cancer”, “Thyroid Carcinoma”, “Thyroid Neoplasms”, or “Thyroid Papillary Carcinoma”. The references of the articles acquired were also searched manually to broaden the search. When there was overlapping data, only the largest and most recent study was selected for this meta-analysis. If the data presented in an article were unclear, we contacted the author for specific raw data.

Inclusion and exclusion criteria

Eligible studies had to meet the following criteria: (1) the association between the RET/PTC fusion gene and the clinicopathological features of patients with PTC was explored; (2) PTC diagnosis was made according to the pathology results; (3) studies were full-text articles; and (4) there was sufficient data for estimating an odds ratio (OR) with a 95% confidence interval (CI). The exclusion criteria were: (1) duplicate publication; (2) article was an abstract, comment, review, conference proceeding, or editorial; (3) insufficient data were reported; and (4) study was not in English or Chinese.

Data extraction

The following items were collected: first name of first author; year of publication; population of study; number of enrolled patients; frequency of RET/PTC fusion gene; detection method; whether study subjects were children or adults; and clinicopathological features (sex, age, radiation history, and ethnicity). The above information was carefully extracted by two independent investigators (Xuan Su and Zhaoqu Li). If the two investigators could not reach a consensus, the result was reviewed by a third investigator (Caiyun He).

Statistical analyses

The strength of the association between RET/PTC and radiation exposure, age, and sex was estimated by OR and 95%CI. Two-sided P-values were evaluated in this meta-analysis, and P < 0.05 was considered statistically significant. The chi-square–based Q test and I2 statistic were used to assess the statistical heterogeneity among studies. For the Q statistic, P < 0.10 was considered statistically significant for heterogeneity. When there was heterogeneity, a random-effects model based on the DerSimonian and Laird method was used to calculate the pooled OR of each study [57]; otherwise, a fixed-effects model based on the Mantel–Haenszel method was used [58]. Publication bias was examined using Begg’s and Egger’s tests [59, 60], where P < 0.10 was considered statistically significant. All analyses were performed using STATA 12.0. All tests were two-sided and the significance level was set at 0.05.

ACKNOWLEDGMENTS AND FUNDING

This study was supported by National Science Foundation (81272955) and Guangdong Province Natural Science Foundation (2014A020212100).

CONFLICTS OF INTEREST

None declared.

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