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Original Article
Thyroid Utilizing Immunoglobulin G4 Immunohistochemistry for Risk Stratification in Patients with Papillary Thyroid Carcinoma Associated with Hashimoto Thyroiditis
- This study categorized Hashimoto thyroiditis (HT) patients into IgG4-related and IgG4-non-related subtypes for the first time, using a new cut-off value of >150 IgG4 positive plasma cells per 2 mm².
- This categorization was achieved through advanced digital pathology techniques and a pre-trained deep-learning model.
- The IgG4-related HT subgroup had more advanced stages of cancer compared to the IgG4-non-related HT group.
Faridul Haq1,2*orcid, Gyeongsin Park3*orcid, Sora Jeon2, Mitsuyoshi Hirokawa4, Chan Kwon Jung1,2,3orcid
Endocrinology and Metabolism 2024;39(3):468-478.
DOI: https://doi.org/10.3803/EnM.2024.1923
Published online: May 20, 2024

1Department of Biomedicine and Health Sciences, The Catholic University of Korea, Seoul, Korea

2Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea

3Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul, Korea

4Department of Diagnostic Pathology and Cytology, Kuma Hospital, Kobe, Japan

Corresponding author: Chan Kwon Jung. Department of Pathology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-1622, Fax: +82-2-2258-1627, E-mail: ckjung@catholic.ac.kr
*These authors contributed equally to this work.
• Received: January 2, 2024   • Revised: February 12, 2024   • Accepted: February 28, 2024

Copyright © 2024 Korean Endocrine Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Background
    Hashimoto thyroiditis (HT) is suspected to correlate with papillary thyroid carcinoma (PTC) development. While some HT cases exhibit histologic features of immunoglobulin G4 (IgG4)-related disease, the relationship of HT with PTC progression remains unestablished.
  • Methods
    This cross-sectional study included 426 adult patients with PTC (≥1 cm) undergoing thyroidectomy at an academic thyroid center. HT was identified based on its typical histologic features. IgG4 and IgG immunohistochemistry were performed. Wholeslide images of immunostained slides were digitalized. Positive plasma cells per 2 mm2 were counted using QuPath and a pre-trained deep learning model. The primary outcome was tumor structural recurrence post-surgery.
  • Results
    Among the 426 PTC patients, 79 were diagnosed with HT. With a 40% IgG4 positive/IgG plasma cell ratio as the threshold for diagnosing IgG4-related disease, a cutoff value of >150 IgG4 positive plasma cells per 2 mm2 was established. According to this criterion, 53% (43/79) of HT patients were classified as IgG4-related. The IgG4-related HT subgroup presented a more advanced cancer stage than the IgG4-non-related HT group (P=0.038). The median observation period was 109 months (range, 6 to 142). Initial assessment revealed 43 recurrence cases. Recurrence-free survival periods showed significant (P=0.023) differences, with patients with IgG4 non-related HT showing the longest period, followed by patients without HT and those with IgG4-related HT.
  • Conclusion
    This study effectively stratified recurrence risk in PTC patients based on HT status and IgG4-related subtypes. These findings may contribute to better-informed treatment decisions and patient care strategies.
Hashimoto thyroiditis (HT) is a chronic autoimmune disorder that affects the thyroid gland. It is the leading cause of hypothyroidism in iodine-sufficient areas of the world [1]. About 20% to 30% of patients with hypothyroidism suffer from HT, whose cause is thought to be a combination of genetic susceptibility and environmental factors that can lead to loss of immunological tolerance with consequent autoimmune attack to the thyroid tissue and appearance of the disease [1]. The disease is characterized by the production of autoantibodies against thyroid antigens, which can lead to lymphocytic infiltration, progressive destruction of thyroid follicles, and oncocytic metaplasia of follicular cells, ultimately reducing thyroid hormone production [2]. HT typically affects more women than men. It is most commonly diagnosed in middle-aged individuals [3]. Diagnosis of HT involves a combination of clinical evaluation, laboratory testing, and imaging studies [1]. Definitive diagnosis of HT is based on characteristic histopathological findings. The most common laboratory findings of HT include elevated levels of thyroid autoantibodies and reduced levels of thyroid hormones. Imaging studies such as ultrasound can reveal a heterogeneous thyroid gland with reduced echogenicity [4].
The association between HT and papillary thyroid carcinoma (PTC) has been well-documented in the scientific literature [5-7]. While the question of a causal link remains a subject of ongoing debate, both conditions exhibit common epidemiological characteristics such as relatively high prevalence, a propensity to affect females, and a tendency to occur in iodine-sufficient regions [5-7]. Notably, in individuals diagnosed with HT, PTC appears with greater frequency but tends to manifest in a less aggressive form [5,7,8]. Nonetheless, the literature did not uniformly support the notion that HT could exert a protective effect against the progression of PTC. Several studies have found no significant correlation between HT and the progression or prognosis of PTC in patients [7].
HT is a heterogeneous disease that can be categorized into two subtypes based on the density of immunoglobulin G4 (IgG4)-positive plasma cells in the thyroid tissue: IgG4-related and non-IgG4-related [9-11]. The IgG4-related subtype exhibits histopathological hallmarks of systemic IgG4-related disease within the thyroid gland. Histological evaluation is crucial for its diagnosis, typically revealing a high concentration of lymphoplasmacytic cells, unique storiform fibrosis, and obliterative phlebitis [12]. However, IgG4-related HT generally does not present with storiform fibrosis, obliterative phlebitis, or systemic manifestations [13]. Various cutoff values have been suggested for IgG4-positive plasma cell counts [13]. Traditionally, IgG4+ and IgG+ cells have been counted using printed photographs taken at a 40× objective lens magnification. However, the advent of digital pathology mandates a shift away from high-power field (HPF) as the standard unit for cell counting. Instead, a more globally standardized unit, square millimeters, should be employed [14]. This shift aligns well with quantitative capabilities of digital image analysis, offering a more standardized and reproducible approach to cell counting. The IgG4+/IgG+ ratio serves as an additional diagnostic criterion for IgG4-related disease, with proposed cutoffs ranging from 0.3 to 0.5 [13]. In most documented cases of IgG4-related disease, the cutoff of IgG4-positive to IgG-positive plasma cell ratio is 40% [15]. This ratio is a more reliable diagnostic tool than merely counting IgG4-positive plasma cells in IgG4-related disease. However, a challenge in utilizing this ratio is a high background staining observed in IgG immunostaining, which can hinder a precise calculation of the IgG4+/IgG+ ratio. In this regard, our study aimed to establish clinically relevant IgG4+ cutoff values using mm2 as the unit of measurement, specifically for patients with PTC.
This study primarily sought to establish a diagnostic methodology for clinical utility of IgG4-related HT using digital pathology and image analysis. Additionally, we aimed to stratify patients with PTC prognostically based on the presence and IgG4-related status of HT in accordance with our newly developed diagnostic criteria.
Study cohort
This study was performed in line with the principles of the Declaration of Helsinki. It was approved by the Institutional Review Board of Seoul St. Mary’s Hospital (KC16SISI0104), College of Medicine, The Catholic University of Korea. Informed consent was waived by the board. The cohort comprised 426 patients who underwent surgical intervention for PTC between January 2008 and December 2010. This research builds upon the same patient group featured in our earlier studies [16-20]. However, patient counts differed due to specimen availability and an unavoidable tissue loss during sectioning and staining processes involving archival tissue blocks. Clinical follow-up data were updated through March 2022.
The different subtypes of PTC were identified based on the 5th edition of the World Health Organization’s Classification of Endocrine and Neuroendocrine Tumors [21,22]. The subtypes include classic PTC (n=376), encapsulated classic PTC (n=24), infiltrative follicular PTC (n=10), invasive encapsulated follicular PTC (n=4), tall cell PTC (n=17), and other subtypes (n=19), such as oncocytic PTC (n=9), Warthin-like PTC (n=7), hobnail PTC (n=2), and diffuse sclerosing PTC (n=1). Cancer staging was determined according to the 8th edition of the American Joint Committee on Cancer (AJCC) staging manual [23].
Structural recurrence was defined as detection of recurrent disease that was identifiable on imaging studies or through pathologic confirmation. This included, but not limited to, identification of malignant tissue within the thyroidectomy bed, regional lymphatic structures, and any distal metastatic sites. For precise assessment of structural recurrence-free survival (RFS), the study design necessitated exclusion of a subset of eight patients who presented with either regional or distant metastatic disease prior to their thyroidectomy or who developed such manifestations within a 6-month window following the surgical procedure. This exclusion criterion was applied to distinguish between persistent primary disease and actual disease recurrence, thereby refining the prognostic utility of the structural RFS metric.
Histomorphological analysis
Histomorphological evaluation of HT entailed microscopic scrutiny of thyroid tissue to identify salient histological hallmarks characteristic of this autoimmune condition. The thyroid gland of patients with HT displayed diffuse lymphoplasmacytic infiltration, lymphoid follicles, and oncocytic metaplasia of follicular cells (Fig. 1A).
Immunohistochemical staining was conducted for IgG and IgG4 utilizing an automated Ventana BenchMark ULTRA Staining System (Roche Diagnostics, Tucson, AZ, USA). From each case, a representative formalin-fixed, paraffin-embedded block was sliced into 4-μm-thick sections. Antigen retrieval was performed for 48 minutes using a Ventana Benchmark CC1 standard program. Subsequently, tissue sections were incubated with an anti-IgG4 mouse monoclonal antibody (clone MRQ-44, prediluted, Roche Diagnostics) at a temperature of 37°C for 16 minutes and an anti-IgG rabbit polyclonal antibody (prediluted, Roche Diagnostics) at room temperature for 12 minutes. The immunoreaction was visualized employing a Ventana OptiView DAB Immunohistochemical Detection Kit (with OptiView HQ Linker for 8 minutes and OptiView HRP Multimer for another 8 minutes) and an OptiView Amplification Kit. Counterstaining was performed using Ventana Hematoxylin II for 4 minutes, followed treatment with a bluing reagent for 4 minutes (Fig. 1B, C). Tonsil tissue served as a positive control for the procedure.
Digital image analysis
All slides were digitally scanned at a 20× magnification, achieving a resolution of 0.46 μm per pixel, using a Hamamatsu NanoZoomer S360 Digital Slide Scanner (Hamamatsu Photonics, Hamamatsu, Japan). For digital image analysis, scanned images were imported into QuPath version 0.4.3 (https://github.com/qupath/qupath/releases/), an open-source software platform specifically designed for whole-slide image (WSI) analysis [24].
To pinpoint “hotspot” areas rich in IgG and IgG4-positive plasma cells, a semi-automated methodology was adopted. The software generated measurement heat maps by visualizing optical density of immunostained plasma cells. Utilizing these heat maps, densities of IgG and IgG4-positive plasma cells were quantitatively assessed. Regions with the highest density of positively stained cells, termed “hotspots,” were manually outlined. Meticulous adjustments were executed to omit areas marred by artifacts or false-positive staining. These heat maps were individually fine-tuned for each WSI to accurately identify and annotate regions with the maximal density of IgG and IgG4-positive plasma cells. Areas susceptible to artifacts, which could result in an erroneous identification of hotspots, were manually excluded from analysis. Plasma cells within a designated area of 2 mm2 were then counted (Fig. 2).
Statistical analysis
Relationships of clinicopathologic features with IgG4-related status of HT were analyzed using a Pearson chi-square or Fisher’s exact for categorical variables as appropriate. The Spearman’s rank-based correlation coefficient (r) was employed to assess the degree of association between two continuous variables. The Kaplan-Meier method was used to analyze RFS and the long-rank test was used to compare groups. RFS was measured from the date of the initial surgery until the identification of structural disease recurrence or until the last follow-up for patients without any signs of recurrence. To determine prognostic significance of clinical features, pathological features, and IgG4 status, Cox proportional hazards regression models were used for both univariate and multivariate analyses. For the multivariate analysis, potential confounders were adjusted for and independent factors that could predict RFS were identified. We calculated hazard ratios and 95% confidence intervals to measure the risk associated with individual variables. All statistical values were calculated using the statistical software program SPSS version 21.0 (IBM Corp., Armonk, NY, USA) and GraphPad Prism version 6.07 (GraphPad, La Jolla, CA, USA). A P<0.05 was considered statistically significant.
Clinical characteristics
This study encompassed 426 patients with PTC who were stratified into two cohorts: those without HT (n=347) and those with HT (n=79) (Table 1). Age distribution between cohorts did not display statistically significant difference (P=0.457), with the majority of both cohorts being younger than 55 years (69.2% in those without HT and 73.4% in those with HT). Sex distribution was significantly skewed towards females, particularly within the HT group (96.2% vs. 71.8% in the non-HT group, P<0.000).
Histologic subtype analysis revealed a predominance of the classic subtype in both patient groups (Table 1). However, the classic subtype was less prevalent in the HT group than in the non-HT group (81.0% vs. 89.9%, P<0.001). Other subtypes, including follicular (n=14) tall cell (n=17) and others (one solid, two hobnail, two Warthin-like, and eight oncocytic PTCs) were comparably distributed between the two groups. The prevalence of histologically aggressive subtypes did not significantly differ between cohorts (P=0.764). HT status was not associated with other pathologic parameters or BRAFV600E.
Determining the threshold value of IgG4 positive plasma cells
We conducted a detailed quantification of IgG and IgG4-positive plasma cells within a 2 mm2 area of histological hotspots using QuPath software. A direct correlation was observed between the absolute number of IgG4-positive (+) cells and the IgG4+/IgG+ plasma cell ratio (Fig. 3). Applying a 40% IgG4+/IgG+ plasma cell ratio as the criterion for IgG4-related disease, we identified a threshold of over 150 IgG4+ plasma cells per 2 mm2. This threshold allowed for the classification of 53% (42 of 79) of HT cases as IgG4-related.
Correlation of IgG4 positive cell density in intratumoral and extratumoral tissues
We counted IgG4 positive cells per 2 mm2 within intratumoral and adjacent non-tumor tissue areas. To determine the correlation between these two microenvironments, we used a scatter plot and a regression analysis. Results showed a weak positive linear relationship with a r of 0.187 (Fig. 4). This suggested that there was a slight tendency for an increase in IgG4 positive cell density in both intratumoral and non-tumoral areas, although this association was not strong. The scatter plot revealed a large spread of data points, further confirming the weak correlation (Fig. 4). Therefore, the density of IgG4 positive cells within tumor tissues cannot be used as a reliable predictor for the density in adjacent non-tumor tissues.
Subclassification of patients with HT according to IgG4 count
Patients were further classified according to the threshold of 150 IgG4+ plasma cells per 2 mm2 into two groups: IgG4-unrelated HT (n=37) and IgG4-related HT (n=42) (Table 2). The analysis did not reveal any significant differences in pathologic T category (P=0.269) or N category (P=0.355). However, patients with IgG4-related HT had a significantly higher incidence of advanced disease than patients with IgG4-unrelated HT (AJCC stage III–IV: 40% vs. 19%, P=0.038). Moreover, the IgG4-related HT group showed a significantly higher rate of structural recurrence than the IgG4-unrelated HT group (19% vs. 0%, P=0.005). In addition, BRAFV600E variant was detected more frequently in the IgG4-related group than in the IgG4-unrelated HT group, although the difference between the two was not statistically significant (88% vs. 73%, P=0.087).
Recurrence-free survival
In the cohort of 426 patients, who underwent surgery for PTC, eight were excluded due to the presence of distant metastasis at the time of surgery or a follow-up period of less than 6 months. Among the remaining 418 patients, the median followed-up period was 109 months (range, 6 to 142) and the structural recurrence, rate was 10.3% (43 of 418 patients).
Using Kaplan-Meier plot and log-rank survival analysis, RFS was analyzed amongst patients with PTC based on the presence and IgG4-related status of HT. We included three groups: PTC free HT (n=339), PTC with IgG4-unrelated HT (n=37), and PTC with IgG4-related HT (n=42). Results of analysis showed significantly different rates of RFS among the three groups (P=0.023) (Fig. 5). Patients with IgG4-unrelated HT experienced no recurrences, whereas those with IgG4-related HT demonstrated the poorest RFS. PTC patients without HT exhibited an intermediate RFS. These results offer supportive evidence on the adverse effect that IgG4-related status of HT can impose on PTC prognosis.
In multivariate analysis, lymph node metastasis, gross extrathyroidal extension, and pT category were independently associated with a diminished RFS (P=0.001, P=0.039, P=0.002, respectively), as shown in Table 3. The presence of IgG4-related HT was also associated with a worse RFS, with a hazard ratio of 2.227 (95% confidence interval, 1.028 to 4.822; P=0.042).
Our study provides a new perspective on the prognostic landscape of PTC when concurrent HT is present, with an emphasis on the usefulness of IgG4 immunohistochemistry as a tool for risk stratification. The present study highlights the significance of determining a specific threshold of IgG4 count (150 IgG-positive cells per 2 mm2) as a predictive marker for PTC behavior in the context of HT. Our findings indicate that exceeding this threshold is associated with advanced cancer stage and higher structural recurrence rate of the disease, suggesting a more aggressive PTC phenotype. Besides being a potential indicator of disease severity, the identified threshold can also help clinicians refine prognostic accuracy while managing PTC in the presence of HT.
A Japanese research team has proposed thyroid-specific cutoff values for the diagnosis of IgG4-related thyroiditis, recommending more than 20 IgG4-positive plasma cells per HPF and an IgG4-to-IgG plasma cell ratio exceeding 30% [25]. As the disease progresses into later stages characterized by increasing fibrosis, the number of plasma cells diminishes, making the IgG4/IgG ratio an increasingly valuable diagnostic indicator. However, a 40% IgG4+/IgG+ plasma cell ratio is conventionally accepted as the diagnostic threshold for IgG4-related diseases. It is considered a more robust diagnostic marker than the absolute count of IgG4-positive cells alone [15,26-29]. We adopted the 40% IgG4+/IgG+ plasma cell ratio as a means of identifying IgG4-related HT.
A significant challenge in the application of this ratio is the nonspecific high background staining commonly associated with IgG immunostainings, which can interfere with accurate ratio determinations. Historically, cell counts for IgG4+ and IgG+ have been conducted through analysis of printed photographs at a magnification of 40×. However, with integration of digital pathology, there has been a paradigm shift from using the HPF as a standard unit of measure to a more universally standardized unit of square millimeters (mm2) [14,30]. Our research sought to delineate IgG4+ cutoff values that could be clinically applicable for PTC patients with HT using mm2 as the measurement standard. The quantification of 150 IgG4-positive plasma cells per 2 mm2 area provides valuable insights into the density and infiltration of these cells within examined tissue samples. This observation indicates a significant presence of IgG4-positive plasma cells and highlights their potential role in the pathogenesis or progression of the studied condition.
The prevalence of IgG4-related HT varies depending on different factors, such as geographic location, patient populations, and diagnostic criteria (Table 4). Previous studies have shown a range of prevalence rates due to variations in diagnostic criteria, particularly IgG4 count and IgG4/IgG ratio [31-40]. Studies conducted in Japan, China, and Korea have demonstrated varying prevalence of IgG4-related HT. Li et al.’s [31] study showed a prevalence ranging from 22.5% to 27.5%, with IgG4 counts of >10/HPF and >20/HPF. In contrast, our study conducted in Korea showed a remarkably higher prevalence of 53%. However, we counted IgG4-positive cells in a larger area (2 mm2). All patients enrolled in our study had PTC. The prevalence of IgG4-related HT also varied by geographic location and institution. For instance, studies from China and Japan showed a prevalence range of 22% to 73%, illustrating substantial variability even within a relatively homogenous East Asian context. Further, studies conducted in the USA indicated a prevalence of 14% to 35% [37,38], while European studies reported a lower prevalence of 16% in Finland [39] and 12.6% in Germany [40]. These differences might be attributable to variations in patient populations, healthcare practices, and possibly differing environmental or genetic predispositions. The prevalence of IgG4- related HT varies significantly based on reasons for thyroidectomy in patients with HT. For instance, a Chinese study in 2016 found a high prevalence rate (73%) in a population primarily suspected for thyroid cancer [35], while studies involving more general HT populations, such as the USA study [37,38], showed lower rates. This suggests that the context of diagnosis plays a crucial role in determining the prevalence of IgG4-related HT. Therefore, there is a need for standardized diagnostic criteria and a better understanding of the underlying mechanisms of this condition. Future research should aim to reconcile these differences possibly through multinational, multi-institutional studies employing uniform diagnostic criteria to provide a more cohesive understanding of the epidemiology of IgG4-related HT.
Chronic exposure to cancer antigen can trigger the class switch of B lymphocytes to produce IgG4. Elevated IgG4 can interact with cancer bound IgG through its Fc-Fc binding property. It can also engage with Fc receptors on immune effector cells [41]. Through its distinct structural and biological characteristics, heightened IgG4 within the cancer microenvironment facilitates an efficient immune escape for cancer [42]. IgG4 antibodies possess unique immunological properties. They might contribute to classical tolerance mechanisms in autoimmune diseases [41]. These antibodies are present in various diseases, including IgG4-related diseases, IgG4 autoimmune diseases, allergy, cancer, rheumatoid arthritis, and parasite infestation [41]. The presence of IgG4-positive plasma cells in HT has been linked to higher frequency of PTC and worse clinical outcome [35]. This was also evidenced by the poorest RFS observed in PTC patients with IgG4-related HT in the present study. We found that patients with IgG4-unrelated HT experienced no recurrence whereas those with IgG4-related HT demonstrated the poorest RFS, with PTC patients having no HT exhibiting an intermediate RFS. These results offer supportive evidence on the adverse effect that IgG4-related status of HT can impose on PTC prognosis. In malignancies, IgG4 antibodies are induced to prevent immune surveillance and promote tumor cell survival [42,43]. Moreover, IgG4 has been implicated in the regulation of immune response and the suppression of inflammation. It can act as a blocking antibody, inhibiting the binding of other antibodies, including IgG1 and IgG4, to their target antigens [41,42]. This inhibitory effect may dampen the immune response in HT, possibly playing a role in sustaining chronic nature of this disease. This phenomenon is associated with unfavorable prognosis in several cancers, such as stomach cancer, melanoma, extrahepatic cholangiocarcinoma, pancreatic cancer, and esophageal cancer [42,43]. Such properties of IgG4 could offer a plausible explanation for the observed facilitation of immune escape in PTC with IgG4-related HT, potentially influencing RFS and response to therapy.
In the present study, we used digital pathology and deep learning-based image analysis software with great precision to quantify the number of IgG4-positive cells. Thus, our findings are highly reliable. However, we must acknowledge that our study has certain limitations due to its retrospective nature. In addition, it was conducted at a single institution, which might affect the generalizability of the IgG4 count threshold. Therefore, it is crucial to conduct a prospective, multicenter study to validate the universality and applicability of the IgG4 count threshold for risk stratification.
In conclusion, we identified the IgG4 count threshold as a new and clinically important marker for PTC patients with HT. This threshold can serve as a basis for future research studies that aim to validate and potentially incorporate IgG4 immunostaining into the management and prognostic assessment of thyroid cancer. With the advent of precision medicine, such biomarkers can be of great value in customizing treatment strategies for individual patients, ultimately leading to improved outcomes in PTC.


No potential conflict of interest relevant to this article was reported.


Conception or design: C.K.J. Acquisition, analysis, or interpretation of data: F.H., G.P., S.J., M.H., C.K.J. Drafting the work or revising: F.H., G.P., S.J., M.H., C.K.J. Final approval of the manuscript: F.H., G.P., S.J., M.H., C.K.J.

This research was supported by a grant (HI21C0940) from the Korean Health Technology R&D Project funded by the Ministry of Health and Welfare, Republic of Korea. This work was also supported by a Korea Medical Device Development Fund grant funded by the Korea government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health & Welfare, the Ministry of Food and Drug Safety) (Project Number: RS-2023-00243633).
Fig. 1.
Histopathological and immunohistochemical features of immunoglobulin G4 (IgG4)-related Hashimoto thyroiditis. (A) Microscopic examination reveals a dense infiltration of lymphocytes and plasma cells, leading to the loss and damage of thyroid follicles. The stromal background appears fibrotic. Follicular cells display oncocytic metaplasia, characterized by plump eosinophilic cytoplasm, enlarged nuclei, and clear chromatin (hematoxylin and eosin stain, digital zoom ×20). (B) Immunohistochemical staining shows a high density of IgG-positive plasma cells (immunohistochemistry, digital zoom ×20). (C) A significant presence of IgG4-positive plasma cells is also noted (immunohistochemistry, digital zoom ×20).
Fig. 2.
An example of hotspot identification for immunoglobulin G4 (IgG4)-positive plasma cells in non-tumor regions using QuPath software. (A) A measurement heat map displaying the area with the highest density of IgG4-positive plasma cells in non-tumor area (immunohistochemistry, digital zoom ×5). A dotted line demarcates the tumor region. (B) A magnified view of the targeted area, highlighting IgG4 immunostaining within the identified hotspot (immunohistochemistry, digital zoom ×20). (C) A processed analytical image depicting differentiation of cells, with negative cells marked in blue and positive cells highlighted in red (immunohistochemistry, digital zoom ×20).
Fig. 3.
Relationship between absolute numbers of immunoglobulin G4 (IgG4)-positive (+) cells and IgG4+/IgG+ plasma cell ratio. A 40% IgG4+/IgG+ plasma cell ratio aligns with 150 IgG4+ plasma cells per 2 mm2.
Fig. 4.
Analysis of correlation of immunoglobulin G4 (IgG4) positive cell density in intratumoral and extratumoral tissues shows a weak positive linear correlation with a correlation coefficient (r) of 0.187.
Fig. 5.
Kaplan-Meier survival analysis showing recurrence-free survival in patients with papillary thyroid carcinoma (PTC) stratified by the presence of Hashimoto thyroiditis (HT) and immunoglobulin G4 (IgG4)-related subtype.
Table 1.
Clinicopathologic Features of 426 Patients with Papillary Thyroid Carcinoma Stratified by Hashimoto Thyroiditis
Characteristic Patients without HT (n=347) Patients with HT (n=79) P value
Age, yr 0.457
 <55 240 (69.2) 58 (73.4)
 ≥55 107 (30.8) 21 (26.6)
Sex <0.000
 Female 249 (71.8) 76 (96.2)
 Male 98 (28.2) 3 (3.8)
Histologic subtype <0.001
 Classic 312 (89.9) 64 (81.0)
 Follicular 13 (3.7) 1 (1.3)
 Tall cell 14 (4.0) 3 (3.8)
 Warthin-like 1 (0.3) 5 (6.3)
 Other 7 (2.0) 6 (7.6)
Histologically aggressive subtype 0.764
 Aggressive subtypea 15 (4.3) 4 (5.1)
 Non-aggressive subtype 332 (95.7) 75 (94.9)
Multifocality 0.961
 Present 146 (42.1) 33 (41.8)
 Absent 201 (57.9) 46 (58.2)
Extrathyroidal extension 0.394
 Present 262 (75.5) 56 (70.9)
 Absent 85 (24.5) 23 (29.1)
Gross extrathyroidal extension 0.152
 Present 73 (21.0) 11 (13.9)
 Absent 274 (79.0) 68 (86.1)
Pathologic (p) T category 0.112
 pT1–2 271 (78.1) 68 (86.1)
 pT3–4 76 (21.9) 11 (13.9)
pN category 0.486
 pN0 126 (36.3) 32 (40.5)
 pN1 221 (63.7) 47 (59.5)
AJCC stage, 8th edition 0.139
 Stage I–II 334 (96.3) 79 (100)
 Stage III–IV 13 (3.7) 0
Structural recurrenceb 0.958
 Present 35 (10.3) 8 (10.1)
 Absent 304 (89.7) 71 (89.9)
BRAFV600E 0.378
 Present 295 (85.0) 64 (81.0)
 Absent 52 (15.0) 15 (19.0)

Values are expressed as number (%).

HT, Hashimoto thyroiditis; AJCC, American Joint Committee on Cancer.

a Aggressive subtype includes tall cell (n=17) and hobnail (n=2) subtypes;

b For the assessment of structural recurrence, we excluded eight patients who manifested regional or distant metastasis prior to thyroidectomy or within a 6-month postoperative interval.

Table 2.
Differences of Clinicopathological Features between IgG4-Related and IgG4-Unrelated Papillary Thyroid Carcinomas in 79 Patients with Hashimoto Thyroiditis
Characteristic IgG4-unrelated HT (n=37) IgG4-related HT (n=42) P value
Age, yr 0.483
 <55 25 (68) 33 (79)
 ≥55 12 (32) 9 (21)
Sex 0.597
 Female 35 (95) 41 (98)
 Male 2 (5) 1 (2)
Histologic subtype 0.254
 Classic 28 (76) 36 (86)
 Follicular 1 (3) 0
 Tall cell 1 (3) 2 (5)
 Warthin-like 3 (8) 2 (5)
 Other 4 (11) 2 (5)
Histologically aggressive subtype 0.896
 Aggressive subtype 2 (5) 2 (5)
 Non-aggressive subtype 35 (95) 40 (95)
Extrathyroidal extension 0.269
 Present 24 (65) 32 (76)
 Absent 13 (35) 10 (24)
Gross extrathyroidal extension 0.453
 Present 4 (11) 7 (17)
 Absent 33 (89) 35 (83)
Pathologic (p) T category 0.269
 pT1–2 13 (35) 10 (24)
 pT3–4 24 (65) 32 (76)
pN category 0.355
 pN0 17 (46) 15 (36)
 pN1 20 (54) 27 (64)
AJCC stage, 8th edition 0.038
 Stage I–II 30 (81) 25 (60)
 Stage III–IV 7 (19) 17 (40)
Structural recurrence 0.005
 Present 0 8 (19)
 Absent 37 (100) 34 (81)
BRAFV600E 0.087
 Present 27 (73) 37 (88)
 Absent 10 (27) 5 (12)

Values are expressed as number (%).

IgG4, immunoglobulin G4; HT, Hashimoto thyroiditis; AJCC, American Joint Committee on Cancer.

Table 3.
Multivariate Cox Regression Analysis of Prognostic Variables for Recurrence-Free Survival in 426 Patients with Papillary Thyroid Carcinoma
Variable Hazard ratio 95% CI P value
Age, yr 0.223
 <55 1 Reference
 ≥55 0.600 0.264–1.363
Sex 0.772
 Female 1 Reference
 Male 1.113 0.541–2.288
Histologic subtype 0.493
 Non-aggressive 1 Reference
 Aggressive 1.517 0.460–4.996
Gross extrathyroidal extension 0.039
 Absent 1 Reference
 Present 4.813 1.086–21.339
Pathologic (p) T category 0.002
 pT1–2 1 Reference
 pT3–4 11.910 2.414–58.756
pN 0.001
 pN0 1 Reference
 pN1 7.380 2.265–24.051
IgG4-related HT 0.042
 Absent 1 Reference
 Present 2.227 1.028–4.822

CI, confidence interval; IgG4, immunoglobulin G4; HT, Hashimoto thyroiditis.

Table 4.
International Studies on the Prevalence of IgG4-Related Cases among Patients with Hashimoto Thyroiditis
Study Country Institutiona Study year Reasons for thyroidectomy in patients with HT (n) IgG4 count IgG4/IgG ratio Prevalence
Li et al. (2020) [31] Japan, China Kuma Hospital, Wakayama Medical University, Taishan Medical University 1983–2017 Marked swelling (57), tracheal stenosis (19), pain and tenderness (4), nodular lesion (13), suspected malignant lymphoma (12), suspected PTC (2), unknown (13) >20/HPF >30% 33/120 (27.5%)
>10/HPF >40% 27/120 (22.5%)
Li et al. (2012) [32] Japan Kuma Hospital 1983–2010 Marked swelling (55), tracheal stenosis (19), pain and tenderness (4), nodule (13), suspicious for lymphoma (12), suspicious for PTC (2) >20/HPF >30% 28/105 (26.6%)
Li et al. (2010) [33] Japan Kuma Hospital 1983–2006 Marked swelling (39), tracheal stenosis (15), suspicious of malignant lymphoma (8), nodular lesion (4), and pain and tenderness (4) >20/HPF >30% 19/70 (27%)
Yu et al. (2018) [34] China Peking University First Hospital 2009–2016 Marked swelling (14), tracheal compression (4), suspected PTC (70), needle biopsies (5) >20/HPF >30% 20/93 (22%)
Yu et al. (2016) [35] China Peking University First Hospital 2009–2014 Suspicious for thyroid cancer (64), tracheal compression (2) >20/HPF >30% 48/66 (73%)
Zhang et al. (2014) [36] China Peking University First Hospital 2009–2012 Suspicious for thyroid cancer (51), tracheal compression (2) >20/HPF > 30% 12/53 (23%)
Deshpande et al. (2012) [37] USA Massachusetts General Hospital NA Histological diagnosis of HT (28), FV of HT (9) >30/HPF >40% 4/28 HT (14%)
6/9 FV of HT (67%)
Raess et al. (2015) [38] USA Oregon Health & Science University 2010–2013 Clinical HT (23) >30/HPF >30% 8/23 (35%)
Malignancy was excluded.
Lintusaari et al. (2020) [39] Finland Fimlab Laboratories, Tampere 2011–2017 Goiter (37), suspicious for malignancy (37), thyrotoxicosis (3), thyroiditis (1), hyperparathyroidism (1), other (3) >20/HPF >30% 13/82 (16%)
Jokisch et al. (2016) [40] Germany Institute of Pathology of the Staedtisches Klinikum Munich 2001–2013 Histological diagnosis of HT (191) >20/HPF >40% 24/191 (12.6%)
Current study Korea Seoul St. Mary’s Hospital 2008–2010 PTC >150/2 mm2 >40% 42/79 (53%)

IgG4, immunoglobulin G4; HT, Hashimoto thyroiditis; PTC, papillary thyroid carcinoma; HPF, high-power field; NA, not available; FV, fibrosing variant.

a These studies conducted by Kuma Hospital and Peking University First Hospital in Japan and China resulted in redundant data due to overlapping patient cohorts.

  • 1. Ragusa F, Fallahi P, Elia G, Gonnella D, Paparo SR, Giusti C, et al. Hashimotos’ thyroiditis: epidemiology, pathogenesis, clinic and therapy. Best Pract Res Clin Endocrinol Metab 2019;33:101367.ArticlePubMed
  • 2. Caturegli P, De Remigis A, Rose NR. Hashimoto thyroiditis: clinical and diagnostic criteria. Autoimmun Rev 2014;13:391–7.ArticlePubMed
  • 3. Lorini R, Gastaldi R, Traggiai C, Perucchin PP. Hashimoto’s thyroiditis. Pediatr Endocrinol Rev 2003;1 Suppl 2:205–11.PubMed
  • 4. Gatto F, Barbieri F, Gatti M, Wurth R, Schulz S, Ravetti JL, et al. Balance between somatostatin and D2 receptor expression drives TSH-secreting adenoma response to somatostatin analogues and dopastatins. Clin Endocrinol (Oxf) 2012;76:407–14.ArticlePubMed
  • 5. Moon S, Chung HS, Yu JM, Yoo HJ, Park JH, Kim DS, et al. Associations between Hashimoto thyroiditis and clinical outcomes of papillary thyroid cancer: a meta-analysis of observational studies. Endocrinol Metab (Seoul) 2018;33:473–84.ArticlePubMedPMCPDF
  • 6. Hussein O, Abdelwahab K, Hamdy O, Awny S, Megahed NA, Hafez MT, et al. Thyroid cancer associated with Hashimoto thyroiditis: similarities and differences in an endemic area. J Egypt Natl Canc Inst 2020;32:7.ArticlePubMedPDF
  • 7. Osborne D, Choudhary R, Vyas A, Kampa P, Abbas LF, Chigurupati HD, et al. Hashimoto’s thyroiditis effects on papillary thyroid carcinoma outcomes: a systematic review. Cureus 2022;14:e28054.ArticlePubMedPMC
  • 8. Xu S, Huang H, Qian J, Liu Y, Huang Y, Wang X, et al. Prevalence of Hashimoto thyroiditis in adults with papillary thyroid cancer and its association with cancer recurrence and outcomes. JAMA Netw Open 2021;4:e2118526.ArticlePubMedPMC
  • 9. Li Y, Inomata K, Nishihara E, Kakudo K. IgG4 thyroiditis in the Asian population. Gland Surg 2020;9:1838–46.ArticlePubMedPMC
  • 10. Li Y, Bai Y, Liu Z, Ozaki T, Taniguchi E, Mori I, et al. Immunohistochemistry of IgG4 can help subclassify Hashimoto’s autoimmune thyroiditis. Pathol Int 2009;59:636–41.ArticlePubMed
  • 11. Han X, Zhang P, Li J, Liu Z, Lu H, Luo X, et al. Clinical features and treatment efficacy for IgG4-related thyroiditis. Orphanet J Rare Dis 2021;16:324.ArticlePubMedPMCPDF
  • 12. Bledsoe JR, Della-Torre E, Rovati L, Deshpande V. IgG4- related disease: review of the histopathologic features, differential diagnosis, and therapeutic approach. APMIS 2018;126:459–76.ArticlePubMedPDF
  • 13. Adams SH, Gitto L, Serinelli S, Curtiss C. Review of IgG4-related Hashimoto thyroiditis with best practice recommendations for diagnosis and reporting. Adv Anat Pathol 2022;29:97–107.ArticlePubMed
  • 14. Cree IA, Tan PH, Travis WD, Wesseling P, Yagi Y, White VA, et al. Counting mitoses: SI(ze) matters! Mod Pathol 2021;34:1651–7.ArticlePubMedPMC
  • 15. Deshpande V, Zen Y, Chan JK, Yi EE, Sato Y, Yoshino T, et al. Consensus statement on the pathology of IgG4-related disease. Mod Pathol 2012;25:1181–92.PubMed
  • 16. Jeong YM, Cho H, Kim TM, Kim Y, Jeon S, Bychkov A, et al. CD73 overexpression promotes progression and recurrence of papillary thyroid carcinoma. Cancers (Basel) 2020;12:3042.ArticlePubMedPMC
  • 17. Kim Y, Kim MH, Jeon S, Kim J, Kim C, Bae JS, et al. Prognostic implication of histological features associated with EHD2 expression in papillary thyroid carcinoma. PLoS One 2017;12:e0174737.ArticlePubMedPMC
  • 18. Bychkov A, Jung CK. Aberrant expression of CD20 in thyroid cancer and its clinicopathologic significance. Hum Pathol 2018;71:74–83.ArticlePubMed
  • 19. Choden S, Keelawat S, Jung CK, Bychkov A. VE1 immunohistochemistry improves the limit of genotyping for detecting BRAFV600E mutation in papillary thyroid cancer. Cancers (Basel) 2020;12:596.ArticlePubMedPMC
  • 20. Oh EJ, Bychkov A, Cho H, Kim TM, Bae JS, Lim DJ, et al. Prognostic implications of CD10 and CD15 expression in papillary thyroid carcinoma. Cancers (Basel) 2020;12:1413.ArticlePubMedPMC
  • 21. Baloch ZW, Asa SL, Barletta JA, Ghossein RA, Juhlin CC, Jung CK, et al. Overview of the 2022 WHO classification of thyroid neoplasms. Endocr Pathol 2022;33:27–63.ArticlePubMedPDF
  • 22. Jung CK, Bychkov A, Kakudo K. Update from the 2022 World Health Organization classification of thyroid tumors: a standardized diagnostic approach. Endocrinol Metab (Seoul) 2022;37:703–18.ArticlePubMedPMCPDF
  • 23. Amin MB, Edge SB, Greene FL, Byrd DR, Brookland RK, Washington MK, et al. AJCC cancer staging manual 8th ed. New York: Springer; 2017 873–90.
  • 24. Bankhead P, Loughrey MB, Fernandez JA, Dombrowski Y, McArt DG, Dunne PD, et al. QuPath: open source software for digital pathology image analysis. Sci Rep 2017;7:16878.ArticlePubMedPMCPDF
  • 25. Takeshima K, Li Y, Kakudo K, Hirokawa M, Nishihara E, Shimatsu A, et al. Proposal of diagnostic criteria for IgG4- related thyroid disease. Endocr J 2021;68:1–6.ArticlePubMed
  • 26. Jeong HJ, Shin SJ, Lim BJ. Overview of IgG4-related tubulointerstitial nephritis and its mimickers. J Pathol Transl Med 2016;50:26–36.ArticlePubMedPMCPDF
  • 27. Sim J, Koh HH, Choi S, Chu J, Kim TS, Kim H, et al. Pulmonary nodular lymphoid hyperplasia with mass-formation: clinicopathologic characteristics of nine cases and review of the literature. J Pathol Transl Med 2018;52:211–8.ArticlePubMedPMCPDF
  • 28. Ramakrishna B, Yewale R, Vijayakumar K, Radhakrishna P, Ramakrishna BS. Gastric IgG4-related disease presenting as a mass lesion and masquerading as a gastrointestinal stromal tumor. J Pathol Transl Med 2020;54:258–62.ArticlePubMedPMCPDF
  • 29. Kim MJ, Song TJ, Kim HJ, Kim SC, Kim MH, Hong SM. Coexisting mucinous cystic neoplasm of the pancreas and type 1 autoimmune pancreatitis. J Pathol Transl Med 2019;53:125–8.ArticlePubMedPMCPDF
  • 30. Cree IA. From counting mitoses to Ki67 assessment: technical pitfalls in the new WHO Classification of Endocrine and Neuroendocrine Tumors. Endocr Pathol 2022;33:3–5.ArticlePubMedPDF
  • 31. Li Y, Wang X, Liu Z, Ma J, Lin X, Qin Y, et al. Hashimoto’s thyroiditis with increased IgG4-positive plasma cells: using thyroid-specific diagnostic criteria may identify early phase IgG4 thyroiditis. Thyroid 2020;30:251–61.ArticlePubMed
  • 32. Li Y, Zhou G, Ozaki T, Nishihara E, Matsuzuka F, Bai Y, et al. Distinct histopathological features of Hashimoto’s thyroiditis with respect to IgG4-related disease. Mod Pathol 2012;25:1086–97.ArticlePubMedPDF
  • 33. Li Y, Nishihara E, Hirokawa M, Taniguchi E, Miyauchi A, Kakudo K. Distinct clinical, serological, and sonographic characteristics of hashimoto’s thyroiditis based with and without IgG4-positive plasma cells. J Clin Endocrinol Metab 2010;95:1309–17.ArticlePubMedPDF
  • 34. Yu Y, Yu N, Lu G, Li T, Zhang Y, Zhang J, et al. Hashimoto’s thyroiditis with elevated serum IgG4 concentrations is not equivalent to IgG4 Hashimoto’s thyroiditis. Clin Endocrinol (Oxf) 2018;88:943–9.ArticlePubMedPDF
  • 35. Yu Y, Zhang J, Lu G, Li T, Zhang Y, Yu N, et al. Clinical relationship between IgG4-positive Hashimoto’s thyroiditis and papillary thyroid carcinoma. J Clin Endocrinol Metab 2016;101:1516–24.ArticlePubMed
  • 36. Zhang J, Zhao L, Gao Y, Liu M, Li T, Huang Y, et al. A classification of Hashimoto’s thyroiditis based on immunohistochemistry for IgG4 and IgG. Thyroid 2014;24:364–70.ArticlePubMed
  • 37. Deshpande V, Huck A, Ooi E, Stone JH, Faquin WC, Nielsen GP. Fibrosing variant of Hashimoto thyroiditis is an IgG4 related disease. J Clin Pathol 2012;65:725–8.ArticlePubMed
  • 38. Raess PW, Habashi A, El Rassi E, Milas M, Sauer DA, Troxell ML. Overlapping morphologic and immunohistochemical features of Hashimoto thyroiditis and IgG4-related thyroid disease. Endocr Pathol 2015;26:170–7.ArticlePubMedPDF
  • 39. Lintusaari J, Vesaniemi E, Kalfert D, Ilvesaro J, Ludvikova M, Kholova I. IgG4-positive plasma cells in Hashimoto thyroiditis: IgG4-related disease or inflammation-related IgG4- positivity? APMIS 2020;128:531–8.ArticlePubMedPDF
  • 40. Jokisch F, Kleinlein I, Haller B, Seehaus T, Fuerst H, Kremer M. A small subgroup of Hashimoto’s thyroiditis is associated with IgG4-related disease. Virchows Arch 2016;468:321–7.ArticlePubMedPDF
  • 41. Koneczny I. Update on IgG4-mediated autoimmune diseases: new insights and new family members. Autoimmun Rev 2020;19:102646.ArticlePubMed
  • 42. Wang H, Xu Q, Zhao C, Zhu Z, Zhu X, Zhou J, et al. An immune evasion mechanism with IgG4 playing an essential role in cancer and implication for immunotherapy. J Immunother Cancer 2020;8:e000661.ArticlePubMedPMC
  • 43. Bianchini R, Karagiannis SN, Jordakieva G, Jensen-Jarolim E. The role of IgG4 in the fine tuning of tolerance in IgE-mediated allergy and cancer. Int J Mol Sci 2020;21:5017.ArticlePubMedPMC

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