OPENACCESS Citation: Yoon JH, Han K, Lee E, Lee J, Kim E-K, Moon HJ, et al. (2020) Radiomics in predicting Purpose mutation status for thyroid cancer: A preliminary To evaluate whether if ultrasonography (US)-based radiomics enables prediction of the study using radiomics features for predicting V600E V600E presence of BRAF mutations among patients diagnosed as papillary thyroid carcni- BRAF mutations in papillary thyroid carcinoma. PLoS ONE 15(2): e0228968. https:// noma (PTC). doi.org/10.1371/journal.pone.0228968 Editor: Jeeun Kang, Johns Hopkins University, Methods UNITED STATES From December 2015 to May 2017, 527 patients who had been treated surgically for PTC V600E Received: August 2, 2019 were included (training: 387, validation: 140). All patients had BRAF mutation analysis Accepted: January 27, 2020 performed on surgical specimen. Feature extraction was performed using preoperative US images of the 527 patients (mean size of PTC: 16.4mm±7.9, range, 10–85 mm). A Radio- Published: February 13, 2020 mics Score was generated by using the least absolute shrinkage and selection operator Copyright:© 2020 Yoon et al. This is an open (LASSO) regression model. Univariable/multivariable logistic regression analysis was per- access article distributed under the terms of the V600E formed to evaluate the factors including Radiomics Score in predicting BRAF mutation. Creative Commons Attribution License, which permits unrestricted use, distribution, and Subgroup analysis including conventional PTC<20-mm (n = 389) was performed (training: reproduction in any medium, provided the original 280, validation: 109). author and source are credited. Data Availability Statement: Data cannot be Results shared publicly because of patient confidentiality Of the 527 patients diagnosed with PTC, 428 (81.2%) were positive and 99 (18.8%) were issues. The institutional review board of Severance V600E Hospital, Yonsei University has given approval for negative for BRAF mutation. In both total 527 cancers and 389 conventional PTC<20- this study, recommending patient confidentiality mm, Radiomics Score was the single factor showing significant association to the presence when using image data. contact: firstname.lastname@example.org. V600E of BRAF mutation on multivariable analysis (all P<0.05). C-statistics for the validation Funding: This work was supported by the National set in the total cancers and the conventional PTCs<20-mm were lower than that of the train- Research Foundation of Korea(NRF) grant funded ing set: 0.629 (95% CI: 0.516–0.742) to 0.718 (95% CI: 0.650–0.786), and 0.567 (95% CI: by the Korea government(MSIT) (2019R1A2C1002375). This study was also 0.434–0.699) to 0.729 (95% CI: 0.632–0.826), respectively. PLOS ONE | https://doi.org/10.1371/journal.pone.0228968 February 13, 2020 1 / 11 V600E Radiomics in predicting BRAF mutation supported by a CMB-Yuhan research grant of Conclusion Yonsei University College of Medicine (6-2017- Radiomics features extracted from US has limited value as a non-invasive biomarker for 0170). The funders had no role in study design, V600E data collection and analysis, decision to publish, or predicting the presence of BRAF mutation status of PTC regardless of size. preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Introduction During the past decade, the incidence of thyroid cancer has rapidly increased worldwide, regardless of the demographic groups [1–3]. The majority of thyroid cancers that are being newly detected are papillary thyroid cancers (PTC) [4,5], a subtype consisting of more than 80% of all differentiated thyroid carcinomas [5,6]. In general, PTC is known to have excellent patient outcomes, 5-year survival rates approaching 98–99% [7,8], but approximately 10–15% of patients had aggressive tumor behavior, local recurrence/distant metastasis after treatment or mortality [9–12]. At present, even with the well-known poor prognostic factors such as age over 45 years, male gender, radioactive iodine resistance , it is difficult to descriminate to predict which patient has more aggressive forms of PTCs, and effort has been made using vari- ous biomarkers in predicting PTC patients with poor outcome. With the advancement in molecular genetics, various genetic alterations have been revealed and used as an adjunctive diagnostic method or for predicting patient prognosis [8,13,14]. V600E BRAF mutation, the most frequent oncogene in PTC, has been reported to be associated with aggressive clinical features such as large tumor size, extrathyroidal extension and presence of lymph node metastasis [8,14–16], leading to recurrence or mortality. But even with the abil- ity of either mutation in detecting aggressive cancer types, genetic analysis requires specimen tissue for analysis, mostly obtained from invasive surgical procedures. Aside from the informa- tion obtained from conventional imaging, radiomics, using data extracted from medical images converted into high-dimensional, mineable, and quantitative imaging features has been applied to revealing tumor physiology. Other studies have linked imaging features to molecular properties of tumors among various organs [17–20], but to the best of our knowl- edge, no studies have applied radiomics in predicting molecular status of thyroid cancer that can be used in predicting tumor aggressiveness. Based on this, we evaluated whether if ultraso- V600E nography (US)-based radiomics enables prediction of the presence of BRAF mutations among patients diagnosed as PTC. Materials & methods This retrospective study has been approved by the institutional review board (IRB) of Sever- ance Hospital, Yonsei University (approval number: 4-2018-0172), with a waiver for patient consent due to the retrospective study design. Signed informed consent was obtained from all patients prior to biopsy or surgical procedures. Images used for data extraction were fully anonymized before data processing according to the instructions of our IRB. Patients We included 527 patients who had been treated surgically with cytologically-proven or suspi- cious thyroid cancer between December 2015 to May 2017 at Severance Hospital, Seoul, V600E Korea. All patients had BRAF mutation analysis performed on surgical specimen. The 387 consecutive patients who had surgery from December 2015 to December 2016 were used as the training cohort: 300 women, 87 men, mean age, 42.1 years±14.0 (range, 15–82 years). PLOS ONE | https://doi.org/10.1371/journal.pone.0228968 February 13, 2020 2 / 11 V600E Radiomics in predicting BRAF mutation The 140 consecutive patients who had surgery from January 2017 to May 2017 were used as the validation cohort: 105 women, 35 men, mean age, 41.3 years±13.4 (range, 15–74 years). Mean age of the 527 patients were 41.9 years±13.8 (range, 15–82 years). Mean size of the thy- roid masses was 16.4 mm±7.9 (range, 10–85 mm). V600E As the frequency of BRAF mutation has been reported to be associated with tumor size and conventional PTC , subgroup analysis was performed including thyroid cancers confirmed as conventional PTCs measuring <20-mm (n = 389). Mean age of the 389 patients was 42.9 years±13.1 (range, 15–80 years). Mean size of the conventional PTCs was 14.9 mm ±4.6 (range, 10–19 mm). Clinicopathologic data regarding tumor size, lymph node metastasis were obtained from review of medical records. Imaging features of the thyroid masses used for analysis were obtained from an institutional database. US image selection and feature extraction One radiologist (J.Y.K.) reviewed the preoperative US examinations of the 527 patients on the picture archiving and communication system (PACS) and selected representative transverse or longitudinal images of the tumor. The selected representative images were converted into JPEG files for manual segmentation. One radiologist (J.H.Y.) who had 9 years of experience in thyroid imaging manually set a region-of-interest (ROI) along the boundary of the selected tumor using Paint software of Windows (Fig 1). Since ROI marking with colored brush using Paint software alters original intensities in image, the manual ROI segmentation is conducted over the duplicate images of collected JPEG files. Before starting ROI extracting procedure, all images were normalized for fair comparison. First the location information of ROI marking (coordinate information of red curves in Fig 1) was sought and then applied to the original JPEG image to extract ROI only. This procedure ensures that the original intensity of the Fig 1. Representative image of tumor segmentation using thyroid US. A diagonal region-of-interest (ROI) was drawn along the tumor border (red line) for feature extraction. https://doi.org/10.1371/journal.pone.0228968.g001 PLOS ONE | https://doi.org/10.1371/journal.pone.0228968 February 13, 2020 3 / 11 V600E Radiomics in predicting BRAF mutation image was not affected by the ROI extraction process. Once ROI was extracted, a total of 730 feature information were gathered. The 730 features include the first order statistics (energy, entropy, kurtosis, skewness and so on), the second order statistics (the gray level co-occurrence matrix (GLCM) and gray level run-length matrix (GLRLM) were established and the corre- sponding features were extracted), and features from four discrete one-level wavelet decompo- sitions. The detailed calculation for these features can be found in . To obtain the feature quantities, the house code in MATLAB 2018b was used. Here, 256 bins using a bin with of 1 were utilized for intensity histogram and 4 angles of 0, 45, 90, and 135 degrees were utilized for GLCM and GLRLM anaylsis. V600E BRAF mutational analysis Direct DNA sequencing was used for the surgical specimen in mutation analysis. Exon 15, V600E which contains the BRAF mutation, was amplified by PCR with the foward primer AGGAAAGCATCTCACCTCATC and the reverse primerGATCACACCTGCCTTAAATTGC. The PCR parameters were as follows: 94˚C for 5 minutes, 35 cycles at 94˚C for 0.5 minutes, 60˚C for 0.5 minutes, and 72˚C for 10 minutes. The amplified products were purified with a QIA- GEN PCR purification kit and sequenced using the foward primer described previously with Big Dye Terminator (ABI Systems, Applied Biosystems, Foster City, CA), and an ABI PRISM 3100 Avant Genetic Analyzer (Perkin-Elmer). Data & statistical analysis For feature selection, LASSO logistic regression model was applied to the 730 texture features extracted from the US images, and a Radiomics Score was calculated for each patient using a linear combination of selected features weighted by the respective coefficients. Univariable and multivariable logistic regression analysis was performed to calculate the odds ratio with 95% confidence intervals (CI), including patient’s age, gender, tumor size, and radiomics score. For internal validation, bootstrap with 1,000 resampling was used. Calibra- tion curves were plotted to assess the calibration of the model built using the factors included, using the Hosmer Lemeshow test. Harrell’s C-index was measured to evaluate the model’s dis- crimination ability. R software (version 3.4.2, http://www.R-project.org) with the R package ‘glmnet’ was used for statistical analysis. Results Among the 527 patients diagnosed with PTC in this study, 428 (81.2%) were positive and 99 V600E (18.8%) were negative for BRAF mutation. Cancer subtype of the 527 masses were proven as follows: 493 (93.5%) as conventional PTC, 23 (4.4%) as follicular variant PTC, 7 (1.3%) as diffuse sclerosing variant PTC, 4 (0.8%) as oncocytic variant of PTC. Demographics according V600E to the presence of BRAF mutations are summarized in Table 1. Mean tumor size was sig- V600E nificantly smaller in nodules positive for BRAF mutation, 16.0±7.6 mm to 18.0±9.1 mm (P = 0.003). Similar tendency was observed in the training cohort (15.8±7.4 mm to 19.6±10.0 mm, P = 0.004), but not in the validation cohort or the conventional PTC <20-mm subgroup. Feature selection and calcuation of radiomics score Eight potential features were selected among 730 texture features in the training cohort with nonzero coefficients in the LASSO logistic regression model (Fig 2A and 2B). These 8 texture features were presented in the calculation formula below used to calculate the Radiomics PLOS ONE | https://doi.org/10.1371/journal.pone.0228968 February 13, 2020 4 / 11 V600E Radiomics in predicting BRAF mutation V600E Table 1. Demographic features of the total thyroid cancers and conventional PTCs<20-mm according to the presence of BRAF mutation. Total (n = 527) P Training cohort (n = 387) P Validation cohort (n = 140) P V600E BRAF mutation Negative Positive Negative Positive Negative Positive (n = 99) (n = 428) (n = 68) (n = 319) (n = 31) (n = 109) Mean age (years) 38.4±13.2 42.7±13.8 0.284 38.3±13.4 43.1±13.9 0.009 38.8±13.1 41.7±13.4 0.288 <55 years 86 (86.9%) 334 (78.0%) 0.064 60 (87.0) 247 (77.7) 0.118 27 (87.1) 86 (78.9) 0.446 �55 years 13 (13.1%) 94 (22.0%) 9 (13.0) 71 (22.3) 4 (12.9) 23 (21.1) Gender 0.523 0.997 0.290 Men 79 (79.8%) 326 (76.2%) 15 (22.7) 72 (22.6) 5 (16.1) 30 (27.5) Women 20 (20.2%) 102 (23.8%) 54 (78.3) 246 (77.4) 26 (83.9) 79 (72.5) Mean size of tumor (mm) 18.0±9.1 16.0±7.6 0.003 19.6±10.0 15.8±7.4 0.004 15.2±7.8 16.2±7.6 0.511 <20mm 67 (67.7%) 341 (79.7%) 0.015 40 (58.0) 254 (79.9) <0.001 27 (87.1) 87 (79.8) 0.511 �20mm 32 (32.3%) 79 (20.3%) 29 (42.0) 64 (20.1) 4 (12.9) 22 (20.2) Radiomics Score (median, 1.486 (1.160, 1.704 (1.501, <0.001 1.615 (1.457, 1.672 (1.519, 0.238 interquartile range) 1.690) 1.836) 1.747) 1.832) Conventional PTC <20-mm (n = 389) Training cohort (n = 280) P Validation cohort (n = 109) P Negative Positive Negative Positive (n = 33) (n = 247) (n = 23) (n = 86) Mean age (years) 41.1±13.9 43.3±13.0 0.386 39.5±13.9 43.0±12.6 0.277 <55 years 27 (81.8) 194 (78.5) 0.837 19 (82.6) 68 (79.1) >0.999 �55 years 6 (18.2) 53 (21.5) 4 (17.4) 18 (20.9) Gender 0.151 0.587 Men 3 (9.1) 53 (21.5) 4 (17.4) 22 (25.6) Women 30 (90.9) 194 (78.5) 19 (82.6) 64 (74.4) Mean size of tumor (mm) 12.9±2.7 13.0±2.3 0.843 13.1±2.0 13.3±2.4 0.720 <20mm - - - - - - - �20mm - - - - - - - Radiomics Score (median, 1.887 (1.734, 2.117 (1.929, <0.001 2.089 (1.920, 2.104 (1.949, 0.827 interquartile range) 2.161) 2.257) 2.246) 2.223) https://doi.org/10.1371/journal.pone.0228968.t001 Score, Radiomics ScoreðtotalÞ ¼ 0:3715483 #0; 0:0179227 X mad 6 0 #0; 0:0202624 X sv 43 0 0:0000068 X HL ene 1 0 #0; 0:0000041 X HL rln 48 0 #0; 0:0769504 X LL uni 13 0 0:0013692 X LL lrlgle 54 0þ 0:0025444 X LL se 42 45þ 0:5554316 X LL se 42 90 For the conventional PTCs measuring <20-mm, 4 potential features were selected among the 730 texture features in the training cohort (Fig 2C and 2D). These 4 texture features were presented in the calculation formula below used to calculate the Radiomics Score (cPTC<20-mm), Radiomics ScoreðcPTC < 20#0; mmÞ ¼ #0; 2:2001791þ 11:4205518 X LH srlgle 52 0#0; 0:7666155 X LL uni 13 0 þ 0:8461400 X LL se 42 90#0; 0:0001180 X LL lrhgle 55 90 PLOS ONE | https://doi.org/10.1371/journal.pone.0228968 February 13, 2020 5 / 11 V600E Radiomics in predicting BRAF mutation Fig 2. Texture feature selection using the least absolute shrinkage and selection operator (LASSO) logistic regression model. (A) Tuning parameter (lambda,λ) selection in the LASSO model used 10-fold cross validation for 527 thyroid cancers. The mean deviance (goodness-of-fit statistics, red dots) was plotted versus log(λ), error bars displaying the range of standard error. Dotted vertical lines were drawn at the point of minimum deviance (λ value = 0.03229), and at the point where maximumλ was obtained among errors smaller than the standard error of minimum deviance (λ value = 0.08984). (B) LASSO coefficient profiles of the 730 texture features. A coefficient profile was plotted versus log(λ). The gray vertical line was drawn at the value selected using 10-fold cross validation, where the optimalλ resulted in 8 nonzero coefficients. (C) Tuning parameter (lambda,λ) selection in the LASSO model used 10-fold cross validation for 389 conventional PTCs <20-mm. The mean deviance (goodness-of-fit statistics, red dots) was plotted versus log(λ), error bars displaying the range of standard error. Dotted vertical lines were drawn at the point of minimum deviance (λ value = 0.0329208), and at the point where maximumλ was obtained among errors smaller than the standard error of minimum deviance (λ value = 0.072595). (D) LASSO coefficient profiles plotted versus log(λ), gray vertical line was drawn at the value selected using 10-fold cross validation, where the optimalλ resulted in 4 nonzero coefficients. https://doi.org/10.1371/journal.pone.0228968.g002 Development, performance, and validation of prediction models Table 2 summarizes the results of univariable and multivariable logistic regression analysis for V600E predicting the presence of BRAF mutations. In the training cohort of the total thyroid cancers, tumor size and Radiomics Score were factors with statistical significance on univari- able analysis. Among the training cohort including conventional PTCs measuring <20-mm, Radiomics Score was the single factor showing statistical significance. In both total cancers and the conventional PTC<20-mm, Radiomics Score was the single factor showing significant V600E association to the presence of BRAF mutation on multivariable analysis (all P<0.05). PLOS ONE | https://doi.org/10.1371/journal.pone.0228968 February 13, 2020 6 / 11 V600E Radiomics in predicting BRAF mutation V600E Table 2. Univariable and multivariable analysis in predicting the presence of BRAF mutation in the training cohort of the total thyroid cancers and conven- tional PTC<20-mm. Clinical features Total Univariable Multivariable OR 95% CI P OR 95% CI P Tumor size 0.953 0.924–0.981 0.001 1.018 0.977–1.060 0.394 Age (�55 years) 1.916 0.948–4.308 0.089 1.948 0.928–4.536 0.096 Gender 1.054 0.573–2.035 0.871 1.757 0.877–3.793 0.129 Radiomics score 6.099 3.124–12.723 <0.001 8.979 3.603–23.920 <0.001 Conventional PTCs<20-mm OR 95% CI P OR 95% CI P Tumor size 1.018 0.875–1.198 0.825 1.030 0.872–1.232 0.738 Age (�55 years) 1.229 0.512–3.431 0.665 1.282 0.495–3.943 0.632 Gender 2.732 0.926–11.701 0.108 4.281 1.166–27.327 0.060 Radiomics score 9.976 3.161–38.451 <0.001 11.279 3.624–44.121 <0.001 US: ultrasonography, PTC: papillary thyroid carcinoma, OR: Odds ratio, 95% CI: 95% confidence interval https://doi.org/10.1371/journal.pone.0228968.t002 V600E The calibration curve of the prediction model for the presence of BRAF mutation demonstrated good agreement between prediction and observation in the training cohort among the thyroid cancers. The Hosmer-Lemeshow test yielded statistics of P = 0.502, suggest- ing good calibration (Fig 3A). C-statistics for the training set was 0.718 (95% CI: 0.650–0.786), and 0.629 (95% CI: 0.516–0.742) for the validation set (Table 3). The calibration curve of V600E the prediction model for the presence of BRAF mutation among conventional PTCs <20-mm demonstrated good calibration, with the Hosmer-Lemeshow test yielding statistics of P = 0.257 (Fig 3B). C-statistics for training set among the conventional PTCs<20-mm was 0.729 (95% CI: 0.632–0.826), and 0.567 (95% CI: 0.434–0.699) for the validation set. Discussion One major challenge for thyroid cancer is how to distinguish patients who need aggressive treatment to survive to those who do not. There are no consistent predictors that reliably sorts out aggressive PTCs, and in addition to the lack of prospective data regarding appropriate treatment for PTCs due to its generally excellent survival , issues regarding overtreatment for low-risk patients who will not experience PTC-related mortality have surfaced and debated over the recent years. This reflects the need for a more effective and accurate biomarker in V600E predicting aggressive PTCs, including molecular analysis such as BRAF mutations. Muta- tion analysis requires invasive procedures such as biopsy or surgical resection to retrive speci- men to be analyzed. Among the non-invasive imaging biomarkers, radiomics is an emerging method that has the potential to predict molecular characteristics of tumors, using quantitative imaging features extracted using data-characterization algorithms. The most widely used imaging modality in radiomics has been computed tomography (CT) or magnetic resonance imaging (MRI), however, US is the most sensitive and accurate imaging modality for the thy- roid which we used in this study. For feature selection in obtaining a Radiomics Score, the LASSO logistic regression model was used, which enables selecting features based on their strength of association on univariable analysis, and combining the selected features into a radiomics signature . The Radiomics Score obtained was the single factor showing significant association in pre- V600E dicting the presence of BRAF mutation in both univariable and multivariable analysis PLOS ONE | https://doi.org/10.1371/journal.pone.0228968 February 13, 2020 7 / 11 V600E Radiomics in predicting BRAF mutation V600E Fig 3. Calibration plots of the grouped prediction models for the presence of BRAF mutation. For each plot, V600E the y-axis represents the actual probability of BRAF mutation, and the x-axis represents the predicted risk for V600E BRAF mutation. (A) Calibration plot for the total thyroid cancers and (B) conventional PTCs measuring <20-mm included in this study. https://doi.org/10.1371/journal.pone.0228968.g003 PLOS ONE | https://doi.org/10.1371/journal.pone.0228968 February 13, 2020 8 / 11 V600E Radiomics in predicting BRAF mutation Table 3. Discrimination ability of the models in the total thyroid cancers and the conventional PTCs<20-mm. Total (n = 527) Conventional PTC<20-mm (n = 389) Original Internal validation Original Internal validation c-statistics 95% CI Boostrapped c-statistics 95% CI c-statistics 95% CI Boostrapped c-statistics 95% CI Training set 0.718 0.650–0.786 0.716 0.652–0.786 0.729 0.632–0.826 0.729 0.634–0.819 Validation set 0.629 0.516–0.742 0.566 0.430–0.701 https://doi.org/10.1371/journal.pone.0228968.t003 in the training cohorts (Table 3), showing good discrimination for thyroid cancers with V600E BRAF mutation in the training set (c-statistics 0.718 (95% CI: 0.650–0.786)), but with lower c-statistics for validation set (0.629 (95% CI: 0.516–0.742). Our results show that US- derived radiomics may have potential as a non-invasive biomarker, but currently does not V600E enable accurate prediction of the presence of BRAF mutation in PTCs. There have been other studies proving the potential of US-derived radiomics in predicting disease-free sur- vival or in predicting lymph node metastasis in patients diagnosed with PTC [24,25], but to the best of our knowledge, there are currently no studies using US radiomics features in pre- V600E dicting the presence of BRAF mutations in patients diagnosed with thyroid cancer. Fur- ther studies including larger number of cases are anticipated in the future to validate our results. V600E Among the clinical variables, higher rates of BRAF mutation was seen in thyroid cancers of smaller size, which showed significant association on univariable analysis. As the tumor size and subtype of thyroid cancer has been reported to have association to the V600E presence of BRAF mutation , we performed a subgroup analysis using a separate Radiomics Score calculated among the 730 texture features from a subset of 389 thyroid cancers confirmed as conventional PTC<20-mm. When using the Radiomics Score (cPTC<20-mm), similar results were obtained with the total 527 PTCs; Radiomics Score (cPTC<20-mm) was the single factor showing significance on both univariable/multivari- able analysis (all P<0.001), with c-statistics of 0.729 (95% CI: 0.632–0.826) for the training set, lower values for the validation set, 0.567 (95% CI: 0.434–0.699). This supports that US- V600E radiomics has limited value in predicting BRAF mutation in PTC patients, regardless of size. There are several limitations to this study. First, as the mutation analysis was performed in a selected group of PTC patients, results of our study does not represent mutation features of the general thyroid cancer population. Second, 81.2% of the PTCs in this study had V600E BRAF mutation analysis, which may have affected our results. PTCs among our popula- V600E tion has been known for its high prevalence for BRAF mutation , and results may have differed when conducted on different populations. Last, US images were used for fea- ture extraction in obtaining a Radiomics Score that may be used in prediction of the pres- V600E ence of BRAF mutation. Inherent observer variability of US compared to computed tomography (CT) or magnetic resonance imaging (MRI) may have affected our results, but since US is currently the generally applied imaging modality for detecting and differentiat- ing thyroid nodules, feature extraction from US images may be more appropriate in extract- ing radiomics data among thyroid imaging. Also, ROIs for feature extraction was obtained from one radiologist, and observer variability among different radiologists were not consid- ered in data analysis. In conclusion, our results show that radiomics features extracted from US has limited value V600E as a non-invasive biomarker for predicting the presence of BRAF mutation status of PTC regardless of size. PLOS ONE | https://doi.org/10.1371/journal.pone.0228968 February 13, 2020 9 / 11 V600E Radiomics in predicting BRAF mutation Author Contributions Conceptualization: Jin Young Kwak. Data curation: Jung Hyun Yoon, Kyunghwa Han, Eunjung Lee, Jin Young Kwak. Formal analysis: Jung Hyun Yoon, Kyunghwa Han, Eunjung Lee. Funding acquisition: Jin Young Kwak. Investigation: Jung Hyun Yoon. Methodology: Jin Young Kwak. Project administration: Jin Young Kwak. Resources: Jandee Lee, Kee Hyun Nam, Jin Young Kwak. Software: Eunjung Lee. Supervision: Eun-Kyung Kim, Hee Jung Moon, Vivian Youngjean Park, Jin Young Kwak. Writing – original draft: Jung Hyun Yoon, Jin Young Kwak. Writing – review & editing: Jung Hyun Yoon, Kyunghwa Han, Eunjung Lee, Jandee Lee, Eun-Kyung Kim, Hee Jung Moon, Vivian Youngjean Park, Kee Hyun Nam, Jin Young Kwak. References 1. Chen AY, Jemal A, Ward EM. Increasing incidence of differentiated thyroid cancer in the United States, 1988–2005. 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Published: Feb 13, 2020
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