Incremental Utility Of Expanded Mutation Panel When Used In Combination With Microrna Classification In Indeterminate Thyroid Nodules

INTRODUCTION Focused and expanded mutation panels were assessed for the incremental utility of using an expanded panel in combination with microRNA risk classification. METHODS Molecular results were reviewed for patients who underwent either a focused mutation panel (ThyGenX (R)) or an expanded mutation panel (ThyGeNEXT (R)) for strong and weak oncogenic driver mutations and fusions. microRNA results (ThyraMIR (R)) predictive of malignancy, including strong positive results highly specific for malignancy, were examined. RESULTS Results of 12 993 consecutive patients were reviewed (focused panel = 8619, expanded panel = 4374). The expanded panel increased detection of strong drivers by 8% (P < .001), with BRAFV600E and TERT promoters being the most common. Strong drivers were highly correlated with positive microRNA results of which 90% were strongly positive. The expanded panel increased detection of coexisting drivers by 4% (P < .001), with TERT being the most common partner often paired with RAS. It increased the detection of weak drivers, with RAS and GNAS being the most common. 49% of nodules with weak drivers had positive microRNA results of which 33% were strongly positive. The expanded panel also decreased the number of nodules lacking mutations and fusions by 15% (P < .001), with 8% of nodules having positive microRNA results of which 22% were strongly positive. CONCLUSIONS Using expanded mutation panels that include less common mutations and fusions can offer increased utility when used in combination with microRNA classification, which helps to identify high risk of malignancy in the cases where risk is otherwise uncertain due to the presence of only weak drivers or the absence of all drivers.