# Development and validation of mRNA expression-based classifiers to predict low-risk thyroid tumors

## TL;DR

This study develops and validates mRNA-based classifiers to preoperatively identify low-risk thyroid tumors, helping avoid unnecessary surgeries and complications.

## Contribution

The novel contribution is the development of high-negative predictive value mRNA expression classifiers for thyroid tumor invasion and lymph node metastasis.

## Key findings

- The low-risk invasion classifier ruled out high-risk tumors with 97.6% negative predictive value in development and 99% in validation.
- The low-risk lymph node metastasis classifier achieved 98.6% negative predictive value in development and 100% in validation.

## Abstract

Molecular variants and fusions in thyroid nodules can provide prognostic information at a population level. However, thyroid cancers harboring the same molecular alterations may exhibit diverse clinical behavior. Leveraging exome-enriched gene expression analysis may overcome the limitations seen in models based on a small number of point mutations or fusions. Here, we developed and validated mRNA-based classifiers with high negative predictive values to preoperatively rule out thyroid tumor invasion and lymph node metastases.

In this retrospective cohort study, histopathology reports from the Afirma Genomic Sequencing Classifier (GSC) algorithm training and consecutive thyroid cancer patients with Bethesda III–VI thyroid nodules in clinical practice (total 697 and ~50%, respectively) were scored for invasion and metastases. mRNA expression-based classifiers were developed utilizing literature-derived signatures as well as differentially expressed genes between samples with or without clinically significant invasion/metastases as the basic building blocks. Machine learning algorithms were employed to develop the final candidate classifiers. The final locked classifiers were validated on a retrospective cohort of 259 patients with Afirma testing who had thyroid surgery and had invasion and metastasis scores assigned based on histopathology while blinded to the classifier results.

A total of 697 (88% female) patient Afirma samples and scored histology reports were used for classifier development. In development, patients had a median age of 51 years. Ten percent of samples were assigned a high risk for invasion label, and 11.3% were assigned a high risk for lymph node metastasis (LNM) label. A low-risk invasion classifier result was assigned to 41.3% of the cohort with a negative predictive value (NPV) of 97.6%, and a low-risk LNM classifier result was assigned to 49.8% of the cohort with an NPV of 98.6%. In the validation cohort, made up of 75% women with a median age of 53 years, 51% of the samples were ruled out for high risk for invasion label with a 99% [95–100] NPV, and 53% were ruled out for high risk for LNM label with 100% [97–100] NPV.

Gene expression-based classifiers that confidently, preoperatively rule out thyroid tumor invasion and lymph node metastasis may help personalize the surgical approach for individuals, reducing overtreatment, surgical complications, and postoperative hypothyroidism.