评估一种更新版微RNA分类器在不确定性和RAS突变甲状腺结节管理中的临床表现：一项多机构研究

将微RNA标记物与下一代测序（NGS）面板结合，可能增强对细胞学上不确定性甲状腺结节的风险评估。ThyGeNEXT-ThyraMIRv1多平台检测的第1版在风险分层RAS突变不确定性甲状腺结节中的应用有限。我们旨在验证更新的ThyraMIRv2平台在临床实践中的表现。ThyGeNEXT/ThyraMIRv2是一种三级微RNA分类器，使用此前多机构队列中的Bethesda III/IV结节进行评估，阳性结果的恶性风险≥10%。此外，还评估了ThyraMIRv2在RAS突变不确定性甲状腺结节中的临床价值。在366个不确定性甲状腺结节中，ThyraMIRv2平台的阳性率为30.3%。与ThyraMIRv2平台阴性结节相比，阳性结节的手术率更高（63.9%对36.1%，P < .0001），以及被诊断为具有类似乳头状核特征的滤泡性甲状腺肿瘤（65.9%对25.0%，P < .0001）。与多平台检测第1版相比，ThyraMIRv2平台的诊断参数未显著改善。在68个RAS突变结节中，ThyraMIRv2将36.8%、55.9%和7.4%的结节分别分类为阳性、中等和阴性。所有中等风险结节的恶性风险均≥10%，且与阳性组合并分析。RAS突变阳性/中等组与阴性组在手术率（81.0%对60.0%，P = .272）或具有乳头状核特征的非侵袭性滤泡性甲状腺肿瘤的诊断率（47.6%对40.0%，P > .999）方面无显著差异。在RAS突变结节中，ThyraMIRv2显示出较高的敏感性（93.8%对64.7%，P = .003）和较低的特异性（4.5%对34.8%，P = .008），但具有类似的阴性预测值（33.3%对40.0%，P = .731）和阳性预测值（58.8%对59.5%，P = .864）。总体而言，ThyraMIRv2平台并未改善与ThyGeNEXT-ThyraMIRv1多平台检测第1版相比的不确定性甲状腺结节的恶性分层，但在检测恶性RAS突变结节方面表现更佳，尽管伴随假阳性率增加。未来需要包含更多手术病理结果的RAS突变结节队列研究，以更好地评估该分类器的性能参数。

Integrating microRNA markers with next-generation sequencing panels may enhance risk assessment of cytologically indeterminate thyroid nodules. The ThyGeNEXT-ThyraMIRv1 multiplatform test version 1 demonstrated limited utility in risk-stratifying RAS-mutated indeterminate thyroid nodules. We sought to validate the updated ThyraMIRv2 platform in clinical practice.ThyGeNEXT/ThyraMIRv2, a 3-tiered microRNA classifier, were evaluated using a previously studied multi-institutional cohort of Bethesda III/IV nodules, with positive results having risk of malignancy ≥10%. In addition, ThyraMIRv2's clinical utility in RAS-mutated indeterminate thyroid nodules was assessed.In 366 indeterminate thyroid nodules, ThyraMIRv2 platform yielded a 30.3% positive-call rate. ThyraMIRv2 platform + nodules had greater operative rates (63.9% vs 36.1%, P < .0001) and cancer/noninvasive follicular thyroid neoplasm with papillary-like nuclear features diagnosis (65.9% vs 25.0%, P < .0001) than ThyraMIRv2 platform nodules. Compared with multiplatform test version 1, ThyraMIRv2 platform's diagnostic testing parameters did not improve significantly. Among 68 RAS-mutated nodules, ThyraMIRv2 classified 36.8%, 55.9%, and 7.4% as positive, moderate, and negative, respectively. All moderate nodules had risk of malignancy ≥10% and were combined with the positive cohort. No significant differences existed in operative rate (81.0% vs 60.0%, P = .272) or cancer/noninvasive follicular thyroid neoplasm with papillary-like nuclear features diagnosis (47.6% vs 40.0%, P > .999) between RAS-mutated positive/moderate and negative groups. For RAS-mutated nodules, ThyraMIRv2 demonstrated improved sensitivity (93.8% vs 64.7, P = .003) and decreased specificity (4.5% vs 34.8%, P = .008) compared with ThyGeNEXT-ThyraMIRv1 multiplatform test version 1, with comparable negative predictive value (33.3% vs 40.0%, P = .731) and positive predictive value (58.8% vs 59.5%, P = .864).ThyraMIRv2 platform does not improve indeterminate thyroid nodule malignancy stratification compared to ThyGeNEXT-ThyraMIRv1 multiplatform test version 1. ThyraMIRv2 improves malignant RAS-mutated nodule detection but increases false positives. Future studies encompassing a larger cohort of RAS-mutated with surgical pathology results are warranted to better characterize the performance parameters of this classifier.