Evolution and Impact of Subclonal Mutations in Papillary Thyroid Cancer

Unlike many cancers, the pattern of tumor evolution in papillary thyroid cancer (PTC) and in its potential role in relapse have not been elucidated. In this study, multi-region whole-exome sequencing (WES) was performed on early stage PTC tumors (n=257 tumor regions) from 79 patients, including 17 who had developed relapse, to understand the temporal and spatial framework within which subclonal mutations catalyze tumor evolution and its potential clinical relevance. Paired primary-relapse tumor tissues were also available for a subset of patients. The resulting catalog of variants was analyzed to explore evolutionary histories, define clonal and subclonal events, and assess the relationship between intra-tumor heterogeneity and relapse-free survival.The multi-region WES approach was key in correctly classifying subclonal mutations, 40% of which would have otherwise been erroneously considered clonal. We observed both linear and branching evolution patterns in our PTC cohort. A higher burden of subclonal mutations was significantly associated with increased risk of relapse.We conclude that relapse in PTC, while generally rare, does not follow a predictable evolutionary path and that subclonal mutation burden may serve as a prognostic factor. Larger studies utilizing multi-region sequencing in relapsed PTC cases with matching primary tissues are needed to confirm these observations.