Bray, F. et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J. Clin. 74, 229–262 (2024).
Google Scholar
Siegel, R. L., Kratzer, T. B., Giaquinto, A. N., Sung, H. & Jemal, A. Cancer statistics 2025. CA Cancer J. Clin. 75, 10–45 (2025).
Google Scholar
Abualkhair, W. H. at al. Trends in incidence of early-onset colorectal cancer in the United States among those approaching screening age. JAMA Netw. Open 3, e1920407 (2020).
Google Scholar
Laskar, R. S. et al. A prospective investigation of early-onset colorectal cancer risk factors — pooled analysis of three large-scale European cohorts. Br. J. Cancer 134, 781–789 (2026).
Google Scholar
Jayakrishnan, T. & Ng, K. Early-onset gastrointestinal cancers: a review. JAMA. 334, 1373–1385 (2025).
Google Scholar
Ciardiello, F. et al. Clinical management of metastatic colorectal cancer in the era of precision medicine. CA Cancer J. Clin. 72, 372–401 (2022).
Google Scholar
Cervantes, A. et al. Metastatic colorectal cancer: ESMO clinical practice guideline for diagnosis, treatment and follow-up. Ann. Oncol. 34, 10–32 (2023).
Google Scholar
Karapetis, C. S. et al. K-ras mutations and benefit from cetuximab in advanced colorectal cancer. N. Engl. J. Med. 359, 1757–1765 (2008).
Google Scholar
Napolitano, S. et al. Targeting the EGFR signaling pathway in metastatic colorectal cancer. Lancet Gastroenterol. Hepatol. 9, 664–676 (2024).
Google Scholar
Elez, E. et al. Encorafenib, cetuximab, and mFOLFOX6 in BRAF-mutated colorectal cancer. N. Engl. J. Med. 392, 2425–2437 (2025).
Google Scholar
André, T. et al. Pembrolizumab in microsatellite instability high advanced colorectal cancer. N. Engl. J. Med. 383, 2207–2218 (2020).
Google Scholar
Diaz, L. A. Jr & Bardelli, A. Liquid biopsies: genotyping circulating tumor DNA. J. Clin. Oncol. 32, 579–586 (2014).
Google Scholar
Bettegowda, C. et al. Detection of circulating tumor DNA in early- and late-stage human malignancies. Sci. Transl. Med. 6, 224ra24 (2014).
Google Scholar
Misale, S., Di Nicolantonio, F., Sartore-Bianchi, A., Siena, S. & Bardelli, A. Resistance to anti-EGFR therapy in colorectal cancer: from heterogeneity to convergent evolution. Cancer Discov. 4, 1269–1280 (2014).
Google Scholar
Yang et al. Longitudinal circulating tumor DNA profiling in metastatic colorectal cancer during anti-EGFR therapy. Front. Oncol. 24, 830816 (2022).
Google Scholar
Caputo, V. et al. Comprehensive genome profiling by next generation sequencing of circulating tumor DNA in solid tumors: a single academic institution experience. Ther. Adv. Med. Oncol. 14, 17588359221096878 (2022).
Google Scholar
Normanno, N., Cervantes, A., Ciardiello, F., De Luca, A. & Pinto, C. The liquid biopsy in the management of colorectal cancer patients: current applications and future scenarios. Cancer Treat. Rev. 70, 1–8 (2018).
Google Scholar
Kahlert, C. et al. Identification of double-stranded genomic DNA spanning all chromosomes with mutated KRAS and p53 DNA in the serum exosomes of patients with pancreatic cancer. J. Biol. Chem. 289, 3869–3875 (2014).
Google Scholar
Patelli, G. et al. Liquid biopsy for prognosis and treatment in metastatic colorectal cancer: circulating tumor cells vs circulating tumor DNA. Target. Oncol. 16, 309–324 (2021).
Google Scholar
Bach, S. et al. Circulating tumor DNA analysis: clinical implications for colorectal cancer patients. a systematic review. JNCI Cancer Spectr. 3, pkz042 (2019).
Google Scholar
Reinert, T. et al. Analysis of plasma cell-free DNA by ultradeep sequencing in patients with stages I to III colorectal cancer. JAMA Oncol. 5, 1124–1131 (2019).
Google Scholar
Patelli, G. et al. Circulating tumor DNA to drive treatment in metastatic colorectal cancer. Clin. Cancer Res. 29, 4530–4539 (2023).
Google Scholar
Tie, J. et al. Circulating tumor DNA analysis detects minimal residual disease and predicts recurrence in patients with stage II colon cancer. Sci. Transl. Med. 8, 346ra92 (2016).
Google Scholar
Batool, S. M. et al. Extrinsic and intrinsic preanalytical variables affecting liquid biopsy in cancer. Cell Rep. Med. 4, 101196 (2023).
Google Scholar
Salvianti, F. et al. The pre-analytical phase of the liquid biopsy. N. Biotechnol. 55, 19–29 (2020).
Google Scholar
Illana, F. J. et al. Circulating tumor DNA in patients with cancer: insights from clinical laboratory. Adv. Lab. Med. 6, 259–276 (2025).
Google Scholar
Diehl, F. et al. Detection and quantification of mutations in the plasma of patients with colorectal tumors. Proc. Natl Acad. Sci. USA 102, 16368–16373 (2005).
Google Scholar
Martínez-Castedo, B. et al. Minimal residual disease in colorectal cancer. Tumor-informed versus tumor-agnostic approaches: unraveling the optimal strategy. Ann. Oncol. 36, 263–276 (2025).
Google Scholar
Li, L. & Sun, Y. Circulating tumor DNA methylation detection as biomarker and its application in tumor liquid biopsy: advances and challenges. MedComm 5, e766 (2024).
Google Scholar
Martín-Arana, J. et al. Whole-exome tumor-agnostic ctDNA analysis enhances minimal residual disease detection and reveals relapse mechanisms in localized colon cancer. Nat. Cancer 6, 1000–1016 (2025).
Google Scholar
Dong, L., Wang, S., Fu, B. & Wang, J. Evaluation of droplet digital PCR and next generation sequencing for characterizing DNA reference material for KRAS mutation detection. Sci. Rep. 8, 9650 (2018).
Google Scholar
Gupta, R. et al. Guardant360 circulating tumor DNA assay is concordant with FoundationOne next-generation sequencing in detecting actionable driver mutations in anti-EGFR naive metastatic colorectal cancer. Oncologist 25, 235–243 (2020).
Google Scholar
Rolfo, C. D. et al. Measurement of ctDNA tumor fraction identifies informative negative liquid biopsy results and informs value of tissue confirmation. Clin. Cancer Res. 30, 2452–2460 (2024).
Google Scholar
Gimeno-Valiente et al. Sequencing paired tumor DNA and white blood cells improves circulating tumor DNA tracking and detects pathogenic germline variants in localized colon cancer. ESMO Open 8, 102051 (2023).
Google Scholar
Gibson, C. J. & Steensma, D. P. New insights from studies of clonal hematopoiesis. Clin. Cancer Res. 24, 4633–4642 (2018).
Google Scholar
Chan, H. T. et al. Clinical significance of clonal hematopoiesis in the interpretation of blood liquid biopsy. Mol. Oncol. 14, 1719–1730 (2020).
Google Scholar
Krishnan, T. et al. Clonal hematopoiesis of indeterminate potential and its association with treatment outcomes and adverse events in patients with solid tumors. Cancer Res. Commun. 5, 66–73 (2025).
Google Scholar
Napolitano, S. et al. Novel clinical tool to estimate risk of false-negative KRAS mutations in circulating tumor DNA testing. JCO Precis Oncol. 7, e2300228 (2023).
Google Scholar
Grasselli, J. et al. Concordance of blood- and tumor-based detection of RAS mutations to guide anti-EGFR therapy in metastatic colorectal cancer. Ann. Oncol. 28, 1294–1301 (2017).
Google Scholar
Vidal, J. et al. Plasma ctDNA RAS mutation analysis for the diagnosis and treatment monitoring of metastatic colorectal cancer patients. Ann. Oncol. 28, 1325–1332 (2017).
Google Scholar
Normanno, N. et al. RAS testing of liquid biopsy correlates with the outcome of metastatic colorectal cancer patients treated with first-line FOLFIRI plus cetuximab in the CAPRI-GOIM trial. Ann. Oncol. 29, 112–118 (2018).
Google Scholar
Stintzing, S. et al. Baseline liquid biopsy in relation to tissue-based parameters in metastatic colorectal cancer: results from the randomized FIRE-4 (AIO-KRK-0114) study. J. Clin. Oncol. 43, 1463–1473 (2025).
Google Scholar
Ciardiello, F. et al. Cetuximab continuation after first progression in metastatic colorectal cancer (CAPRI-GOIM): a randomized phase II trial of FOLFOX plus cetuximab versus FOLFOX. Ann. Oncol. 27, 1055–1061 (2016).
Google Scholar
Vitiello, P. P. et al. Clinical practice use of liquid biopsy to identify RAS/BRAF mutations in patients with metastatic colorectal cancer (mCRC): a single institution experience. Cancers 11, 1504 (2019).
Google Scholar
Bachet, J. B. et al. RAS mutation analysis in circulating tumor DNA from patients with metastatic colorectal cancer: the AGEO RASANC prospective multicenter study. Ann. Oncol. 29, 1211–1219 (2018).
Google Scholar
Bachet, J. B. et al. Circulating tumour DNA at baseline for individualised prognostication in patients with chemotherapy-naïve metastatic colorectal cancer. An AGEO prospective study. Eur. J. Cancer 189, 112934 (2023).
Google Scholar
Yaeger, R. et al. Clinical validity of FoundationOne liquid CDx for detection of BRAFV600E in colorectal cancer. Cancer Res. Commun. 5, 1566–1573 (2025).
Google Scholar
Cremolini, C. et al. Negative hyper-selection of metastatic colorectal cancer patients for anti-EGFR monoclonal antibodies: the PRESSING case-control study. Ann. Oncol. 28, 3009–3014 (2017).
Google Scholar
Morano, F. et al. Negative hyperselection of patients with RAS and BRAF wild-type metastatic colorectal cancer who received panitumumab-based maintenance therapy. J. Clin. Oncol. 37, 3099–3110 (2019).
Google Scholar
Pietrantonio, F. et al. Maintenance therapy with panitumumab alone vs panitumumab plus fluorouracil-leucovorin in patients with RAS wild-type metastatic colorectal cancer: a phase 2 randomized clinical trial. JAMA Oncol. 5, 1268–1275 (2019).
Google Scholar
Manca, P. et al. The added value of baseline circulating tumor DNA profiling in patients with molecularly hyperselected, left-sided metastatic colorectal cancer. Clin. Cancer Res. 27, 2505–2514 (2021).
Google Scholar
Watanabe, J. et al. Panitumumab vs bevacizumab added to standard first-line chemotherapy and overall survival among patients with RAS wild-type, left-sided metastatic colorectal cancer: a randomized clinical trial. JAMA. 329, 1271–1282 (2023).
Google Scholar
Shitara, K. et al. Baseline ctDNA gene alterations as a biomarker of survival after panitumumab and chemotherapy in metastatic colorectal cancer. Nat. Med. 30, 730–739 (2024).
Google Scholar
Martini, G. et al. Efficacy and safety of a biomarker-driven cetuximab-based treatment regimen over 3 treatment lines in mCRC patients with RAS/BRAF wild type tumors at start of first line: the CAPRI 2 GOIM trial. Front. Oncol. 13, 1069370 (2023).
Google Scholar
Ciardiello, D. et al. Comprehensive genomic profiling by liquid biopsy captures tumor heterogeneity and identifies cancer vulnerabilities in patients with RAS/BRAFV600E wild-type metastatic colorectal cancer in the CAPRI 2-GOIM trial. Ann. Oncol. 35, 1105–1115 (2024).
Google Scholar
Ciardiello, D. et al. Comprehensive genomic profiling by liquid biopsy portrays metastatic colorectal cancer mutational landscape to predict antitumor efficacy of FOLFIRI plus cetuximab in the CAPRI-2 GOIM trial. ESMO Open 10, 104511 (2025).
Google Scholar
Ciardiello, D. Integrating tissue and liquid biopsy comprehensive genomic profiling to predict efficacy of anti-EGFR therapies in metastatic colorectal cancer: findings from the CAPRI-2 GOIM study. Eur. J. Cancer 226, 115642 (2025).
Google Scholar
Casak, S. J. et al. FDA approval summary: tucatinib with trastuzumab for advanced unresectable or metastatic, chemotherapy refractory, HER2-positive RAS wild-type colorectal cancer. Clin. Cancer Res. 29, 4326–4330 (2023).
Google Scholar
Meric-Bernstam, F. et al. ctDNA analysis in ERBB2-amplified colorectal cancer: biomarker analysis of the MyPathway trial. Clin. Cancer Res. 31, 2935–2944 (2025).
Google Scholar
Riedl, J. M. et al. Genomic landscape of clinically acquired resistance alterations in patients treated with KRASG12C inhibitors. Ann. Oncol. 36, 682–692 (2025).
Google Scholar
Tan, L. et al. A phase Ib/II trial of combined BRAF and EGFR inhibition in BRAF V600E positive metastatic colorectal cancer and other cancers: the EVICT (erlotinib and vemurafenib in combination trial) study. Clin. Cancer Res. 29, 1017–1030 (2023).
Google Scholar
Kopetz, S. et al. Molecular profiling of BRAF-V600E-mutant metastatic colorectal cancer in the phase 3 BEACON CRC trial. Nat. Med. 30, 3261–3271 (2024).
Google Scholar
Siravegna, G., Marsoni, S., Siena, S. & Bardelli, A. Integrating liquid biopsies into the management of cancer. Nat. Rev. Clin. Oncol. 14, 531–548 (2017).
Google Scholar
Siravegna et al. Clonal evolution and resistance to EGFR blockade in the blood of colorectal cancer patients. Nat. Med. 21, 795–801 (2015).
Google Scholar
Parseghian, C. M. et al. Anti-EGFR-resistant clones decay exponentially after progression: implications for anti-EGFR re-challenge. Ann. Oncol. 30, 243–249 (2019).
Google Scholar
Ciardiello, D. et al. The role of anti-EGFR rechallenge in metastatic colorectal cancer, from available data to future developments: a systematic review. Cancer Treat. Rev. 124, 102683 (2024).
Google Scholar
Sartore-Bianchi, A. et al. Circulating tumor DNA to guide rechallenge with panitumumab in metastatic colorectal cancer: the phase 2 CHRONOS trial. Nat. Med. 28, 1612–1618 (2022).
Google Scholar
Ciracì, P. et al. Re-treatment with panitumumab followed by regorafenib versus the reverse sequence in chemorefractory metastatic colorectal cancer patients with RAS and BRAF wild-type circulating tumor DNA: the PARERE study by GONO. Ann. Oncol. 37, 79–91 (2026).
Google Scholar
Napolitano et al. Panitumumab plus trifluridine-tipiracil as anti-epidermal growth factor receptor rechallenge therapy for refractory RAS wild-type metastatic colorectal cancer: a phase 2 randomized clinical trial. JAMA Oncol. 9, 966–970 (2023).
Google Scholar
Ciardiello, D. et al. Comprehensive genomic profiling by liquid biopsy in refractory metastatic colorectal cancer patients who are candidate for anti-EGFR rechallenge therapy: findings from the CAVE-2 GOIM trial. ESMO Open 10, 105491 (2025).
Google Scholar
Kagawa, Y. et al. Longitudinal ctDNA monitoring and prediction of anti-EGFR rechallenge outcomes in RAS/BRAF wild-type metastatic colorectal cancer (mCRC): the REMARRY & PURSUIT trials. J. Clin. Oncol. 43, 3514–3514 (2025).
Google Scholar
Montagut, C. et al. Circulating tumour (ct) DNA-guided anti-EGFR rechallenge strategy in metastatic colorectal cancer (mCRC): final results of the phase II randomized CITRIC trial [abstract LBA33]. Ann. Oncol. 36, S1576–S1577 (2025).
Google Scholar
Elez, E. et al. Impact of circulating tumor DNA mutant allele fraction on prognosis in RAS-mutant metastatic colorectal cancer. Mol. Oncol. 13, 1827–1835 (2019).
Google Scholar
Argilés, G. et al. Localised colon cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann. Oncol. 31, 1291–1305 (2020).
Google Scholar
Grothey, A. et al. Duration of adjuvant chemotherapy for stage III colon cancer. N. Engl. J. Med. 378, 1177–1188 (2018).
Google Scholar
Eng, C. et al. Colorectal cancer. Lancet. 404, 294–310 (2024).
Google Scholar
Thierry, A. et al. Effect of duration of adjuvant chemotherapy for patients with stage III colon cancer (IDEA collaboration): final results from a prospective, pooled analysis of six randomised, phase 3. Lancet Oncol. 21, 1620–1629 (2020).
Google Scholar
Taieb, J. et al. Prognostic value and relation with adjuvant treatment duration of ctDNA in stage III colon cancer: a post hoc analysis of the PRODIGE-GERCOR IDEA-France trial. Clin. Cancer Res. 27, 5638–5646 (2021).
Google Scholar
Tajeb, J. et al. Combined analyses of circulating tumor DNA and immunoscore in patients with stage III colon cancer: a post hoc analysis of the PRODIGE-GERCOR IDEA-France/HORG-IDEA-Greece trials. J. Clin. Oncol. 43, 1564–1577 (2025).
Google Scholar
Henriksen, T. V. et al. Circulating tumor DNA in stage III colorectal cancer, beyond minimal residual disease detection, toward assessment of adjuvant therapy efficacy and clinical behavior of recurrences. Clin. Cancer Res. 28, 507–517 (2022).
Google Scholar
Taniguchi, H. et al. CIRCULATE-Japan: circulating tumor DNA-guided adaptive platform trials to refine adjuvant therapy for colorectal cancer. Cancer Sci. 112, 2915–2920 (2021).
Google Scholar
Nakamura, Y. et al. ctDNA-based molecular residual disease and survival in resectable colorectal cancer. Nat. Med. 30, 3272–3283 (2024).
Google Scholar
Bando, H. et al. A randomized, double-blind, phase III study comparing trifluridine/tipiracil (FTD/TPI) versus placebo in patients with molecular residual disease following curative resection of colorectal cancer (CRC): the ALTAIR study [abstract]. J. Clin. Oncol. 43, LBA22 (2025).
Google Scholar
Tie, J. et al. Circulating tumor DNA analysis guiding adjuvant therapy in stage II colon cancer. N. Engl. J. Med. 386, 2261–2272 (2022).
Google Scholar
Tie, J. et al. Circulating tumor DNA analysis guiding adjuvant therapy in stage II colon cancer: 5-year outcomes of the randomized DYNAMIC trial. Nat. Med. 31, 1509–1518 (2025).
Google Scholar
Tie, J. et al. Circulating tumor DNA-guided adjuvant therapy in locally advanced colon cancer: the randomized phase 2/3 DYNAMIC-III trial. Nat. Med. 31, 4291–4300 (2025).
Google Scholar
Lonardi, S. et al. The PEGASUS trial: post-surgical liquid biopsy-guided treatment of stage III and high-risk stage II colon cancer patients [abstract LBA28]. Ann. Oncol. 34, S1268–S1269 (2023).
Google Scholar
Marsoni, S. et al. Post-surgical liquid biopsy-guided treatment of stage III and high-risk stage II colon cancer patients: final results of the PEGASUS trial [abstract 723O]. Ann. Oncol. 36, S474 (2025).
Google Scholar
Sahin, I. H. et al. Minimal residual disease-directed adjuvant therapy for patients with early-stage colon cancer: CIRCULATE-US. Oncology 36, 604–608 (2022).
Google Scholar
Hofheinz, R. D. et al. Localised rectal cancer: ESMO clinical practice guideline for diagnosis, treatment and follow-up. Ann. Oncol. 36, 1007–1024 (2025).
Google Scholar
Conroy, T. Neoadjuvant chemotherapy with FOLFIRINOX and preoperative chemoradiotherapy for patients with locally advanced rectal cancer (UNICANCER-PRODIGE 23): a multicentre, randomised, open-label, phase 3 trial. Lancet Oncol. 22, 702–715 (2021).
Google Scholar
Akiyoshi, T. et al. ctDNA longitudinal analysis during total neoadjuvant therapy and non-operative management for locally advanced rectal cancer: a biomarker study from the NOMINATE trial. Clin. Cancer Res. 31, 5188–5197 (2025).
Google Scholar
Amatu, A. et al. Total neoadjuvant therapy followed by non-operative management or surgery in stage II-III rectal cancer (NO-CUT): a multicentre, single-arm, phase 2 trial. Lancet Oncol. 26, 1612–1625 (2025).
Google Scholar
Cremolini, C. et al. Rechallenge for patients with RAS and BRAF wild-type metastatic colorectal cancer with acquired resistance to first-line cetuximab and irinotecan: a phase 2 single-arm clinical trial. JAMA Oncol. 5, 343–350 (2019).
Google Scholar
Masuishi, T. et al. Phase 2 study of irinotecan plus cetuximab rechallenge as third-line treatment in KRAS wild-type metastatic colorectal cancer: JACCRO CC-08. Br. J. Cancer 123, 1490–1495 (2020).
Google Scholar
Tsuji, A. et al. Phase II study of third-line panitumumab rechallenge in patients with metastatic wild-type KRAS colorectal cancer who obtained clinical benefit from first-line panitumumab-based chemotherapy: JACCRO CC-09. Target. Oncol. 16, 753–760 (2021).
Google Scholar
Sunakawa, Y. et al. RAS mutations in circulating tumor DNA and clinical outcomes of rechallenge treatment with anti-EGFR antibodies in patients with metastatic colorectal cancer. JCO Precis. Oncol. 4, 898–911 (2020).
Google Scholar
Martinelli, E. et al. Cetuximab rechallenge plus avelumab in pretreated patients with RAS wild-type metastatic colorectal cancer: the phase 2 single-arm clinical cave trial. JAMA Oncol. 7, 1529–1535 (2021).
Google Scholar
Izawa, N. et al. A phase II trial of trifluridine/tipiracil in combination with cetuximab rechallenge in patients with RAS wild-type mCRC refractory to prior anti-EGFR antibodies: WJOG8916G trial. Target. Oncol. 18, 369–381 (2023).
Google Scholar
Napolitano, S. et al. Panitumumab plus trifluridine/tipiracil as anti-EGFR rechallenge therapy in patients with refractory RAS wild-type metastatic colorectal cancer: overall survival and subgroup analysis of the randomized phase II VELO trial. Int. J. Cancer 153, 1520–1528 (2023).
Google Scholar
Sgouros, J. et al. Anti-EGFR re-challenge with chemotherapy in RAS wild-type advanced colorectal cancer (A-REPEAT study): efficacy and correlations with tissue and plasma genotyping. ESMO Gastrointest. Oncol. 7, 100120 (2025).
Google Scholar
Weiss, L. et al. FIRE-4 (AIO KRK-0114): randomized study evaluating the efficacy of cetuximab re-challenge in patients with metastatic RAS wild-type colorectal cancer responding to first-line treatment with FOLFIRI plus cetuximab [abstract]. J. Clin. Oncol. 43, 3513 (2025).
Google Scholar
Tie, J. et al. Circulating tumor DNA analyses as markers of recurrence risk and benefit of adjuvant therapy for stage III colon cancer. JAMA Oncol. 5, 1710–1717 (2019).
Google Scholar
Tarazona, N. et al. Targeted next-generation sequencing of circulating-tumor DNA for tracking minimal residual disease in localized colon cancer. Ann. Oncol. 30, 1804–1812 (2019).
Google Scholar
Parikh, A. R. et al. Minimal residual disease detection using a plasma-only circulating tumor DNA assay in patients with colorectal cancer. Clin. Cancer Res. 27, 5586–5594 (2021).
Google Scholar
Kotani, D. et al. Molecular residual disease and efficacy of adjuvant chemotherapy in patients with colorectal cancer. Nat. Med. 29, 127–134 (2023).
Google Scholar
