Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Liquid biopsy: monitoring cancer-genetics in the blood

Abstract

Cancer is associated with mutated genes, and analysis of tumour-linked genetic alterations is increasingly used for diagnostic, prognostic and treatment purposes. The genetic profile of solid tumours is currently obtained from surgical or biopsy specimens; however, the latter procedure cannot always be performed routinely owing to its invasive nature. Information acquired from a single biopsy provides a spatially and temporally limited snap-shot of a tumour and might fail to reflect its heterogeneity. Tumour cells release circulating free DNA (cfDNA) into the blood, but the majority of circulating DNA is often not of cancerous origin, and detection of cancer-associated alleles in the blood has long been impossible to achieve. Technological advances have overcome these restrictions, making it possible to identify both genetic and epigenetic aberrations. A liquid biopsy, or blood sample, can provide the genetic landscape of all cancerous lesions (primary and metastases) as well as offering the opportunity to systematically track genomic evolution. This Review will explore how tumour-associated mutations detectable in the blood can be used in the clinic after diagnosis, including the assessment of prognosis, early detection of disease recurrence, and as surrogates for traditional biopsies with the purpose of predicting response to treatments and the development of acquired resistance.

Key Points

  • Under representation of the heterogeneity of a tumour and poor sample availability means tissue biopsies are of limited value for the assessment of tumour dynamics in the advanced stages of disease

  • Extended periods between sampling and clinical application of the results, as well as additional lines of treatment between sampling, might result in an altered genetic composition of the tumour

  • Circulating free DNA can be extracted from the blood and tumour-specific aberrations assessed to provide a genetic landscape of the cancerous lesions in a patient

  • Tracking tumour-associated genetic aberrations in the blood can be used to assess the presence of residual disease, recurrence, relapse and resistance

  • Monitoring the emergence of tumour-associated genetic aberrations in the blood can be used to detect the emergence of resistant cancer cells 5–10 months before conventional methods

  • To implement circulating tumour DNA testing in the clinic, standardization of techniques, assessment of reproducibility and cost-effectiveness is required as well as prospective validation in clinical trials

Your institute does not have access to this article

Relevant articles

Open Access articles citing this article.

Access options

Buy article

Get time limited or full article access on ReadCube.

$32.00

All prices are NET prices.

Figure 1: Release and extraction of cfDNA from the blood.
Figure 2: Monitoring tumour-specific aberrations to detect recurrence and resistance.

References

  1. Diamantis, A., Magiorkinis, E. & Koutselini, H. Fine-needle aspiration (FNA) biopsy: historical aspects. Folia Histochem. Cytobiol. 47, 191–197 (2009).

    PubMed  Article  Google Scholar 

  2. Gerlinger, M. et al. Intratumor heterogeneity and branched evolution revealed by multiregion sequencing. N. Engl. J. Med. 366, 883–892 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  3. Robertson, E. G. & Baxter, G. Tumour seeding following percutaneous needle biopsy: the real story! Clin. Radiol. 66, 1007–1014 (2011).

    CAS  PubMed  Article  Google Scholar 

  4. Hompes, D. & Ruers, T. Review: incidence and clinical significance of bevacizumab-related non-surgical and surgical serious adverse events in metastatic colorectal cancer. Eur. J. Surg. Oncol. 37, 737–746 (2011).

    CAS  PubMed  Article  Google Scholar 

  5. Mandel, P. & Metais, P. Les acides nucleiques du plasma sanguin chez l'homme. C. R. Seances Soc. Biol. Fil. 142, 241–243 (1948).

    CAS  PubMed  Google Scholar 

  6. Koffler, D., Agnello, V., Winchester, R. & Kunkel, H. G. The occurrence of single-stranded DNA in the serum of patients with systemic lupus erythematosus and other diseases. J. Clin. Invest. 52, 198–204 (1973).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  7. Diaz, L. A. Jr et al. The molecular evolution of acquired resistance to targeted EGFR blockade in colorectal cancers. Nature 486, 537–540 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  8. Misale, S. et al. Emergence of KRAS mutations and acquired resistance to anti-EGFR therapy in colorectal cancer. Nature 486, 532–536 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  9. Chan, K. C. et al. Cancer genome scanning in plasma: detection of tumor-associated copy number aberrations, single-nucleotide variants, and tumoral heterogeneity by massively parallel sequencing. Clin. Chem. 59, 211–224 (2013).

    CAS  PubMed  Article  Google Scholar 

  10. Jung, K., Fleischhacker, M. & Rabien, A. Cell-free DNA in the blood as a solid tumor biomarker--a critical appraisal of the literature. Clin. Chim. Acta 411, 1611–1624 (2010).

    CAS  PubMed  Article  Google Scholar 

  11. Gormally, E., Caboux, E., Vineis, P. & Hainaut, P. Circulating free DNA in plasma or serum as biomarker of carcinogenesis: practical aspects and biological significance. Mutat. Res. 635, 105–117 (2007).

    CAS  PubMed  Article  Google Scholar 

  12. Schwarzenbach, H., Hoon, D. S. & Pantel, K. Cell-free nucleic acids as biomarkers in cancer patients. Nat. Rev. Cancer 11, 426–437 (2011).

    CAS  PubMed  Article  Google Scholar 

  13. Pisetsky, D. S. & Fairhurst, A. M. The origin of extracellular DNA during the clearance of dead and dying cells. Autoimmunity 40, 281–284 (2007).

    CAS  PubMed  Article  Google Scholar 

  14. Mantovani, A., Sozzani, S., Locati, M., Allavena, P. & Sica, A. Macrophage polarization: tumor-associated macrophages as a paradigm for polarized M2 mononuclear phagocytes. Trends Immunol. 23, 549–555 (2002).

    CAS  Article  PubMed  Google Scholar 

  15. Viorritto, I. C., Nikolov, N. P. & Siegel, R. M. Autoimmunity versus tolerance: can dying cells tip the balance? Clin. Immunol. 122, 125–134 (2007).

    CAS  PubMed  Article  Google Scholar 

  16. Stroun, M. & Anker, P. Nucleic acids spontaneously released by living frog auricles. Biochem. J. 128, 100P–101P (1972).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  17. Anker, P., Stroun, M. & Maurice, P. A. Spontaneous release of DNA by human blood lymphocytes as shown in an in vitro system. Cancer Res. 35, 2375–2382 (1975).

    CAS  PubMed  Google Scholar 

  18. Stroun, M., Lyautey, J., Lederrey, C., Olson-Sand, A. & Anker, P. About the possible origin and mechanism of circulating DNA apoptosis and active DNA release. Clin. Chim. Acta 313, 139–142 (2001).

    CAS  PubMed  Article  Google Scholar 

  19. Rogers, J. C., Boldt, D., Kornfeld, S., Skinner, A. & Valeri, C. R. Excretion of deoxyribonucleic acid by lymphocytes stimulated with phytohemagglutinin or antigen. Proc. Natl Acad. Sci. USA 69, 1685–1689 (1972).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  20. Garcia-Olmo, D. C. et al. Cell-free nucleic acids circulating in the plasma of colorectal cancer patients induce the oncogenic transformation of susceptible cultured cells. Cancer Res. 70, 560–567 (2010).

    CAS  PubMed  Article  Google Scholar 

  21. Trejo-Becerril, C. et al. Cancer progression mediated by horizontal gene transfer in an in vivo model. PLoS ONE 7, e52754 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  22. Zhou, J., Shi, Y. H. & Fan, J. Circulating cell-free nucleic acids: promising biomarkers of hepatocellular carcinoma. Semin. Oncol. 39, 440–448 (2012).

    CAS  PubMed  Article  Google Scholar 

  23. Akca, H. et al. Utility of serum DNA and pyrosequencing for the detection of EGFR mutations in non-small cell lung cancer. Cancer Genet. 206, 73–80 (2013).

    CAS  PubMed  Article  Google Scholar 

  24. Morton, N. E. Parameters of the human genome. Proc. Natl Acad. Sci. USA 88, 7474–7476 (1991).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  25. Perkins, G. et al. Multi-purpose utility of circulating plasma DNA testing in patients with advanced cancers. PLoS ONE 7, e47020 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  26. Punnoose, E. A. et al. Evaluation of circulating tumor cells and circulating tumor DNA in non-small cell lung cancer: association with clinical endpoints in a phase II clinical trial of pertuzumab and erlotinib. Clin. Cancer Res. 18, 2391–2401 (2012).

    CAS  PubMed  Article  Google Scholar 

  27. Diehl, F. et al. Circulating mutant DNA to assess tumor dynamics. Nat. Med. 14, 985–990 (2008).

    CAS  PubMed  Article  Google Scholar 

  28. Wang, J. Y. et al. Molecular detection of APC, K-ras, and p53 mutations in the serum of colorectal cancer patients as circulating biomarkers. World J. Surg. 28, 721–726 (2004).

    PubMed  Google Scholar 

  29. Dawson, S. J. et al. Analysis of circulating tumor DNA to monitor metastatic breast cancer. N. Engl. J. Med. 368, 1199–1209 (2013).

    CAS  Article  PubMed  Google Scholar 

  30. Sorenson, G. D. Detection of mutated KRAS2 sequences as tumor markers in plasma/serum of patients with gastrointestinal cancer. Clin. Cancer Res. 6, 2129–2137 (2000).

    CAS  PubMed  Google Scholar 

  31. Sorenson, G. D. A review of studies on the detection of mutated KRAS2 sequences as tumor markers in plasma/serum of patients with gastrointestinal cancer. Ann. NY Acad. Sci. 906, 13–16 (2000).

    CAS  PubMed  Article  Google Scholar 

  32. Mouliere, F. et al. High fragmentation characterizes tumour-derived circulating DNA. PLoS ONE 6, e23418 (2011).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  33. Thierry, A. R. et al. Origin and quantification of circulating DNA in mice with human colorectal cancer xenografts. Nucleic Acids Res. 38, 6159–6175 (2010).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  34. Frattini, M. et al. Quantitative and qualitative characterization of plasma DNA identifies primary and recurrent colorectal cancer. Cancer Lett. 263, 170–181 (2008).

    CAS  PubMed  Article  Google Scholar 

  35. Chen, X. Q. et al. Microsatellite alterations in plasma DNA of small cell lung cancer patients. Nat. Med. 2, 1033–1035 (1996).

    CAS  PubMed  Article  Google Scholar 

  36. 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).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  37. Leary, R. J. et al. Detection of chromosomal alterations in the circulation of cancer patients with whole-genome sequencing. Sci. Transl. Med. 4, 162ra154 (2012).

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  38. Forshew, T. et al. Noninvasive identification and monitoring of cancer mutations by targeted deep sequencing of plasma DNA. Sci. Transl. Med. 4, 136ra168 (2012).

    Article  CAS  Google Scholar 

  39. Jahr, S. et al. DNA fragments in the blood plasma of cancer patients: quantitations and evidence for their origin from apoptotic and necrotic cells. Cancer Res. 61, 1659–1665 (2001).

    CAS  PubMed  Google Scholar 

  40. Board, R. E. et al. Detection of PIK3CA mutations in circulating free DNA in patients with breast cancer. Breast Cancer Res. Treat. 120, 461–467 (2010).

    CAS  Article  PubMed  Google Scholar 

  41. Mead, R., Duku, M., Bhandari, P. & Cree, I. A. Circulating tumour markers can define patients with normal colons, benign polyps, and cancers. Br. J. Cancer 105, 239–245 (2011).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  42. Higgins, M. J. et al. Detection of tumor PIK3CA status in metastatic breast cancer using peripheral blood. Clin. Cancer Res. 18, 3462–3469 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  43. Brooks, J. D. Translational genomics: the challenge of developing cancer biomarkers. Genome Res. 22, 183–187 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  44. Wang, Y. et al. High quality copy number and genotype data from FFPE samples using Molecular Inversion Probe (MIP) microarrays. BMC Med. Genomics 2, 8 (2009).

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  45. Srinivasan, M., Sedmak, D. & Jewell, S. Effect of fixatives and tissue processing on the content and integrity of nucleic acids. Am. J. Pathol. 161, 1961–1971 (2002).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  46. Silva, J. M. et al. Persistence of tumor DNA in plasma of breast cancer patients after mastectomy. Ann. Surg. Oncol. 9, 71–76 (2002).

    PubMed  Article  Google Scholar 

  47. Silva, J. M. et al. Tumor DNA in plasma at diagnosis of breast cancer patients is a valuable predictor of disease-free survival. Clin. Cancer Res. 8, 3761–3766 (2002).

    CAS  PubMed  Google Scholar 

  48. Schwarzenbach, H. et al. Loss of heterozygosity at tumor suppressor genes detectable on fractionated circulating cell-free tumor DNA as indicator of breast cancer progression. Clin. Cancer Res. 18, 5719–5730 (2012).

    CAS  PubMed  Article  Google Scholar 

  49. Frattini, M. et al. Quantitative analysis of plasma DNA in colorectal cancer patients: a novel prognostic tool. Ann. NY Acad. Sci. 1075, 185–190 (2006).

    CAS  PubMed  Article  Google Scholar 

  50. Hamana, K. et al. Monitoring of circulating tumour-associated DNA as a prognostic tool for oral squamous cell carcinoma. Br. J. Cancer 92, 2181–2184 (2005).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  51. Hsieh, J. S. et al. APC, K-ras, and p53 gene mutations in colorectal cancer patients: correlation to clinicopathologic features and postoperative surveillance. Am. Surg. 71, 336–343 (2005).

    PubMed  Google Scholar 

  52. Kuhlmann, J. D. et al. LOH at 6q and 10q in fractionated circulating DNA of ovarian cancer patients is predictive for tumor cell spread and overall survival. BMC Cancer 12, 325 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  53. Castells, A. et al. K-ras mutations in DNA extracted from the plasma of patients with pancreatic carcinoma: diagnostic utility and prognostic significance. J. Clin. Oncol. 17, 578–584 (1999).

    CAS  PubMed  Article  Google Scholar 

  54. Yamada, T. et al. Detection of K-ras gene mutations in plasma DNA of patients with pancreatic adenocarcinoma: correlation with clinicopathological features. Clin. Cancer Res. 4, 1527–1532 (1998).

    CAS  PubMed  Google Scholar 

  55. Salazar, R. et al. Gene expression signature to improve prognosis prediction of stage II and III colorectal cancer. J. Clin. Oncol. 29, 17–24 (2011).

    Article  PubMed  Google Scholar 

  56. Paik, S. et al. A multigene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer. N. Engl. J. Med. 351, 2817–2826 (2004).

    CAS  Article  PubMed  Google Scholar 

  57. Maak, M. et al. Independent validation of a prognostic genomic signature (ColoPrint) for patients with stage II colon cancer. Ann. Surg. 257, 1053–1058 (2013).

    PubMed  Article  Google Scholar 

  58. van 't Veer, L. J. et al. Gene expression profiling predicts clinical outcome of breast cancer. Nature 415, 530–536 (2002).

    CAS  Article  PubMed  Google Scholar 

  59. Nygaard, A. D., Garm Spindler, K. L., Pallisgaard, N., Andersen, R. F. & Jakobsen, A. The prognostic value of KRAS mutated plasma DNA in advanced non-small cell lung cancer. Lung Cancer 79, 312–317 (2013).

    PubMed  Article  Google Scholar 

  60. Camps, C. et al. The identification of KRAS mutations at codon 12 in plasma DNA is not a prognostic factor in advanced non-small cell lung cancer patients. Lung Cancer 72, 365–369 (2011).

    PubMed  Article  Google Scholar 

  61. Shinozaki, M. et al. Utility of circulating B-RAF DNA mutation in serum for monitoring melanoma patients receiving biochemotherapy. Clin. Cancer Res. 13, 2068–2074 (2007).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  62. Cohn, S. L. et al. The International Neuroblastoma Risk Group (INRG) classification system: an INRG Task Force report. J. Clin. Oncol. 27, 289–297 (2009).

    PubMed  PubMed Central  Article  Google Scholar 

  63. Brodeur, G. M. Neuroblastoma: biological insights into a clinical enigma. Nat. Rev. Cancer 3, 203–216 (2003).

    CAS  Article  PubMed  Google Scholar 

  64. Yu, A. L. et al. Anti-GD2 antibody with GM-CSF, interleukin-2, and isotretinoin for neuroblastoma. N. Engl. J. Med. 363, 1324–1334 (2010).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  65. Matthay, K. K. et al. Long-term results for children with high-risk neuroblastoma treated on a randomized trial of myeloablative therapy followed by 13-cis-retinoic acid: a children's oncology group study. J. Clin. Oncol. 27, 1007–1013 (2009).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  66. Matthay, K. K. et al. Treatment of high-risk neuroblastoma with intensive chemotherapy, radiotherapy, autologous bone marrow transplantation, and 13-cis-retinoic acid. Children's Cancer Group. N. Engl. J. Med. 341, 1165–1173 (1999).

    CAS  Article  PubMed  Google Scholar 

  67. Ambros, P. F. et al. International consensus for neuroblastoma molecular diagnostics: report from the International Neuroblastoma Risk Group (INRG) Biology Committee. Br. J. Cancer 100, 1471–1482 (2009).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  68. Schneiderman, J. et al. Clinical significance of MYCN amplification and ploidy in favorable-stage neuroblastoma: a report from the Children's Oncology Group. J. Clin. Oncol. 26, 913–918 (2008).

    PubMed  Article  Google Scholar 

  69. Combaret, V. et al. Influence of neuroblastoma stage on serum-based detection of MYCN amplification. Pediatr. Blood Cancer 53, 329–331 (2009).

    PubMed  PubMed Central  Article  Google Scholar 

  70. Combaret, V. et al. Circulating MYCN DNA as a tumor-specific marker in neuroblastoma patients. Cancer Res. 62, 3646–3648 (2002).

    CAS  PubMed  Google Scholar 

  71. Combaret, V., Bergeron, C., Noguera, R., Iacono, I. & Puisieux, A. Circulating MYCN DNA predicts MYCN-amplification in neuroblastoma. J. Clin. Oncol. 23, 8919–8920 (2005).

    PubMed  Article  Google Scholar 

  72. Daniotti, M. et al. Detection of mutated BRAFV600E variant in circulating DNA of stage III-IV melanoma patients. Int. J. Cancer 120, 2439–2444 (2007).

    CAS  PubMed  Article  Google Scholar 

  73. Van Cutsem, E., Oliveira, J. & ESMO Guidelines Working Group. Primary colon cancer: ESMO clinical recommendations for diagnosis, adjuvant treatment and follow-up. Ann. Oncol. 20 (Suppl. 4), 49–50 (2009).

    PubMed  Google Scholar 

  74. Kataja, V., Castiglione, M. & ESMO Guidelines Working Group. Primary breast cancer: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann. Oncol. 20 (Suppl. 4), 10–14 (2009).

    PubMed  Google Scholar 

  75. D'Addario, G., Felip, E. & ESMO Guidelines Working Group. Non-small-cell lung cancer: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann. Oncol. 20 (Suppl. 4), 68–70 (2009).

    PubMed  Google Scholar 

  76. Jeffery, M., Hickey, B. E. & Hider, P. N. Follow-up strategies for patients treated for non-metastatic colorectal cancer. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD002200. http://dx.doi.org/10.1002/14651858.CD002200.pub2.

  77. Srikantharajah, D., Ghuman, A., Nagendran, M. & Maruthappu, M. Is computed tomography follow-up of patients after lobectomy for non-small cell lung cancer of benefit in terms of survival? Interact. Cardiovasc. Thorac. Surg. 15, 893–898 (2012).

    PubMed  PubMed Central  Article  Google Scholar 

  78. Sozzi, G. et al. Analysis of circulating tumor DNA in plasma at diagnosis and during follow-up of lung cancer patients. Cancer Res. 61, 4675–4678 (2001).

    CAS  PubMed  Google Scholar 

  79. Uhr, J. W. & Pantel, K. Controversies in clinical cancer dormancy. Proc. Natl Acad. Sci. USA 108, 12396–12400 (2011).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  80. Shaw, J. A. et al. Genomic analysis of circulating cell-free DNA infers breast cancer dormancy. Genome Res. 22, 220–231 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  81. Tsumita, T. & Iwanaga, M. Fate of injected deoxyribonucleic acid in mice. Nature 198, 1088–1089 (1963).

    CAS  PubMed  Article  Google Scholar 

  82. Jiao, L. et al. K-ras mutation and p16 and preproenkephalin promoter hypermethylation in plasma DNA of pancreatic cancer patients: in relation to cigarette smoking. Pancreas 34, 55–62 (2007).

    CAS  PubMed  Article  Google Scholar 

  83. Magistrelli, P. et al. K-ras mutations in circulating DNA from pancreatic and lung cancers: bridging methodology for a common validation of the molecular diagnosis value. Pancreas 37, 101–102 (2008).

    PubMed  Article  Google Scholar 

  84. Huang, X. H. et al. Codon 249 mutation in exon 7 of p53 gene in plasma DNA: maybe a new early diagnostic marker of hepatocellular carcinoma in Qidong risk area, China. World J. Gastroenterol. 9, 692–695 (2003).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  85. Bai, H. et al. Influence of chemotherapy on EGFR mutation status among patients with non-small-cell lung cancer. J. Clin. Oncol. 30, 3077–3083 (2012).

    PubMed  PubMed Central  Article  Google Scholar 

  86. Kreso, A. et al. Variable clonal repopulation dynamics influence chemotherapy response in colorectal cancer. Science 339, 543–548 (2013).

    CAS  Article  PubMed  Google Scholar 

  87. di Magliano, M. P. & Logsdon, C. D. Roles for KRAS in pancreatic tumor development and progression. Gastroenterology 144, 1220–1229 (2013).

    CAS  PubMed  Article  Google Scholar 

  88. Powell, S. M. et al. APC mutations occur early during colorectal tumorigenesis. Nature 359, 235–237 (1992).

    CAS  PubMed  Article  Google Scholar 

  89. Nickerson, M. L. et al. Improved identification of von Hippel-Lindau gene alterations in clear cell renal tumors. Clin. Cancer Res. 14, 4726–4734 (2008).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  90. Rechsteiner, M. P. et al. VHL gene mutations and their effects on hypoxia inducible factor HIFα: identification of potential driver and passenger mutations. Cancer Res. 71, 5500–5511 (2011).

    CAS  PubMed  Article  Google Scholar 

  91. Bardelli, A. et al. Mutational analysis of the tyrosine kinome in colorectal cancers. Science 300, 949 (2003).

    CAS  PubMed  Article  Google Scholar 

  92. National Cancer Institute. The Cancer Genome Atlas [online], (2013).

  93. International Cancer Genome Consortium. ICGC Cancer Genome Projects [online], (2013).

  94. Allegra, C. J. et al. American Society of Clinical Oncology provisional clinical opinion: testing for KRAS gene mutations in patients with metastatic colorectal carcinoma to predict response to anti-epidermal growth factor receptor monoclonal antibody therapy. J. Clin. Oncol. 27, 2091–2096 (2009).

    PubMed  Article  Google Scholar 

  95. Shaw, A. T. & Engelman, J. A. ALK in lung cancer: past, present, and future. J. Clin. Oncol. 31, 1105–1111 (2013).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  96. Gonzalez, D. et al. BRAF mutation testing algorithm for vemurafenib treatment in melanoma: recommendations from an expert panel. Br. J. Dermatol. 168, 700–707 (2013).

    CAS  PubMed  Article  Google Scholar 

  97. Simon, R. & Roychowdhury, S. Implementing personalized cancer genomics in clinical trials. Nat. Rev. Drug Discov. 12, 358–369 (2013).

    CAS  PubMed  Article  Google Scholar 

  98. Gevensleben, H. et al. Non-invasive detection of HER2 amplification with plasma DNA digital PCR. Clin. Cancer Res. 19, 3276–3284 (2013).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  99. Shah, S. S. et al. Impact of American Society of Clinical Oncology/College of American Pathologists guideline recommendations on HER2 interpretation in breast cancer. Hum. Pathol. 41, 103–106 (2010).

    CAS  PubMed  Article  Google Scholar 

  100. Bean, J. et al. MET amplification occurs with or without T790M mutations in EGFR mutant lung tumors with acquired resistance to gefitinib or erlotinib. Proc. Natl Acad. Sci. USA 104, 20932–20937 (2007).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  101. Spindler, K. L., Pallisgaard, N., Vogelius, I. & Jakobsen, A. Quantitative cell-free DNA, KRAS, and BRAF mutations in plasma from patients with metastatic colorectal cancer during treatment with cetuximab and irinotecan. Clin. Cancer Res. 18, 1177–1185 (2012).

    CAS  PubMed  Article  Google Scholar 

  102. Spindler, K. L. et al. Phase II trial of temsirolimus alone and in combination with irinotecan for KRAS mutant metastatic colorectal cancer: outcome and results of KRAS mutational analysis in plasma. Acta Oncol. 52, 963–970 (2013).

    CAS  PubMed  Article  Google Scholar 

  103. Weber, B. et al. Complete pathologic response in lung tumors in two patients with metastatic non-small cell lung cancer treated with erlotinib. J. Thorac. Oncol. 6, 1946–1949 (2011).

    PubMed  Article  Google Scholar 

  104. Martini, M., Vecchione, L., Siena, S., Tejpar, S. & Bardelli, A. Targeted therapies: how personal should we go? Nat. Rev. Clin. Oncol. 9, 87–97 (2011).

    PubMed  Article  CAS  Google Scholar 

  105. Murtaza, M. et al. Non-invasive analysis of acquired resistance to cancer therapy by sequencing of plasma DNA. Nature 497, 108–112 (2013).

    CAS  Article  PubMed  Google Scholar 

  106. Kosaka, T. et al. Analysis of epidermal growth factor receptor gene mutation in patients with non-small cell lung cancer and acquired resistance to gefitinib. Clin. Cancer Res. 12, 5764–5769 (2006).

    CAS  Article  PubMed  Google Scholar 

  107. Balak, M. N. et al. Novel D761Y and common secondary T790M mutations in epidermal growth factor receptor-mutant lung adenocarcinomas with acquired resistance to kinase inhibitors. Clin. Cancer Res. 12, 6494–6501 (2006).

    CAS  PubMed  Article  Google Scholar 

  108. Zhang, Z. et al. Activation of the AXL kinase causes resistance to EGFR-targeted therapy in lung cancer. Nat. Genet. 44, 852–860 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  109. Pao, W. et al. Acquired resistance of lung adenocarcinomas to gefitinib or erlotinib is associated with a second mutation in the EGFR kinase domain. PLoS Med. 2, e73 (2005).

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  110. Kobayashi, S. et al. EGFR mutation and resistance of non-small-cell lung cancer to gefitinib. N. Engl. J. Med. 352, 786–792 (2005).

    CAS  PubMed  Article  Google Scholar 

  111. Nakamura, T. et al. Application of a highly sensitive detection system for epidermal growth factor receptor mutations in plasma DNA. J. Thorac. Oncol. 7, 1369–1381 (2012).

    CAS  PubMed  Article  Google Scholar 

  112. Taniguchi, K. et al. Quantitative detection of EGFR mutations in circulating tumor DNA derived from lung adenocarcinomas. Clin. Cancer Res. 17, 7808–7815 (2011).

    CAS  PubMed  Article  Google Scholar 

  113. Yun, C. H. et al. The T790M mutation in EGFR kinase causes drug resistance by increasing the affinity for ATP. Proc. Natl Acad. Sci. USA 105, 2070–2075 (2008).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  114. Zhou, W. et al. Novel mutant-selective EGFR kinase inhibitors against EGFR T790M. Nature 462, 1070–1074 (2009).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  115. Li, D. et al. BIBW2992, an irreversible EGFR/HER2 inhibitor highly effective in preclinical lung cancer models. Oncogene 27, 4702–4711 (2008).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  116. Engelman, J. A. et al. PF00299804, an irreversible pan-ERBB inhibitor, is effective in lung cancer models with EGFR and ERBB2 mutations that are resistant to gefitinib. Cancer Res. 67, 11924–11932 (2007).

    CAS  Article  PubMed  Google Scholar 

  117. Cortot, A. B. et al. Resistance to irreversible EGF receptor tyrosine kinase inhibitors through a multistep mechanism involving the IGF1R pathway. Cancer Res. 73, 834–843 (2013).

    CAS  PubMed  Article  Google Scholar 

  118. Brevet, M., Johnson, M. L., Azzoli, C. G. & Ladanyi, M. Detection of EGFR mutations in plasma DNA from lung cancer patients by mass spectrometry genotyping is predictive of tumor EGFR status and response to EGFR inhibitors. Lung Cancer 73, 96–102 (2011).

    PubMed  Article  Google Scholar 

  119. Yung, T. K. et al. Single-molecule detection of epidermal growth factor receptor mutations in plasma by microfluidics digital PCR in non-small cell lung cancer patients. Clin. Cancer Res. 15, 2076–2084 (2009).

    CAS  PubMed  Article  Google Scholar 

  120. Johannessen, C. M. et al. COT drives resistance to RAF inhibition through MAP kinase pathway reactivation. Nature 468, 968–972 (2010).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  121. Villanueva, J. et al. Acquired resistance to BRAF inhibitors mediated by a RAF kinase switch in melanoma can be overcome by cotargeting MEK and IGF-1R/PI3K. Cancer Cell 18, 683–695 (2010).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  122. Poulikakos, P. I. et al. RAF inhibitor resistance is mediated by dimerization of aberrantly spliced BRAFV600E. Nature 480, 387–390 (2011).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  123. Shi, H. et al. Melanoma whole-exome sequencing identifies (V600E)B-RAF amplification-mediated acquired B-RAF inhibitor resistance. Nat. Commun. 3, 724 (2012).

    PubMed  Article  CAS  Google Scholar 

  124. Nazarian, R. et al. Melanomas acquire resistance to B-RAF(V600E) inhibition by RTK or N-RAS upregulation. Nature 468, 973–977 (2010).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  125. Page, K. et al. Detection of HER2 amplification in circulating free DNA in patients with breast cancer. Br. J. Cancer 104, 1342–1348 (2011).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  126. Flaherty, K. T. et al. Combined BRAF and MEK inhibition in melanoma with BRAF V600 mutations. N. Engl. J. Med. 367, 1694–1703 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  127. Das Thakur, M. et al. Modelling vemurafenib resistance in melanoma reveals a strategy to forestall drug resistance. Nature 494, 251–255 (2013).

    CAS  Article  PubMed  Google Scholar 

  128. Wagle, N. et al. Dissecting therapeutic resistance to RAF inhibition in melanoma by tumor genomic profiling. J. Clin. Oncol. 29, 3085–3096 (2011).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  129. Nagalingam, A. et al. Med1 plays a critical role in the development of tamoxifen resistance. Carcinogenesis 33, 918–930 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  130. Cui, J. et al. Cross-talk between HER2 and MED1 regulates tamoxifen resistance of human breast cancer cells. Cancer Res. 72, 5625–5634 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  131. Isakoff, S. J. et al. Breast cancer-associated PIK3CA mutations are oncogenic in mammary epithelial cells. Cancer Res. 65, 10992–11000 (2005).

    CAS  PubMed  Article  Google Scholar 

  132. Knudsen, E. S. & Knudsen, K. E. Tailoring to RB: tumour suppressor status and therapeutic response. Nat. Rev. Cancer 8, 714–724 (2008).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  133. Wu, C. C., Yu, C. T., Chang, G. C., Lai, J. M. & Hsu, S. L. Aurora-A promotes gefitinib resistance via a NF-κB signaling pathway in p53 knockdown lung cancer cells. Biochem. Biophys. Res. Commun. 405, 168–172 (2011).

    CAS  PubMed  Article  Google Scholar 

  134. Sequist, L. V. et al. Genotypic and histological evolution of lung cancers acquiring resistance to EGFR inhibitors. Sci. Transl. Med. 3, 75ra26 (2011).

    PubMed  PubMed Central  Article  Google Scholar 

  135. Watanabe, S. et al. Clinical responses to EGFR-tyrosine kinase inhibitor retreatment in non-small cell lung cancer patients who benefited from prior effective gefitinib therapy: a retrospective analysis. BMC Cancer 11, 1 (2011).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  136. Turke, A. B. et al. Preexistence and clonal selection of MET amplification in EGFR mutant NSCLC. Cancer Cell 17, 77–88 (2010).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  137. Di Nicolantonio, F. et al. Cancer cell adaptation to chemotherapy. BMC Cancer 5, 78 (2005).

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  138. Board, R. E. et al. Isolation and extraction of circulating tumor DNA from patients with small cell lung cancer. Ann. NY Acad. Sci. 1137, 98–107 (2008).

    CAS  PubMed  Article  Google Scholar 

  139. Chen, X. et al. Detecting tumor-related alterations in plasma or serum DNA of patients diagnosed with breast cancer. Clin. Cancer Res. 5, 2297–2303 (1999).

    CAS  PubMed  Google Scholar 

  140. Wang, M., Block, T. M., Steel, L., Brenner, D. E. & Su, Y. H. Preferential isolation of fragmented DNA enhances the detection of circulating mutated k-ras DNA. Clin. Chem. 50, 211–213 (2004).

    CAS  PubMed  Article  Google Scholar 

  141. Page, K. et al. The importance of careful blood processing in isolation of cell-free DNA. Ann. NY Acad. Sci. 1075, 313–317 (2006).

    CAS  PubMed  Article  Google Scholar 

  142. Guadalajara, H. et al. The concentration of deoxyribonucleic acid in plasma from 73 patients with colorectal cancer and apparent clinical correlations. Cancer Detect. Prev. 32, 39–44 (2008).

    CAS  PubMed  Article  Google Scholar 

  143. Thijssen, M. A., Swinkels, D. W., Ruers, T. J. & de Kok, J. B. Difference between free circulating plasma and serum DNA in patients with colorectal liver metastases. Anticancer Res. 22, 421–425 (2002).

    PubMed  Google Scholar 

  144. Andersen, R. F., Spindler, K. G., Jakobsen, A., Pallisgaard, N. Plasma is superior to serum for cfDNA mutation detection and monitoring [abstract 479]. Eur. J. Cancer 48 (Suppl. 6), 148–149 (2012).

    Article  Google Scholar 

  145. Morgan, S. R. et al. Comparison of KRAS mutation assessment in tumor DNA and circulating free DNA in plasma and serum samples. Clin. Med. Insights Pathol. 5, 15–22 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  146. Müller, I. et al. Identification of loss of heterozygosity on circulating free DNA in peripheral blood of prostate cancer patients: potential and technical improvements. Clin. Chem. 54, 688–696 (2008).

    PubMed  Article  CAS  Google Scholar 

  147. Liu, P. et al. Potential clinical significance of plasma-based KRAS mutation analysis using the COLD-PCR/TaqMan®–MGB probe genotyping method. Exp. Ther. Med. 4, 109–112 (2012).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  148. Chen, Z. et al. Analysis of cancer mutation signatures in blood by a novel ultra-sensitive assay: monitoring of therapy or recurrence in non-metastatic breast cancer. PLoS ONE 4, e7220 (2009).

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  149. Heitzer, E. et al. Tumor associated copy number changes in the circulation of patients with prostate cancer identified through whole-genome sequencing. Genome Med. 5, 30 (2013).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  150. Li, C. N. et al. Cell-free DNA is released from tumor cells upon cell death: a study of tissue cultures of tumor cell lines. J. Clin. Lab. Anal. 17, 103–107 (2003).

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  151. Haas, J., Katus, H. A. & Meder, B. Next-generation sequencing entering the clinical arena. Mol. Cell. Probes 25, 206–211 (2011).

    CAS  PubMed  Article  Google Scholar 

  152. Santarpia, L. et al. Mutation profiling identifies numerous rare drug targets and distinct mutation patterns in different clinical subtypes of breast cancers. Breast Cancer Res. Treat. 134, 333–343 (2012).

    CAS  PubMed  Article  Google Scholar 

  153. Press, M. F. et al. Diagnostic evaluation of HER-2 as a molecular target: an assessment of accuracy and reproducibility of laboratory testing in large, prospective, randomized clinical trials. Clin. Cancer Res. 11, 6598–6607 (2005).

    CAS  PubMed  Article  Google Scholar 

  154. McBride, D. J. et al. Use of cancer-specific genomic rearrangements to quantify disease burden in plasma from patients with solid tumors. Genes Chromosomes Cancer 49, 1062–1069 (2010).

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  155. Tamborini, E. et al. Functional analyses and molecular modeling of two c-Kit mutations responsible for imatinib secondary resistance in GIST patients. Oncogene 25, 6140–6146 (2006).

    CAS  Article  PubMed  Google Scholar 

  156. Choi, Y. L. et al. EML4-ALK mutations in lung cancer that confer resistance to ALK inhibitors. N. Engl. J. Med. 363, 1734–1739 (2010).

    CAS  PubMed  Article  Google Scholar 

  157. Kakimoto, Y., Yamamoto, N. & Shibahara, T. Microsatellite analysis of serum DNA in patients with oral squamous cell carcinoma. Oncol. Rep. 20, 1195–1200 (2008).

    CAS  PubMed  Google Scholar 

Download references

Acknowledgements

We would like to thank Giulia Siravegna and Elisa Scala (IRCC, Institute for Cancer Research at Candiolo, Italy) for their assistance with technical aspects concerning methods of DNA extraction from blood. Work in the authors' laboratories is supported by 'Fondazione Piemontese per la Ricerca sul Cancro—ONLUS grant 'Liquid Biopsy—5 per mille 2010 Sanità'; AIRC 2010 Special Program Molecular Clinical Oncology 5xMille, Project n. 9970 (A. Bardelli); AIRC, grants MFAG 11349 (F. Di Nicolantonio) and IG 12812 (A. Bardelli); 'Fondazione Piemontese per la Ricerca sul Cancro—ONLUS grant 'Farmacogenomica—5 per mille 2009 MIUR'—(F. Di Nicolantonio); the European Community's Seventh Framework Programme under grant agreement n. 259015 COLTHERES; Intramural Grants Fondazione Piemontese per la Ricerca sul Cancro ONLUS (5 per mille 2008 Ministero dell'Istruzione, dell'Università e della Ricerca) to A. Bardelli and F. Di Nicolantonio. E. Crowley is supported by the Marie-Curie Incoming Fellowship.

Author information

Authors and Affiliations

Authors

Contributions

E. Crowley researched the data for the article, and all authors made a substantial contribution to discussion of the content, to writing the article and to reviewing or editing the manuscript before submission.

Corresponding author

Correspondence to Alberto Bardelli.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Crowley, E., Di Nicolantonio, F., Loupakis, F. et al. Liquid biopsy: monitoring cancer-genetics in the blood. Nat Rev Clin Oncol 10, 472–484 (2013). https://doi.org/10.1038/nrclinonc.2013.110

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrclinonc.2013.110

Further reading

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing