Liquid Biopsy in Gastrointestinal Oncology: Clinical Applications and Translational Integration of ctDNA, CTCs, and sEVs

Rita Palieri¹Maria De Luca¹Francesco Balestra¹Giorgia Panzetta¹Claudio Lotesoriere¹Federica Rizzi²Angela Ricci¹Rita Mastrogiacomo³Maria Lucia Curri³Luigi Laghi⁴Gianluigi Giannelli¹Nicoletta Depalo²Maria Principia Scavo^1*

• ¹National Institute of Gastroenterology S. de Bellis Research Hospital (IRCCS), Bari, Italy
• ²Istituto per i Processi Chimico-Fisici Consiglio Nazionale delle Ricerche Unita Organizzativa di Supporto di Bari, Bari, Italy
• ³Universita degli Studi di Bari Aldo Moro Dipartimento di Chimica, Bari, Italy
• ⁴Universita degli Studi di Parma Dipartimento di Medicina e Chirurgia, Parma, Italy

Abstract. Background & Aims: Liquid biopsy offers a minimally invasive tool to detect actionable mutations, monitor minimal residual disease (MRD), and guide therapy in gastrointestinal (GI) cancers. We critically review the clinical utility of circulating tumor DNA (ctDNA), circulating tumor cells (CTCs), and small extracellular vesicles (sEVs) across GI malignancies and propose a framework for their integration into clinical practice. Methods: We synthesized evidence from over 200 studies, including prospective trials and translational research, to assess diagnostic accuracy, prognostic value, and clinical actionability of each biomarker type in esophageal, gastric, colorectal, pancreatic, hepatocellular, and biliary cancers. Results: ctDNA has shown strong potential for MRD detection and treatment monitoring, particularly in colorectal and pancreatic cancer. CTCs offer insights into metastatic risk and therapeutic resistance, while sEVs provide molecular cargo relevant to immunomodulation and disease progression. Emerging microfluidics and AI-driven multi-omics approaches may overcome current limitations. Conclusions: The integration of liquid biopsy technologies into GI oncology holds promise for early detection and precision therapy. We propose a five-phase clinical roadmap and outine the key research gaps that need to be addressed before widespread implementation in routine care.