Fig. 4

Workflow to improve the detection yield of actionable variants and their implications for cancer patient’s outcome and clinical management. The flow chart suggests the use of an integrated cfDNA, tumor and germline analysis by next-generation sequencing comprehensive panels in order to increase the yield of actionable variants. The suggested workflow is based on our results obtained in 23 patients with diverse and rare tumor types. For this reason, consider confirming these findings on larger cohorts and prospective clinical trials to support this approach. Our recommendation is to perform the concurrent tumor tissue and cfDNA molecular profiling, when possible. Identification of germline actionable variants is possible through a germline-focused analysis of tumor/cfDNA using a robust and sensitive bioinformatic analysis, opening to genetic counselling and secondary germline testing protocols, as well as cascade testing in family members. The figure also addresses the interpretation of discordant data between tumor tissue biopsy versus liquid biopsy and their clinical implications. While actionable variants found only in tumor DNA and both in tumor DNA and cfDNA are candidate for clinical and therapeutically management, we suggest that actionable variants found only in ctDNA need further confirmation with orthogonal sensitive methods and, if confirmed, longitudinal monitoring is indicated, prior to consideration for therapy treatment and implications on patient outcomes