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From concept to clinic: emerging paradigms and novel insights into liquid biopsy
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Wenjie Guo1, Yang Liu2, Haiying Dong3, Xiang Li4, Xu Guo1, Haitao Guo1, Kaixiang Zhou1, Jinliang Xing1
Cancer Biology & Medicine | 2026, 23(2) : 155 - 161
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Cancer Biology & Medicine | 2026, 23(2): 155-161
• Editorial •
From concept to clinic: emerging paradigms and novel insights into liquid biopsy
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Wenjie Guo1, Yang Liu2, Haiying Dong3, Xiang Li4, Xu Guo1, Haitao Guo1, Kaixiang Zhou1, Jinliang Xing1
Affiliations
  • 1State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and Department of Physiology and Pathophysiology, Fourth Military Medical University, Xi’an 710032, China
  • 2State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and Department of Clinical Diagnosis, Tangdu Hospital, Fourth Military Medical University, Xi’an 710038, China
  • 3Institute of Medical Research, Northwestern Polytechnical University, Xi’an 710129, China
  • 4Department of Pharmacy, The Fourth Affiliated Hospital of China Medical University, Shenyang 110032, China
About Author:

Author contributions

Conceived and designed the paper: Jinliang Xing and Kaixiang Zhou.

Collected and synthesized the literature: Wenjie Guo and Yang Liu.

Contributed data or analysis tools: Haiying Dong and Xiang Li.

Wrote the paper: Wenjie Guo and Yang Liu.

Performed the analysis: Xu Guo and Haitao Guo.

Reviewed and revised the paper: Jinliang Xing and Kaixiang Zhou.

Published: 2026-02-15 doi: 10.20892/j.issn.2095-3941.2025.0830
Outline
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Wenjie Guo, Yang Liu, Haiying Dong, Xiang Li, Xu Guo, Haitao Guo, Kaixiang Zhou, Jinliang Xing. From concept to clinic: emerging paradigms and novel insights into liquid biopsy[J]. Cancer Biology & Medicine, 2026 , 23 (2) : 155 -161 . DOI: 10.20892/j.issn.2095-3941.2025.0830
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Liquid biopsy has emerged as a transformative, minimally invasive strategy for disease detection and longitudinal monitoring through the analysis of circulating molecular components, including cell-free DNA (cfDNA), cell-free RNA, extracellular vesicles, and circulating proteins in bodily fluids. Its central objective is to enable a continuum of precision clinical interventions, from early detection and diagnosis to therapeutic guidance and disease surveillance, thereby improving patient outcomes (Figure 1). Holistic integrative medicine is a patient-centered, systems-level framework that integrates prevention, screening, diagnosis, treatment, and rehabilitation into whole-process disease management. Advances in high-throughput sequencing and digital polymerase chain reaction (PCR) have markedly improved the detection of tumor-derived alterations in plasma, urine, and saliva. These technologies have enhanced both sensitivity and specificity in identifying genetic and epigenetic changes. In oncology, circulating tumor DNA (ctDNA) captures the spatial and temporal heterogeneity of tumors and provides a dynamic window into disease evolution, with resolution often surpassing that of single-site tissue biopsies1. Importantly, the scope of liquid biopsy is rapidly expanding beyond cancer to include prenatal testing, infectious diseases, neurodegenerative disorders, and immune-mediated conditions.
Despite these advances, key challenges persist. The low abundance of tumor-derived cfDNA, particularly in early-stage disease, as well as the variability introduced during sample collection, processing, and storage, continue to limit clinical robustness2. However, ongoing innovations in single-molecule sequencing, fragmentomics, and bioinformatics are accelerating the clinical translation of liquid biopsy technologies3. This Editorial highlights emerging paradigms in liquid biopsy research, spanning technological and economic considerations, expanding clinical applications, and integrative insights from immunogenomics and microbiome studies. Notably, we discuss pioneering work on cell-free mitochondrial DNA (cf-mtDNA) fragmentomics, illustrating how exploration beyond nuclear genomes may open new avenues for early cancer detection and precision medicine.
Foundation and clinical motivations
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Liquid biopsy is based on the premise that circulating molecular biomarkers in disease states systematically diverge from those in healthy individuals, and therefore can reflect perturbations in genetic, epigenetic, and regulatory networks. These alterations are both disease-specific and stage-dependent, and they mirror the dynamic molecular evolution that accompanies disease initiation, progression, and therapeutic response. Seminal observations of fetal DNA in maternal circulation provided early evidence that pathological tissues, including tumors and virally infected or degenerating cells, release nucleic acids into the bloodstream, thereby enabling indirect molecular interrogation of otherwise inaccessible sites4. These circulating signals encompass diverse molecular phenotypes, including somatic mutations, chromosomal rearrangements, aberrant methylation patterns, and viral integration events.
The clinical utility of this paradigm is exemplified by non-invasive prenatal testing (NIPT), in which analysis of cell-free fetal DNA has transformed prenatal screening for chromosomal aneuploidies and substantially decreased the need for invasive diagnostic procedures. Similarly, in infectious diseases such as hepatitis B, hepatitis C, and AIDS, circulating viral nucleic acids are routinely used to guide antiviral therapy, assess treatment efficacy, and monitor adherence5. Together, these circulating biomarkers constitute a molecular “fingerprint” providing near-real-time insight into ongoing pathological processes, thus underscoring the central role of liquid biopsy in precision medicine.
In oncology, early detection is a primary clinical goal. The ability to detect trace amounts of ctDNA in asymptomatic or early-stage patients has promise for diagnosing malignancies in curable stages. Beyond diagnosis, longitudinal ctDNA profiling enables real-time monitoring of clonal dynamics, early identification of resistance mechanisms, and informed selection of subsequent therapeutic strategies6. Importantly, liquid biopsy enables repeated sampling with minimal patient burden, thereby overcoming the limitations of serial tissue biopsies, which are often invasive and impractical. Emerging fragmentomic approaches that exploit tumor-specific differences in cfDNA fragment size and genomic breakpoints further enhance analytical sensitivity and biological resolution6.
A central ongoing debate concerns biomarker strategy, i.e., whether to prioritize highly specific, disease-defined markers or broader, pan-disease signatures. Canonical examples such as EGFR mutations in non-small cell lung cancer or BCR-ABL fusions in chronic myeloid leukemia provide precise diagnostic and therapeutic value7. In contrast, pan-cancer approaches, such as assays targeting shared methylation or fragmentomic patterns, might be better suited for population-scale screening when the tissue of origin is unknown8. To successfully integrate these complementary strategies, careful optimization of sensitivity, specificity, and cost-effectiveness will be necessary, thus underscoring the need for rational assay design aligned with clinical intent.
Heterogeneity in disease applications
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Metastatic malignancies, including advanced lung, pancreatic, and breast cancers, comprise diverse subclonal populations with distinct genetic and epigenetic landscapes9. Single-site tissue biopsies, which capture only a limited spatial snapshot, can therefore overlook clinically relevant subclones bearing resistance-associated alterations. In contrast, longitudinal profiling of ctDNA enables systemic and dynamic assessment of tumor evolution, and can reveal adaptive responses to therapeutic pressure in near real time. This comprehensive view supports more informed treatment stratification, facilitates early detection of emerging resistance, and provides a rationale for timely therapeutic switching or combination strategies aimed at delaying disease progression.
Importantly, the utility of liquid biopsy is not confined to conditions with extensive genomic heterogeneity. In disorders with more constrained genetic variability, circulating biomarkers can still yield clinically actionable insights. For example, pre-eclampsia arises from complex maternal-fetal interactions rather than extensive clonal diversification. Nevertheless, placental-derived cfDNA can exhibit early, disease-associated epigenetic signatures or fragmentomic patterns that signal elevated risk, thus enabling earlier clinical intervention10. Similarly, neurodegenerative diseases such as Alzheimer’s disease and Parkinson’s disease lack the overt clonal dynamics typical of cancer, thus complicating biomarker discovery. However, emerging evidence suggests that subtle yet reproducible cfDNA alterations may precede overt clinical manifestations, thereby offering a potential avenue for presymptomatic detection and disease monitoring. These findings exemplify how the adaptability of liquid biopsy supports its transformative potential in neurodegenerative research, by providing novel biomarkers that might reshape diagnostic pathways.
ctDNA vs. total cfDNA: complementary strategies
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Liquid biopsy research in oncology has traditionally centered on ctDNA, with a goal of identifying tumor-specific genetic or epigenetic alterations. This targeted paradigm enables precise detection of clinically actionable mutations, such as EGFR variants in non-small cell lung cancer or ALK/ROS1 rearrangements, thereby directly informing personalized therapeutic decisions11. However, in early-stage disease, ctDNA often constitutes only a minute fraction of total circulating cfDNA and therefore poses substantial analytical challenges. To address this limitation, ultrasensitive platforms, including digital droplet PCR and error-corrected targeted next-generation sequencing, have been developed to enhance detection sensitivity and specificity.
In parallel, an emerging paradigm emphasizes analysis of total cfDNA rather than a focus on only tumor-derived fragments. This holistic approach interrogates global features such as fragmentation profiles, DNA methylation landscapes, and chromatin accessibility patterns across the entire cfDNA pool. By capturing system-wide molecular perturbations, total cfDNA analysis can reveal early disease-associated signals, infer tissue of origin, and reflect broader pathological states, including inflammation or multi-organ involvement. Although this strategy might sacrifice mutation-level specificity, it offers a more integrative view of disease biology. As analytical technologies continue to mature, the key challenge is no longer choosing between ctDNA-focused and global cfDNA approaches, but developing integrative frameworks that harness their complementary strengths to deliver more sensitive, informative, and clinically actionable liquid biopsy assays.
Immunogenomic insights and microbiome profiling
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Beyond tumor- or tissue-derived biomarkers, the immunogenomic information provided by circulating cfDNA provides an additional dimension for understanding disease progression and therapeutic response. Profiling circulating T-cell receptor and B-cell receptor repertoires provides insights into adaptive immune dynamics in cancer, infection, and immune-mediated disorders12. Clonal expansion or contraction of specific lymphocyte populations detectable in plasma has been associated with responses to immunotherapies, including immune checkpoint blockade13. Beyond serving as descriptive immune snapshots, repertoire features can be mechanistically informative. Antigen-driven activation may lead to clonal expansion and diminished diversity, whereas effective therapy can alter these dynamics over time. In contrast, loss of dominant clones may indicate immune escape. In agreement with this possibility, recent data have suggested that circulating T-cell receptor signals can track tumor immune dynamics during checkpoint blockade and complement tumor-derived cfDNA in monitoring treatment response14. Integrating immune repertoire features with tumor-derived cfDNA may therefore enable more precise monitoring of immune activation, exhaustion, and treatment responsiveness, and consequently inform personalized immunotherapeutic strategies.
In parallel, circulating microbial cfDNA has emerged as a complementary and increasingly informative analyte. Disruptions in microbial homeostasis across the gut, oral cavity, or other niches can allow bacterial or viral DNA fragments to enter the bloodstream, thereby reflecting systemic dysbiosis or occult infection. Accumulating evidence suggests that specific microbial signatures influence tumor biology and modulate responses to immunotherapy by shaping the tumor microenvironment and host immune tone15. Consequently, longitudinal profiling of microbial cfDNA may aid in predicting therapeutic efficacy, detecting treatment-related complications, and contextualizing inflammatory states.
Novel frontiers: cf-mtDNA fragmentomics in early tumor screening
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Because of the high copy number of mitochondrial genomes per cell, cf-mtDNA is often detectable at higher baseline levels than nuclear cfDNA, even in early-stage malignancies. Beyond copy number changes, recent studies have demonstrated that cf-mtDNA fragmentomic features, including fragment length distributions, 5′ end motifs, and sequence preferences, can robustly distinguish tumor-associated signals from healthy backgrounds16.
Multicenter studies have shown that cf-mtDNA fragmentomics enables sensitive detection of early-stage colorectal cancer and advanced adenomas, and frequently outperforms conventional DNA methylation-based assays17. Early neoplastic lesions are consistently characterized by features such as relatively short fragment sizes, altered 5′ end base composition, and diminished motif diversity. Importantly, integrating cf-mtDNA fragmentomics with established nuclear cfDNA assays further enhances diagnostic performance, thereby underscoring their complementarity. Similar aberrant cf-mtDNA fragmentation patterns have been observed across multiple solid tumors, including liver, breast, and lung cancers16. Large-scale multi-cancer analyses have indicated that cf-mtDNA fragmentomic signatures not only can discriminate states of cancer vs. health but also can inform tissue-of-origin prediction. In hepatocellular carcinoma, whose early diagnosis remains challenging, cf-mtDNA fragment-level alterations appear early in tumorigenesis and show promise for early detection and disease monitoring18.
Despite its promising performance in early neoplasia detection, cf-mtDNA fragmentomics faces challenges in specificity. Circulating mtDNA can increase in non-malignant conditions such as tissue injury and sterile inflammation, in which it serves as a damage-associated molecular pattern and correlates with inflammatory mediators. Future studies should benchmark cf-mtDNA signatures against common inflammatory and autoimmune conditions, and prioritize large-scale prospective cohorts to assess false-positive risk and refine decision thresholds.
Collectively, these findings position cf-mtDNA fragmentomics as a robust and scalable strategy for pan-cancer early screening. Capture-based sequencing approaches targeting mtDNA offer high coverage at relatively low cost, and support simultaneous assessment of copy number, mutations, and fragmentation patterns. Although mechanistic understanding and large prospective validation remain ongoing challenges, cf-mtDNA fragmentomics is a compelling frontier poised to reshape noninvasive cancer detection paradigms.
From theory and mechanism to translation
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Liquid biopsy research exemplifies the iterative progression from conceptual discovery to mechanistic understanding and ultimately clinical translation. The initial detection of cfDNA in maternal plasma established the foundational concept that pathological tissues can release nucleic acids into circulation4. Subsequent mechanistic studies elucidated active and passive DNA release pathways, including exosomal secretion, apoptosis, and necrosis, thus revealing that fragmentation patterns and molecular endpoints contain biologically meaningful information19. Investigations on virus-associated malignancies, such as Epstein-Barr virus–driven nasopharyngeal carcinoma and hepatitis B virus–associated hepatocellular carcinoma, have further clarified how infectious agents and host immunity shape circulating DNA profiles. More recently, immunogenomic analyses of circulating T- and B-cell receptor repertoires have expanded this framework, by capturing adaptive immune dynamics in response to disease and therapy20. Parallel advances in multi-cancer early detection assays based on ctDNA methylation underscore the feasibility of translating mechanistic insights into scalable clinical applications8.
The current central challenge is integrating these diverse insights, spanning ctDNA, global cfDNA features, microbial cfDNA, and cf-mtDNA, into a unified, patient-centric diagnostic paradigm (Figure 2). Achieving this goal will require standardized pre-analytical workflows, analytically validated assays, comprehensive reference datasets, and computational frameworks capable of synthesizing multi-omic signals into clinically actionable outputs. As illustrated by recent advances in cf-mtDNA fragmentomics, bridging molecular innovation with clinical utility is particularly critical for early cancer detection. Successful translation will depend on rigorous prospective validation, regulatory alignment, and cost-effective implementation, with implications extending beyond oncology to immunological, autoimmune, and transplant-related diseases.
Future perspectives
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As liquid biopsy advances toward broader clinical implementation, the extreme scarcity of tumor-derived DNA within the total cfDNA pool, particularly in early-stage disease, remains a central challenge. This “needle-in-a-haystack” problem is compounded by background cfDNA originating from normal tissue turnover and leukocyte lysis, which can obscure low-frequency tumor signals. Continued progress will therefore require improvements in analytical sensitivity and signal-to-noise discrimination. Technologies such as droplet digital PCR and single-molecule sequencing have substantially advanced rare-variant detection by minimizing amplification bias and background interference. Nevertheless, technical gains alone are insufficient. Pre-analytical variability, including blood collection, processing time, storage conditions, and centrifugation protocols, remains a major source of inconsistency. Therefore, standardized workflows and rigorously enforced quality controls are needed. For example, the choice of blood collection tube (e.g., standard EDTA vs. cfDNA-stabilizing tubes) and delays in plasma processing can increase leukocyte lysis-derived background DNA, thereby altering fragment-size distributions and hindering tumor signal detection21. Similarly, differences in centrifugation protocols (e.g., single-spin vs. double-spin) affect residual debris and genomic DNA contamination, thus highlighting the need for standardized workflows. Community efforts are increasingly promoting harmonized practices and quality assurance guidelines for ctDNA testing22.
Beyond technical considerations, economic feasibility is a critical determinant of large-scale use, particularly for population-level screening in asymptomatic individuals. Although sequencing costs continue to decline, comprehensive multi-analyte assays remain resource-intensive. Future solutions will require a balance between analytical depth and cost efficiency, supported by automation, optimized sequencing strategies with reduced read depth requirements, and artificial intelligence–driven bioinformatics pipelines for rapid interpretation and data integration. For multi-cancer early detection tests, population implementation introduces additional considerations beyond analytical performance. Key issues include the effects of false positives, diagnostic burden, cost-effectiveness, resource use, and integration into clinical pathways. Evidence frameworks emphasize the need for well-designed prospective studies that capture detection metrics, clinical harms, diagnostic trajectories, and health outcomes, to enable informed integration into screening programs.
In the future, the field is expected to combine multiple liquid biopsy dimensions, including ctDNA mutations, global cfDNA fragmentomics, immunogenomic signals, microbial cfDNA, and cf-mtDNA, into unified, clinically actionable frameworks. Such integration promises a more holistic and dynamic view of disease biology from a single blood draw. As validation in large prospective cohorts progresses, and regulatory and economic barriers are addressed, liquid biopsy is likely to become a cornerstone of precision medicine, by enabling earlier detection, real-time monitoring, and increasingly proactive disease management in oncology and beyond.
Funding
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  • This work was supported by the National Natural Science Foundation of China (Grant Nos. 82330073 and 82402731).
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Appendix
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Year 2026 volume 23 Issue 2
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Article Info
doi: 10.20892/j.issn.2095-3941.2025.0830
  • Receive Date：2025-12-25
  • Online Date：2026-11-07
  • Published：2026-02-15
Article Data
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History
  • Received：2025-12-25
  • Accepted：2026-01-21
Funding
This work was supported by the National Natural Science Foundation of China (Grant Nos. 82330073 and 82402731).
Affiliations
    1State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and Department of Physiology and Pathophysiology, Fourth Military Medical University, Xi’an 710032, China
    2State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and Department of Clinical Diagnosis, Tangdu Hospital, Fourth Military Medical University, Xi’an 710038, China
    3Institute of Medical Research, Northwestern Polytechnical University, Xi’an 710129, China
    4Department of Pharmacy, The Fourth Affiliated Hospital of China Medical University, Shenyang 110032, China

Corresponding:

Correspondence to: Kaixiang Zhou and Jinliang Xing, E-mail: and
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表12种不同金属材料的力学参数
科
Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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