Evolution of Neo-RAS-WT in Circulating Tumor DNA from First-Line to Subsequent Therapies in Metastatic Colorectal Cancer

<b>Background/Objectives</b>: In metastatic colorectal cancer (mCRC), liquid biopsy has enabled the identification of "neo-RAS-Wild-Type (WT)", a transient phase characterized by the disappearance of RAS mutations, with significant clinical implications for re-sensitization to EGFR blockade. This study aimed to prospectively track the kinetics of neo-RAS-WT in circulating tumor DNA (ctDNA) among RAS-mutant mCRC patients receiving first-line and subsequent systemic therapies. <b>Methods</b>: A total of 380 serial blood samples from 35 patients were analyzed. Each patient provided a median of 10 ctDNA samples at three-month intervals during first-line and subsequent therapies. The patients were categorized into three groups: neo-RAS-WT, non-shedding, and persistent mutant. <b>Results</b>: During first-line treatment, 68% of patients transitioned to RAS-WT. Of these, 17% were neo-RAS-WT, while the majority were classified as non-shedding. In the second-line setting, the percentage of neo-RAS-WT increased to 34%, which dropped to 8.5% during the third-line setting. The duration of the neo-RAS-WT window was significantly longer in neo-RAS-WT patients compared to non-shedding patients (<i>p</i> = 0.037). Patients who achieved RAS-WT status had improved progression-free survival (PFS) compared to those with persistent mutant, with significant differences observed across all treatment lines: first-line (<i>p</i> = 0.004), second-line (<i>p</i> < 0.0001), and third-line (<i>p</i> = 0.001). Multivariate analysis revealed that the duration of the RAS-WT window correlated with extended first-line PFS (HR: 0.78; 95% CI: 0.69-0.89; <i>p</i> < 0.0001), second-line PFS (HR: 0.66; 95% CI: 0.52-0.84; <i>p</i> = 0.001), and overall survival (OS) (HR: 0.82; 95% CI: 0.72-0.95; <i>p</i> = 0.006). <b>Conclusions</b>: While the neo-RAS-WT window is transient in non-shedding, it is durable in neo-RAS-WT patients, persisting until disease progression. These findings highlight the potential utility of ctDNA testing in refining treatment strategies for RAS-mutant mCR.