Systematic benchmarking of low-input whole exome sequencing workflows for longitudinal ctDNA profiling in pancreatic ductal adenocarcinoma

Whole exome sequencing (WES) of circulating tumour DNA (ctDNA) enables longitudinal monitoring of tumour dynamics, evolution and treatment response but remains technically challenging in low-input, low-shedding settings such as pancreatic ductal adenocarcinoma (PDAC). Here, we systematically compared three commercially available low-input WES workflows incorporating Agilent (V6, V8) and Qiagen exome capture designs using ultra-low input cfDNAs extracted from multiple matched longitudinal plasma samples from PDAC patients. Using predefined performance metrics including coverage, duplication rate and variant detection and additional metrics relevant for clinical genomic profiling in patient care, we show that all three workflows produced high-quality sequencing data, even from very low input cfDNA. Within the conditions tested here, the Agilent V8 workflow provided the most favourable balance of coverage uniformity, sequencing efficiency and hotspot coverage for low input, low tumour fraction cfDNA WES. These findings demonstrate that workflow design, including capture footprint, substantially influences ctDNA WES performance in low-input clinical contexts. These findings are particularly relevant in early stage and/or minimal residual disease settings, where tumour fractions are low and recovery of genomic information from limited-input samples is critical.