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Background  Novel biomarkers and molecular monitoring tools hold potential to improve outcome for patients following resection of pancreatic ductal adenocarcinoma (PDAC). We hypothesized that the combined longitudinal analysis of mutated cell-free plasma  KRAS  (cf KRAS   mu t ) and CA 19–9 during adjuvant treatment and follow-up might more accurately predict disease course than hitherto available parameters.    Methods  Between 07/2015 and 10/2018, we collected 134 plasma samples from 25 patients after R0/R1-resection of PDAC during adjuvant chemotherapy and post-treatment surveillance at our institution. Highly sensitive discriminatory multi-target ddPCR assays were employed to screen plasma samples for cf KRAS   mut  . cf KRAS   mu t  and CA 19–9 dynamics were correlated with recurrence-free survival (RFS) and overall survival (OS). Patients were followed-up until 01/2020.    Results  Out of 25 enrolled patients, 76% had undergone R0 resection and 48% of resected PDACs were pN0. 17/25 (68%) of patients underwent adjuvant chemotherapy. Median follow-up was 22.0 months, with 19 out of 25 (76%) patients relapsing during study period. Median RFS was 10.0 months, median OS was 22.0 months. Out of clinicopathologic variables, only postoperative CA 19–9 levels and administration of adjuvant chemotherapy correlated with survival endpoints. cf KRAS   mu t.  was detected in 12/25 (48%) of patients, and detection of high levels inversely correlated with survival endpoint. Integration of cf KRAS   mut   and CA 19–9 levels outperformed either individual marker. cf KRAS   mut   outperformed CA 19–9 as dynamic marker since increase during adjuvant chemotherapy and follow-up was highly predictive of early relapse and poor OS.    Conclusions  Integrated analysis of cf KRAS   mut   and CA 19–9 levels is a promising approach for molecular monitoring of patients following resection of PDAC. Larger prospective studies are needed to further develop this approach and dissect each marker’s specific potential.    Supplementary Information  The online version contains supplementary material available at 10.1186/s12885-020-07736-x.

Longitudinal analysis of cell-free mutated KRAS and CA 19–9 predicts survival following curative resection of pancreatic cancer