Next Article in Journal
An m6A-Driven Prognostic Marker Panel for Renal Cell Carcinoma Based on the First Transcriptome-Wide m6A-seq
Next Article in Special Issue
Current Concepts of Precancerous Lesions of Hepatocellular Carcinoma: Recent Progress in Diagnosis
Previous Article in Journal
A Non-Conventional Review on Multi-Modality-Based Medical Image Fusion
Previous Article in Special Issue
NCR, an Inflammation and Nutrition Related Blood-Based Marker in Colon Cancer Patients: A New Promising Biomarker to Predict Outcome
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Diagnostics
Volume 13
Issue 5
10.3390/diagnostics13050822
diagnostics-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

KRAS Mutational Profiles among Colorectal Cancer Patients in the East Coast of Peninsular Malaysia

by
Hidayati Husainy Hasbullah
1,
Sarina Sulong
1,
Nur Asyilla Che Jalil
2,
Ahmad Aizat Abdul Aziz
1,
Nurfadhlina Musa
1 and
Marahaini Musa
1,*
1
Human Genome Centre, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu 16150, Malaysia
2
Department of Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu 16150, Malaysia
*
Author to whom correspondence should be addressed.
Diagnostics 2023, 13(5), 822; https://doi.org/10.3390/diagnostics13050822
Submission received: 17 January 2023 / Revised: 12 February 2023 / Accepted: 13 February 2023 / Published: 21 February 2023
(This article belongs to the Special Issue Gastrointestinal Cancer: Diagnosis, Prognosis and Therapy Response Prediction)
Browse Figures
Versions Notes

Abstract

:
Background: KRAS is a key driver gene in colorectal carcinogenesis. Despite this, there are still limited data on the mutational status of KRAS amongst colorectal cancer (CRC) patients in Malaysia. In the present study, we aimed to analyze the KRAS mutational profiles on codons 12 and 13 amongst CRC patients in Hospital Universiti Sains Malaysia, Kelantan, located on the East Coast of Peninsular Malaysia. Methods: DNA were extracted from formalin-fixed, paraffin-embedded tissues obtained from 33 CRC patients diagnosed between 2018 and 2019. Amplifications of codons 12 and 13 of KRAS were conducted using conventional polymerase chain reaction (PCR) followed by Sanger sequencing. Results: Mutations were identified in 36.4% (12/33) of patients, with G12D (50%) being the most frequent single-point mutation observed, followed by G12V (25%), G13D (16.7%), and G12S (8.3%). No correlation was found between mutant KRAS and location of the tumor, staging, and initial carcinoembryonic antigen (CEA) level. Conclusion: Current analyses revealed that a significant proportion of CRC patients in the East Coast of Peninsular Malaysia have KRAS mutations, where this frequency is higher compared to those in the West Coast. The findings of this study would serve as a precursor for further research that explores KRAS mutational status and the profiling of other candidate genes among Malaysian CRC patients.

1. Introduction

Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide and it is one of the leading causes of cancer death, second only to lung cancer [1]. By 2030, CRC cases are predicted to increase by 60% to more than 2.2 million new cases and 1.1 million deaths [2]. In Malaysia, CRC is the most common cancer diagnosed in males and second in females according to the Malaysia National Cancer Registry 2012–2016 [3]. The majority of CRC cases are diagnosed at the advanced stage of malignancy. This contributes to the high morbidity and mortality due to this disease.
The global burden of CRC necessitates the development of a novel biomarker that aims to improve the detection, management, and/or treatment outcome of patients diagnosed with this cancer. One such marker is KRAS proto-oncogene, GTPase. Recent studies have shown that KRAS mutational status is a robust negative predictive marker for response to anti-epidermal growth factor receptor (EGFR) monoclonal antibodies, namely cetuximab and panitumumab. These EGFR-directed therapies are now routinely used as first-line and subsequent-line therapy for metastatic CRC in combination with standard chemotherapy.
Here, KRAS, known as Kirsten rat sarcoma viral oncogene homolog, is a member of the RAS type GTPase family of genes. The gene encodes KRAS protein, a small GTPase transductor protein, located downstream from EGFR in the RAS/RAF/MEK/ERK pathway. This pathway is one of the most important mitogen-activated protein kinase (MAPK) signaling pathways involved in cell proliferation and differentiation [4]. Mutations in KRAS result in EGFR-independent activation of the MAPK pathway by reducing the GTPase activity. This will lead to uncontrolled cell proliferation, potentially occurring in the early stages of colorectal carcinogenesis, as postulated in the chromosomal instability (CIN) pathway [5]. The CIN pathway is the most important pathway for the development of CRC, representing up to 80% of sporadic CRC cases. Mutation in KRAS is proposed to drive the progression of a small adenoma to a large adenoma before further genetic alterations result in the development of carcinoma and its progression.
To date, more than 90% of the activating KRAS mutations identified in CRC occurred at codons 12 and 13 in exon 2 of the gene. Single base substitution of glycine to aspartate (G12D) and glycine to valine (G12V) on codon 12 are the most common mutations observed [6,7]. Although mutations at exons 3 and 4 have also been recorded, these accounted for only about 1–4% of KRAS mutations [6,8,9].
The KRAS mutational rates among CRC patients vary according to the population studied, ranging from 30 to 52% [10,11,12]. The explanation for the differences in the prevalence of KRAS mutations among CRC patients across the globe is uncertain. In Malaysia, the prevalence is lower (approximately 20%), as previously reported [13,14,15]. Despite this, KRAS remained as one of the most common genes mutated in CRC patients in Malaysia [16]. These previous studies, however, were limited to CRC patients who underwent surgical treatment in Kuala Lumpur and Selangor. The population demographic of these two states on the West Coast of Peninsular Malaysia is strikingly different from those on the East Coast. Kuala Lumpur, for instance. has a population comprised of approximately 40% Malays, 40% Chinese, and 10% Indians. In contrast, more than 90% of Kelantanese are Malays, while Chinese and Indians encompass less than 5% of the population, respectively [17]. Another state in the East Coast of Peninsular Malaysia, Terengganu, also has a similar demographic and ethnic group distribution. Murad et al. (2012) [13] reported that KRAS mutations were found more commonly in Chinese patients than in other ethnicities, and this may be due to differences in the genetic susceptibility toward CRC.
Cases of CRC continue to rise in Kelantan, with an increment of 16% of new cases reported from 2012–2016 in comparison to previous data from 2007–2011 [3]. Recent data from the Endoscopy Unit and Pathology Department showed that around 6% of patients who underwent colonoscopy from January to August 2020 were subsequently diagnosed with CRC or colonic adenoma (unpublished data) at Hospital Universiti Sains Malaysia (USM), which is one of the main public hospitals in Peninsular Malaysia.
To the best of our knowledge, no published local study has yet explored the KRAS mutational status among CRC patients from the East Coast of Peninsular Malaysia. Knowing the mutational status of this important gene in CRC among patients in this region is central to developing background data on the pattern of gene mutations involved in Malaysian CRC patients. In this era where precision medicine and targeted therapy is the current treatment goal for cancer, the findings of this study may also provide clinicians and pathologists with the necessary input in the development of relevant genetic testing as part of a diagnostic workup for CRC patients in this region in the near future.

2. Materials and Methods

Ethical clearance was obtained from the Human Research Ethics Committee of USM (USM/JEPeM/21030249) before the commencement of this study.

2.1. Participants

A total of 33 formalin-fixed-paraffin-embedded (FFPE) tissue samples were obtained. These specimens were collected from CRC patients who underwent colon and/or rectal resection surgery with confirmed histopathology diagnosis of CRC in Hospital USM from January 2018 to December 2019. Detailed information regarding the clinicopathological and demographic data of each patient including age, gender, ethnicity, histological differentiation, location of the primary tumor, nodal status, distant metastasis, treatment received, and American Joint Committee on Cancer (AJCC) stage were collected from the medical records and laboratory information system (LIS) of the Hospital USM. Exclusion criteria were (1) a family history of hereditary colorectal carcinoma, (2) multiple primary malignancies, (3) previous treatment with anti-EGFR monoclonal antibodies, (3) histology showing conditions other than adenocarcinoma, and (4) secondary cancer which metastasized to the colon. Images of hematoxylin and eosin (H&E)-stained slides of selected cases were acquired from the Department of Pathology, USM, and reviewed by the pathologist.

2.2. DNA Extraction from CRC FFPE Tissues

Genomic DNA was extracted using a commercial QIAamp® DNA FFPE Advanced Kit (Qiagen, Hilden, Germany), according to manufacturer’s instructions. Quantification of the extracted DNA was performed using Infinite® M200 NanoQuant (Tecan Group Ltd., Mannedorf, Switzerland).

2.3. Detection of Mutations in Codons 12 and 13 of KRAS

For amplification of codons 12 and 13 of KRAS, polymerase chain reaction (PCR) was performed on all extracted DNA samples using Agilent SureCycler 8800 Thermal Cycler (Agilent Technologies, Inc., Santa Clara, CA, USA). The primer sequences (5′–3′) were adopted from previous study [14]. The forward primer sequence used was ACCTTATGTGTGCATGTTC while the reverse primer sequence used was CTATTGTTGGATCATATTCG. Cycling conditions were as follows: a pre-denaturing incubation at 95 °C for 2 min, 35 cycles of 95 °C for 30 s, annealing temperature of 50 °C for 30 s, and 72 °C for 30 s followed by a final extension at 72 °C for 5 min. Each PCR reaction contained 100 ng genomic DNA, 2.5 mM MgCl2, 0.20 mM of each deoxynucleotide triphosphate (dNTP), 0.2 µM of each primer, and 1U of Taq DNA polymerase, in a final reaction volume of 20 µL. The PCR product quality was confirmed by gel electrophoresis using 2% agarose gel, run at 90 volts for 45 min. A distinct band at 175 bp was produced for each PCR product, corresponding to the primers used (Figure 1). Purification of the PCR product and DNA sequencing were performed by a commercial company (Apical Scientific Sdn. Bhd., Selangor). The DNA chromatograms and sequences were examined using the BioEdit® v7.2.3 Sequence Alignment Editor (Informer Technologies, Inc., Los Angeles, CA, USA) and the BLAST sequence analysis tool, respectively. Tumors with KRAS mutations were classified as mutant KRAS, while those without KRAS mutations were classified as wild-type KRAS.

2.4. Statistical Analysis

Results were presented as frequency (n) and percentage (%) for categorical variables. Comparison between groups was made using the chi-squared test or Fisher’s exact test. Statistical analysis was performed using IBM SPSS Statistics V27.0 (IBM Corp., Armonk, NY, USA) software. Statistical significance was set at a p-value of 0.05 or less.

3. Results

3.1. Patient Clinical Characteristics

The clinical characteristics of the participants are summarized in Table 1, according to KRAS mutation status.
The samples were collected from 18 (54.5%) female and 15 (45.5%) male CRC patients. The median age of the participants was 62 years (range 29–84). A total of 84.8% (n = 28) of the patients were of Malay ethnicity while the remaining 15.2% (n = 5) were Chinese. No patients from Indian or other ethnicities were documented in this study. Majority of recruited patients have primary tumors located on the left side of the colon (n = 25, 75.8%) whereas only 3 (9.1%) cases had right-sided CRC and 5 (15.2%) patients had rectal tumors. Pathological staging analysis of the tissues showed that nearly 70% (n = 23) of the samples were classified at either stage III or IV of the malignancy. Most of the CRC samples were moderately differentiated adenocarcinoma (n = 27, 82%) while one sample was noted to be a mucinous adenocarcinoma subtype. Figure 2 shows representatives of the H&E-stained slides from selected patients. The median initial serum CEA was 20.4 ng/mL (range 1.9–914.8). A positive CEA level, defined as a value of >5 ng/mL was observed at initial diagnosis in 24 (72.7%) of the participants.

3.2. Mutation Characteristic of KRAS

Among the 33 tumor samples tested, 12 (36.4%) had KRAS mutations at the respective codons: 83.3% (10/12) were single-point mutations at codon 12, while 16.7% (2/12) mutations were observed at codon 13. The most common point mutation detected was G12D (6/12, 50%), followed by G12V (3/12, 25%), G13D (2/12, 16.7%), and G12S (1/12, 8.3%) (Table 2). Figure 3 represents the DNA sequencing analysis of codons 12 and 13 of the KRAS gene in selected cases.

3.3. Relationship between Clinicopathological Features of CRC and KRAS Mutations

As shown in Table 1, KRAS mutations were not associated with gender, age, and ethnicity of the CRC patients studied (p = 0.469; p = 0.392; p = 0.630, respectively). No correlation was found between mutant KRAS and the location of the tumor, staging, and initial CEA level (p = 0.420; p = >0.950; p = >0.950, p = 0.429, respectively).
Table 3 shows that liver (9/13, 69%) and lung (8/13, 62%) are the two most common sites of distant metastases in all stage IV CRC cases, while 38% (5/13) had both liver and lung involvement. All advanced CRC KRAS-mutant patients had lung metastases (5/5, 100%) while only half of stage IV wild-type KRAS patients (4/8, 50%) had lung involvement. The clinicopathological features of patients with mutant KRAS are summarized in Table 4.

4. Discussion

Various strategies can be employed for the detection of mutations in KRAS including Sanger sequencing, pyrosequencing, and ARMS/Scorpion real-time PCR. We use Sanger sequencing as it is an established method for mutation analysis and also due to the limited availability of equipment and expertise in our laboratory. Although the overall sensitivity of direct sequencing is modest in comparison to more recent techniques, the rate of detection of KRAS mutations has been shown to be increased in specimens with advanced CRC [18].
Using direct sequencing, we identified that a significant proportion of CRC patients (12/33, 36.4%) had mutations in codon 12 or 13 of KRAS. This finding is consistent with various published reports [8,9,19]. Interestingly, our data indicated that CRC patients in the East Coast of Malaysia had a higher KRAS mutation rate compared to those from the West Coast (36.4% vs. 22%) [13,14,15]. Murad et al. (2012) [13] suggested that KRAS mutations were seen more commonly in the Chinese population compared to in Malays. However, in the present study, Malay patients constituted the majority of the participants (84.8%) and there was no significant association between ethnicity and KRAS mutational status (p = 0.630). Current finding suggested that more than race, other aspects, such as environment, diet, or lifestyle factors, may play a significant and prominent role in the acquirement of KRAS mutations in CRC. These observations are in agreement with reports by Cefalì et al. (2021) [20], who noted that KRAS mutations were observed more frequently in African Americans compared to in Africans living in their native country (37% vs. 21%). In addition, a study conducted in Mexico demonstrated that the KRAS mutation rate varies from 40% in the North Pacific region to 59% in the central Mexican region [20,21]. Both studies attributed the discrepancy in KRAS mutation rates to different dietary cultures between the studied groups. Residents in the North Pacific region of Mexico, for instance, consumed a diet less heavy in meat compared to those in the central Mexican region.
In the Malaysian population, it was established that smoking, red meat intake, and a high fat, high energy, and low fiber diet have a significant association with the risk of CRC [22,23]. However, the environment, dietary patterns, and lifestyles of Malaysian citizens vary according to geographical location. The Malaysian National Health and Morbidity Survey 2019 [24] reported that the prevalence of adult obesity and inadequate intake of vegetables was higher in Kelantan state compared to in Kuala Lumpur and Selangor states. None of the literature explicitly explores red meat consumption and other CRC high-risk foods or nutrient intakes (i.e., heme iron and fat) among residents in different regions of Malaysia. In one study, high levels of vegetable intake were associated with a reduced risk of KRAS mutations [25]. The protective effect of vegetables against KRAS mutation is believed to be due to the richness of fiber and bioactive compounds that act to prevent the formation of nitroso compounds in the intestine. Nitroso compound is known to induce guanine base alkylation, which can lead to G to A base substitution in KRAS if not repaired [26]. However, a systematic review exploring the associations between nutritional factors and KRAS mutations showed highly conflicting and inconsistent results [26]. Further research, preferably a prospective study design using a bigger sample population exploring these factors and twin studies, is necessary to support our observation.
The spectrum of KRAS mutations in the present study is also in accordance with published data. The most common KRAS mutation occurred at codon 12 (83.3%) with G12D (50%) and G12V (25%) being the two most frequent single-point mutations observed, followed by G13D (16.7%). Various studies are being conducted exploring the true prognostic role of a specific codon mutations in CRC but, to date, no consensus has been obtained [11,27,28].
Recently, G12C mutation gained considerable interest after the FDA approved the use of sotorasib, a KRAS-G12C protein inhibitor, in metastatic non-small cell lung carcinoma (NSCLC) with G12C mutation. In CRC, the benefit of sotorasib is still under evaluation, but has shown considerable potential [29]. The G12C mutation is seen in approximately 2–4% of CRC patients, but was lacking in the present study cohort, possibly due to small sample size.
Our results showed that there is no significant association between KRAS mutational status and location of the primary tumor. This finding is in agreement with multicentered RASCAL I and RASCAL II collaborative studies and various published reports [10,30,31]. However, recent studies by Xie et al. (2019) [32], which include meta-analysis of the previous literature, demonstrated that right-sided CRC has a significantly higher rate of mutated KRAS. The correlation between tumor sidedness and KRAS mutations is highly controversial. The inconsistent findings across different studies in the literature may be partly due to a lack of uniformity in the definition of the right-sided and left-sided colon. Some studies categorized rectum under the left-sided CRC [12,33]. Similarly, tumors located at the transverse colon may be categorized separately or included under right-sided CRC. We separated the rectum from left-sided CRC, as the rectum represents a separate anatomical and topographical entity with a different risk for carcinogenesis compared to colonic mucosa [34].
It is widely accepted that right-sided and left-sided colon cancer has a distinct molecular carcinogenesis. This distinctive genetic makeup may be attributed to differences in embryonic origin, microbial load, and some discrete physiological functions of the right and left colon [35]. Right-sided colon cancer commonly exhibits the microsatellite instability-high (MSI-H) tumor subtype, while left-sided colon cancer is characterized by mutations in the CIN-related pathway [36,37]. Sporadic MSI-H tumors develop due to defects in the mismatch repair (MMR) genes, for example hyper-methylation of MSH1, or mutations in other MMR genes, such as MSH6, MSH2, and MLH3. On the other hand, CIN tumors are characterized by various copy number variants (CNV) in the tumor tissue, caused by aneuploidy, insertions, deletions, amplifications, and loss of heterozygosity (LOH). The genes commonly involved in CIN carcinogenesis include APC, KRAS, and TP53. Although in a theory proposed by Fearon and Vogelstein in 1990, the adenomas progress to carcinomas in a sequential of events involving loss or mutation of APC, mutation of KRAS, and mutation of TP53, recent studies have shown that only 6.6% of CRC cases have mutations involving all these three driver genes [38]. Taken together, our findings suggest that KRAS mutation is not indicative of CRC tumor location, despite being proposed as part of the CIN carcinogenesis pathway.
We included all stages of CRC in our study, with stage I and II cases categorized together to represent early-stage CRC. We noted that around 70% of cases were at the advanced stage of the malignancy at diagnosis, in accordance with national data [3]. The high proportion of CRC patients with advanced diseases corresponds to the low uptake of CRC screening among the general Malaysian population. A huge study exploring the uptake for CRC screening in various Asian countries revealed that only 1.2% Malaysian respondents went for CRC screening, in contrast to Singapore (20.3%), Thailand (18.8%), and Brunei (8.8%) [39]. In the Malaysian National Strategic Plan for Colorectal Cancer (2021–2025) [40], the Health Ministry aim to improve the screening rate of the target age group by increasing the screening coverage from 10.8% to 40.0%, and to subsequently decrease the CRC cases by 25% by the year 2030.
In addition to that, we discovered that there were no significant differences in the distribution of KRAS mutations across all stages. Our finding is consistent with various published reports [8,10]. This may suggest that KRAS is not involved in the progression of CRC and that other driver genes are responsible for the development of advanced CRC. Yuen et al. (2002) [41] showed that the KRAS mutation rates were similar in both sporadic colorectal adenoma and carcinoma, supporting the role of KRAS in early CRC tumorigenesis. On another spectrum, various reports have also shown that there is no preponderance for certain types of KRAS mutations during the metastatic process of CRC, indicating that KRAS is not crucial in the acquirement of metastatic ability [42]. Furthermore, the concordance rate of KRAS mutation status between the primary CRC tumor and its corresponding metastases is high, supporting the notion that these mutations are acquired before the dissemination of the tumor cells to distant organs [43].
We noted that amongst the 13 patients with metastatic CRC (mCRC), 38.5% of cases had KRAS mutations, corresponding to published data. Interestingly, in this present study cohort, all advanced CRC patients with mutated KRAS had lung metastases, while only half of wild-type KRAS patients had lung involvement. Various studies had demonstrated that the lung is the most common site of distant metastases in KRAS-mutated CRC, compared to other solid organs, such as the liver and brain [9,43]. However, the explanation for this observation remains unclear.
Our data also revealed that there is no correlation between mutant KRAS and initial CEA level (p = 0.429), although the majority of our mutant KRAS patients presented with positive CEA at diagnosis. Wojciechowicz et al. (2000) [44] demonstrated that KRAS mutant cells expressed significant CEA levels in their colorectal cell culture studies. However, clinical research exploring their associations showed conflicting results. A study by Selcukbirik et al. (2003) [45] suggested a significant correlation between KRAS mutations and high initial CEA level, while Zhao et al. (2021) [46] claimed no differences in CEA levels between wild-type and mutant KRAS in CRC. The laboratory test for CEA is simple, inexpensive, and typically uses an established automated assay. Various studies explored its association with KRAS mutations to determine if CEA levels are predictive for a KRAS-mutant tumors, but most studies are against its predictive role.
Our present study focuses only on KRAS mutational status and does not include other biomarkers that also predict lack of response to anti-EGFR therapy, such as NRAS and BRAF. Follow-up studies exploring the presence of mutations within these genes—especially among the wild-type KRAS patients—are desirable.
It is worth mentioning that our results need to be interpreted with caution, as the present study is susceptible to potential biases due to its small sample size. This is a major limitation of the current study and is due to the limited resources and time available. Further studies with participation from more patients across different health institutions within the East Coast of Peninsular Malaysia are suggested to increase the robustness of this current finding. Future analyses of NRAS and BRAF would also benefit from increased sample sizes, as mutations within these genes are present at a low frequency among CRC patients. Our study did not explore KRAS mutations at other codons, for example codon 61 or 146. Although codons 12 and 13 represent the majority of the known, associated KRAS mutations in the CRC, there is a possibility that our data may underestimate the true KRAS mutational rate in the study cohort. Despite these limitations, we believe that present study has provided the necessary background information regarding the KRAS mutational profiles among the local CRC patients in this region.

5. Conclusions

In conclusion, a significant proportion of CRC patients from the East Coast of Peninsular Malaysia have KRAS mutations. To the best of our knowledge, the present study is the first to demonstrate that the frequency of KRAS mutations among CRC patients is higher in our region compared to those in the West Coast of Peninsular Malaysia, as reported in the previous literature. Further study is warranted to explore the underlying factors that influence the difference in KRAS mutational rates between these two regions. The correlation between KRAS mutation status and clinicopathological features of CRC remains inconclusive despite extensive research to elucidate their associations. We reported that KRAS mutations are not associated with ethnicity, location and stage of the tumor, and initial CEA level. Clinically, KRAS is most useful as a predictive marker for response to anti-EGFR monoclonal antibodies, although it is anticipated to gain more significance in the future following the discovery of a KRAS-G12C protein inhibitor. The findings of this study would serve as a preliminary data for further research that explores KRAS mutational status and other candidate genes in the development and progression of CRC in a bigger sample and unique population of Malaysia.

Author Contributions

Conceptualization, M.M., S.S. and H.H.H.; methodology, A.A.A.A. and M.M.; validation, A.A.A.A. and N.M.; formal analysis, A.A.A.A. and H.H.H.; investigation, H.H.H.; resources, A.A.A.A., N.M. and N.A.C.J.; data curation, H.H.H.; writing—original draft preparation, H.H.H.; writing—review and editing, M.M., S.S. and N.A.C.J.; visualization, M.M., S.S., N.A.C.J. and H.H.H.; supervision, M.M.; project administration, H.H.H.; funding acquisition, M.M. All authors have read and agreed to the published version of the manuscript.

Funding

This study was supported by the PPSP Incentive Postgraduate Studies Development Fund, School of Medical Sciences, USM (grant no. 1001/PPSP/8070011).

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and was approved by the Human Research Ethics Committee of USM (USM/JEPeM/21030249, 6 July 2021).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Data obtained and analyzed during the study are available from the corresponding author upon request. The data are not publicly available as they contained information that may compromise the privacy of the participants.

Acknowledgments

The authors wish to thank all the staff of the Molecular Genetics Laboratory, Human Genome Centre in USM for their excellent technical assistance.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Sung, H.; Ferlay, J.; Siegel, R.L.; Laversanne, M.; Soerjomataram, I.; Jemal, A.; Bray, F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J. Clin. 2021, 71, 209–249. [Google Scholar] [CrossRef] [PubMed]
  2. Arnold, M.; Sierra, M.S.; Laversanne, M.; Soerjomataram, I.; Jemal, A.; Bray, F. Global patterns and trends in colorectal cancer incidence and mortality. Gut 2017, 66, 683–691. [Google Scholar] [CrossRef] [Green Version]
  3. Azizah, A.; Hashimah, B.; Nirmal, K.; Siti Zubaidah, A.; Puteri, N.; Nabihah, A.; Sukumaran, R.; Balqis, B.; Nadia, S.; Sharifah, S.; et al. Malaysia National Cancer Registry Report (MNCR); National Cancer Institute, Ministry of Health: Putrajaya, Malaysia, 2019. [Google Scholar]
  4. Tumors, K.; Drosten, M.; Barbacid, M. Review Targeting the MAPK Pathway. Cancer Cell 2020, 37, 543–550. [Google Scholar]
  5. Fang, J.Y.; Richardson, B.C. The MAPK signalling pathways and colorectal cancer. Lancet Oncol. 2005, 6, 322–327. [Google Scholar] [CrossRef] [PubMed]
  6. Neumann, J.; Zeindl-eberhart, E.; Kirchner, T.; Jung, A. Pathology—Research and Practice Frequency and type of KRAS mutations in routine diagnostic analysis of metastatic colorectal cancer. Pathol. Res. Pract. 2009, 205, 858–862. [Google Scholar] [CrossRef] [PubMed]
  7. Sullivan, K.M.; Kozuch, P.S. Impact of KRAS Mutations on Management of Colorectal Carcinoma. Pathol. Res. Int. 2011, 2011, 219309. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  8. Brink, M.; De Goeij, A.F.; Weijenberg, M.P.; Roemen, G.M.; Lentjes, M.H.; Pachen, M.M.; Smits, K.M.; De Bruïne, A.P.; Goldbohm, R.A.; van den Brandt, P. K-ras oncogene mutations in sporadic colorectal cancer in The Netherlands Cohort Study. Carcinogenesis 2003, 24, 703–710. [Google Scholar] [CrossRef] [Green Version]
  9. Meng, M.; Zhong, K.; Jiang, T.; Liu, Z.; Yee, H. Biomedicine & Pharmacotherapy The current understanding on the impact of KRAS on colorectal cancer. Biomed. Pharm. 2021, 140, 111717. [Google Scholar]
  10. Andreyev, H.J.; Norman, A.R.; Cunningham, D.; Oates, J.; Dix, B.R.; Iacopetta, B.J.; Young, J.; Walsh, T.; Ward, R.; Hawkins, N.; et al. Kirsten ras mutations in patients with colorectal cancer: The ‘RASCAL II’ study. Br. J. Cancer 2001, 85, 962–969. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  11. Hayama, T.; Hashiguchi, Y.; Okamoto, K.; Okada, Y.; Ono, K.; Shimada, R.; Ozawa, T.; Toyoda, T.; Tsuchiya, T.; Iinuma, H.; et al. G12V and G12C mutations in the gene KRAS are associated with a poorer prognosis in primary colorectal cancer. Int. J. Color. Dis. 2019, 34, 1491–1496. [Google Scholar] [CrossRef]
  12. Scott, A.; Goffredo, P.; Ginader, T.; Hrabe, J.; Gribovskaja-Rupp, I.; Kapadia, M.R.; Weigel, R.J.; Hassan, I. The Impact of KRAS Mutation on the Presentation and Prognosis of Non-Metastatic Colon Cancer: An Analysis from the National Cancer Database. J. Gastrointest. Surg. 2020, 24, 1402–1410. [Google Scholar] [CrossRef] [PubMed]
  13. Abdul Murad, N.A.; Othman, Z.; Khalid, M.; Abdul Razak, Z.; Hussain, R.; Nadesan, S.; Sagap, I.; Mohamed Rose, I.; Wan Ngah, W.Z.; Jamal, R. Missense Mutations in MLH1, MSH2, KRAS, and APC Genes in Colorectal Cancer Patients in Malaysia. Dig. Dis. Sci. 2012, 57, 2863–2872. [Google Scholar] [CrossRef] [PubMed]
  14. Yip, W.K.; Choo, C.W.; Leong, V.C.-S.; Leong, P.P.; Jabar, M.F.; Seow, H.F. Molecular alterations of Ras-Raf-mitogen-activated protein kinase and phosphatidylinositol 3-kinase-Akt signaling pathways in colorectal cancers from a tertiary hospital at Kuala Lumpur, Malaysia. APMIS 2013, 121, 954–966. [Google Scholar] [CrossRef] [PubMed]
  15. Othman, Z. Predominance of G to A codon 12 mutation K-ras gene in Dukes ’ B colorectal cancer. Singap. Med. J. 2012, 53, 26–31. [Google Scholar]
  16. Lee, C.B.; Kien, Y.W.; Dusa, N.; Mohtarrudin, N.; Fong, S.H. Identifying common mutations in colorectal cancer using a 7-gene panel by next generation sequencing. Malays. J. Med. Health Sci. 2019, 15, 95–102. [Google Scholar]
  17. Malaysia, D. Current Population Estimates, Malaysia. 2022. Available online: https://www.dosm.gov.my/v1/index.php?r=column/pdfPrev&id=dTZXanV6UUdyUEQ0SHNWOVhpSXNMUT09 (accessed on 5 October 2022).
  18. Malapelle, U.; Bellevicine, C.; Salatiello, M.; de Luca, C.; Rispo, E.; Riccio, P.; Sparano, L.; De Stefano, A.; Carlomagno, C.; Maiello, F.M.; et al. Sanger sequencing in routine KRAS testing: A review of 1720 cases from a pathologist’s perspective. J. Clin. Pathol. 2012, 65, 940–944. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  19. Korphaisarn, K.; Pongpaibul, A.; Roothumnong, E.; Pongsuktavorn, K.; Thamlikitkul, L.; Anekpuritanang, T.; Poungvarin, N.; Thongnoppakhun, W.; Pithukpakorn, M. High frequency of KRAS codon 146 and FBXW7 mutations in Thai patients with stage II-III colon cancer. Asian Pacific. J. Cancer Prev. 2019, 20, 2319. [Google Scholar] [CrossRef] [Green Version]
  20. Cefalì, M.; Epistolio, S.; Palmarocchi, M.C.; Frattini, M.; De Dosso, S. Research progress on KRAS mutations in colorectal cancer. J. Cancer Metastasis Treat. 2021, 7, 26. [Google Scholar] [CrossRef]
  21. Sanchez-Ibarra, H.E.; Jiang, X.; Gallegos-Gonzalez, E.Y.; Cavazos-González, A.C.; Chen, Y.; Morcos, F.; Barrera-Saldaña, H.A. KRAS, NRAS, and BRAF mutation prevalence, clinicopathological association, and their application in a predictive model in Mexican patients with metastatic colorectal cancer: A retrospective cohort study. PLoS ONE 2020, 15, e0235490. [Google Scholar] [CrossRef]
  22. Ghee, L.K. A review of colorectal cancer research in Malaysia. Med. J. Malays. 2014, 69, 23–32. [Google Scholar]
  23. Sharif, R.; Mohammad, N.M.A.; Xin, Y.J.; Hamid, N.H.A.; Shahar, S.; Ali, R.A.R. Dietary Risk Factors and Odds of Colorectal Adenoma in Malaysia: A Case Control Study. Nutr. Cancer 2022, 74, 2757–2768. [Google Scholar] [CrossRef] [PubMed]
  24. Institute for Public Health, National Institute of Health & Malaysia, Ministry of Health Malaysia. National Health and Morbidity Survey (NHMS) 2019: Vol. I: NCDs—Non-Communicable Diseases: Risk Factors and other Health Problems; Institute for Public Health, National Institutes of Health, Ministry of Health Malaysia: Selangor, Malaysia, 2020. Available online: https://iku.gov.my/images/IKU/Document/REPORT/NHMS2019/Report_NHMS2019-HCD-eBook_p.pdf (accessed on 26 September 2022).
  25. Slattery, M.L.; Wolff, R.K.; Herrick, J.S. Diet, physical activity, and body size associations with rectal tumor mutations and epigenetic changes. Cancer Causes Control. 2010, 21, 1237–1245. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  26. El Asri, A.; Zarrouq, B.; El Kinany, K.; Bouguenouch, L.; Ouldim, K.; El Rhazi, K. Associations between nutritional factors and KRAS mutations in colorectal cancer: A systematic review. BMC Cancer 2020, 20, 1–21. [Google Scholar] [CrossRef] [PubMed]
  27. Li, W.; Liu, Y.; Cai, S.; Yang, C.; Lin, Z.; Zhou, L.; Liu, L.; Cheng, X.; Zeng, W. Not all mutations of KRAS predict poor prognosis in patients with colorectal cancer. Int. J. Clin. Exp. Pathol. 2019, 12, 957. [Google Scholar]
  28. Osterlund, E.; Ristimäki, A.; Kytölä, S.; Kuopio, T.; Heervä, E.; Muhonen, T.; Halonen, P.; Kallio, R.; Soveri, L.-M.; Sundström, J.; et al. KRAS-G12C Mutation in One Real-Life and Three Population-Based Nordic Cohorts of Metastatic Colorectal Cancer. Front. Oncol. 2022, 12, 274. [Google Scholar] [CrossRef]
  29. Fakih, M.G.; Kopetz, S.; Kuboki, Y.; Kim, T.W.; Munster, P.N.; Krauss, J.C.; Falchook, G.S.; Han, S.W.; Heinemann, V.; Muro, K.; et al. Sotorasib for previously treated colorectal cancers with KRAS G12C mutation (CodeBreaK100): A prespecified analysis of a single-arm, phase 2 trial. Lancet Oncol. 2022, 23, 115–124. [Google Scholar] [CrossRef]
  30. Zlobec, I.; Bihl, M.P.; Schwarb, H.; Terracciano, L.; Lugli, A. Clinicopathological and protein characterization of BRAF- and K-RAS-mutated colorectal cancer and implications for prognosis. Int. J. Cancer 2010, 127, 367–380. [Google Scholar]
  31. Zihui Yong, Z.; Ching, G.T.H.; Ching, M.T.C. Metastatic Profile of Colorectal Cancer: Interplay Between Primary Tumor Location and KRAS Status. J. Surg. Res. 2020, 246, 325–334. [Google Scholar] [CrossRef]
  32. Xie, M.Z.; Li, J.L.; Cai, Z.M.; Li, K.Z.; Hu, B.L. Impact of primary colorectal Cancer location on the KRAS status and its prognostic value. BMC Gastroenterol. 2019, 19, 46. [Google Scholar] [CrossRef]
  33. Bylsma, L.C.; Gillezeau, C.; Garawin, T.A.; Kelsh, M.A.; Fryzek, J.P.; Sangaré, L.; Lowe, K.A. Prevalence of RAS and BRAF mutations in metastatic colorectal cancer patients by tumor sidedness: A systematic review and meta-analysis. Cancer Med. 2020, 9, 1044–1057. [Google Scholar] [CrossRef] [Green Version]
  34. Paschke, S.; Jafarov, S.; Staib, L.; Kreuser, E.-D.; Maulbecker-Armstrong, C.; Roitman, M.; Holm, T.; Harris, C.C.; Link, K.-H.; Kornmann, M. Are colon and rectal cancer two different tumor entities? A proposal to abandon the term colorectal cancer. Int. J. Mol. Sci. 2018, 19, 2577. [Google Scholar] [CrossRef] [Green Version]
  35. Mukund, K.; Syulyukina, N.; Ramamoorthy, S.; Subramaniam, S. Right and left-sided colon cancers-specificity of molecular mechanisms in tumorigenesis and progression. BMC Cancer 2020, 20, 1–15. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  36. Baran, B.; Ozupek, N.M.; Tetik, N.Y.; Acar, E.; Bekcioglu, O.; Baskin, Y. Difference between left-sided and right-sided colorectal cancer: A focused review of literature. Gastroenterol Res 2018, 11, 264. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  37. Lim, D.R.; Kuk, J.K.; Kim, T.; Shin, E.J. Comparison of oncological outcomes of right-sided colon cancer versus left-sided colon cancer after curative resection. Medicine 2017, 96, e8241. [Google Scholar] [CrossRef] [PubMed]
  38. Hardiman, K.M. Update on Sporadic Colorectal Cancer Genetics. Clin. Colon Rectal Surg. 2018, 31, 147–152. [Google Scholar] [CrossRef] [PubMed]
  39. Ooi, C.Y.; Hanafi, N.S.; Liew, S.M. Knowledge and practice of colorectal cancer screening in an urban setting: Cross-sectional survey of primary care physicians in government clinics in Malaysia. Singap. Med. J. 2019, 60, 596. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  40. Ministry of Health Malaysia. National Strategic Plan for Colorectal Cancer (2021–2025). 2021. Available online: https://www.moh.gov.my/moh/resources/Penerbitan/Rujukan/NCD/Kanser/National_Strategic_Plan_for_Colorectal_Cancer_(NSPCRC)_2021-2025.pdf (accessed on 18 September 2022).
  41. Yuen, S.T.; Davies, H.; Chan, T.L.; Ho, J.W.; Bignell, G.R.; Cox, C.; Stephens, P.; Edkins, S.; Tsui, W.W.; Chan, A.S.; et al. Similarity of the phenotypic patterns associated with BRAF and KRAS mutations in colorectal neoplasia. Cancer Res. 2002, 62, 6451–6455. [Google Scholar]
  42. Artale, S.; Sartore-Bianchi, A.; Veronese, S.M.; Gambi, V.; Sarnataro, C.S.; Gambacorta, M.; Lauricella, C.; Siena, S. Mutations of KRAS and BRAF in Primary and Matched Metastatic Sites of Colorectal Cancer. J. Clin. Oncol. 2008, 26, 4217–4219. [Google Scholar] [CrossRef] [Green Version]
  43. Cejas, P.; López-Gómez, M.; Aguayo, C.; Madero, R.; Carpeño, J.D.C.; Belda-Iniesta, C.; Barriuso, J.; Garcia, V.M.; Larrauri, J.; Lopez, R.; et al. KRAS mutations in primary colorectal cancer tumors and related metastases: A potential role in prediction of lung metastasis. PLoS ONE 2009, 4, e8199. [Google Scholar] [CrossRef] [Green Version]
  44. Wojciechowicz, D.C.; Park, P.Y.; Datta, R.V.; Paty, P.B. CEA is the major PHA-L-reactive glycoprotein in colon carcinoma cell lines and tumors: Relationship between K-ras activation and β1-6 branching of N-linked carbohydrate on CEA. Biochem. Biophys. Res. Commun. 2000, 273, 147–153. [Google Scholar] [CrossRef]
  45. Selcukbiricik, F.; Bilici, A.; Tural, D.; Erdamar, S.; Soyluk, O.; Buyukunal, E.; Demirelli, F.; Serdengecti, S. Are high initial CEA and CA 19-9 levels associated with the presence of K-ras mutation in patients with metastatic colorectal cancer? Tumor Biol. 2013, 34, 2233–2239. [Google Scholar] [CrossRef] [PubMed]
  46. Zhao, N.; Cao, Y.; Yang, J.; Li, H.; Wu, K.; Wang, J.; Peng, T.; Cai, K. Serum Tumor Markers Combined with Clinicopathological Characteristics for Predicting MMR and KRAS Status in 2279 Chinese Colorectal Cancer Patients: A Retrospective Analysis. Front. Oncol. 2021, 11, 582244. [Google Scholar] [CrossRef] [PubMed]
Diagnostics 13 00822 g001 550
Figure 1. Gel electrophoresis image of selected PCR products targeting codons 12 and 13 of KRAS.
Figure 1. Gel electrophoresis image of selected PCR products targeting codons 12 and 13 of KRAS.
Diagnostics 13 00822 g001
Diagnostics 13 00822 g002 550
Figure 2. Histological examinations (H&E stain, 200×) in selected cases. (a) Well-differentiated adenocarcinoma in Case 1 (G12D mutation), showing tumor cells arranged in an irregular glandular pattern infiltrating the stroma; (b) well-differentiated adenocarcinoma in Case 2 (G12S mutation), exhibiting malignant glands arranged mainly in a complex glandular pattern which infiltrates into the muscularis propria (black arrow); (c) moderately differentiated adenocarcinoma in Case 11 (G13D mutation). Surrounding stroma shows a marked desmoplastic reaction; (d) moderately differentiated adenocarcinoma in Case 15 (wild-type KRAS) with area of necrosis; (e) moderately differentiated adenocarcinoma in Case 19 (wild-type KRAS) exhibiting a cribiform pattern with perineural invasion (black arrow).
Figure 2. Histological examinations (H&E stain, 200×) in selected cases. (a) Well-differentiated adenocarcinoma in Case 1 (G12D mutation), showing tumor cells arranged in an irregular glandular pattern infiltrating the stroma; (b) well-differentiated adenocarcinoma in Case 2 (G12S mutation), exhibiting malignant glands arranged mainly in a complex glandular pattern which infiltrates into the muscularis propria (black arrow); (c) moderately differentiated adenocarcinoma in Case 11 (G13D mutation). Surrounding stroma shows a marked desmoplastic reaction; (d) moderately differentiated adenocarcinoma in Case 15 (wild-type KRAS) with area of necrosis; (e) moderately differentiated adenocarcinoma in Case 19 (wild-type KRAS) exhibiting a cribiform pattern with perineural invasion (black arrow).
Diagnostics 13 00822 g002
Diagnostics 13 00822 g003 550
Figure 3. Chromatogram highlighting codons 12 and 13 of KRAS in selected cases. Arrows indicate the location of the single-point mutations. (a) Wild-type KRAS sequence (GGT GGC); (b) c.35G > A (G12D) mutation in case 4; (c) c.38G > A (G13D) mutation in case 9; (d) c.35G > T (G12V) mutation in case 12.
Figure 3. Chromatogram highlighting codons 12 and 13 of KRAS in selected cases. Arrows indicate the location of the single-point mutations. (a) Wild-type KRAS sequence (GGT GGC); (b) c.35G > A (G12D) mutation in case 4; (c) c.38G > A (G13D) mutation in case 9; (d) c.35G > T (G12V) mutation in case 12.
Diagnostics 13 00822 g003
Table
Table 1. Clinicopathological features of CRC patients according to KRAS mutational status.
Table 1. Clinicopathological features of CRC patients according to KRAS mutational status.
FeaturesKRAS Statusp-Value
Wild-Type
n (%)		Mutant
n (%)
Total21 (63.6)12 (36.4)
Gender
Male
Female
11 (73.3)
10 (55.6)
4 (26.7)
8 (44.4)		0.469
Age (years)
≤60
>60
9 (56.3)
12 (70.6)
7 (43.8)
5 (29.4)		0.392
Ethnicity
Malay
Chinese
17 (60.7)
4 (80)
11 (39.3)
1 (20)		0.630
Tumor site
Right colon
Left colon
Rectum
3 (100)
15 (60)
3 (60)
0 (0)
10 (40)
2 (40)		0.420
Differentiation
Well
Moderate
Poor
4 (57.1)
16 (64.0)
-
3 (42.9)
9 (36.0)
-		>0.950
AJCC Stage
I or II
III
IV
7 (70)
6 (60)
8 (61.5)
3 (30)
4 (40)
5 (38.5)		>0.950
CEA (ng/mL)
≤5
>5
7 (77.8)
14 (58.3)
2 (22.2)
10 (41.7)		0.429
Table
Table 2. Frequency of KRAS mutations.
Table 2. Frequency of KRAS mutations.
MutationBase ChangeFrequency,
n (%)
G12Dc.35G > A6 (50)
G12Vc.35G > T3 (25)
G12Sc.34G > A1 (8.3)
G13Dc.38G > A2 (16.7)
Table
Table 3. Stage IV CRC with its corresponding metastatic site and KRAS mutation status.
Table 3. Stage IV CRC with its corresponding metastatic site and KRAS mutation status.
CaseKRAS Mutation StatusPrimary CRC LocationCorresponding
Metastatic Site(s)
3G12DLeft colonLiver, Lung, Spine
5G12VLeft colonLung
6G12DLeft colonLiver, Lung
9G13DLeft colonLung, Adrenal
11G13DLeft colonLung
14Wild-typeLeft colonLiver
16Wild-typeLeft colonLung
19Wild-typeLeft colonLiver, Lung
23Wild-typeLeft colonLiver, Peritoneum
24Wild-typeRectumLiver
26Wild-typeRight colonLiver, Lung
28Wild-typeLeft colonLiver
30Wild-typeRectumLiver, Lung
Table
Table 4. Characteristics of colorectal cancer patients with mutant KRAS and their clinicopathological features.
Table 4. Characteristics of colorectal cancer patients with mutant KRAS and their clinicopathological features.
CaseAge
(Years)		RaceTumorInitial CEA
(ng/mL)		KRAS Mutations, Amino Acid Changes
SiteDifferentiationStage
130MalayRectumWellI0.3c.35G > A, G12D
272MalayLeft sideWellIII3.8c.34G > A, G12S
351ChineseLeft sideModerateIV914.8c.35G > A, G12D
458MalayLeft sideModerateIII12.6c.35G > A, G12D
571MalayLeft sideModerateIV28.1c.35G > T, G12V
639MalayLeft sideModerateIV166.9c.35G > A, G12D
782MalayLeft sideWellI12.2c.35G > A, G12D
840MalayLeft sideModerateIII66.5c.35G > A, G12D
960MalayLeft sideModerateIV173.2c.38G > A, G13D
1083MalayRectumModerateIII25.0c.35G > T, G12V
1178MalayLeft sideModerateIV276.1c.38G > A, G13D
1259MalayLeft sideModerateII27.0c.35G > T, G12V
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Hasbullah, H.H.; Sulong, S.; Che Jalil, N.A.; Abdul Aziz, A.A.; Musa, N.; Musa, M. KRAS Mutational Profiles among Colorectal Cancer Patients in the East Coast of Peninsular Malaysia. Diagnostics 2023, 13, 822. https://doi.org/10.3390/diagnostics13050822

AMA Style

Hasbullah HH, Sulong S, Che Jalil NA, Abdul Aziz AA, Musa N, Musa M. KRAS Mutational Profiles among Colorectal Cancer Patients in the East Coast of Peninsular Malaysia. Diagnostics. 2023; 13(5):822. https://doi.org/10.3390/diagnostics13050822

Chicago/Turabian Style

Hasbullah, Hidayati Husainy, Sarina Sulong, Nur Asyilla Che Jalil, Ahmad Aizat Abdul Aziz, Nurfadhlina Musa, and Marahaini Musa. 2023. "KRAS Mutational Profiles among Colorectal Cancer Patients in the East Coast of Peninsular Malaysia" Diagnostics 13, no. 5: 822. https://doi.org/10.3390/diagnostics13050822

APA Style

Hasbullah, H. H., Sulong, S., Che Jalil, N. A., Abdul Aziz, A. A., Musa, N., & Musa, M. (2023). KRAS Mutational Profiles among Colorectal Cancer Patients in the East Coast of Peninsular Malaysia. Diagnostics, 13(5), 822. https://doi.org/10.3390/diagnostics13050822

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop