Prevalence and risk factors of colon polyps and other colonic lesions in acromegaly: Insights from colonoscopy screening

Abstract

Purpose
The existing data on colon lesions in acromegaly is notably heterogeneous. This study aimed to analyze the endoscopic and histopathological characteristics of colon polyps and other colonic lesions in acromegaly patients.

Methods
This case-control study included 192 acromegaly patients and 256 controls. Colon polyps were categorized based on their size and histopathological classification. Colon malignancies and other colonic lesions, such as anal fissures, hemorrhoids, and diverticulosis, were also documented.

Results
The prevalence of colon polyps was higher in the acromegaly group than in controls (p = 0.003), however, no differences were observed in the number, size, or histopathological subtypes of the polyps. Polyps in acromegaly patients were predominantly located in the distal colon and rectum. Multiple polyp locations and histopathological subtypes were more frequent in the control group (p = 0.042 and p = 0.018). Rates of low-grade dysplasia, high-grade dysplasia, and malignancy were similar between groups. Anal fissures were more common in the acromegaly group, whereas diverticulosis was less frequent (p = 0.001 and p < 0.001; respectively). Logistic regression analysis identified no significant clinical or laboratory predictors for colon polyps in acromegaly.

Conclusion
Patients with acromegaly exhibited a higher prevalence of colon polyps, predominantly located in the distal colon, which typically displayed a single histopathological subtype. No increased rates of colonic dysplasia, colon cancer, or other colonic lesions were observed in patients with acromegaly, except for an elevated prevalence of anal fissures.

Full text

RESEARCH
Pituitary (2025) 28:44
https://doi.org/10.1007/s11102-025-01513-4
adenoma. This complex condition is associated with vari-
ous comorbidities, including diabetes mellitus (DM), hyper-
tension, cardiovascular diseases, obstructive sleep apnea
syndrome (OSAS), and respiratory problems [1]. The asso-
ciation between acromegaly and increased rates of solid
organ malignancies, including colorectal, thyroid, breast,
and prostate cancers, remains a subject of ongoing debate,
with the literature on this topic being highly heterogeneous
[2, 3]. Among the morbidities associated with acromegaly,
premalignant and malignant colon lesions remain prominent
areas of interest and continue to garner signicant attention
from researchers due to the lack of denitive consensus in
the existing literature.
Elevated IGF-1 levels have been found to promote
increased cellular proliferation and anti-apoptotic activity
in the colorectal epithelium, which are responsible for the
development of colon polyps and malignancies [2]. Despite
inconsistencies regarding the increased rate of colon cancer,
Introduction
Acromegaly is an endocrine disorder characterized by
excessive growth hormone (GH) and insulin-like growth
factor-1 (IGF-1) levels, commonly caused by a pituitary
Sema Hepşen
semahepsen@gmail.com
1 Department of Endocrinology and Metabolism, Ankara Etlik
City Hospital, Ankara, Türkiye
2 Department of Gastroenterology, Ankara Etlik City Hospital,
Ankara, Türkiye
3 Department of Gastroenterology, University of Health
Sciences, Ankara Training and Research Hospital, Ankara,
Türkiye
4 Endocrine and Diabetes Division, University of Minnesota
Twin Cities, Minneapolis, USA
Abstract
Purpose The existing data on colon lesions in acromegaly is notably heterogeneous. This study aimed to analyze the endo-
scopic and histopathological characteristics of colon polyps and other colonic lesions in acromegaly patients.
Methods This case-control study included 192 acromegaly patients and 256 controls. Colon polyps were categorized based
on their size and histopathological classication. Colon malignancies and other colonic lesions, such as anal ssures, hemor-
rhoids, and diverticulosis, were also documented.
Results The prevalence of colon polyps was higher in the acromegaly group than in controls (p = 0.003), however, no dif-
ferences were observed in the number, size, or histopathological subtypes of the polyps. Polyps in acromegaly patients were
predominantly located in the distal colon and rectum. Multiple polyp locations and histopathological subtypes were more
frequent in the control group (p = 0.042 and p = 0.018). Rates of low-grade dysplasia, high-grade dysplasia, and malignancy
were similar between groups. Anal ssures were more common in the acromegaly group, whereas diverticulosis was less
frequent (p = 0.001 and p < 0.001; respectively). Logistic regression analysis identied no signicant clinical or laboratory
predictors for colon polyps in acromegaly.
Conclusion Patients with acromegaly exhibited a higher prevalence of colon polyps, predominantly located in the distal
colon, which typically displayed a single histopathological subtype. No increased rates of colonic dysplasia, colon cancer, or
other colonic lesions were observed in patients with acromegaly, except for an elevated prevalence of anal ssures.
Keywords Acromegaly · Colonoscopy · Colon polyps · Colon lesions · Colon cancer
Accepted: 4 March 2025 / Published online: 1 April 2025
© The Author(s) 2025
Prevalence and risk factors of colon polyps and other colonic lesions in
acromegaly: Insights from colonoscopy screening
SemaHepşen1· EnesÜçgül1· BurakMenekşe1· Burçak CavnarHelvacı1· Ceren KaraçalıkÜnver1· HalilDurantaş1·
OğulcanBoz1· YusufCoşkun2· BaşakÇakal3· MuhammedKızılgül1,4· ErmanÇakal1
1 3
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Pituitary (2025) 28:44
it is widely accepted that colon polyps are more preva-
lent in patients with acromegaly compared to the general
population [4, 5]. Furthermore, malignancies have become
a comparable cause of death to cardiovascular diseases
in acromegaly [6, 7]. Therefore, in acromegaly patients,
although some recommendations may vary based on age,
most current guidelines recommend performing a screening
colonoscopy at the time of diagnosis, followed by regular
surveillance colonoscopies [8–10]. However, some recent
reports have concluded that the incidence of malignancy in
acromegaly is decreasing and is now comparable to that of
the reference population, likely due to the increased rate of
early disease detection and advances in therapeutic options
[11]. In line with these ndings, some guidelines do not
recommend a routine cancer screening program specic to
acromegaly [12].
Endoscopic ndings, including the size and location of
colon polyps in patients with acromegaly, as well as the
histopathological classication of polyps, are reported to be
heterogeneous in the literature [4, 13]. Additionally, data on
the risk factors associated with polyps, such as age, disease
duration, obesity, GH and IGF-1 levels, fasting glucose, and
insulin levels, show signicant variability across studies,
and these factors have not yet been suciently claried.
This large-scale, single-center study aimed to conduct a
comparative analysis of the endoscopic and histopathologi-
cal characteristics of colon polyps and other colonic lesions
in patients with acromegaly and to identify the risk factors
associated with colon polyps.
Materials and methods
Study design
This retrospectively designed case-control study was
approved by the Ethics Committee of Ministry of Health
Ankara Etlik City Hospital in accordance with the princi-
ples of the Helsinki Declaration. The written informed con-
sent forms were obtained from all participants.
Patient inclusion
A total of 252 acromegaly patients followed in our clinic
between January 2016 and December 2024 were assessed.
Among them, 192 patients who underwent a colonoscopy
either at the time of diagnosis or during follow-up were
included in the study. The details of the patients who did not
undergo a colonoscopy are presented in Fig. 1.
For the control group, consecutive 801 patients who
underwent colonoscopy at the outpatient gastroenterology
unit of our hospital between January 2024 and May 2024
were evaluated. Patients who underwent colonoscopy due
to gastrointestinal complaints, a positive fecal occult blood
test, detection of a colon lesion on another imaging modal-
ity, a diagnosis of iron deciency, a known malignancy, or
surveillance for a known colon disease were excluded from
the study. Additionally, patients in whom the procedure
could not be completed due to inadequate bowel prepara-
tion were also excluded. The remaining 256 patients who
Fig. 1 Flow chart of patient inclusion
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Pituitary (2025) 28:44
underwent colonoscopy for screening purposes constituted
the control group. The owchart of patient inclusion is pre-
sented in Fig. 1.
Baseline data
Demographic data and comorbidities, such as DM, hyper-
tension, coronary artery disease, and OSAS, were recorded
for the participants. IGF-1 and GH levels, as well as the size
of the pituitary adenoma at the time of diagnosis were also
documented. The initial treatment of the patients, whether
surgery or somatostatin analogue, was recorded.
Colonoscopy evaluation
Bowel preparation adequacy data was recorded for all
participants. Colonic lesions were classied into four cat-
egories: colon polyps, colon dysplasia, malignant lesions,
and perianal diseases, which included anal ssures, hem-
orrhoids, and diverticulosis. Colon polyps were further
classied based on their histopathological results using the
World Health Organization classication as neoplastic and
non-neoplastic polyps [14]. Neoplastic polyps included
tubular, villous, and tubulovillous adenomas, while non-
neoplastic polyps included inammatory, hamartomatous,
and hyperplastic polyps [15, 16]. Dysplasia was classied
into low-grade and high-grade dysplasia [14]. Polyp size is
categorized based on the size of the largest polyp as < 5 mm,
5–10 mm, and ≥ 10 mm, in accordance with the 2024 Euro-
pean Society of Gastroenterology Guideline [17].
Statistical analysis
The normality of variables was evaluated using the Kol-
mogorov-Smirnov and Shapiro-Wilk tests. Comparisons of
categorical variables were performed using the Chi-square
test, or Fisher’s exact test when the Chi-square assump-
tions were not met due to low expected frequencies. The
Mann-Whitney U test was used for comparisons of non-
parametric variables between acromegaly patients and
controls. Categorical variables were presented as numbers
and percentages, while non-normally distributed variables
were reported as medians with interquartile ranges (IQR,
25th–75th percentile). Spearman’s correlation coecients
and their signicance were used to analyze the associations
between the number of colon polyps and other variables in
both groups. Univariate analysis was performed to iden-
tify potential factors for inclusion in multivariable logistic
regression analysis to determine the nal predictive factors
for colon polyp presence in acromegaly patients. Model t
was assessed using the Hosmer-Lemeshow goodness-of-
t test. A 5% type I error level was used to infer statistical
signicance, and p-values less than 0.05 were considered
statistically signicant for all tests.
Results
Baseline data
A total of 192 patients with acromegaly and 256 controls
were analyzed. Age and sex distributions were comparable
between the groups (p = 0.09 and p = 0.231, respectively).
Baseline characteristics, comorbidities, and acromegaly-
specic data are summarized in Table 1.
Comparative analysis
Among the acromegaly patients, colonoscopy was per-
formed at the time of diagnosis in 179 patients (93.2%) and
during follow-up in 13 patients (6.8%). Adequate bowel
preparation was achieved in 141 patients (73.4%) in the
acromegaly group and 210 patients (82%) in the control
group (p = 0.028).
The prevalence of colon polyps was higher in the acro-
megaly group compared to the control group, with 72
patients (37.5%) in the acromegaly group and 64 patients
(25%) in the control group (p = 0.003). The number and size
Table 1 Baseline data belonging to acromegaly patients and controls
Acromegaly
(N = 192)
Controls
(N = 256)
P
value
Age, years 54 (42–63) 55
(48–64)
0.09
Female sex, n (%) 105 (54.6) 134
(52.34)
0.231
BMI, kg/m229.4
(26.6–33.2)
Smoking, n (%) 49 (25.5) 44 (17.1) 0.069
Comorbidities
Diabetes mellitus, n (%) 55 (28.6) 57 (22.3) 0.116
Hypertension, n (%) 78 (40.6) 56 (21.8) < 0.001
Coronary artery disease, n (%) 19 (10) 26 (10.1) 0.244
OSAS, n (%) 26 (13.5) 4 (1.6) 0.002
Data belonging to acromegaly
Initial adenoma size, mm 15 (10–25)
IGF-1 level at the diagnosis
time, ng/mL
657
(512–901)
GH level at the diagnosis time,
mcg/L
9.2
(4.9–21.6)
Somatostatin analogue for
initial treatment, n (%)
15 (7.9)
Surgery for initial treatment,
n (%)
177 (92.2)
BMI: Body mass index, IGF-1: Insulin like growth factor-1, GH:
Growth hormone, OSAS: Obstructive sleep apnea syndrome
Categorical data are presented as numbers and percentages, non-
parametric data are presented as medians (IQR 25–75)
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Pituitary (2025) 28:44
and the control group (p > 0.005 for each). Anal ssures were
more frequently detected in the acromegaly group com-
pared to the control group, whereas diverticulosis was less
common (p = 0.001 and p < 0.001; respectively). The rate of
hemorrhoids was similar across the groups (p = 0.419).
Correlation and regression analysis
In the correlation analysis, age was found to be positively
correlated with the number of colon polyps in the control
group (r = 0.189, p < 0.001), whereas no correlation was
observed with sex. However, no relationship was found
between the number of colon polyps and age, sex, body
mass index (BMI), adenoma size, basal GH, or IGF-1 levels
in the acromegaly group (p > 0.005 for each).
Univariate analysis suggested that the presence of DM
was associated with the presence of colon polyps in acro-
megaly patients (p = 0.037, R² = 0.025). However, sex, BMI,
the presence of OSAS, smoking, basal IGF-1, and GH lev-
els were not found to be associated.
Based on these ndings, a multivariable logistic regres-
sion model was conducted to analyze the predictive factors
for the presence of colon polyps in acromegaly, including
age, sex, DM, and basal IGF-1 and GH levels. None of these
parameters were identied as independent predictive factors
for polyp presence in patients with acromegaly.
of polyps were similar between the two groups (p = 0.273
and p = 0.233, respectively). The prevalence of colon polyps
was higher in the acromegaly group among patients with
adequate colon cleansing (p = 0.007). However, when par-
tial colon cleansing was achieved, polyp rates were simi-
lar between the acromegaly and control groups (p = 0.679).
No dierences were observed in the subtypes of neoplastic
and non-neoplastic polyps between the groups (p > 0.005
for each). The details of the endoscopic and histopathologi-
cal characteristics are presented in Table 2. Figure 2 shows
the percentages of colon polyp subtypes across the entire
groups. Colon polyps in patients with acromegaly tended to
be located in the distal segments of the colon and rectum.
However, no dierences were observed in the distribution
of polyps across specic colon segments in the comparative
analysis (p > 0.005 for each). The distribution of colon polyp
localization through colon segments is illustrated in Fig. 3.
Among patients with colon polyps, multiple polyp settle-
ments were observed more frequently in the control group
compared to the acromegaly group (17 [23.6%] vs. 26
[40.6%], p = 0.042). Similarly, multiple histopathological
subtypes of colon polyps were more common in the con-
trol group than in the acromegaly group (6 [8.3%] vs. 15
[23.4%], p = 0.018).
Rates of low-grade dysplasia, high-grade dysplasia, and
malignancy were similar between patients with acromegaly
Fig. 2 Histopathological subtypes of detected colon polyps
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Pituitary (2025) 28:44
similar to those observed in the control group. Colon polyps
in patients with acromegaly were more commonly located
in the distal segments of the colon. Additionally, polyps in
acromegaly tended to manifest as a single histopathological
subtype located in a specic region of the colon, rather than
as multiple localized lesions or varied subtypes. While age
was positively associated with the number of colon polyps
in the control group, neither age nor any other clinical or
laboratory factor was associated with polyp number in acro-
megaly patients. Other colon lesions, including malignancy
and dysplasia rates apart from anal ssures, do not appear to
be increased in acromegaly.
Sporadic forms of colon cancer develop on the basis of
various epigenetic and genetic changes, leading to cell pro-
liferation and dierentiation [18]. This process rst results
in the formation of neoplastic colon adenomas, which sub-
sequently transform to dysplasia and colon cancer [19].
However, in patients with acromegaly, the development of
colon polyposis and its malignant transformation is distinct
from non-acromegalic colon tumorigenesis [19]. Excessive
GH and IGF-1 secretion are postulated to play pivotal roles
in stimulating cell proliferation, promoting angiogenesis,
and increasing the risk of mutations [20, 21].
The increased rate of colon polyps in acromegaly has
been conrmed by many studies and is widely accepted by
experts [22, 23]. However, reported endoscopic character-
istics, such as polyp number, size, and localization, show
signicant alterations. Current epidemiological data show
that, in the general population, the proximal colon, distal
colon, and rectum each account for approximately one-third
of colon polyps, with their prevalence increasing with age
[24]. Several studies have shown that the localization of
colon polyps in acromegaly diers from that in the general
population, with polyps more frequently located on the right
Discussion
This study conrmed that the prevalence of colon polyps is
higher in patients with acromegaly compared to controls.
However, the number and size of polyps were found to be
Table 2 Data belonging to detected colon polyps and other colon
lesions in patients with acromegaly and controls
Acro-
megaly
(N = 192)
Controls
(N = 256)
P
value
Patients with detected polyp, n (%) 72 (37.5) 64 (25) 0.003
Polyp number, median (IQR) 2.25
(1–2)
2 (1–2) 0.273
Polyp size of the largest polyp* 0.233
< 5 mm, n (%) 56 (77.8) 43 (67.2)
5–10 mm, n (%) 11 (15.3) 11 (17.2)
≥ 10 mm, n (%) 5 (6.9) 10 (15.6)
Patients with neoplastic polyps,
n (%)
37 (19.2) 41 (16) 0.653
Tubular adenoma, n (%) 33 (17.1) 41 (16) 0.039
Villous adenoma, n (%) 2 (1) 6 (2.3) 0.998
Tubulovillous adenoma, n (%) 6 (3.1) 7 (2.7) 0.772
Patients with dysplasia, n (%)
Low grade dysplasia, n (%) 1 (0.5) 3 (1.2) 1.00
High grade dysplasia, n (%) 1 (0.5) 4 (1.6) 0.369
Patients with non-neoplastic
polyps, n (%)
Inammatory polyp, n (%) 2 (1) 6 (2.3) 1.00
Hyperplastic polyp, n (%) 36 (18.8) 24 (9.4) 0.120
Malign sitology, n (%) 1 (0.5) 1 (0.4) 1.00
Other lesions, n (%)
Anal ssure, n (%) 4 (2.1) 1 (0.4) 0.001
Hemorrhoids, n (%) 38 (20) 60 (23.4) 0.419
Diverticulosis, n (%) 5 (2.6) 22 (8.6) < 0.001
*The percentages for polyp size have been provided among the
detected polyps
Fig. 3 The distribution of colon polyp localization through colon segments
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Pituitary (2025) 28:44
IGF-1 levels [22]. An observational study including 210
acromegaly patients was found a strong relationship with
insulin levels and colon polyps [30]. Another retrospective
observational study also found an increased risk of polyps in
patients with a history of previous polyps and higher IGF-1
levels [31]. In contrast, Renehan et al. indicated no asso-
ciation between colon neoplasms and GH or IGF-1 levels,
as well as disease duration [4]. Gonzales et al. found that
the prevalence of colon polyps was higher among acro-
megaly patients with DM [26]. Considering the ndings of
these previous studies, IGF-1 levels, the presence of DM,
and glucose metabolism parameters, such as insulin levels,
emerged as prominent factors among all potential associa-
tions [32]. The present study demonstrated a positive asso-
ciation between DM and colon polyps in the acromegaly
group; however, this association was not maintained in the
multivariable regression analysis. Our nding conrmed
that age is not an independent risk factor for colon polyps in
acromegaly, unlike in controls. All guidelines, except those
of the British Society of Gastroenterology, recommend
performing an initial colonoscopy at the time of diagnosis
[8–10, 33]. In contrast, the recent Danish guideline opposes
routine colonoscopy screening in acromegaly and recom-
mends following the general national screening guidelines
[12]. All recent study data, including ours, may highlight the
need for updated recommendations in the future guidelines.
Previous studies have identied an increased risk of
colon cancer in patients with acromegaly [3, 34]. A recent
study involving 70 acromegaly patients concluded that
while the rate of low-grade dysplasia was similar, the rate of
high-grade dysplasia was higher in their acromegaly cohort
[27]. In contrast to these ndings, some recent studies and
reviews have concluded that the incidence of colon cancer,
as well as low- and high-grade dysplasia, in acromegaly is
not higher than in the general population (11). The simi-
lar rates of colon cancer and dysplasia in acromegaly and
control groups observed in the present study align with the
ndings of these latest reports.
Contrary to these numerous studies focusing on colon
polyps in acromegaly, data on other colonic lesions is lim-
ited. A few studies reported an increased rate of diverticulo-
sis in acromegaly, which contrasts with our ndings [8, 28].
The increased rate of anal ssures in the present acromegaly
cohort, compared to controls, is a new nding that contrib-
utes to the literature.
Lastly, due to slower colon transit in acromegaly, insu-
cient colon preparation is more frequently observed in acro-
megaly patients compared to the general population [23].
Slow transit and longer colon length are the primary reasons
why total colonoscopy is preferred over sigmoidoscopy in
patients with acromegaly [19]. Our ndings were consistent
with this observation, as a higher rate of colon polyps was
side of the colon and tended to be larger than 10 mm [4, 25].
Despite these ndings, some recent studies have reported
a higher rate of polyps in the descending colon [26, 27]. A
study involving 178 patients with acromegaly reported nd-
ings were consistent with those of the present study, with
polyps predominantly located in the sigmoid colon and rec-
tum [13]. However, in their study, polyp size and number
were greater in patients with acromegaly. In contrast, the
ndings of the current study demonstrated that the size and
number of colon polyps in acromegaly patients were simi-
lar to those in the control group. Additionally, our ndings
introduced a novel contribution to the literature, suggest-
ing that colon polyps in acromegaly tended to localize to a
specic part of the colon rather than involving multiple seg-
ments. These results may be explained by the fact that most
colonoscopies in our cohort were performed at the time of
diagnosis, which allowed for the detection of polyps while
they were smaller in size and fewer in number, during the
early stages of the disease.
The histopathological characteristics of colon polyps
in acromegaly remain controversial, as many studies have
not used the standardized classication systems outlined
in pathological guidelines. A meta-analysis involving 701
acromegaly patients concluded that both hyperplastic pol-
yps and adenomas were more common in acromegaly
patients [2]. However, a detailed analysis of each histopath-
ological subtype was not provided due to the heterogene-
ity of the included studies. A single-center study involving
Turkish patients reported that hyperplastic polyps were
more common in acromegaly patients, while other histo-
pathological subtypes were not [28]. Another study indi-
cated that advanced histopathological ndings, such as
tubulovillous adenomas, were more commonly observed in
acromegaly patients than in controls [4]. No signicant dif-
ferences among the histopathological subtypes were identi-
ed in our cohort. However, similar to polyp localization,
the histopathological subtype of colon polyps in acromegaly
also tends to be a unique subtype rather than encompassing
multiple subtypes.
Independent factors such as advanced age, smoking,
obesity, insulin resistance, dyslipidemia, and DM have been
found to be associated with colon carcinogenesis in non-
acromegaly patients [29]. Several studies have explored the
eects of these factors on premalignant and malignant colon
lesions in acromegaly. However, the literature presents
extremely heterogeneous results regarding the factors asso-
ciated with colon polyps, primarily due to variations among
acromegaly patients included in these studies. In an Italian
cohort, colon polyps were found to be positively associated
with GH, IGF-1, fasting glucose, and insulin levels (8). Peng
et al. demonstrated an independent association between the
presence of colon polyps and both GH adenoma volume and
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Pituitary (2025) 28:44
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noted in acromegaly patients with adequate colon cleansing,
while those with insucient colon preparation showed rates
similar to the control group.
The limitations of this study include its retrospective
design and single-center setting. Although strict exclusion
criteria were applied, and only patients who underwent colo-
noscopy for screening purposes were included, a potential
selection bias cannot be completely ruled out in the control
group. However, considering the sample size, a key strength
of the study is its position as one of the largest single-center
studies in the eld. Additionally, endoscopic characteristics
and histopathological results were assessed according to the
most recent classications.
In conclusion, the rate of colon polyps was higher in
patients with acromegaly, regardless of age, gender, pres-
ence of DM, adenoma size, or IGF-1 and GH levels in the
present cohort. The polyps in acromegaly tended to be
located in the distal parts of the colon and to present as a
unique histopathological subtype rather than exhibiting
multiple distinct subtypes. Patients with acromegaly are not
considered to have a higher risk of colonic dysplasia, colon
cancer, or other colonic lesions, except for anal ssures.
Acknowledgements None.
Author contributions Conceptualization; S.H., B.C.H., M.K., E.Ü,
B.M, Y.C., E.Ç. Data curation; S.H., B.C.H., E.Ü, B.M, M.K, B.Ç.,
Y.C., C.K.Ü., H.D., O.B. Formal analysis; S.H., M.K. Methodology:
S.H., M.K., Y.C., B.Ç., E.Ç. Supervision: M.K, E.Ç. Writing - original
draft; S.H. Writing - review & editing; S.H., M.K, E.Ç. All authors
read and approved the nal manuscript.
Funding Open access funding provided by the Scientic and Techno-
logical Research Council of Türkiye (TÜBİTAK).
The authors did not receive support from any organization for the sub-
mitted work.
Data availability The datasets used and/or analysed during the current
study available from the corresponding author on reasonable request.
Declarations
Ethical approval This study was performed in line with the principles
of the Declaration of Helsinki. Approval was granted by “Scientic
Research Assessment and Ethics Committee of Ankara Etlik City Hos-
pital” (Date: 06/11/2024 No: AEŞH-BADEK-2024-999).
Consent to participate Informed consent was obtained from partici-
pants.
Financial interests The authors declare they have no nancial inter-
ests.
Competing interests The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format,
1 3
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