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BMC Gastroenterology
Coexistence ofearly gastric cancer
andbenign submucosal lesions mimic invasive
cancer: aretrospective multicenter experience
Huawei Yang1, Zhen Li1, Zhi Wei2, Guodong Li3, Yi Li2, Shanbin Wu3 and Rui Ji1*
Abstract
Objective To present a study to identify the characteristics of coexisting early gastric cancer (EGC) and benign sub-
mucosal lesions, with the aim of reducing the adverse consequences of overdiagnosis and overtreatment.
Methods In this retrospective study, we searched the endoscopic databases of three tertiary centers. We screened
of patients suspected of early gastric cancer submucosal infiltration by conventional endoscopy and ultimately
selected for endoscopic submucosal dissection treatment after endoscopic ultrasonography and magnifying
endoscopy with narrow-band imaging examination. Patients with coexisting EGC and benign submucosal lesions
in histological sections were included. Clinical data and endoscopic images were reviewed. To evaluate the preci-
sion of endoscopists’ diagnoses for this type of lesion, eight endoscopists with different experiences were recruited
to judge the infiltration depth of these lesions and analyze the accuracy rate.
Results We screened 520 patients and retrospectively identified 18 EGC patients with an invasive cancer-like mor-
phology. The most common lesion site was the cardia (12/18, 66.67%). The coexisting submucosal lesions could be
divided into solid (5/18, 27.78%) and cystic (13/18, 72.22%). The most common type of submucosal lesion was gastritis
cystica profunda (12/18, 66.67%), whereas leiomyoma was the predominant submucosal solid lesion (3/18, 16.67%).
Ten (55.56%) patients < underwent endoscopic ultrasonography; submucosal lesions were definitively diagnosed in 6
patients (60.00%). The accuracy of judgement of the infiltration depth was significantly lower in cases of coexistence
of EGC with benign submucosal lesions (EGC-SML) than in EGC (38.50% versus 65.60%, P = 0.0167). The rate of over-
diagnosis was significantly higher within the EGC-SML group compared to the EGC group (59.17% versus 10.83%,
P < 0.0001).
Conclusions We should be aware of the coexistence of EGC and benign submucosal lesions, the most common
of which is early cardiac-differentiated cancer with gastritis cystica profunda.
Keywords Early gastric cancer, Submucosal lesions, Endoscopic ultrasonography, Gastritis cystica profunda,
Infiltration depth
Introduction
Endoscopic submucosal dissection (ESD) has been
established as a first-line treatment modality for
selected early gastric cancer (EGC). Whether EGC can
be treated endoscopically depends mainly on the risk
of lymph node metastasis, which correlates with the
invasion depth of the tumor [1]. erefore, accurate
*Correspondence:
Rui Ji
qljirui@email.sdu.edu.cn
1 Department of Gastroenterology, Qilu Hospital of Shandong University,
No. 107, Wenhuaxi Road, Jinan 250012, China
2 Shandong Second Provincial General Hospital, Jinan 250022, China
3 The First Affiliated Hospital of Shandong First Medical University,
Jinan 250014, China
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Page 2 of 11
Yangetal. BMC Gastroenterology (2023) 23:409
prediction of the tumor invasion depth is of great
importance in planning an appropriate treatment strat-
egy and promising curative resection [2]. Computed
tomography (CT), magnetic resonance imaging (MRI),
and positron emission tomography are mainly used to
evaluate advanced gastric cancer, but these methods are
not accurate in predicting the infiltration depth of EGC
[3]. Currently, judgement of the infiltration depth of
mucosal neoplastic lesions relies on white-light endos-
copy (WLE), magnifying endoscopy with narrow-band
imaging (ME-NBI), and endoscopic ultrasonography
(EUS); however, each approach has its limitations [2].
Until now, there has been no consensus regarding the
need for preoperative EUS. Several studies have sug-
gested that the infiltration depth of EGC can be initially
determined by WLE, and EUS is recommended only
when it is difficult to determine the infiltration depth
of gastric cancer by WLE [4–6]. Several studies have
reported the accuracy of EUS in assessing the infiltra-
tion depth of EGC, with results ranging from 41.4–86%
[7–10]. Especially in the upper third of the stomach,
combined with ulcers or low-differentiated carcinoma,
the diagnostic accuracy of EUS is low, which might eas-
ily lead to misdiagnosis [8].
According to the endoscopic diagnosis and treatment
guideline, when a lesion is resected en bloc; is < 3 cm in
diameter, predominantly differentiated type, pT1b (SM1,
cancerous tissue confined to < 500 μm from the muscu-
laris mucosae); has no lymphovascular infiltration; has
negative surgical margins, curative resection is considered
for expanded indications [11]. Surgical treatment is rec-
ommended for lesions with infiltration deeper than SM1.
us, over-staging, in particular, tends to expose patients to
unnecessary surgical trauma. Many studies have shown that
the level of elevated mucosal lesions is related to the depth
of infiltration [12]. e coexistence of EGC and benign
submucosal lesions can imitate the illusion of submucosal
infiltration, interfering with endoscopists’ judgement of the
infiltration depth. Recently, our clinical work has found that
collision EGCs have become more frequent; therefore, we
present the first study to identify the characteristics of coex-
isting early gastric cancer and benign submucosal lesions.
Fig. 1 Flow diagram of the patients included in the study. EGC, early gastric cancer; ESD, endoscopic submucosal dissection
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Page 3 of 11
Yangetal. BMC Gastroenterology (2023) 23:409
Methods
Study design andpopulation
is retrospective, multicenter, observational study was
conducted at three hospitals (Qilu Hospital, Shandong
University; Shandong Second Provincial General Hos-
pital; and e First Affiliated Hospital of Shandong First
Medical University). is study was approved by the Eth-
ics Committee of Qilu Hospital, Shandong University,
and was performed in accordance with the declaration of
Helsinki (NO.2022-029).
We screened of patients suspected of EGC submucosal
infiltration by WLE and ultimately selected for endo-
scopic submucosal dissection treatment after EUS and
ME-NBI examination. Patients with early cancer infiltra-
tion above SM1 (confined to < 500 μm from the muscu-
laris mucosae) and coexisting benign submucosal lesions
were selected by tracking the pathological findings.
Patients who selected surgical treatment, those with infil-
tration depth of EGCs exceeding SM2, and those with
simple EGC confined to SM1 were excluded.
We retrospectively reviewed the medical records of all
cases. Data such as age, sex, endoscopic performance, site
and type of lesion, endoscopic ultrasonography results,
and pathological findings were recorded.
We recruited eight endoscopists from three cent-
ers and divided them into two groups: experienced and
Table 1 Eighteen cases of coexistence of early gastric cancer and benign submucosal lesions
F Female, M Male, EP Epithelial mucosa, LPM Lamina propria mucosa, MM Muscularis mucosa, SM1 Conned to < 500 μm from the muscularis mucosae, EUS Endoscopic
ultrasonography
Case number Age (years)/Sex Lesion site Type of mucosal
lesion Paris classication Inltration
depth Type of submucosal
lesion Performed EUS
1 67/F Cardia High-grade intraepi-
thelial neoplasia 0-IIa EP Leiomyoma Yes
2 63/F Cardia Intermediate-differ-
entiated intramucosal
adenocarcinoma
0-IIa EP Hamartoma-like
hyperplasia No
3 64/M Cardia High-grade intraepi-
thelial neoplasia 0-IIa EP Pyloric gland ectopic Yes
4 54/M Cardia High-grade intraepi-
thelial neoplasia 0-Is EP Leiomyoma Yes
5 69/M Cardia Low-differentiation
adenocarcinoma 0-IIa MM Gastritis cystica
profunda No
6 71/M Cardia High-grade intraepi-
thelial neoplasia 0-IIa + IIc SM1 Gastritis cystica
profunda No
7 68/M Cardia High-grade intraepi-
thelial neoplasia 0-IIa + IIc EP Gastritis cystica
profunda No
8 81/M Cardia Gastric foveolar epi-
thelium dysplasia 0-IIa EP Gastritis cystica
profunda Yes
9 62/M Cardia Gastral tubular adeno-
carcinoma 0-IIa + IIc SM1 Gastritis cystica
profunda Yes
10 61/M Cardia Gastral tubular adeno-
carcinoma 0-IIa + IIc MM Leiomyoma No
11 80/M Cardia High-grade intraepi-
thelial neoplasia 0-IIa + IIc EP Gastritis cystica
profunda No
12 67/M Cardia High-grade intraepi-
thelial neoplasia 0-IIa MM Gastritis cystica
profunda No
13 63/F Gastric body Low-grade intraepi-
thelial neoplasia 0-IIa + IIc EP Ectopic pancreas Yes
14 66/F Gastric body High-grade intraepi-
thelial neoplasia 0-IIa EP Gastritis cystica
profunda No
15 61/M Gastric body High-grade intraepi-
thelial neoplasia 0-IIa EP Gastritis cystica
profunda Yes
16 77/M Gastric body High-grade intraepi-
thelial neoplasia 0-IIa + IIc MM Gastritis cystica
profunda Yes
17 74/M Gastric body Intramucosal tubular
adenocarcinoma 0-IIa MM Gastritis cystica
profunda Yes
18 62/M Gastric body Intramucosal tubular
adenocarcinoma 0-IIa + IIc MM Gastritis cystica
profunda Yes
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Yangetal. BMC Gastroenterology (2023) 23:409
inexperienced, according to the time and cases of endo-
scopic operations. e four experienced endoscopists
(hereafter referred to, in no particular order, as A, B, C,
and D, respectively) who had each performed endoscopy
for at least 5 years, including > 3,000 endoscopic proce-
dures each, and the other four endoscopists (E, F, G, and
H, respectively) who had 1–3 years of endoscopic experi-
ence were considered inexperienced. Endoscopic white-
light and narrow-band imaging magnified images of cases
in this study (coexistence of EGC and benign submucosal
lesions, EGC-SML group) and some EGCs (EGC group)
were made into a test questionnaire for these eight physi-
cians, who had not seen these cases before, to judge the
depth of infiltration. e questionnaire consisted of a
total of 45 cases and in addition to the 15 cases included
in our study, there were 15 cases of EGC with infiltra-
tive depth limited to within SM1 and 15 with infiltrative
depth exceeding the SM1. Following a randomization of
Table 2 Patient and lesion characteristics
EP Epithelial mucosa, LPM Lamina propria mucosa, MM Muscularis mucosa, SM1 Conned to < 500 μm from the muscularis mucosae, EUS Endoscopic ultrasonography
Frequency Percentage
Sex Male 14 77.78
Female 4 22.22
Performed EUS Yes 10 55.56
No 8 44.44
Lesion position Cardia 12 66.67
Gastric body 6 33.33
Type of mucosal lesion High-grade intraepithelial neoplasia 10 55.56
Low-grade intraepithelial neoplasia 2 11.11
Gastral adenocarcinoma 6 33.33
Infiltrating depth EP 10 55.56
MM 6 33.33
SM1 2 11.11
Paris classification 0-IIa 9 50
0-IIa + IIc 8 44.45
0-Is 1 5.55
Type of submucosal lesion Gastritis cystica profunda 12 66.67
Leiomyoma 3 16.68
Hamartoma-like hyperplasia 1 5.55
Pyloric gland ectopic 1 5.55
Ectopic pancreas 1 5.55
Table 3 Characteristics of coexistence of EGC and benign submucosal cystic lesions
EGC Early gastric cancer, EUS Endoscopic ultrasonography
Cystic lesions (n = 13)
Position Cardia 8 (61.54%)
Gastric body 5 (38.46%)
Morphology (Paris classification) 0-IIa 7 (53.85%)
0-IIa + IIc 6 (46.15%)
0-Is 0 (0)
EUS Definitive diagnosis 4 (30.77%)
Indefinite diagnosis 3 (23.08%)
Not performed 6 (46.15%)
Type of submucosal lesion Gastritis cystica profunda 12 (92.31%)
Pyloric gland ectopic 1 (7.69%)
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Yangetal. BMC Gastroenterology (2023) 23:409
the order, eight physicians were asked to assess the infil-
tration depths and the results were analyzed.
Statistical analysis
All statistical analyses were performed using GraphPad
Prism, version 9.0.0 (GraphPad Software). e accuracy
of the judgement of the infiltration depth was calculated,
and the two groups were compared using the paired
t-test. Statistical significance was set at P < 0.05.
Results
We screened 520 patients and retrospectively identified
18 EGC patients with invasive cancer-like morphology
(Fig. 1); the characteristic information is presented in
Table 1. We performed simple statistical analysis of the
data (Tables2 and 3). e patients consisted of 14 men
and 4 women (male: female ratio = 3.5:1) with a mean age
of 67.22 ± 7.14 years (range, 54–81 years). All patients
were treated with en bloc ESD.
Ten of the 18 patients underwent EUS, and submucosal
lesions were found in 6 cases (ratio = 60%). e main
lesion sites in these cases were the cardia (12/18, 66.67%),
followed by the gastric body (6/18, 33.33%). High-grade
intraepithelial neoplasia was the most common histo-
pathological diagnosis (10/18, 55.56%), followed by gas-
tric adenocarcinoma (6/18, 33.33%). e predominant
morphologies were 0-IIa (9/18, 50.00%) and 0-IIa + IIc
(8/18, 44.45%), according to the Paris classification. Most
of the early cancer and precancerous lesions were con-
fined to the mucosal layer (16/18, 88.89%), with a small
percentage invading the submucosa (2/18, 11.11%).
Based on different endoscopic and pathological fea-
tures, coexisting submucosal lesions can be divided into
two categories. One type was solid submucosal lesion
(5/18, 27.78%), including leiomyoma (n = 3), hamartoma-
like hyperplasia (n = 1), and ectopic pancreas (n = 1). is
type of lesion is easier to diagnose by using conventional
endoscopy and EUS. Another type of EGC combined
with cystic submucosal lesions (13/18, 72.22%), such
as gastritis cystica profunda (GCP) or ectopic pyloric
glands, is more difficult to diagnose and can easily be
confused with deep submucosal infiltration of EGCs.
Fig. 2 Case 15: A An elevated lesion measuring approximately 1.5x2.0 cm with a central depression, and a rough, red surface mucosa is seen
on the posterior wall of the upper middle part of the gastric body. B Microglandular duct disorder and microvascular dilatation on magnification
endoscopy. C The mucosal layer of the lesion is significantly thickened; the submucosal layer is slightly thickened; irregular hypoechoic clusters
are visible within; and the intrinsic muscle layer is clear. D High-grade intraepithelial neoplasia of the mucosal layer combined with gastritis cystica
profunda below (magnification 40x)
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Yangetal. BMC Gastroenterology (2023) 23:409
In these 13 cases, the cardia remained the most com-
mon site, and the Paris classification was type 0-II (0-IIa,
53.85%; 0-IIa + IIc, 46.15%); 12 cases (92.31%) of submu-
cosal lesions were gastritis cystica profunda. Seven of
these 13 patients underwent EUS, and only 4 cases were
definitively diagnosed because of echoless structures
in the submucosa. In the other 3 patients, the diagnosis
was not confirmed because the EUS observation only
revealed thickening of the submucosal layer without a
distinct demarcation, which made it difficult to distin-
guish it from EGC submucosal infiltration. ese three
patients opted for diagnostic ESD, with definitive diag-
nosis relying on postoperative histopathological findings.
We selected 4 typical cases for presentation (Figs.2, 3, 4
and 5).
Accuracy of the infiltration depth in the coexist-
ence of EGC and benign submucosal lesions was sig-
nificantly lower among experienced and inexperienced
endoscopists than in EGC group (P = 0.0167, Fig. 6A,
B). We analyzed two groups of misdiagnosis cases, in
which the majority were over-diagnosed in the EGC-SML
group, with a significantly higher proportion than in the
EGC group (P < 0.0001, Fig.6C).
Discussion
is is the first study to summarize the clinical char-
acteristics of coexistent EGC and benign submucosal
lesions. Judgement of the infiltration depth in such cases
is challenging for both experienced and inexperienced
endoscopists. We found that these cases were important
causes of inaccurate judgement and over-staging. In clin-
ical practice, overestimation of the depth of EGC lesion
infiltration leads to unnecessary surgery, whereas under-
estimation of the depth of infiltration increases the risk of
secondary surgery.
For simple EGC, most studies and treatment guidelines
recommend conventional endoscopy as the most effec-
tive method to determine the infiltration depth, whereas
EUS should be used as an auxiliary method rather than a
routine examination [13, 14]. From another perspective,
EUS is the most effective method for the diagnosis of sub-
mucosal lesions. EUS can visualize submucosal lesions of
the upper digestive tract and provide information regard-
ing the layered structure of the digestive tract wall, origi-
nating layer of the lesions, and relationship between the
lesion and surrounding tissues, peripheral lymph nodes,
and adjacent organs [15, 16]. A retrospective study found
Fig. 3 Case 3: A A 1.5x1.5cm type II-a lesion with mucosal hyperemia and erosion is seen on the less curved side of the cardia on white-light
endoscopy. B The opening of the glandular duct can be seen at the edge of the lesion. C Microvascular and microglandular duct disorders seen
on magnification endoscopy. D High-grade intraepithelial neoplasia of the mucosal layer and submucosal pyloric gland ectopic (magnification 40x)
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Yangetal. BMC Gastroenterology (2023) 23:409
that the diagnostic accuracies of EUS were 80.4% for stro-
mal tumors and 68.0% for leiomyomas, with the highest
diagnostic accuracy for lesions located in the muscula-
ris mucosa [17]. However, the diagnosis of heterotopic
pancreas, inflammation, benign cyst, glomus tumor,
hamartoma, solitary fibroma, lymphangioma, angiogenic
tumor, and angiolipoma using EUS is difficult because of
their rarity and lack of characteristic features [17]. Accu-
rate assessments of EUS are crucial for the diagnosis of
these cases, and according to our study, the diagnostic
accuracy of EUS for submucosal solid lesions is relatively
high (100%), and all 3 cases of EGC coexisting with sub-
mucosal solid lesions were confirmed, which is consist-
ent with previous reports. Submucosal cystic lesions and
submucosal infiltration are indeed difficult to differenti-
ate, and only 4 of the seven cases (57.14%) in which EUS
was performed were properly diagnosed. Despite its
lower diagnostic efficiency, EUS plays a valuable role in
reducing the over-diagnosis of patients, and we recom-
mend its use when suspecting such diseases.
In addition to common leiomyomas and lipomas, the
types of submucosal lesions that coexist with early carci-
nomas include profound cystic gastritis, ectopic glands,
and inverted polyps. In our study, there was a high per-
centage of GCP, especially lesions in the cardia area. GCP
is common in elderly men and mainly located in the car-
dia and posterior and anterior walls of the gastric body;
the results of our case are similar to those reported in the
literature. Histopathological characteristics include gas-
tric glands extending into the submucosal layer owing to
hyperplasia and cystic dilatation [18]. GCP often presents
as a submucosal tumor, solitary polyps, gastric mucosal
fold, or even surface mucosa with no abnormal appear-
ance [19, 20]. Although GCP is a benign lesion, approxi-
mately 3% of gastric cancers coexist with this lesion. is
close association between GCP and malignancy suggests
that GCP may be a pre-malignant lesion or a concur-
rent sharing of causative factors common to both disease
conditions [20–22]. e diagnosis of EGC within GCP
is difficult using endoscopy or biopsy. EUS is valuable
Fig. 4 Case 4: A A 1.0x2.0cm elevated lesion on the posterior wall of the cardia with a rough mucosal surface and a slight central depression.
B ME-NBI shows an increase in the microvascular diameter and irregular microglandular pattern. C Endoscopic ultrasonography scan showing
a 2.0x1.6cm hypoechoic cluster with homogeneous internal echogenicity. D A leiomyoma in the submucosa (magnification 40x). ME-NBI,
magnifying endoscopy with narrow-band imaging
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Yangetal. BMC Gastroenterology (2023) 23:409
for the endoscopic diagnosis of GCP, but it is often con-
fused with other submucosal gastric lesions without typi-
cal manifestations [23]. It is primarily anechoic, mixed
heterogeneous with thickened overlying mucosa, or
hypoechoic with microcysts [19]. ESD is also an effec-
tive method for the diagnosis of such cases. Once GCP is
detected, monitoring for EGC needs to be the focus.
Since it is difficult to diagnose such diseases by endos-
copy alone, all patients in this study underwent enhanced
CT before ESD surgery, which provided suggestive infor-
mation in only two cases of submucosal solid lesions, in
other cases CT examination did not reveal valuable find-
ings about submucosal lesions. is limitation can be
attributed to factors such as the small size of the lesions,
inadequate gastric filling in patients with low water
intake, and the poor contrast of the contrast agent. CT
and MRI do have significant limitations in predicting the
depth of EGC infiltration. EGC with suspected deep infil-
tration requires careful selection of the treatment strate-
gies. Based on our study, we designed a flow diagram for
the diagnosis of coexisting EGC and benign submucosal
lesions (Fig.7). It seems more reasonable to consider that
the two categories based on submucosal lesions are solid
or cystic, with the former being easily diagnosed and the
latter requiring careful differentiation. In cases where
there is a suspicion of EGC coexisting with submucosal
cystic lesions, the option of diagnostic endoscopic resec-
tion may be considered, with additional surgical proce-
dures if necessary according to postoperative pathologic
results. Based on the characteristics of the cases in this
study, we have summarized five typical features that
help to confirm the diagnosis when EGCs are combined
with the following characteristics: (1) there are glandu-
lar duct openings on the surface of the lesion, and cystic
fluid outflow is visible; (2) the lesion is located in the
cardia; (3) the patient is an elderly male; (2) the bound-
ary of the lesion is poorly defined on EUS, and an echo-
genic area is visible; and (4) the surface mucosa is mostly
differentiated from early carcinomas or precancerous
lesions. Among the 13 cases in this study, all patients
Fig. 5 Case 13: A A type IIa+IIc lesion measuring approximately 2.0x3.0 cm is seen in the lower curvature of the gastric body with clear borders.
B Magnification endoscopy showing a disorganized surface with a microvascular diameter and microglandular pattern. C A yellow tumor
with indistinct borders is seen in the submucosa after dissection. D Low-grade intraepithelial neoplasia in the mucosal layer and submucosal
ectopic pancreas (magnification 40x)
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Yangetal. BMC Gastroenterology (2023) 23:409
(13/13,100%) satisfied two predictor factors, 10 (10/13,
76.9%) fulfilled three factors, and 3 (3/13, 30.8%) met four
factors. e more characteristics that apply, the higher
the possibility of suspected early cancer synchronous
with submucosal cystic lesions; therefore, diagnostic ESD
is recommended. In the future, we intend to augment the
sample size to further validate.
is study has a couple of limitations. First, because the
data were analyzed retrospectively, there may have been
a selection bias. Second, a subgroup analysis between
the submucosal solid and cystic groups could not be
conducted because of the small number of patients. Our
experiences mainly provide an suggestions for future
directions, and further studies are needed to prove our
inference.
Conclusion
e coexistence of EGC and benign submucosal lesions
is challenging for endoscopists because of the ease of
overdiagnosis. Early cardiac-differentiated cancer with
Fig. 6 A Accuracy rate in diagnosing the EGC-SML and EGC infiltration depth for each endoscopist. B Comparison of the diagnostic accuracy
between the EGC-SML and EGC group, P=0.0167. C Over-diagnosis rate in group EGC-SML and EGC, P<0.0001. EGC-SML, coexistence of early gastric
cancer and benign submucosal lesions; EGC, simple early gastric cancer
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Yangetal. BMC Gastroenterology (2023) 23:409
gastritis cystica profunda is the most common condition.
In the diagnosis and treatment of EGC and precancerous
lesions, no diagnostic criterion is absolute, and the more
comprehensive the preoperative consideration, the more
scientific the treatment plan.
Acknowledgements
Not applicable.
Authors’ contributions
Author contributions: Huawei YANG, MD: conception and design; analysis and
interpretation of the data; drafting of the article; final approval of the article.
Zhen LI, MD, PhD: analysis and interpretation of the data; critical revision of the
article for intellectual content; final approval of the article. Zhi WEI, MD: analysis
and interpretation of the data; final approval of the article. Guodong LI, MD, PhD:
analysis and interpretation of the data; final approval of the article. Yi LI, MD:
analysis and interpretation of the data; final approval of the article. Shanbin WU,
MD: analysis and interpretation of the data; final approval of the article. Rui JI,
MD, PhD: conception and design; analysis and interpretation of the data; critical
revision of the article for intellectual content; final approval of the article.
Funding
The study was supported by Nature Science Foundation of Shandong Prov-
ince, China (ZR2020LZL003) and the Taishan Scholars Program of Shandong
Province.
Availability of data and materials
The datasets used and/or analysed during the current study available from the
corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The authors declare that all procedures performed in studies were in accord-
ance with the ethical standards of the institutional and/or national research
committee and with the 1964 Helsinki declaration and its later amendments.
This study was approved by the Ethics Committee of Qilu Hospital, Shandong
University (NO.2022-029). Written informed consent was waived by Ethical
committee of Qilu Hospital, Shandong University (NO.2022-029).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Received: 22 May 2023 Accepted: 8 November 2023
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