Serum CA 19 − 9 and CA 72 − 4 levels in hashimoto’s thyroiditis: a prospective case-control study

Abstract

Background

Hashimoto’s thyroiditis is a common autoimmune thyroid disorder and a leading cause of subclinical hypothyroidism. Tumor markers such as CA 19 − 9 and CA 72 − 4 may also be elevated in certain benign inflammatory conditions. This study aimed to investigate the levels of CA 19 − 9 and CA 72 − 4 in patients with subclinical hypothyroidism due to Hashimoto’s thyroiditis and to evaluate the effects of levothyroxine treatment.

Methods

This prospective case-control study included 30 patients with subclinical hypothyroidism due to Hashimoto’s thyroiditis and 30 healthy controls matched by age and sex. Serum levels of CA 19 − 9, CA 72 − 4, TSH, free T4, TPOAb, and TgAb were measured at baseline and after 6 weeks of levothyroxine therapy. Additionally, correlations between tumor markers and thyroid function parameters were analyzed.

Results

Initially, there were no significant differences in CA 19 − 9 and CA 72 − 4 levels between the patient and control groups. Following treatment, a significant decrease in CA 19 − 9 levels was observed in patients who achieved euthyroidism (p = 0.020), whereas no significant change was detected in CA 72 − 4 levels.

Conclusions

CA 19 − 9 and CA 72 − 4 levels do not appear to differ significantly between patients with subclinical hypothyroidism due to Hashimoto’s thyroiditis and healthy individuals. However, CA 19 − 9 levels may decrease upon restoration of euthyroidism, potentially reflecting a reduction in thyroid-related inflammation. Further studies with larger cohorts and longer follow-up periods are warranted to confirm and clarify these observations.

Background

Hashimoto’s thyroiditis is an autoimmune disease and the leading cause of hypothyroidism in iodine-sufficient regions [1, 2]. Both cellular and humoral immune responses play a role in the pathogenesis of Hashimoto’s thyroiditis [3]. Nearly all patients with this condition exhibit elevated serum levels of antibodies to thyroglobulin (TgAb) and thyroid peroxidase (TPOAb). The onset of Hashimoto’s thyroiditis is typically attributed to a combination of genetic susceptibility and environmental factors [4]. In patients with mild (subclinical) hypothyroidism—characterized by slightly elevated thyroid-stimulating hormone (TSH) levels, normal free thyroxine (T4) concentrations, and the presence of antithyroid antibodies—overt hypothyroidism progresses at a rate of approximately 5% per year [5, 6].

Tumor markers are commonly used in clinical practice to monitor cancer recurrence and metastasis. Carbohydrate Antigen 19 − 9 (CA 19 − 9) and Carbohydrate Antigen 72 − 4 (CA 72 − 4) are glycoproteins involved in tissue adhesion, and their levels may be elevated in conditions characterized by increased cell turnover and inflammation. CA 19 − 9 is present in the normal epithelial lining of the biliary tract, gastric mucosa, pancreatic duct, and bronchial glands. CA 19 − 9 and CA 72 − 4 are used in the follow-up of various malignancies, including cholangiocellular carcinoma, pancreatic cancer, hepatoma, gastric cancer, colorectal cancer, and gynecological cancers [7]. They can also be elevated in less common malignancies such as lung cancer, mediastinal teratoma, ovarian cystic teratoma, prostate cancer, transitional cell carcinoma, and thyroid cancer. Additionally, CA 19 − 9 and CA 72 − 4 may be elevated in benign conditions like cirrhosis, primary sclerosing cholangitis, inflammatory bowel diseases, splenic cysts, pyelonephritis, urethral strictures, hydronephrosis, subacute thyroiditis, thyroid nodules, collagen vascular diseases, and bronchiectasis [8].

In this study, we aimed to compare the levels of CA 19 − 9 and CA 72 − 4 in patients with subclinical hypothyroidism caused by Hashimoto’s thyroiditis to those of healthy volunteers, as well as to investigate the impact of oral levothyroxine treatment on these marker levels.

Materials and methods

The study involved 30 patients diagnosed with subclinical hypothyroidism resulting from Hashimoto’s thyroiditis as the patient group and 30 healthy volunteers as the control group. Approval for the study was obtained from Turgut Özal University Faculty of Medicine Clinical Local Ethics Committee (Ethical approval number: 99950669-6; clinical trial number: not applicable). Exclusion criteria for the study included a history of malignancy, being under 18 or over 70 years old, pregnancy, other autoimmune diseases, endocrine disorders, patients with gallstones (even if asymptomatic), liver damage (such as fatty liver disease), diabetes, or individuals who consume excessive amounts of tea. Additional exclusions included patients with gastritis, gastric ulcers, Helicobacter pylori infection, cigarette smokers, cirrhosis, primary sclerosing cholangitis, inflammatory bowel diseases, celiac disease, splenic cysts, pyelonephritis, urethral strictures, hydronephrosis, subacute thyroiditis, thyroid nodules, collagen vascular diseases, bronchiectasis, and those diagnosed with or treated for overt hypothyroidism or hyperthyroidism due to Hashimoto’s thyroiditis. This study was conducted in accordance with the guidelines of the Declaration of Helsinki. Written informed consent was obtained from all individual participants.

CA 19 − 9, CA 72 − 4, TSH, free T4, and thyroid autoantibodies (TPOAb and TgAb) were measured, and thyroid ultrasonography was performed on all participants, including healthy volunteers. Patients with abnormal CA 19 − 9 and CA 72 − 4 test results underwent further diagnostic evaluations, including assessments for celiac antibodies, chest radiography, colonoscopy, abdominal ultrasonography, and upper gastrointestinal endoscopy. In cases where abnormalities were detected during endoscopic or colonoscopic examinations, biopsies were obtained to exclude underlying malignancies, celiac disease, or inflammatory bowel disease. The presence of TPOAb and TgAb, along with heterogeneous parenchyma observed during thyroid ultrasonography, served as diagnostic criteria for Hashimoto’s thyroiditis. In contrast, a high TSH level (> 4 mIU/L) with normal free T4 and the absence of clinical manifestations of overt hypothyroidism were criteria for diagnosing subclinical hypothyroidism [9]. We acknowledge that there is no universal consensus on the upper limit of TSH or the necessity of thyroxine therapy in subclinical hypothyroidism. The treatment decisions were made in accordance with the American Thyroid Association guidelines (ATA), the European Thyroid Association guidelines, and institutional practice patterns. Oral levothyroxine treatment (25–75 micrograms per day) was prescribed to manage subclinical hypothyroidism according to the ATA for hypothyroidism treatment [9–11].

Patients were re-evaluated six weeks after their initial examination, and the levels of CA 19 − 9, CA 72 − 4, TSH, free T4, TPOAb, and TgAb were measured again. Blood samples collected in gel tubes were allowed to clot for 20 min upon arrival at the laboratory. The samples were centrifuged at 4000 rpm for 10 min, and the separated serum was stored at −80 °C. TSH, free T4, TPOAb, TgAb, CA 72 − 4, and CA 19 − 9 levels were measured using the Roche Cobas 6000 series e601 (Roche Diagnostics, Mannheim, Germany) via an electrochemiluminescence immunoassay method. Thyroid gland ultrasonography was conducted using a Philips IU22 device with an L12-5 probe.

Statistical analyses were conducted using SPSS software (version 22.0, SPSS Inc., Chicago, IL, USA). Descriptive statistics are reported as percentages and frequencies for categorical variables and as quartile ranges (QR) for continuous variables. The Kolmogorov-Smirnov test was used to assess the normality of the data distribution. T-tests were used to compare TSH, free T4, TPOAb, TgAb, CA 19 − 9, and CA 72 − 4 levels between the subclinical hypothyroidism and control groups, as well as these parameters pre- and post-treatment in the subclinical hypothyroidism group. The chi-square test compared categorical variables. Pearson correlation analysis was utilized for parametric data, while Spearman correlation analysis was employed for nonparametric data. A p-value of < 0.05 was considered statistically significant.

Results

The mean age of the patient group was 37.5 years (range: 18–59), whereas the mean age of the control group was 35 years (range: 23–52), with no statistically significant difference between the groups. Both the patient group, consisting of individuals with subclinical hypothyroidism due to Hashimoto’s thyroiditis, and the control group included 26 females (86.7%) and 4 males (13.3%), indicating a comparable gender distribution. Serum TSH levels (6.35 IU/mL [IQR: 5.00–7.46] vs. 1.99 IU/mL [IQR: 0.48–3.90]), TPOAb levels (534.30 U/mL [IQR: 35.49–4000] vs. 8.66 U/mL [IQR: 5.00–33.19]), and TgAb levels (318.17 U/mL [IQR: 18.60–1789] vs. 17.25 U/mL [IQR: 6.32–51.01]) were significantly higher in the patient group compared to the controls (p = 0.009, p = 0.005, and p = 0.006, respectively) (Table 1). There were no significant differences in CA 19 − 9 levels between the patient and control groups (13.84 U/mL [IQR: 2.72–25.41] vs. 15.38 U/mL [IQR: 2.63–30.91], p = 0.350). Similarly, CA 72 − 4 levels did not differ significantly between the groups (0.99 U/mL [IQR: 0.62–6.86] vs. 0.55 U/mL [IQR: 0.21–5.17], p = 0.450). Additionally, free T4 levels were comparable between the groups (1.09 ng/dL [IQR: 0.8–1.70] vs. 1.19 ng/dL [IQR: 0.94–1.69]), with no significant difference observed (p = 0.40) (Table 1).

Table 1.

Demographic and laboratory characteristics of the study population

Variables	Patient Group (n = 30)	Control Group (n = 30)	P-value
Age, years (mean, range)	37.50 (18–59)	35.00 (23–52)	0,524
Sex (female/male), n (%)	26 (86.7%)/4 (13.3%)	26 (86.7%)/4 (13.3%)	0,421
TSH (IU/mL), median (IQR)	6.35 (5.00–7.46)	1.99 (0.48–3.90)	0.009
TPOAb (U/mL), median (IQR)	534.30 (35.49–4000)	8.66 (5.00–33.19)	0.005
TgAb (U/mL), median (IQR)	318.17 (18.60–1789)	17.25 (6.32–51.01)	0.006
CA 19 − 9 (U/mL), median (IQR)	13.84 (2.72–25.41)	15.38 (2.63–30.91)	0.350
CA 72 − 4 (U/mL), median (IQR)	0.99 (0.62–6.86)	0.55 (0.21–5.17)	0.450
Free T4 (ng/dL), median (IQR)	1.09 (0.80–1.70)	1.19 (0.94–1.69)	0.400

TSH Thyroid-stimulating hormone, TPOAb Thyroid peroxidase antibody, TgAb Thyroglobulin antibody, CA Carbohydrate antigen, T4 Thyroxine

Post-treatment TSH levels were significantly lower compared to pre-treatment values in patients with subclinical hypothyroidism due to Hashimoto’s thyroiditis (2.75 IU/mL [IQR: 0.31–6.25] vs. 6.35 IU/mL [IQR: 5.00–7.46], p = 0.001), while free T4 levels were significantly higher (1.30 ng/dL [IQR: 0.91–2.22] vs. 1.09 ng/dL [IQR: 0.8–1.70], p = 0.01) (Table 2). However, there were no significant differences in TPOAb, TgAb, and CA 72 − 4 levels between pre- and post-treatment measurements (p = 0.25, p = 0.10, and p = 0.470, respectively). In contrast, CA 19 − 9 levels were significantly higher after treatment compared to baseline (14.90 U/mL [IQR: 2.67–36.14] vs. 13.84 U/mL [IQR: 2.72–25.41], p = 0.04) (Table 2).

Table 2.

Evaluation of patients with subclinical hypothyroidism due to hashimoto’s thyroiditis before and after treatment

Pa Variables	Pre-treatment (n = 30) Median (IQR)	Post-treatment (n = 30) Median (IQR)	P-value
TSH, IU/mL	6.35 (5.00–7.46)	2.75 (0.31–6.25)	0.001
TPOAb, U/mL	534.30 (35.49–4000)	234.50 (36.2–4000)	0.250
TgAb, U/mL	318.00 (18.60–1789)	197.6 (20.40–1792)	0.100
CA 19 − 9, U/mL	13.84 (2.72–25.41)	14.90 (2.67–36.14)	0.040
CA 72 − 4, U/mL	0.99 (0.62–6.86)	1.05 (0.65–5.47)	0.470
Free T4, ng/dL	1.09 (0.80–1.70)	1.30 (0.91–2.22)	0.010

TSH Thyroid-stimulating hormone, TPOAb Thyroid peroxidase antibody, TgAb Thyroglobulin antibody, CA Carbohydrate antigen, T4 Thyroxine, IQR Interquartile range

A significant correlation was identified between pre-treatment CA 72 − 4 levels and both TSH and TPOAb levels in patients with subclinical hypothyroidism due to Hashimoto’s thyroiditis (p = 0.007, r = 0.484; and p = 0.001, r = 0.799, respectively). Furthermore, a significant correlation was observed between post-treatment CA 19 − 9 levels and TSH levels in these patients (p = 0.003, r = 0.518) (Table 3). When the pre-treatment and post-treatment groups were compared according to sex, no significant differences were found in CA 19 − 9 or CA 72 − 4 levels (p = 0.339 and p = 0.540, respectively).

Table 3.

Correlation table of TSH, tgab, and TPOAb with CA 19 − 9 and CA 72 − 4 for the patient group

Pre-treatment		TSH	T4	TgAb	TPOAb
CA 19 − 9, U/mL	r	0.284	0.084	0.217	0.142
	p	0.128	0.660	0.248	0.454
CA 72 − 4, U/mL	r	0.484	−0.125	0.081	0.799
	p	0.007	0.509	0.67	0.001
Post-treatment
CA 19 − 9, U/mL	r	0.518	0.055	0.042	0.293
	p	0.003	0.772	0.824	0.116
CA 72 − 4, U/mL	r	−0.145	0.183	−0.078	−0.052
	p	0.445	0.334	0.684	0.783
Control
CA 19 − 9, U/mL	r	0.039	0.053	−0.012	0.058
	p	0.838	0.783	0.952	0.760
CA 72 − 4, U/mL	r	−0.148	0.113	0.144	−0.322
	p	0.434	0.553	0.449	0.083

TSH Thyroid-stimulating hormone, TPOAb Thyroid peroxidase antibody, TgAb Thyroglobulin antibody, CA Carbohydrate antigen, T4 Thyroxine

Changes in CA 19 − 9 and CA 72 − 4 levels after achieving euthyroid status

In the subgroup of 12 patients who achieved euthyroid status after treatment, CA 19 − 9 levels showed a statistically significant decrease (p = 0.020). TSH and free T4 levels improved as expected with levothyroxine replacement (p = 0.002 and p = 0.005, respectively). Antibody titers (TPOAb and TgAb) showed a decreasing trend, but this change was not statistically significant. These results are presented in Table 4, and also the changes in CA 19 − 9 and CA 72 − 4 levels before and after treatment are illustrated in Figs. 1 and 2, respectively.

Table 4.

Changes in CA 19 − 9 and CA 72 − 4 before and after achieving euthyroidism in patients with hashimoto’s thyroiditis

Variables	Pre-treatment (n = 12) Median (IQR)	Post-treatment (n = 12) Median (IQR)	P-value
TSH (IU/mL)	7.45 (4.25–8.35)	1.95 (0.40–3.40)	0.002
TPOAb (U/mL)	640.00 (80.00–3000)	400.00 (70.00–2700)	0.150
TgAb (U/mL)	360.00 (45.00–1250)	210.00 (35.00–1180)	0.120
CA 19 − 9 (U/mL)	18.90 (11.40–29.80)	11.20 (4.80–16.50)	0.020
CA 72 − 4 (U/mL)	0.95 (0.60–3.20)	0.90 (0.65–2.80)	0.500
Free T4 (ng/dL)	0.92 (0.78–1.10)	1.35 (1.10–1.60)	0.005

TSH Thyroid-stimulating hormone, TPOAb Thyroid peroxidase antibody, TgAb Thyroglobulin antibody, CA Carbohydrate antigen, T4 Thyroxine, IQR Interquartile range

Fig. 1.

Comparison of CA 19 − 9 levels before and after achieving euthyroid status in patients with Hashimoto’s thyroiditis

Fig. 2.

Comparison of CA 72 − 4 levels before and after achieving euthyroid status in patients with Hashimoto’s thyroiditis

Discussion

In this study, we investigated the alterations in CA 19 − 9 and CA 72 − 4 levels in patients with subclinical hypothyroidism due to Hashimoto’s thyroiditis and evaluated their relationship with thyroid function parameters before and after treatment. Our findings demonstrated that serum TSH, TPOAb, and TgAb levels were significantly higher in the patient group compared to healthy controls, as expected in the context of autoimmune thyroiditis. Although CA 19 − 9 levels were lower and CA 72 − 4 levels were higher in patients than in controls, these differences did not reach statistical significance. Following levothyroxine therapy, a significant reduction in TSH levels and an increase in free T4 levels were observed, confirming the effectiveness of treatment in achieving euthyroidism. Notably, while CA 19 − 9 levels showed a significant increase in the overall patient group after treatment, a subgroup analysis revealed a significant decrease in CA 19 − 9 levels among those who achieved euthyroid status. Furthermore, correlations were identified between pre-treatment CA 72 − 4 levels and both TSH and TPOAb levels, as well as between post-treatment CA 19 − 9 levels and TSH levels.

The gender and age distribution in our study is similar to those reported in the literature [12]. Studies indicate that Hashimoto’s thyroiditis is a prevalent condition among middle-aged individuals and occurs more frequently in women than in men [13]. In the present study, there is no significant difference in CA 19 − 9 and CA 72 − 4 levels between the patient and control groups. In the literature, conflicting results are associated with this finding [14–17]. For instance, in a study by Sezer et al., no significant difference in CA 19− 9 levels was observed between hypothyroid and euthyroid patients with Hashimoto’s thyroiditis. Although their study involved a larger sample size (n = 71), our research similarly found no difference in CA 19 − 9 and CA 72 − 4 levels between patients with subclinical hypothyroidism due to Hashimoto’s thyroiditis and the control group [15]. In contrast, a case report described a patient presenting with weight loss and an elevated CA19-9 level. After a thorough evaluation, no malignancy was detected. The TSH level was 7.71 mIU/L, and following the initiation of levothyroxine replacement, the CA 19 − 9 level gradually decreased and returned to normal [16]. These differences in the literature may result from the severity of Hashimoto’s thyroiditis. We know that CA 19 − 9 and CA 72 − 4 are secreted jointly from tumors that produce mucin, including those in the organ and gland. These glycoproteins are often released by tumors and inflamed tissues, reflecting the processes of cell turnover and fibrosis. The increase in these markers is typically linked to malignancies characterized by an accelerated cell cycle and fibrosis [18]. Hashimoto’s thyroiditis, characterized by an initial inflammatory response that leads to fibrosis, involves complex immune processes and cytokine release [14, 19]. This autoimmune and inflammatory process may cause elevation of CA 19 − 9 and CA 72 − 4 levels.

CA 19 − 9 levels were significantly higher in certain autoimmune diseases, including rheumatoid arthritis, systemic sclerosis, and autoimmune hepatitis, as reported in the literature [20–22]. In our study, no significant differences were observed in CA 19 − 9 and CA 72 − 4 levels between healthy controls and individuals with subclinical hypothyroidism secondary to Hashimoto’s thyroiditis. This finding may be explained by the fact that, unlike studies involving rheumatologic diseases, which often include patients with systemic involvement such as pulmonary complications, our study specifically excluded individuals with any benign or malignant pulmonary conditions. Moreover, our exclusion criteria were comprehensive, aiming to eliminate potential confounding factors that could influence tumor marker levels.

In the present study, we demonstrated that after achieving euthyroidism, there was a significant reduction in CA 19 − 9 levels, and TPOAb and TgAb levels also decreased; however, this finding was not statistically significant. These results may be attributed to the mitigation of the inflammatory process. In the literature, levothyroxine replacement therapy is a well-known and accepted treatment for hypothyroidism caused by Hashimoto’s thyroiditis. The literature presents conflicting data regarding the reduction of thyroid autoantibodies and the suppression of inflammation with levothyroxine treatment in Hashimoto’s thyroiditis [23]. Guclu et al. showed that after a 10–12 week period of thyroxine replacement, there is a significant reduction in anti-TPO and anti-TG levels, and a significant decrease in interleukin-12 serum levels [24]. In our study, no significant reduction was observed in thyroid autoantibody levels (TPOAb and TgAb) following six weeks of levothyroxine treatment. These conflicting results may be attributed to variations in sample size and the heterogeneity in the severity of Hashimoto’s thyroiditis among patients. Furthermore, the initial analysis of the overall patient group revealed an increase in CA 19 − 9 levels, which may suggest the persistence of underlying inflammatory activity. However, in the subgroup analysis of patients who achieved euthyroid status, a significant decrease in CA 19 − 9 levels was identified. The decline in CA 19 − 9 levels could reflect a decrease in systemic or local inflammation associated with thyroid dysfunction, supporting the hypothesis that successful thyroid hormone replacement not only restores euthyroidism but may also have favorable effects on inflammatory markers.

CA 19 − 9, a sialylated Lewis antigen, is recognized for its role as a tumor marker in gastrointestinal cancers. However, emerging evidence suggests it may also be involved in cellular processes such as proliferation and differentiation. In vitro studies indicate that CA 19 − 9 can be expressed in non-cancerous cells, particularly epithelial cells, which may contribute to cellular adhesion and signaling pathways related to cell growth and differentiation [25–27]. Additionally, research has shown that CA 19 − 9 levels may be elevated in conditions associated with tissue injury, such as increased cellular turnover or regenerative processes [28–30]. This raises the possibility that elevated CA 19 − 9 levels in patients with Hashimoto’s thyroiditis may suggest a proliferative process in the thyroid or other tissues affected by hypothyroidism. Similarly, CA 72 − 4, a mucin-like glycoprotein, has been linked to various stages of cancer progression, particularly in gastric and ovarian cancers [31–33]. However, it has also been proposed that CA 72 − 4 may regulate apoptosis and cell differentiation, especially in epithelial tissues. In patients with Hashimoto’s thyroiditis, where autoimmune-mediated damage to the thyroid can lead to compensatory tissue remodeling, elevated CA 72 − 4 levels may indicate this regenerative process rather than an inflammatory or malignant response [32, 34, 35].

This study has several limitations that should be considered when interpreting the findings. First, the relatively small sample size may have limited the statistical power to detect subtle differences in CA 19 − 9 and CA 72 − 4 levels, thereby restricting the generalizability of the results. Second, the follow-up duration of six weeks was relatively short, which may not have been sufficient to capture the long-term biochemical effects of levothyroxine therapy or sustained changes in tumor marker levels. Third, not all patients achieved biochemical euthyroidism during this period, which may have introduced variability into the results. Fourth, the single-center design limits the external validity of the study and may reduce its applicability to broader populations. Despite these limitations, the study also has several strengths. Its prospective design enabled systematic evaluation of biochemical changes before and after treatment within the same cohort, thereby reducing potential biases. The application of rigorous and comprehensive exclusion criteria minimized confounding factors, enhancing the reliability of the results. Furthermore, the use of standardized laboratory methods improved the consistency and reproducibility of biochemical measurements. Importantly, by exploring tumor markers in patients with Hashimoto’s thyroiditis and subclinical hypothyroidism, the study provides new insights into an underexplored area with potential clinical relevance, particularly for the interpretation of CA 19 − 9 and CA 72 − 4 levels in this patient population.

Conclusions

In patients with subclinical hypothyroidism due to Hashimoto’s thyroiditis, levothyroxine replacement improved thyroid function and was associated with a significant reduction in CA 19 − 9 levels among those who achieved euthyroidism. These findings suggest that fluctuations in CA 19 − 9 might not only indicate malignancy but could potentially be associated with autoimmune-mediated inflammation or regenerative responses linked to thyroid tissue injury and remodeling. Therefore, careful interpretation of this biomarker is necessary to prevent unnecessary diagnostic interventions. Larger, multicenter studies with longer follow-up are warranted to understand better the clinical importance and potential utility of CA 19 − 9 and CA 72 − 4 in autoimmune thyroid disorders.

Abbreviations

TSH

Thyroid stimulating hormone

TPOAb

Thyroid peroxidase antibody

TgAb

Thyroglobulin antibody

CA 19-9

Carbohydrate antigen 19-9

CA 72-4

Carbohydrate antigen 72-4

T4

Thyroxine

ATA

American thyroid association

IQR

Interquartile range

Authors’ contributions

H.D. E.U., E.A., and H.U. contributed to the concept and design of the study. H.D. E.U. and E.A. contributed to the data acquisition. H.D., E.A., and H.U. performed the statistical analysis. H.D. and E.U. drafted the manuscript. All authors contributed to the analysis and interpretation of the data and critically revised the manuscript. All authors have approved the final version of the manuscript.

Funding

The authors did not receive support from any organization for the submitted.

work.

Data availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study conformed to the guidelines of the Declaration of Helsinki, and the study procedures were reviewed and approved by Turgut Özal University Faculty of Medicine Clinical Local Ethics Committee (Ethics Committee Approval Number: 99950669-6). Each patient agreed to participate and signed the informed consent form.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.