Abstract
Background
Computed tomography pulmonary angiography (CTPA) is widely used for diagnosing pulmonary embolism (PE) and frequently reveals incidental pulmonary nodules. However, data regarding the prevalence and malignant outcomes of incidental pulmonary nodules, particularly among patients with PE, remain limited in Thailand. This study aimed to investigate the prevalence of incidental pulmonary nodules detected on CTPA and to evaluate malignancy outcomes, particularly in patients with concurrent PE.
Methods
This retrospective cohort study included patients aged ≥18 years who underwent CTPA at King Chulalongkorn Memorial Hospital between January 2017 and December 2018. Patients with active lung cancer or known pulmonary metastases were excluded. Clinical characteristics, CTPA findings, and follow-up data were reviewed. Pulmonary nodules were followed until a definitive diagnosis was established, until May 2024, or for a minimum of 2 years in the absence of interval growth.
Results
A total of 376 patients were included in the analysis. Incidental pulmonary nodules were identified in 129 patients (34.3%), while PE was diagnosed in 110 patients (29.3%). The prevalence of incidental pulmonary nodules did not differ significantly between the PE-positive and PE-negative groups (29.1% vs. 36.5%; P=0.17). Category-specific analyses demonstrated that patients with PE had a higher proportion of pulmonary nodules >8 mm (21.9% vs. 9.3%) and malignant outcomes (18.8% vs. 3.1%) than those without PE. Relative risks (RRs) with corresponding 95% confidence intervals (CIs) are reported in the Results section. Among the 9 patients ultimately diagnosed with malignancy, most received a definitive diagnosis within 6 months following CTPA.
Conclusions
The prevalence of incidental pulmonary nodules detected on CTPA were common and occurred more frequently than previously reported in several international studies. Patients with concurrent PE were more likely to have pulmonary nodules >8 mm and malignant outcomes than patients without PE. These findings suggest that incidental pulmonary nodules detected in patients with concomitant PE may identify a subgroup warranting careful clinical follow-up. Because of the retrospective design and limited number of malignant outcomes, larger prospective studies are required before changes to current surveillance strategies can be recommended.
Keywords: Pulmonary embolism (PE), incidental pulmonary nodule, computed tomography pulmonary angiography (CTPA), lung malignancy, cancer-associated thrombosis
Highlight box.
Key findings
• Incidental pulmonary nodules were identified in 34.3% of patients undergoing computed tomography pulmonary angiography (CTPA).
• Patients with pulmonary embolism (PE) demonstrated significantly higher malignancy rates and larger pulmonary nodules.
What is known and what is new?
• Incidental pulmonary nodules are commonly detected on CTPA.
• This study demonstrated a higher proportion of malignant outcomes among PE-positive patients in a Thai tertiary-care cohort.
What is the implication, and what should change now?
• Pulmonary nodules detected during PE evaluation may represent a higher-risk subgroup.
• Incidental pulmonary nodules with concomitant PE may warrant closer follow-up.
Introduction
Pulmonary embolism (PE) is a common and potentially life-threatening condition that contributes substantially to global morbidity and mortality. Computed tomography pulmonary angiography (CTPA) is currently the imaging modality of choice for the diagnosis of PE and has consequently become increasingly utilized in routine clinical practice (1-3).
In addition to detecting PE, CTPA frequently identifies incidental thoracic abnormalities. Previous studies have demonstrated that non-PE findings are common, with pulmonary nodules representing one of the most clinically significant incidental findings because of their potential association with underlying malignancy (2,3). Prior studies from North America and Europe have reported pulmonary nodule detection rates ranging from approximately 4% to 9% among patients undergoing CTPA, with a subset subsequently diagnosed with lung cancer (1-3).
In Thailand, data regarding incidental pulmonary nodules detected on CTPA remain limited. A previous Thai study reported incidental lung cancer findings in patients undergoing CTPA for suspected PE (4), while another study from King Chulalongkorn Memorial Hospital demonstrated a high prevalence of malignancy among patients with solitary pulmonary nodules detected on computed tomography (5). However, the prevalence and malignant outcomes of incidental pulmonary nodules detected during CTPA evaluation, particularly among patients with concurrent PE, remain poorly characterized in the Thai population.
Therefore, this study aimed to investigate the prevalence of incidental pulmonary nodules detected on CTPA at King Chulalongkorn Memorial Hospital and to evaluate malignancy outcomes following longitudinal follow-up, particularly in patients with concurrent PE. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1524/rc).
Methods
Study design and setting
This retrospective cohort study was conducted at King Chulalongkorn Memorial Hospital, a tertiary-care university hospital in Bangkok, Thailand. Consecutive adult patients who underwent CTPA between January 1, 2017 and December 31, 2018 were identified from the institutional radiology database without additional sampling to minimize selection bias.
Study population
All patients aged ≥18 years who underwent CTPA at King Chulalongkorn Memorial Hospital between January 1, 2017 and December 31, 2018 were included consecutively regardless of the indication for CTPA.
Patients were eligible for inclusion if they were aged ≥18 years and underwent CTPA during the study period. Patients with active lung cancer or pulmonary metastases from other malignancies were excluded from the study.
Imaging evaluation and definitions
CTPA findings were retrospectively reviewed from official radiology reports and electronic medical records. Pulmonary nodules were defined as focal rounded pulmonary opacities measuring ≤3 cm in maximum diameter and surrounded by lung parenchyma. Pulmonary masses were defined as pulmonary lesions measuring >3 cm in maximum diameter (6,7).
CTPA examinations were performed using multidetector CT scanners according to the institutional protocol. Images were reconstructed as thin-section axial images with multiplanar reformations when necessary for pulmonary nodule measurement. Pulmonary nodule size was determined using the maximum axial diameter, with multiplanar reformations used when appropriate according to routine clinical practice.
Pulmonary nodules were categorized according to maximal diameter as: <6, 6–8, and >8 mm based on the Fleischner Society classification. And pulmonary nodules were additionally categorized according to number of nodules (single or multiple), and laterality (unilateral or bilateral). Other non-pulmonary nodule abnormalities identified on CTPA were also recorded. Because pulmonary nodules were identified from finalized radiology reports, detailed morphologic characteristics (solid vs. subsolid appearance, ground-glass opacity, spiculation, calcification, upper-lobe predominance, and interval growth pattern) were not consistently available and therefore were not analyzed.
In this study, active lung cancer was defined as stage I lung cancer undergoing treatment or within 2 years after completion of treatment, and stage II–IV lung cancer undergoing treatment or within 5 years after completion of treatment.
Pulmonary metastasis was defined as metastatic involvement of the lung originating from extrapulmonary malignancies, supported by abnormalities detected on chest radiography, computed tomography imaging, or histopathologic findings.
Data collection
Electronic medical records were reviewed to obtain demographic and clinical data, including age, sex, presenting symptoms, underlying diseases, history of malignancy, CTPA findings, pulmonary nodule characteristics, diagnostic procedures, and follow-up outcomes.
Follow-up and outcome assessment
Patients with incidentally detected pulmonary nodules underwent longitudinal follow-up through review of electronic medical records, imaging studies, histopathologic reports, and clinical documentation. Patients were followed through review of electronic medical records until a definitive diagnosis was established, until May 2024, or for a minimum of 2 years in the absence of interval growth.
Malignant outcomes were defined by either histopathologic confirmation or characteristic radiologic progression interpreted by board-certified radiologists in conjunction with multidisciplinary clinical assessment. Benign nodules were defined according to finalized radiologic reports indicating benign characteristics or interval stability during follow-up. Indeterminate nodules referred to lesions without sufficient evidence for definitive benign or malignant classification based on finalized radiologic reports during the follow-up period. Nodules were classified as unknown when follow-up information or final diagnostic data were unavailable. Four malignant cases were confirmed histopathologically, whereas five were diagnosed on the basis of radiologic progression during follow-up.
Statistical analysis
Categorical variables are presented as frequencies and percentages, whereas continuous variables are presented as mean ± standard deviation (SD) or median [interquartile range (IQR)], as appropriate. Comparisons between categorical variables were performed using Pearson’s Chi-squared test or Fisher’s exact test, as appropriate. For variables with more than two categories, omnibus comparisons were performed initially, followed by prespecified category-specific analyses (malignant vs. non-malignant outcomes and pulmonary nodules >8 vs. ≤8 mm). Generalized linear models were used to estimate relative risks (RRs) and corresponding 95% confidence intervals (CIs) for these category-specific analyses. A two-sided P value <0.05 was considered statistically significant.
The minimum sample size was calculated using a single-population proportion formula based on a previously reported prevalence of incidental pulmonary nodules of 4% among patients undergoing CTPA (3), assuming a precision of 5% and a two-sided α of 0.05. Although the calculated minimum sample size was 65 patients after adjustment for incomplete data, all consecutive eligible patients during the predefined study period were included to maximize statistical precision.
Ethical statement
This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of the Faculty of Medicine, Chulalongkorn University (certificate No. 0916/2024, dated July 8, 2024). The requirement for informed consent was waived due to the retrospective nature of the study.
Results
A total of 449 patients who underwent CTPA between January 1, 2017 and December 31, 2018 were identified. After excluding 43 patients with pulmonary metastases and 30 patients with active lung cancer, 376 patients were included in the final analysis. (Figure 1).
Figure 1.
Study flow diagram. CTPA, computed tomography pulmonary angiography; PE, pulmonary embolism.
The baseline characteristics of the study population are summarized in Table 1. The mean age was 61.84 years, and the study population was predominantly female (61.7%). The most common presenting symptoms were desaturation (34.8%) and dyspnea (28.2%). A history of malignancy was identified in 114 patients (30.3%), most commonly extrapulmonary malignancies without evidence of pulmonary metastasis.
Table 1. Baseline characteristics of patients undergoing CTPA.
| Baseline characteristic | Value (N=376) |
|---|---|
| Age (years) | |
| Mean | 61.84 |
| Median | 63 |
| Min | 18 |
| Max | 98 |
| Sex | |
| Male | 144 (38.3) |
| Female | 232 (61.7) |
| Presenting symptom/indication | |
| Desaturation | 131 (34.84) |
| Dyspnea | 106 (28.19) |
| Follow-up imaging | 56 (14.89) |
| High D-dimer | 28 (7.45) |
| Evaluation for CTEPH | 23 (6.12) |
| Confirm diagnosis PE | 12 (3.19) |
| Post procedure | 7 (1.86) |
| Post arrest | 5 (1.33) |
| Chest pain | 5 (1.33) |
| Evaluation for PH | 3 (0.80) |
| Underlying disease | |
| Non-cancer | 262 (69.68) |
| Cancer | 114 (30.01) |
| Lung cancer inactive disease | 4 (1.06) |
| CA lung stage I (post Sx >2 years) | 3 (0.80) |
| CA lung stage II (post Sx/RT >5 years) | 1 (0.27) |
| Other cancer without pulmonary metastasis | 110 (29.26) |
Data are presented as n (%), unless otherwise specified. CA, carcinoma; CTEPH, chronic thromboembolic pulmonary hypertension; CTPA, computed tomography pulmonary angiography; PE, pulmonary embolism; PH, pulmonary hypertension; post Sx, post surgery; RT, radiotherapy.
CTPA findings are summarized in Table 2. PE was identified in 110 patients (29.3%), whereas 266 patients (70.7%) showed no evidence of PE. Incidental pulmonary nodules were detected in 129 patients, accounting for 34.3% of the study population. During follow-up, 9 of 129 patients (6.98%) with incidental pulmonary nodules were diagnosed with malignancy, 26 (20.16%) had benign lesions, 75 (58.14%) had indeterminate nodules, and 19 (14.73%) had unavailable follow-up data.
Table 2. The CTPA findings (n=376).
| CTPA finding | Number | % |
|---|---|---|
| PE finding | ||
| PE negative | 266 | 70.74 |
| PE positive | 110 | 29.26 |
| Incidental pulmonary nodule | ||
| No | 247 | 65.69 |
| Yes | 129 | 34.31 |
| Final diagnosis among incidental pulmonary nodules (n=129) | ||
| Malignancy | 9 | 6.98 |
| Benign | 26 | 20.16 |
| Indeterminate | 75 | 58.14 |
| Unknown | 19 | 14.73 |
| Other finding (non-pulmonary nodule) | ||
| Enlarge pulmonary trunk | 99 | 26.33 |
| Atelectasis | 91 | 24.2 |
| Pleural effusion | 86 | 22.87 |
| Infiltration | 65 | 17.29 |
| Cardiomegaly | 40 | 10.64 |
| Lymphadenopathy mediastinum | 33 | 8.78 |
| Pericardial effusion | 21 | 5.59 |
| Consolidation | 13 | 3.46 |
| Lymphadenopathy cervical/SPC | 7 | 1.86 |
| Pneumothorax | 7 | 1.86 |
| Pulmonary edema | 5 | 1.33 |
| Pulmonary mass | 5 | 1.33 |
| Pulmonary AVM | 4 | 1.06 |
| Emphysema | 4 | 1.06 |
| Pulmonary infarction | 4 | 1.06 |
| Pleural metastasis | 3 | 0.8 |
| Bronchiectasis | 1 | 0.27 |
AVM, arteriovenous malformation; CTPA, computed tomography pulmonary angiography; PE, pulmonary embolism; SPC, supraclavicular.
The association between pulmonary nodule characteristics and PE status is shown in Table 3. The prevalence of incidental pulmonary nodules did not differ significantly between patients with and without PE (29.1% vs. 36.5%; P=0.17). Prespecified category-specific analyses (Table 4) demonstrated that pulmonary nodules >8 mm were more frequent among patients with PE than among those without PE (21.9% vs. 9.3%; P=0.02). Similarly, malignant outcomes were more common in the PE group (18.8% vs. 3.1%; P=0.01), with a corresponding RR of 3.08 (95% CI: 1.73–5.46).
Table 3. Characteristics of incidental pulmonary nodules according to pulmonary embolism status.
| Variable | Pulmonary embolism | P value | |
|---|---|---|---|
| Negative | Positive | ||
| Prevalence of pulmonary nodules† | |||
| Pulmonary nodule | 0.17 | ||
| Yes | 97 (36.47) | 32 (29.09) | |
| No | 169 (63.53) | 78 (70.91) | |
| Characteristic of pulmonary nodule‡ | |||
| Number of pulmonary nodule | 0.97 | ||
| Multiple | 58 (59.79) | 19 (59.38) | |
| Single | 39 (40.21) | 13 (40.62) | |
| Size of pulmonary nodule | 0.02 | ||
| <6 mm | 11 (11.34) | 8 (25.00) | |
| 6–8 mm | 77 (79.38) | 17 (53.12) | |
| >8 mm | 9 (9.28) | 7 (21.88) | |
| Location of pulmonary nodule | 0.13 | ||
| Unilateral | 45 (46.39) | 10 (31.25) | |
| Bilateral | 52 (53.61) | 22 (68.75) | |
| Final diagnosis | 0.01 | ||
| Malignancy | 3 (3.09) | 6 (18.75) | |
| Benign | 20 (20.62) | 6 (18.75) | |
| Indeterminate | 62 (63.92) | 13 (40.62) | |
| Unknown | 12 (12.37) | 7 (21.88) | |
Data are presented as n (%). †, negative (n=266), positive (n=110); ‡, negative (n=97), positive (n=32).
Table 4. Prespecified category-specific analyses of pulmonary nodule size and malignant outcomes according to pulmonary embolism status.
| Variable | PE negative | PE positive | RR (95% CI) | P value |
|---|---|---|---|---|
| Pulmonary nodule >8 vs. ≤8 mm | 9/97 (9.3%) | 7/32 (21.9%) | 1.98 (1.03–3.81) | 0.041 |
| Malignant vs. non-malignant | 3/97 (3.1%) | 6/32 (18.8%) | 3.08 (1.73–5.46) | <0.001 |
CI, confidence interval; PE, pulmonary embolism; RR, relative risk.
No statistically significant differences were observed in pulmonary nodule multiplicity or laterality according to PE status.
The clinical and radiologic characteristics of patients diagnosed with malignancy are summarized in Tables 5,6. Among the 9 patients ultimately diagnosed with malignancy, PE was present in 6 patients (66.7%). Multiple nodules were observed in 6 patients (66.7%), and nodules >8 mm were identified in 4 patients (44.4%). The final diagnosis was established by histopathologic confirmation in 4 patients and by imaging findings in 5 patients. Pulmonary metastasis was the most common diagnosis (66.7%), followed by primary lung adenocarcinoma (33.3%).
Table 5. Clinical and radiologic characteristics of patients with malignant pulmonary nodules detected incidentally on computed tomography pulmonary angiography (n=9).
| Variable | Number | % |
|---|---|---|
| Presenting symptom/indication | ||
| Desaturation | 3 | 33.33 |
| Dyspnea | 3 | 33.33 |
| Follow-up imaging | 2 | 22.22 |
| Evaluation for CTEPH | 1 | 11.11 |
| PE status | ||
| PE positive | 6 | 66.67 |
| PE negative | 3 | 33.33 |
| Number of pulmonary nodule | ||
| Multiple | 6 | 66.67 |
| Single | 3 | 33.33 |
| Size of pulmonary nodule | ||
| <6 mm | 3 | 33.33 |
| 6–8 mm | 2 | 22.22 |
| >8 mm | 4 | 44.44 |
| Laterality | ||
| Unilateral | 6 | 66.67 |
| Bilateral | 3 | 33.33 |
| Diagnostic method | ||
| Histopathologic confirmation | 4 | 44.44 |
| Radiologic progression with clinical assessment | 5 | 55.56 |
| Final diagnosis | ||
| Primary lung adenocarcinoma | 3 | 33.33 |
| Pulmonary metastasis | 6 | 66.67 |
| Time to diagnosis | ||
| <1 month | 2 | 22.22 |
| 1–3 months | 3 | 33.33 |
| 3–6 months | 2 | 22.22 |
| >6 months | 2 | 22.22 |
CTEPH, chronic thromboembolic pulmonary hypertension; PE, pulmonary embolism.
Table 6. Individual clinical and radiologic characteristics of the nine patients with malignant pulmonary nodules.
| No. | Sex, age (years) | Presenting symptom/indication | PE status | Number | Size (mm) | Location | Diagnostic procedure | Final diagnosis | Time to diagnosis |
|---|---|---|---|---|---|---|---|---|---|
| 1 | F, 66 | Evaluation for CTEPH | PE (−) | Multiple | <6 | Unilateral | Histopatho. | AdenoCA | 1 month |
| 2 | F, 70 | Desaturation | PE (−) | Multiple | >8 | Bilateral | Histopatho. | Metastasis | 1 month |
| 3 | F, 77 | Follow-up imaging | PE (+) | Multiple | >8 | Bilateral | Imaging | Metastasis | <1 month |
| 4 | M, 67 | Dyspnea | PE (+) | Multiple | <6 | Unilateral | Imaging | Metastasis | 2 months |
| 5 | F, 75 | Desaturation | PE (+) | Multiple | 6–8 | Bilateral | Imaging | Metastasis | 3 months |
| 6 | F, 53 | Dyspnea | PE (−) | Single | <6 | Unilateral | Imaging | Metastasis | 3 months |
| 7 | M, 84 | Dyspnea | PE (+) | Single | 6–8 | Unilateral | Imaging | Metastasis | 7 years† |
| 8 | F, 42 | Follow-up imaging | PE (+) | Multiple | >8 | Unilateral | Histopatho. | AdenoCA | <1 month |
| 9 | M, 84 | Desaturation | PE (+) | Single | >8 | Unilateral | Histopatho. | AdenoCA | 10 months |
†, diagnosis was established 7 years after the index CTPA following loss to follow-up. AdenoCA, primary lung adenocarcinoma; CTEPH, chronic thromboembolic pulmonary hypertension; CTPA, computed tomography pulmonary angiography; F, female; Histopatho., histopathologic confirmation; Imaging, diagnosis based on radiologic progression with multidisciplinary clinical assessment; M, male; Metastasis, pulmonary metastasis; PE (−), pulmonary embolism negative; PE (+), pulmonary embolism positive.
Most malignant pulmonary nodules were diagnosed within three months after the index CTPA, although two patients required longer than six months to establish a definitive diagnosis. Detailed characteristics of the nine malignant cases are presented in Tables 5,6.
Discussion
In this retrospective cohort study, incidental pulmonary nodules were identified in approximately one-third of patients undergoing CTPA. Although the prevalence of pulmonary nodules did not differ significantly according to PE status, patients with concurrent PE had a greater proportion of pulmonary nodules >8 mm and malignant outcomes during follow-up. These findings represent an observed association and should not be interpreted as evidence of a causal relationship.
The prevalence of incidental pulmonary nodules in the present study (34.3%) was considerably higher than that reported in previous studies, in which prevalence ranged from approximately 4% to 9% (1-3). Several factors may explain this difference. First, our study was conducted at a tertiary-care referral center that manages patients with more complex underlying diseases and a higher prevalence of malignancy. Second, more than half of the patients underwent CTPA because of respiratory symptoms such as dyspnea or oxygen desaturation rather than isolated suspicion of PE, increasing the likelihood of detecting additional thoracic abnormalities. Third, differences in CT acquisition protocols, reporting practices, and radiologist awareness may also have contributed to the higher prevalence observed.
During longitudinal follow-up, malignant outcomes were identified in 9 of 129 patients (7.0%) with incidental pulmonary nodules, while most nodules remained indeterminate. The observed proportion of malignant outcomes was numerically higher than that reported in the IDEAL study (7.0% vs. 3.6%) (6). However, this comparison should be interpreted cautiously because of differences in study populations, inclusion criteria, and pulmonary nodule definitions. Our study included all incidental pulmonary nodules detected on CTPA in a tertiary-care referral center, whereas the IDEAL study evaluated a different patient population with different nodule selection criteria. Conversely, the substantially higher malignancy rate reported in a previous Thai study (29.7%) likely reflects its inclusion of patients referred specifically for evaluation of solitary pulmonary nodules rather than incidentally detected nodules (5).
Our findings are consistent with previous studies demonstrating that pulmonary nodule size is an important predictor of malignancy (8). Patients with concurrent PE had a higher proportion of pulmonary nodules >8 mm than those without PE. Because larger pulmonary nodules are associated with an increased likelihood of malignancy, this difference may partly explain the higher proportion of malignant outcomes observed in the PE group. However, the small number of malignant cases limits definitive interpretation of this association.
Patients with concurrent PE also had a higher proportion of malignant pulmonary nodules than those without PE. This observation is biologically plausible because venous thromboembolism is a well-recognized manifestation of cancer-associated thrombosis. Previous studies have shown that occult malignancy may be diagnosed within the first year after an episode of venous thromboembolism, particularly in patients with lung and other solid-organ cancers (7). Nevertheless, because of the retrospective design, the limited number of malignant cases, and the absence of multivariable adjustment for important confounders such as smoking history and previous malignancy, our findings should be interpreted as an observed association rather than evidence of an independent predictive effect of PE. Most malignant pulmonary nodules were diagnosed within three months after the index CTPA, supporting the importance of timely follow-up after incidental nodule detection. Current Fleischner Society recommendations stratify surveillance according to pulmonary nodule size and established clinical risk factors rather than the presence of PE (9). Although our findings suggest an association between concurrent PE and malignant pulmonary nodules, the available evidence is insufficient to support modification of existing surveillance recommendations. Instead, these findings highlight the importance of careful clinical assessment and adherence to current guideline-based follow-up while awaiting confirmation from larger prospective studies.
This study has several limitations. First, its retrospective single-center design may limit the generalizability of the findings and is subject to selection and referral bias. Second, only nine malignant outcomes were identified, limiting statistical power and precluding multivariable analyses to adjust for important confounding factors. Third, pulmonary nodule characteristics were obtained from finalized radiology reports rather than centralized image review; therefore, detailed morphologic features such as attenuation, spiculation, calcification, and upper-lobe location were not consistently available for analysis. Fourth, five malignant outcomes were diagnosed based on radiologic progression rather than histopathologic confirmation, which may have introduced outcome misclassification. Finally, smoking history, family history of lung cancer, and other established predictors of malignancy were incompletely documented because of the retrospective nature of the study.
Conclusions
Incidental pulmonary nodules were commonly detected on CTPA in this Thai tertiary-care cohort. Although the prevalence of pulmonary nodules did not differ according to PE status, patients with concurrent PE had a higher proportion of pulmonary nodules >8 mm and malignant outcomes. These findings suggest an association between concurrent PE and malignant pulmonary nodules; however, they should be interpreted cautiously given the retrospective design and limited number of malignant cases. Larger prospective studies are needed to validate these findings before any modification of current surveillance recommendations can be considered.
Supplementary
The article’s supplementary files as
Acknowledgments
None.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of the Faculty of Medicine, Chulalongkorn University (certificate No. 0916/2024, dated July 8, 2024), and informed consent was waived due to the retrospective nature of the study.
Footnotes
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1524/rc
Funding: None.
Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1524/coif). The authors have no conflicts of interest to declare.
Data Sharing Statement
Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1524/dss
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