Research on Omitting Sentinel Lymph Node Biopsy after Neoadjuvant Therapy in cN1 Breast Cancer Patients.

1
Introduction
Over the past decade, neoadjuvant therapy (NAT) has become the standard‐of‐care for early‐stage breast cancer, offering significant advancements in clinical outcomes [1]. NAT can effectively reduce primary tumor burden and downstage axillary lymph nodes (ALNs); 35%–63% of patients initially presenting with ALN‐positive (cN+) disease achieve axillary pathological complete response (apCR) after NAT [2]. For these patients who convert to clinically node‐negative (ycN0) status post‐NAT, sentinel lymph node biopsy (SLNB) is now a standard, less invasive alternative to axillary lymph node dissection (ALND) [3]. However, SLNB is not without morbidity. Reported complications include lymphedema (incidence: 5.9% at 24 months), reduced arm range of motion (17%), persistent pain (11%–16% at 6 months), sensory impairments (2%–22%), and motor impairments (0%–9%) [4].
Due to complications associated with axillary surgery in breast cancer, an increasing number of studies have focused on the de‐escalating axillary procedures. The recently completed INSEMA trial investigated the non‐inferiority of omitting SLNB or ALND, evaluating patient‐reported outcomes (PROs) among three approaches for clinically node‐negative patients: no axillary surgery, SLNB only, and ALND after SLNB. The results demonstrated that omitting axillary surgery improved arm symptoms and function, without significant differences in other outcome measures [5]. Similarly, The SOUND trial examined the non‐inferiority of omitting SLNB versus performing SLNB in patients with cT1N0 breast cancer, revealing that the SLNB group experienced worse early postoperative physical function and symptoms [6].
Both the INSEMA and Italian SOUND trials focused on cN0 patients; limited research has directly evaluated the safety of omitting axillary surgery in initially node‐positive (cN1) patients who achieve node‐negative status after NAT. In HER2 + and TNBC subtypes, the apCR rate can reach 60% and 50%–67% respectively [6, 7]. Suggesting that further axillary treatment may be unnecessary for patients with no residual nodeal disease. However, given the variable efficacy of NAT across individuals, accurate identification of patients who can safely avoid further invasive axillary procedures remains critical. Therefore, this study aimed to identify predictive factors for omitting SLNB in cN1 patients following NAT, potentially providing evidence to guide future axillary de‐escalation strategies in this population.

2
Methods
2.1
Study Population
This study was approved by the Ethics Committee of the Affiliated Hospital of Southwest Medical University [Ethics Committee number: KY2025334].
In this study, we included 357 patients with primary invasive breast cancer who were diagnosed at the Department of Breast Surgery at the Affiliated Hospital of Southwest Medical University between January 2020 and April 2025.
The inclusion criteria were as follows: (1) female patients; (2) breast cancer confirmed by pathological histology; (3) received neoadjuvant therapy; (4) lymph node metastasis confirmed by lymph node biopsy prior to NAT; (5) underwent breast surgery and received ALND after NAT; and (6) initial diagnosis staged as cT1‐4 N1. The exclusion criteria were as follows: (1) male patients; (2) bilateral breast cancer; (3) did not complete standard NAT; (4) cN2‐3; and (5) incomplete clinical data.
The NAT regimens employed for patients included eight cycles of sequential chemotherapy based on anthracyclines and taxanes, six cycles of chemotherapy based on platinum and taxanes, and six cycles of chemotherapy based on taxanes, anthracyclines, and cyclophosphamide. For HER2‐positive cases, trastuzumab and/or pertuzumab‐targeted therapy was added [8]. After NAT, patients underwent breast surgeries, such as mastectomy, breast‐conserving surgery, and breast reconstruction surgery.
The clinical and pathological data included age at first diagnosis, breast surgery, neoadjuvant treatment regimen, menstrual status, affected side, tumor quadrant, number of malignant lesions, cT, ycT, preoperative pathological type, WHO grade, ER, PR, HER2, Ki‐67%, immunohistochemical subtype, and ypT (whether pCR was achieved).
Patients were staged according to the 8th edition of the American Joint Committee on Cancer (AJCC) manual [9]. Estrogen receptor (ER) status, progesterone receptor (PR) status, HER2 status, and Ki‐67 expression were assessed using immunohistochemistry (IHC). ER < 1% was considered negative, 1%–10% weakly positive, and > 10% positive; PR‐positive (+) was defined as nuclear staining in ≥ 1% of tumor cells; < 1% was PR‐negative (−) [10]. HER2 status was determined according to the American Society of Clinical Oncology (ASCO) guidelines. Ki‐67 expression was defined as low expression (≤ 30%) or high expression (> 30%) [2]. Patients were classified into five subtypes based on HR and HER2 status: luminal A, luminal B HER2+, luminal B HER2−, HER2 overexpression, and triple‐negative breast cancer (TNBC). The WHO grading and histological classification of breast cancer were based on the fifth edition of the WHO Classification of Breast Tumors.
Breast pCR(bpCR) was defined as the absence of invasive carcinoma, although ductal carcinoma in situ may be present [11]. ypN0 was defined as the absence of macrometastasis and micrometastasis in the axillary lymph nodes or the presence of only isolated tumor cells (ITC). ITC refers to lymph node metastases ≤ 0.2 mm, while micrometastasis refer to lymph node metastases 0.2–2 mm [12].
MRI was used to assess the radiologic response of tumors and lymph nodes before and after NAT. Radiologic complete response (rCR) was defined as the absence of enhancement in the tumor bed region on early and delayed phase MR images during preoperative MRI, consistent with most previously published literature. Minimal residual contrast enhancement in the original tumor area (with signal intensity similar to or lower than surrounding normal breast tissue) was considered physiological. Post‐NAT breast MRI findings were independently analyzed by two radiologists blinded to pathological results [13, 14, 15].

2.2
Statistical Analysis
Data were analyzed using SPSS 26.0 statistical software. The chi‐square test and Fisher's exact test were used to compare the five breast cancer subtypes and identify the association between variables and ypN0. Multivariate regression analysis was conducted to determine the independent variables associated with ypN0, and odds ratios (ORs) with 95% confidence intervals (CI) were calculated. The significance level α was set at 0.05 for all analyses. In the regression results, statistical significance was considered when the 95% CI for OR did not include 1, and the p‐value was < 0.05. To evaluate the statistical robustness of the subtype‐specific findings, a post hoc power analysis was performed using the pwr package in R software. Furthermore, to account for treatment heterogeneity, a multivariate logistic regression model was constructed by incorporating neoadjuvant regimens as a covariate to determine the independent predictive value of molecular subtypes and clinical response (e.g., breast pCR) on ypN0 status.

3
Results
A cohort of 357 cT1‐4 N1 breast cancer patients (median age at dx: 50.7 y, range 29.0–78.0 y) was analyzed, comprising 147 ycN0 and 210 ycN1 cases. Immunohistochemical (IHC) subtype distribution: Luminal A (n = 12, 3.36%), Luminal B HER2‐ (n = 120, 33.61%), Luminal B HER2+ (n = 120, 33.61%), HER2‐enriched (n = 53, 14.85%), and TNBC (n = 52, 14.57%), with full baseline characteristics detailed in Table 1.
Univariate analysis demonstrated significant associations between ypN0 status and: breast surgery type, NAT regimen, post‐NAT clinical T stage (ycT), estrogen receptor (ER) status, progesterone receptor (PR) status, HER2 status, IHC subtype, bpCR, MRI radiological complete response of primary tumor (MRI‐rCR (PT)), and MRI‐rCR (LN).
3.1
ycN0
3.1.1
The Relationship Between bpCR and ypN0 in Different Breast Cancer Subtypes
Among BC subtypes, significant bpCR‐ypN0 association occurred exclusively in Luminal B HER2+ subtype. This cohort demonstrated significantly higher ypN0 rates with bpCR (97%) vs. non‐bpCR (50%) (p < 0.001). No significant associations were observed in Luminal A, Luminal B HER2‐, HER2‐enriched, or TNBC (Table 2).
The mechanism may involve sustained ER/HER2 co‐expression (> 90%) in LN mets from triple‐positive BC, enabling systemic Rx targeting the primary tumor to concurrently eradicate nodal disease. Conversely, HER2‐enriched subtypes show only 67% co‐expression, suggesting resistant metastatic clones. In TNBC, chemotherapeutic agents exhibit reduced concentration/bioavailability in LN microenvironment vs. primary site. Thus, significant bpCR‐ypN0 correlation is unique to triple‐positive molecular subtype.

3.1.2
The Relationship Between MRI‐rCR (PT) and ypN0 in Different Breast Cancer Subtypes
A significant MRI‐rCR (PT)‐ypN0 association was observed exclusively in the Luminal B HER2+ subtype, where the ypN0 rate was significantly higher in patients achieving primary tumor rCR (96%) versus non‐rCR (62%) (p = 0.002), with no statistically significant associations detected in Luminal A, Luminal B HER2−, HER2‐enriched, or TNBC subtypes; these findings suggest that for cN1 Luminal B HER2+ BC patients down‐staged to ycN0 post‐NAT, attaining MRI‐rCR (PT) correlates with increased ypN0 probability (Table 3).

3.1.3
The Relationship Between MRI‐rCR (LN) and ypN0 in Different Breast Cancer Subtypes
When comparing ypN0 rates between patients achieving MRI‐rCR (LN) and those without rCR across breast cancer subtypes, observable differences in rates were noted. However, none of these differences reached statistical significance in any subtype (all p > 0.05) (Table 4).
These results indicate that for patients down‐staged to ycN0 after neoadjuvant therapy (NAT), MRI‐rCR (LN) cannot reliably predict ypN0 status.

3.1.4
Multivariate Logistic Regression Analysis
In the multivariate analysis, achieving bpCR emerged as the sole independent predictor of ypN0 status (β = −1.889, p < 0.001). The odds ratio (OR) was 0.151 (95% CI: 0.055–0.419), indicating that bpCR was significantly associated with a markedly increased likelihood of achieving ypN0 (Table 5).

3.2
ycN1
3.2.1
The Relationship Between bpCR and ypN0 in Different Breast Cancer Subtypes
Across multiple subtypes, bpCR was significantly associated with higher ypN0 rates:
Luminal B HER2‐: ypN0 rate was 60% with pCR vs. 14% without pCR (p = 0.032).

Luminal B HER2+: ypN0 rate was 90% with pCR vs. 15% without pCR (p < 0.001).

HER2‐enriched (non‐luminal): ypN0 rate was 95% with pCR vs. 50% without pCR (p = 0.022).

TNBC: ypN0 rate was 78% with pCR vs. 21% without pCR (p = 0.005).

Within the Luminal A subtype, no ypN0 events were observed in either the pCR or non‐pCR groups, precluding statistical analysis.
These findings demonstrate that bpCR is strongly associated with ypN0 status, with particularly robust associations observed in HER2‐positive (Luminal B HER2+ and HER2‐enriched) and TNBC subtypes (Table 6).

3.2.2
The Relationship Between MRI‐rCR (PT) and ypN0 in Different Breast Cancer Subtypes
A significant MRI‐rCR (PT)‐ypN0 association was observed exclusively in the Luminal B HER2+ subtype, wherein patients achieving primary tumor rCR demonstrated significantly higher ypN0 rates versus non‐rCR counterparts (76% vs. 40%, p = 0.005), with no statistically significant associations detected in Luminal A, Luminal B HER2−, HER2‐enriched, or TNBC subtypes; these results suggest that for cN1 Luminal B HER2+ BC patients with persistent ycN1 status post‐NAT, attaining MRI‐rCR (PT) correlates with increased probability of achieving ypN0 (Table 7).

3.2.3
The Relationship Between MRI‐rCR (LN) and ypN0 in Different Breast Cancer Subtypes
In the two subtypes, MRI‐rCR (LN) was significantly associated with a higher ypN0 rate.
Luminal B HER2‐: ypN0 rate was 26% with pCR vs. 6% without pCR (p = 0.031).

Luminal B HER2+: ypN0 rate was 70% with pCR vs. 38% without pCR (p = 0.018).

Although the HER2‐enriched and TNBC had higher ypN0 rates, the differences between the groups were not statistically significant.
These results indicate that MRI‐rCR (LN) is strongly associated with ypN0 status, with this correlation being particularly significant in Luminal B (Luminal B HER2+ and Luminal B HER2‐) subtype (Table 8).

3.2.4
Multivariate Logistic Regression Analysis
In multivariate analysis, both bpCR and MRI‐rCR (LN) were independent predictors for achieving ypN0 status.
bpCR: β = −3.268, p < 0.001, OR = 0.038 (95% CI: 0.015–0.098).

MRI‐rCR (LN): β = −1.021, p = 0.017, OR = 0.36 (95% CI: 0.156–0.832).

These indicate that both bpCR and MRI‐rCR (LN) are closely associated with a significantly increased likelihood of achieving ypN0 (Table 9).

3.2.5
Statistical Robustness and Multivariate Adjustment
The post hoc power analysis showed that the statistical power for Luminal B and HER2‐enriched subtypes exceeded 0.98, while the Luminal A group reached a power of 0.725 (Table 10). After adjusting for neoadjuvant regimens in the multivariate logistic regression model, the HER2‐enriched subtype remained a significant independent predictor for ypN0 (OR = 13.21, 95% CI: 1.35–168.70, p = 0.033). Notably, the achievement of breast pCR was consistently the strongest predictor of ypN0 (OR = 12.67, p < 0.001), regardless of the treatment regimen administered (Table 11).

4
Discussion
This study analyzed predictive factors for achieving ypN0 in 357 cT1‐4 N1 breast cancer patients. We identified significant associations between ypN0 and the following variables: surgical approach, NAT regimen, ycT, ER status, PR status, HER2 status, immunohistochemical subtype, bpCR, MRI‐rCR(PT), and MRI‐rCR(LN). Patients undergoing BCS demonstrated higher ypN0 rates, potentially attributable to tumor downsizing via NAT to facilitate breast conservation. Given the molecular concordance between primary tumors and metastatic lymph nodes, NAT enables synchronous eradication of both sites, thereby increasing the likelihood of ypN0 in BCS candidates. Among patients receiving the TCbHP regimen (predominantly HER2+ disease), homogeneous treatment responses in primary and nodal sites contributed to elevated ypN0 rates, aligning with Xiangmin Ma et al.'s findings of higher axillary pCR (apCR) with TCbHP [16]. Patients achieving ycT0/ycT1 status post‐NAT also exhibited higher ypN0 probability, reflecting the frequent molecular concordance between primary tumors and axillary lymph nodes, which permits concurrent treatment response. ER‐negative/low, PR‐negative, and HER2+ status correlated with increased ypN0 probability. Hormone receptor (HR)‐negative tumors typically exhibit elevated proliferative indices (Ki‐67); as chemotherapy targets rapidly dividing cells, higher proliferative activity enhances chemosensitivity and pCR rates [17]. In HER2+ disease, targeted agents inhibit HER2 signaling pathways, synergizing with chemotherapy to achieve superior pCR [18]. Consequently, Luminal B HER2‐positive and HER2‐enriched subtypes demonstrated higher ypN0 rates. Notably, triple‐negative breast cancer (TNBC) did not show improved ypN0 outcomes in our cohort, possibly due to reduced drug concentration and bioavailability in nodal microenvironments compared to primary sites.
Subgroup analysis of ycN0 versus ycN1 patients revealed that in the ycN0 cohort, only bpCR significantly correlated with post‐NAT ypN0 status, whereas MRI‐rCR (LN) failed to predict ypN0. This discrepancy arises because post‐NAT lymph nodes may demonstrate persistent abnormal MRI signals due to inflammation or fibrosis, leading to non‐rCR classification despite pathologic confirmation of ypN0, thereby compromising MRI predictive accuracy and generating false‐positive findings in ycN0 patients; additionally, conventional imaging modalities including MRI exhibit inherently limited sensitivity for detecting micrometastases. Consequently, some lymph nodes harboring minimal residual disease may still present as clinically/radiographically negative (ycN0), where MRI would inaccurately assess them as achieving rCR [19]. In ycN1, both bpCR and MRI‐rCR(LN) significantly predicted ypN0, as larger nodal tumor burdens reduce MRI false‐negative rates and improve pathologic‐radiologic concordance. Achieving bpCR or MRI‐rCR status post‐NAT positively correlated with ypN0, particularly in Luminal B HER2‐positive disease. This suggests selected patients with specific characteristics may potentially qualify for omission of sentinel lymph node biopsy (SLNB) after NAT.
The surgical field is increasingly advocating surgical de‐escalation to reduce the physiological burden of axillary interventions while enhancing adjuvant therapeutic efficacy, a trend substantiated by multiple clinical trials. For cN0 patients, Alison U Barron et al. demonstrated that HER2‐positive or triple‐negative breast cancer (TNBC) patients achieving breast pathologic complete response (bpCR) exhibited lymph node positivity rates < 2%, supporting axillary surgery omission in this subgroup [20]. Our study revealed that cN1 HER2(+) patients similarly showed significantly increased ypN0 rates following bpCR attainment. However, TNBC patients within the cN1 cohort displayed bpCR‐apCR dissociation (i.e., primary tumor response not translating synchronously to axillary nodal response), potentially attributable to insufficient drug exposure in metastatic lymph node foci.
Regarding cN+ patients, Tinterri et al. confirmed no statistically significant prognostic difference between sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) in cN+ patients downstaged to ycN0 post‐neoadjuvant chemotherapy (NAC), validating SLNB safety in this population [21]. The following year, the team further observed and compared the long‐term outcomes of axillary lymph node dissection (ALND) versus sentinel lymph node biopsy (SLNB) in breast cancer patients with cN+ status who achieved ycN0 after neoadjuvant therapy. The results demonstrated that patients in the SLNB group exhibited significantly better 3‐year, 5‐year, and 10‐year recurrence‐free survival (RFS), distant disease‐free survival (DDFS), overall survival (OS), and breast cancer‐specific survival (BCSS) compared to those in the ALND group [22]. While our investigation similarly included these patients, we focused on ypN0‐associated characteristics and innovatively proposed that selected patients meeting specific criteria may qualify for complete SLNB omission. Soong June Bae et al. established SLNB reliability for NAT‐responsive cN1 patients [23]. Although both studies assessed MRI responses, our protocol mandated axillary lymph node (ALN) apCR achievement as a prerequisite for surgical omission—surpassing their allowance for SLN micrometastases. Montagna et al. reported that 41% of cN1 patients avoided ALND post‐NAC [24]. While their apCR predictors partially overlapped with ours, our study innovatively incorporated ycN1 subcohort analysis, demonstrated bpCR/rCR‐ypN0 correlations, and advanced comprehensive axillary intervention omission (including SLNB) in selected cN1 patients. Given NAT's tumor downstaging effects and evidence that 40%–70% of ALN‐positive patients achieve apCR with standard NAT, research on axillary surgery omission in cN+ disease is expanding [25, 26]. The ATNEC trial—aligning with our conceptual framework—is evaluating axillary treatment omission versus ALND/radiotherapy in T1‐3N1M0 breast cancer [27]. Future investigations must prioritize defining precise indications for surgical omission in initially diagnosed cN1 patients.
Given the limited evidence regarding the omission of SLNB following NAT in patients presenting with cN1 breast cancer, this study focuses on this specific area. By integrating clinical, pathological, and MRI features, it aims to identify the common characteristics of patients achieving ypN0 after NAT and to explore the potential criteria for omitting axillary surgery. Sanaz Samiei et al. confirmed that achieving bpCR post‐NAT in cN0 patients is significantly associated with ypN0 status; our study found that the same association exists in cN1 patients, indicating that achieving bpCR significantly increases the probability of ypN0 regardless of the initial nodal status (cN0 or cN1) [28]. The study by M.E.M. van der Noordaa et al. in cN0 patients incorporated MRI rCR of the primary tumor, finding that TNBC or HER2(+) patients achieving breast rCR had a post‐neoadjuvant chemotherapy nodal positivity rate of < 3% [13]. The innovative aspect of our study lies in its focus on the cN1 population and the incorporation of MRI‐rCR(LN) for evaluation. We found that HER2(+) patients achieving MRI‐rCR(LN) had a significantly higher ypN0 rate; however, MRI‐rCR(PT) showed no significant correlation with ypN0. This lack of correlation may be attributed to persistent enhancement on MRI due to post‐treatment inflammation/fibrosis in the primary tumor bed, potentially leading to a false‐positive interpretation (misclassifying an actual primary pCR as non‐rCR). Furthermore, heterogeneity in treatment response between the primary tumor and lymph nodes in some patients, reflecting potential differences in biological behavior, may lead to asynchronous responses. In conclusion, incorporating features such as MRI‐rCR(LN) can aid in assessing axillary nodal status post‐NAT, suggesting that a subset of cN1 patients may meet criteria for omitting SLNB, thereby improving quality of life.
This retrospective analysis has inherent limitations including potential bias from incomplete/inaccurate historical records and restricted generalizability due to single‐center data acquisition, which may reflect local diagnostic/therapeutic standards while limiting diversity in disease stages/treatment strategies. This study was designed as a retrospective study, which was limited by the historical pathological reporting standards. Key details such as micro‐metastases (which were not distinguished from macro‐metastases) and extranodal extension, as well as post‐treatment fibrosis, were not systematically recorded. Consequently, it was difficult to conduct in‐depth analysis of differences among tumor burden subgroups. The conclusions of this study should be interpreted with caution when applied to clinical decision‐making under current precision staging. Future prospective studies should adopt unified and detailed pathological criteria to overcome this limitation. Furthermore, the assessment of MRI responses in this study (e.g., delineation of residual tumor extent, differentiation between active tissue and therapeutic fibrosis) inherently carries subjectivity. Even when interpreted according to criteria such as RECIST, the identification of lesion margins may vary among evaluators, constituting potential inter‐observer variability. Consequently, larger multicenter datasets, more standardized diagnostic protocols, and prospective studies are required to evaluate the feasibility of safely omitting SLNB in patients with cN1 stage breast cancer. Besides, We acknowledge that treatment regimens vary significantly across subtypes, which reflects real‐world clinical practice. However, our adjusted model demonstrates that the biological subtype remains an independent driver of axillary response. One limitation of this study is the small sample size of certain subgroups (e.g., Luminal A, n = 12), which resulted in a lower statistical power (0.725). These specific results should be interpreted as exploratory evidence that warrants validation in larger multi‐center cohorts.
The study identified predictors for post‐NAT ypN0 status across cN1 BC subtypes, specifically examining associations between bpCR, MRI rCR, and ypN0. Key findings demonstrate ten features (including ER status) correlate with ypN0, especially in patients who achieved bpCR or MRI rCR, where the probability of reaching ypN0 after NAT was significantly increased—particularly in the Luminal B HER2+ subtypes. Observed ypN0 rates were 61.90% in ycN0 versus 42.38% in ycN1 patients post‐NAT. These outcomes cannot justify ALND omission in cN1 patients following NAT, necessitating more accurate axillary LN (ALN) assessment methods to validate the reliability of sentinel lymph node biopsy (SLNB) omission. The results inform axillary surgical decision‐making but require prospective validation to establish SLNB omission criteria for eligible cN1 BC patients to avoid invasive procedures.

5
Conclusion
The results of the study indicate that cN1 patients who achieve bpCR and MRI rCR after neoadjuvant therapy are highly likely to achieve ypN0, identifying bpCR and MRI rCR may make it possible for some patients to omit axillary surgery. Further research is required in this area.

Author Contributions

Maoshan Chen: supervision, writing – review and editing. Xinrui Wu: data curation, writing – review and editing. Zhaoyu Huang: data curation, writing – review and editing. Jie Min: supervision, writing – review and editing. Jianzhe Chen: methodology, writing – original draft. Jiao Bai: writing – review and editing, methodology, supervision, project administration. Jiabei Shang: conceptualization, methodology, writing – original draft, data curation, project administration. Ruchun Zheng: writing – review and editing, project administration. Guangrui Pan: project administration, writing – review and editing, conceptualization, supervision, methodology. Bin Wu: project administration, writing – review and editing. Huaiquan Zuo: writing – review and editing, supervision. Yi Quan: project administration, writing – review and editing. Hua Fu: writing – review and editing, project administration. Yuepin Wan: writing – review and editing, data curation.

Funding
This work was supported by Doctoral Research Initiation Fund of Affiliated Hospital of Southwest Medical University (18098). Luzhou Multidisciplinary Precision Diagnosis and Treatment Quality Control Center for Breast Cancer, 2024 (YLZK2024050), Beijing Vlove Charity Foundation (JVII2024‐0051223016) and the Sichuan Medical Science and Technology Innovation Research Association (YCH‐KY‐YCZD2024‐234). The funders had no role in manuscript preparation, submission decisions, or any aspect of the research process.

Ethics Statement
This study was ethically approved by the Ethics Committeeof the Affiliated Hospital of Southwest Medical University on June 20,2025 (Ethics Committee No.: KY2025334).

Consent
The authors had nothing to report.

Conflicts of Interest
The authors decalre no conflicts of interest.