{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T22:34:52Z","timestamp":1791326092887,"version":"4.3.1"},"reference-count":60,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,2,19]],"date-time":"2026-02-19T00:00:00Z","timestamp":1771459200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background: Gallbladder cancer (GBC) is a highly lethal malignancy that is often asymptomatic in its early stages and difficult to treat once clinical symptoms appear. Although established risk factors include female sex, gallstones, and chronic biliary inflammation, other clinical contexts associated with GBC remain insufficiently characterized. Multiple primary malignancies (MPMs), in which more than one primary cancer develops in the same individual, have recently attracted attention; however, their relationship with GBC has only rarely been examined. In this study, we aimed to clarify the clinical features of MPM-related GBC and explore its implications for early detection. Methods: We retrospectively compared 22 patients with GBC associated with other malignancies (MPM-positive GBC) and 16 patients with GBC alone (MPM-negative GBC). Clinical characteristics, major risk factors, tumor presentation, and imaging findings were evaluated. Special attention was paid to the sequence of cancer development and the diagnostic utility of contrast-enhanced ultrasonography (CEUS). Results: In all MPM-positive cases, GBC occurred as a second primary malignancy, most commonly following gastrointestinal cancers (12\/22). Gallstones were significantly less frequent in the MPM-positive group than in the MPM-negative group (2\/22 vs. 6\/16). The MPM-positive group showed a slight male predominance (12 males and 10 females). Neither pancreaticobiliary maljunction nor porcelain gallbladder was identified in either group. CEUS was useful for both the detection and qualitative diagnosis of GBC in all patients. Conclusions: MPM-related GBC frequently develops as a second primary malignancy in patients with prior gastrointestinal cancer and may arise in the absence of classical risk factors. Careful long-term surveillance after cancer treatment is therefore essential for identifying second primary GBC at a potentially resectable stage. The combined use of ultrasonography and CEUS may facilitate earlier and more accurate diagnosis in this clinical setting.<\/jats:p>","DOI":"10.3390\/diagnostics16040605","type":"journal-article","created":{"date-parts":[[2026,2,19]],"date-time":"2026-02-19T08:51:09Z","timestamp":1771491069000},"page":"605","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Multiple Primary Malignancy-Related Gallbladder Cancer: An Important Recommendation for the Early Detection of Gallbladder Cancer"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5175-568X","authenticated-orcid":false,"given":"Hiroko","family":"Naganuma","sequence":"first","affiliation":[{"name":"Department of Gastroenterology, Yokote Municipal Hospital, Akita 013-8602, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5625-6748","authenticated-orcid":false,"given":"Hideaki","family":"Ishida","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, Akita Red Cross Hospital, Akita 010-1495, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9982-6130","authenticated-orcid":false,"given":"Naoki","family":"Matsumoto","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo 101-8309, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2154-7999","authenticated-orcid":false,"given":"Masahiro","family":"Ogawa","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo 101-8309, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,19]]},"reference":[{"key":"ref_1","first-page":"221","article-title":"Gallbladder cancer","volume":"3","author":"Patrlj","year":"2014","journal-title":"Hepatobiliary Surg. Nutr."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1038\/s41572-022-00398-y","article-title":"Gallbladder cancer","volume":"8","author":"Roa","year":"2022","journal-title":"Nat. Rev. Dis. Primers"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1007\/s00423-024-03261-8","article-title":"Outcomes of patients with gallbladder cancer presenting with acute cholecystitis","volume":"409","author":"Franco","year":"2024","journal-title":"Langenbecks Arch. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Thakur, C., Mahato, R.K., Marasini, S., Timalsena, D., Sharma, K.S., and Karmacharya, B.M. (2025). Risk factors of gallbladder cancer in Nepal: A case control study. PLoS ONE, 20.","DOI":"10.1371\/journal.pone.0317249"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1197","DOI":"10.1093\/aje\/kwae027","article-title":"Gallbladder cancer mortality in Chile: Has the government program targeting young gallstone patients had an impact?","volume":"193","author":"Cid","year":"2024","journal-title":"Am. J. Epidemiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"20220152","DOI":"10.1259\/bjr.20220152","article-title":"Risk of developing gallbladder cancer in patients with gallbladder polyps detected on transabdominal ultrasound: A systemic review and meta-analysis","volume":"95","author":"Foley","year":"2022","journal-title":"Br. J. Radiol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"383","DOI":"10.1155\/2007\/383949","article-title":"Gallbladder carcinoma associated with anomalous pancreaticobiliary duct junction","volume":"21","author":"Kang","year":"2007","journal-title":"Can. J. Gastroenterol."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Valenzuela-Fuenzalida, J.J., Beas-Gambi, A., Matta-Leiva, J., Mart\u00ednez-Hern\u00e1ndez, D., Milos, D., Orellana-Donoso, M., Santib\u00e1\u00f1ez, A.S., Bruna-Mejias, A., Riveros, A.S., and Becerra-Farfan, A. (2025). A systemic review and meta-analysis on the prevalence of variants in the pancreatobiliary duct junction and its association with cancer. Biomedicines, 13.","DOI":"10.3390\/biomedicines13051039"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"216","DOI":"10.1007\/s00423-025-03678-9","article-title":"Risk assessment of gallbladder cancer in patients with primary sclerosing cholangitis and gallbladder polyps: A systemic review","volume":"410","author":"Grikyte","year":"2025","journal-title":"Langenbecks Arch. Surg."},{"key":"ref_10","first-page":"440","article-title":"Laparoscopic cholecystectomy foe entirely calcified porcelain gallbladder: Challenges, management, and literature review","volume":"14","author":"Pipal","year":"2024","journal-title":"J. West. Afr. Coll. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"296","DOI":"10.1186\/s12957-024-03582-4","article-title":"Impact of high body mass index on gallbladder and biliary tract cancer in China: A comprehensive analysis of trends from 1990 to 2021","volume":"22","author":"Zhan","year":"2024","journal-title":"World J. Surg. Oncol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1612","DOI":"10.1093\/ajcn\/nqab235","article-title":"Unrestrained eating behavior and risk of digestive system cancers: A prospective cohort study","volume":"114","author":"Zhang","year":"2021","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Pan, S.-Y., Huang, C.-P., and Chen, W.-C. (2022). Synchronous\/metachronous multiple primary malignancies: Review of associated risk factors. Diagnostics, 12.","DOI":"10.3390\/diagnostics12081940"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2759","DOI":"10.1038\/s41598-021-82248-7","article-title":"Second primary malignancies in colorectal cancer patients","volume":"11","author":"Halamkova","year":"2021","journal-title":"Sci. Rep."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"541","DOI":"10.1007\/s00384-022-04105-x","article-title":"Risk of extracolonic second primary cancers following a primary colorectal cancer:a systemic review and meta-analysis","volume":"37","author":"Robertson","year":"2022","journal-title":"Int. J. Color. Dis."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"4215","DOI":"10.3748\/wjg.v11.i27.4215","article-title":"Clinical analysis of multiple primary malignancies in the digestive system: A hospital-based study","volume":"11","author":"Cheng","year":"2005","journal-title":"World J. Gastroenterol."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Oprita, A.V., Nitipir, C., Achim, E., and Grama, F.A. (2025). Synchronous Versus Metachronous Multiple Malignant Tumors Involving the Digestive Tract: Predictors of Survival from a Single-Center Retrospective Study. Medicina, 61.","DOI":"10.3390\/medicina61111962"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Yang, E.-J., Lee, J.-H., Lee, A.-J., Kim, N.-R., Ouh, Y.-T., Kim, M.-K., Shim, S.-H., Lee, S.-J., Kim, T.-J., and So, K.-A. (2021). Multiple Primary Malignancies in Patients with Gynecologic Cancer. J. Clin. Med., 11.","DOI":"10.3390\/jcm11010115"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1313","DOI":"10.21873\/invivo.11605","article-title":"Breast Cancer and Multiple Primary Malignant Tumors: Case Report and Review of the Literature","volume":"33","author":"Frusone","year":"2019","journal-title":"Vivo"},{"key":"ref_20","first-page":"e69092","article-title":"Synchronous primary gallbladder and colon adenocarcinoma: A case report and systemic literature review","volume":"10","author":"Dedopoulou","year":"2024","journal-title":"Cureus"},{"key":"ref_21","first-page":"e13415","article-title":"A series of biliary tract cancer with coexisting non-biliary second malignancy from Himalayan region of India","volume":"13","author":"Rajput","year":"2021","journal-title":"Cureus"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"2967","DOI":"10.3748\/wjg.v26.i22.2967","article-title":"Benign gallbladder diseases: Imaging techniques and tips for differentiating with malignant gallbladder diseases","volume":"26","author":"Yu","year":"2020","journal-title":"World J. Gastroenterol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"744","DOI":"10.3748\/wjg.v24.i6.744","article-title":"Value of contrast-enhanced ultrasound in the differential diagnosis of gallbladder lesion","volume":"24","author":"Zhang","year":"2018","journal-title":"World J. Gastroenterol."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Zhang, X., Xu, C., Zhang, H., Du, X., Zhang, Q., Lu, M., Ma, Y., and Ma, W. (2024). Gallbladder cancer incidence and mortality rate trends in China: Analysis of data from the population-based cancer registry. BMC Public Health, 24.","DOI":"10.1186\/s12889-024-20584-9"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1016\/j.hpb.2022.09.010","article-title":"Diagnosis and management of choledochal cysts","volume":"25","author":"Brown","year":"2023","journal-title":"HPB"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1507","DOI":"10.4240\/wjgs.v16.i6.1507","article-title":"Current consideration for the surgical management of gallbladder adenomas","volume":"16","author":"Pavlidis","year":"2024","journal-title":"World J. Gastrointest. Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"20220115","DOI":"10.1259\/bjr.20220115","article-title":"Gallbladder polyps and adenomyomas","volume":"96","author":"Riddell","year":"2023","journal-title":"Br. J. Radiol."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Cotovanu, A., Cosma, C.D., Molnar, C., Gurzu, S., Beleaua, M.A., Butiurca, V.O., and Botoncea, M. (2025). Dual tumor pathogenesis in the gastrointestinal tract: Synchronous rectal schwannoma and gallbladder papillary adenocarcinoma-a case report. Reports, 9.","DOI":"10.20944\/preprints202511.0540.v1"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Brierley, J.D., Gospodarowicz, M.K., and Wittekind, C. (2017). TNM Classification of Malignant Tumours, Wiley-Blackwell. [8th ed.].","DOI":"10.1002\/9780471420194.tnmc26.pub3"},{"key":"ref_30","unstructured":"Amin, M.B., Edge, S.B., Greene, F.L., Byrd, D.R., Brookland, R.K., Washington, M.K., Gershenwald, J.E., Compton, C.C., Hess, K.R., and Sullivan, D.C. (2017). AJCC Cancer Staging Manual, Springer. [8th ed.]."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"641","DOI":"10.4254\/wjh.v12.i9.641","article-title":"Surgical treatment of gallbladder cancer: An eight-year experience in a single center","volume":"12","author":"Kamada","year":"2020","journal-title":"World J. Hepatol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1186\/1477-7819-9-84","article-title":"Synchronous double primary malignant tumor of the gallbladder and liver: A case report","volume":"9","author":"Kim","year":"2011","journal-title":"World J. Surg. Oncol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"3440","DOI":"10.3748\/wjg.15.3440","article-title":"Metachronous bile duct cancer nine years after resection of gallbladder cancer","volume":"15","author":"Joo","year":"2009","journal-title":"World J. Gastroenterol."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Xu, Y., Chen, Q.-N., Wang, H., Liu, N.-B., and Shi, B.-M. (2020). Synchronous hepatocellular carcinoma and gallbladder adenocarcinoma with neuroendocrine differentiation: A case report and literature review. BMC Surg., 20.","DOI":"10.1186\/s12893-020-00905-6"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"110029","DOI":"10.4254\/wjh.v17.i10.110029","article-title":"Unusual presentation of synchronous double primary gallbladder and hepatic malignancies: A case report","volume":"17","author":"Zhang","year":"2025","journal-title":"World J. Hepatol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"e45857","DOI":"10.1097\/MD.0000000000045857","article-title":"Synchronous primary gallbladder squamous cell carcinoma and colon adenocarcinoma: A case report and literature review","volume":"104","author":"Shin","year":"2025","journal-title":"Medicine"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"e33162","DOI":"10.1097\/MD.0000000000033162","article-title":"Acquired crizotinb-resistant pulmonary adenocarcinoma and subsequent primary gallbladder cancer: A case report","volume":"102","author":"Zhang","year":"2023","journal-title":"Medicine"},{"key":"ref_38","first-page":"664","article-title":"Successful surgical treatment for metachronous advanced cancers of the gallbladder and the common bile duct-case report","volume":"51","author":"Yuzawa","year":"2004","journal-title":"Hepatogastroenterology"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1186\/s12957-016-0848-y","article-title":"Synchronous malignancies of the gallbladder and common bile duct: A case report","volume":"14","author":"Kodaganur","year":"2016","journal-title":"World J. Surg. Oncol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"4659","DOI":"10.21873\/anticanres.17812","article-title":"Synchronous gallbladder cancer and distal cholangiocarcinoma without pancreaticobiliary maljunction: A case report with literature review","volume":"45","author":"Uemura","year":"2025","journal-title":"Anticancer. Res."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Zhang, Z.-G., Chen, Y., Ji, R., Zhao, Y.-J., Wang, J., Robinson, L., Chen, X.-P., and Zhang, L. (2018). Synchronous cancers of gallbladder carcinoma and combined hepatocellular cholangiocarcinoma: An unusual case and literature review. BMC Cancer, 18.","DOI":"10.1186\/s12885-018-4969-2"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"358","DOI":"10.1007\/s12029-017-9922-0","article-title":"Double trouble: Synchronous adenocarcinoma of gallbladder and pancreas","volume":"49","author":"Vijayaraj","year":"2018","journal-title":"J. Gastrointest. Cancer"},{"key":"ref_43","first-page":"e946739","article-title":"Rare coexisting hepatocellular and gallbladder carcinomas: A case report","volume":"26","author":"Nosakova","year":"2025","journal-title":"Am. J. Case Rep."},{"key":"ref_44","first-page":"828","article-title":"Metachronous pancreatic head adenocarcinoma three years after resection of gallbladder cancer","volume":"6","author":"Chen","year":"2013","journal-title":"Int. J. Clin. Exp. Med."},{"key":"ref_45","first-page":"e34445","article-title":"A rare case of synchronous primary gallbladder and sigmoid colon neoplasms","volume":"15","author":"Galanis","year":"2023","journal-title":"Cureus"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1007\/s12029-013-9551-1","article-title":"Nonfamilial synchronous double primary malignancies of the gallbladder and rectum","volume":"45","author":"Gupta","year":"2014","journal-title":"Gastrointest. Cancer"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1016\/j.ijscr.2019.02.001","article-title":"Synchronous gallbladder adenocarcinoma and gastrointestinal stromal tumor: A case report and literature review","volume":"56","author":"Gregorio","year":"2019","journal-title":"Int. J. Surg. Case Rep."},{"key":"ref_48","first-page":"S958","article-title":"An unusual case series of synchronous primary malignancies: Carcinoma of the gallbladder with renal cell carcinoma, carcinoma of the gallbladder with carcinoma of the colon, and carcinoma of the gallbladder with carcinoma of the breast","volume":"15","author":"Sashibhusan","year":"2019","journal-title":"J. Cancer Res. Ther."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"169","DOI":"10.47717\/turkjsurg.2022.4457","article-title":"Synchronous pancreas and gallbladder cancer with concomitant alopecia totalis","volume":"39","author":"Kumar","year":"2023","journal-title":"Turk. J. Surg."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"109344","DOI":"10.1016\/j.ijscr.2024.109344","article-title":"Synchronous tumors of gastric carcinoma with combined gallbladder cancer and pseudotumor chronic pancreatitis","volume":"116","author":"Nguyen","year":"2024","journal-title":"Int. J. Surg. Case Rep."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"rjab587","DOI":"10.1093\/jscr\/rjab587","article-title":"Double trouble: Synchronous extrahepatic cholangiocarcinoma and gallbladder cancer in a Caucasian patient without pancreaticobiliary maljunction","volume":"2022","author":"Simpson","year":"2022","journal-title":"J. Surg. Case Rep."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1186\/s40792-021-01160-4","article-title":"Triple metachronous primary pancreatic and gallbladder cancer associated with pancreaticobiliary maljunction: A case report","volume":"7","author":"Kuhara","year":"2021","journal-title":"Surg. Case Rep."},{"key":"ref_53","first-page":"869","article-title":"Synchronous multiple primary gallbladder and gastric malignancies: Report of two cases and review of the literature","volume":"7","author":"Zhou","year":"2017","journal-title":"Mol. Clin. Oncol."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1186\/s12957-022-02628-9","article-title":"Laparoscopic hepatopancreaticoduodenectomy for synchronous gallbladder cancer and extrahepatic cholangiocarcinoma: A case report","volume":"20","author":"Yao","year":"2022","journal-title":"World J. Surg. Oncol."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"1535","DOI":"10.2147\/OTT.S129220","article-title":"Risk of subsequent primary malignancies among patients with prior colorectal cancer: A population-based cohort study","volume":"10","author":"Yang","year":"2017","journal-title":"Onco Targets Ther."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"448","DOI":"10.1177\/0846537120923273","article-title":"Gallbladder cancer: Imaging appearance and pitfalls in diagnosis","volume":"71","author":"John","year":"2020","journal-title":"Can. Assoc. Radiol. J."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"149","DOI":"10.1007\/s10396-019-00989-5","article-title":"Role of conventional ultrasonography in the diagnosis of gallbladder polypoid lesions","volume":"48","author":"Okaniwa","year":"2021","journal-title":"J. Med. Ultrason."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1148\/radiol.213079","article-title":"Management of incidentally detected gallbladder polyps: Society of Radiologists in Ultrasound Consensus Conference","volume":"305","author":"Kamaya","year":"2022","journal-title":"Radiology"},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"101397","DOI":"10.1016\/j.jceh.2024.101397","article-title":"Contrast enhanced CT versus MRI for accurate diagnosis of wall-thickening type gallbladder cancer","volume":"14","author":"Kalage","year":"2024","journal-title":"J. Clin. Exp. Hepatol."},{"key":"ref_60","doi-asserted-by":"crossref","unstructured":"Sugimoto, M., Irie, H., Takasumi, M., Hashimoto, M., Oka, Y., Takagi, T., Suzuki, R., Konno, N., Asama, H., and Sato, Y. (2021). A simple method for diagnosing gallbladder malignant tumors with subserosa invasion by endoscopic ultrasonography. BMC Cancer, 21.","DOI":"10.1186\/s12885-021-08017-x"}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/4\/605\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,19]],"date-time":"2026-02-19T08:59:42Z","timestamp":1771491582000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/4\/605"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,19]]},"references-count":60,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,2]]}},"alternative-id":["diagnostics16040605"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics16040605","relation":{},"ISSN":["2075-4418"],"issn-type":[{"value":"2075-4418","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,19]]}}}