Incidental elastofibroma dorsi on chest computed tomography A cross-sectional study of prevalence and diagnostic oversight among radiologists

Authors: Asma’a Al-Mnayyis, Mohammed Alorjani, Naser Obeidat, Amani Khasawneh

Abstract

Elastofibroma dorsi is a rare, benign fibroelastic tumor primarily affecting the subscapular region. Despite its characteristic imaging features, misdiagnosis is common, usually leading to unnecessary interventions. This study aims to assess the prevalence of elastofibroma dorsi among computed tomography (CT) scans of 2000 patients, to analyze the demographic and clinical characteristics of the patients and assess radiologists’ diagnostic accuracy regarding this condition. In this cross-sectional study a total of 2000 CT scans were retrospectively reviewed, scans positive for elastofibroma dorsi were then further analyzed for demographic and clinical features, including age, sex, comorbidities and lesions laterality. Additionally, 168 radiologists were assessed for their ability to accurately diagnose elastofibroma dorsi. A total of 45 patients has elastofibroma dorsi, representing a prevalence of 2.25%. The mean age of elastofibroma-patients was 73.49 ± 10.52 years, with a nearly equal sex distribution (48.89% male, 51.11% female). The most common disease or indication for the assessed CT images was malignancy (51.11%). Right sided involvement was predominant (86.67% of patients had right sided involvement whether alone or as part of bilateral involvement). Bilateral cases were 44.44%. Among the 168 radiologists, only 11.90% correctly identified elastofibroma dorsi on imaging. The most frequent misdiagnoses were mass or tumor (42.27%) and muscle (26.19%). Despite its distinct imaging characteristics, elastofibroma dorsi is frequently misdiagnosed, highlighting the need for increased awareness among radiologists. Due to its prevalence in elderly patients, elastofibroma dorsi should be included in the differential diagnosis of subscapular lesions to avoid misdiagnosis and unnecessary interventions.

1. Introduction

Elastofibroma dorsi (ED) is a rare, benign soft tissue tumor that typically arises in the subscapular region, often near the inferior angle of the scapula. First described by Jarvi and Saxén in 1961^[1]^ as a slow-growing, nonencapsulated fibroelastic pseudotumor characterized histologically by a mixture of collagenous and elastic fibers interspersed with fibroblasts. The lesion predominantly affects elderly individuals, with a higher prevalence among women and is frequently bilateral.^[2]^ Although its exact etiology remains uncertain, theories suggest a multifactorial origin involving mechanical stress, degenerative changes, and genetic predisposition.^[2,3]^

Clinically, ED is often asymptomatic and discovered incidentally during imaging studies for unrelated conditions. However, in symptomatic cases, patients may report a deep, ill-defined swelling in the subscapular region, which can be associated with mild pain, stiffness, or snapping sensations during shoulder movements. The slow-growing nature and benign behavior of the lesion often result in delayed diagnosis, with most cases identified in patients over the age of 50.^[2]^ The condition’s female predominance and its frequent occurrence in individuals with a history of repetitive mechanical stress, such as manual laborers, suggest that chronic friction between the scapula and thoracic wall may play a role in its development.^[3]^

The pathogenesis of ED remains debated, with 2 prevailing hypotheses. The first posits a reactive process secondary to repetitive microtrauma, leading to fibroelastic proliferation in the deep subscapular fascia. This theory is supported by the lesion’s common location in the inferior scapular region and its increased prevalence among individuals engaged in physically demanding activities. The second hypothesis suggests a genetic predisposition, as familial clustering has been reported in some studies. Notably, chromosomal aberrations involving 1q, 6p, and 15q have been identified in ED cases, indicating a potential hereditary component.^[2,4]^

If the patient has radiological image and the radiologist or the physician who interprets the images is not aware of the radiological features of ED, it can be misdiagnosed as a more serious pathologies like primary malignant chest wall tumors or metastasis.^[5–7]^ In case of incorrect diagnosis, the follow up imaging, unnecessary consultations, biopsies or resection of the lesion can increase the burden on the healthcare system.^[7,8]^

In the past, due to the limited radiological modalities and physicians’ familiarity with ED imaging features, biopsy and surgical excision were overused to exclude other serious pathologies.^[5]^ Being familiar with the characteristic imaging findings is important for accurately labeling ED with biopsy being just reserved for cases with atypical features.^[4,9]^

Management of ED depends on the severity of symptoms. Asymptomatic lesions generally require no intervention and can be monitored with periodic imaging if necessary. Symptomatic cases, particularly those causing functional impairment or significant discomfort, may necessitate surgical excision.^[3,8,10]^ Complete resection typically results in symptom relief with a low recurrence rate. However, due to the lesion’s deep location and its proximity to the thoracic wall and scapular muscles, surgery should be approached cautiously to avoid unnecessary morbidity.^[10,11]^

The prevalence of incidental ED among elderly Saudi patients was assessed in a study by AlAwaji et al and found to be 0.8% with a right sided predominance and a greater occurrence in females.^[12]^ Another study by Brandser et al reported a prevalence of 2% as revealed by CT scans.^[13]^ The presence of bilateral lesions can greatly guide physicians toward the diagnosis of ED instead of more serious lesions.^[5]^

The aim of this study was to assess the prevalence of ED found incidentally in computed tomography (CT) scans in a sample of Jordanian patients and to have a clinicopathological characterization of ED-positive cases with insights into their radiological imaging features. In addition, a short, cross-sectional survey was utilized to assess radiologists’ ability to accurately diagnose ED on CT scans.

2. Material and methods

2.1. Retrospective review of chest CT scan and the analysis of elastofibroma dorsi cases

In this cross-sectional study, the sample size of required chest CT scans number was calculated based on previous studies which showed that the prevalence of ED is about 2%.^[11,12,14–17]^ Therefore, the minimum sample size required for this study is 753 CT scans (for ±1% precision at 95% confidence). However, a total of 2000 CT scans (938 females and 1062 males) were retrieved and screened for the presence of ED, which exceeded the required sample. Most of the retrieved CT scans (1745 CT scans, 87.25%) were with intravenous contrast media and the rest of the scans were without contrast (255 scans, 12.75%). Patients were scanned with either Philips (128 slices Ingenuity) or Philips (64 slices Brilliance) CT scanner. The slice thickness varied from 1.5 to 2.5 mm depending on the protocol. The indications of the obtained CT scans were variable, including part of an oncologic staging workup or follow up, detection of pulmonary embolism, chest infection, and interstitial lung disease. The process was started after getting the institutional review board approval (IRB/2025/92).

The anonymous CT scans were selected randomly from the picture archiving and communication system (PACS) at King Abdullah University Hospital, a 678 bed-tertiary care referral center covering the northern region in Jordan. The hospital is affiliated with the Jordan University of Science and Technology (JUST) and is in Al-Ramtha, in the north of Jordan. The scans were given serial numbers, and data from the images (age and sex) were recorded. All CT images were screened in all planes, the axial, sagittal and coronal.

The inclusion criteria were chest CT studies for patients who were 18 years and above at time of CT scan and Jordanians (the reference was the identity card). The exclusion criteria were the scans for patients with nationalities other than Jordanian, for patients with previous posterior thoracic wall surgery, injury or known locally invasive tumor at the region of interest with poor images’ quality and motion (defined by the presence of high noise, low spatial and contrast resolution and artifact), and for patients with excessive chest wall edema.

ED was diagnosed in the CT scan-based on the typical location and appearance of the lesion as usually being ill-defined, containing fibrous and fatty layers, with overall density that is close to that of muscles.^[4]^ Using the positive cases out of the total sample size, the prevalence was assessed.

The initial CT reports of the cases with elastofibroma were reviewed to assess lesions’ recognition at time of reporting.

Then the medical files for ED-positive cases were reviewed for clinicopathological features including age, sex, comorbidities, and the related histopathological report if available. In addition, all relevant available radiological imaging modalities for those patients were screened with their corresponding reports including magnetic resonance imaging (MRI), CT scans, and positron emission tomography (PET). Two musculoskeletal radiologists – with >10 years of experience in radiology-independently screened and reviewed the images. The results were compared.

A histopathology report was available for 1 patient whose lesion had not been reported on an earlier chest CT scan performed for another indication. Later, the patient underwent surgery for an upper back mass, which was diagnosed as ED by histopathology. Retrospective review of the initial CT scan revealed that the lesion was in fact visible but had been previously overlooked. To confirm the diagnosis, the pathology slides were independently reviewed by a second pathologist who was blinded to the original findings.

2.2. Assessment of radiologists’ ability to diagnose elastofibroma dorsi

A short cross-sectional survey was designed to assess radiologists’ ability to identify a lesion as ED on CT scan. The survey contained 2 demographic part (age, sex, and level of training – whether they are radiology residents or radiology specialists) and a CT scan-based diagnosis. Participants were shown an anonymized CT image for a confirmed case of ED, with being able to assess the whole CT study provided as an anonymous multiplanar scan and they were asked to provide the diagnosis. The provided CT scan was validated by 5 expert radiologists to ensure diagnostic accuracy. The survey underwent expert review to ensure content validity, followed by pilot testing with a small group of radiologists to assess validity and clarity. The survey was conducted via an online platform (Google Form). An invitation to participate, containing a secure survey link, was sent through social media and responses were obtained and analyzed accordingly. Participation was voluntary and anonymous, with informed consent approved by all participants at the beginning of the survey.

Our inclusion criterion was that participants were radiologists or radiology residents at the time of this study (January 2025) regardless of the level of radiology training or prior exposure to ED cases. Our exclusion criterion was that participants weren’t radiology specialists or radiology residents.

Data was evaluated for correct answers regarding the image. Answers other than ED or elastofibroma were considered incorrect. The CT image in Figure 5D was used in the survey.

2.3. Statistical analysis

The statistical analysis in the study was performed using IBM SPSS Statistics (version 27-Armonk, NY: IBM Corp). Descriptive statistics were carried out to assess the study variables. Data were presented as frequency distributions (numbers, n and percentages, %) for categorical variables and mean ± standard error of the mean (SD) for continuous variables. Pearson’s chi-squared test was used to assess the relationship between the sex and the presence of ED and to assess the association between ED site and sex. The statistically significant association was indicated by a P-value of <.05.

2.4. Ethical consideration

This study has been reviewed and approved by the Institutional Review Board (IRB) of Yarmouk University under approval number IRB/2025/92. All research procedures comply with the ethical guidelines set by Yarmouk University and international ethical standards, including the Declaration of Helsinki.

3. Results

3.1. Demographic and ED prevalence in the study sample

A total of 2000 chest CT scans were reviewed independently by the 2 radiologists to assess the prevalence of ED. The results of the cases with the lesion were the same for the radiologists, which can ensure the fact that being familiar with the radiological findings is crucial to diagnose accurately and avoid unnecessary workup. The mean age for all patients in the study was about 58.08 years (1062 males, mean age of 58.21 years and 938 females, mean age of 57.93 years), with an age range of 18 to 107 years for all patients. The overall prevalence of ED in the sample was 2.25% (Table 1) which is within the range of the previously reported prevalence in different populations.^[11,12,14]^

3.2. Radiological description of ED in the cases

ED was seen in the subscapular region in all cases. The lesion appeared in the CT images as right sided, left sided or bilateral well- or ill-defined, heterogeneous soft tissue mass with interspersed fatty streaks, producing the classic “striped” or “layered” pattern. It didn’t invade adjacent structures, which was consistent with the typical appearance.^[4,11,15,16]^ This CT appearance is demonstrated in Figures 1, 2A, 3A, and 4A, B for different patients with ED.

All other related available imaging modalities were retrieved for the positive cases. MRI was evaluated whenever available for ED-positive cases. It appeared isointense to skeletal muscle on T1-weighted MRI sequences, had a fasciculated appearance with alternating high-intensity fatty streaks and fibrous components on T2-weighted images. The appearance was also consistent with the description in the literature.^[4,5,15,17,18]^ The appearance on MRI is demonstrated in Figure 2B which shows a left sided ED, and the CT scan for the same patient is shown in Figure 2B.

The available fludeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) scans for ED-positive cases were evaluated. Elastofibroma showed mild to moderate FDG uptake ranging from mild (SUV < 2) to moderate (SUV 2–5), which was considered typical when compared to other studies.^[18–20]^ Examples of ED in FDG-PET/CT scans from the scanned cases are shown in Figures 3B, C and 4C.

The appearance of ED lesions was described in the pathology report as well as by another pathologist who read the slides – at the time of this study, as microscopically ill-defined dermal-to-subcutis-based hypocellular lesion showing spindle cells and collagenized stroma, with entrapment of subcutaneous fat. Scattered abnormal elastic fibers are noted in the form of densely eosinophilic thin fibers and variably sized globules and beaded structures (beads on a string). Elastic (Verhoef Van-Gieson) special stain showed intense black-staining of elastic fibers. This was in line with the literature description of ED.^[21,22]^ Figure 5 demonstrates the histopathology images as well as the CT image.

3.3. Demographic and clinical characteristics of patients found to have ED

Among the 2000 chest CT scans, 45 patients were identified to have ED, which represents a prevalence of 2.25%. All those patients were over the age of 50 years, with an average age of 73.49 ± 10.52 years (mean ± standard deviation). Of the 1062 males in the study sample, 22 were identified to have ED (2.07%), and of the 938 females in the study sample, 23 were identified to have the lesion (2.45%; Tables 1 and 2).

When looking at the 45 ED-positive patients, they were 22 males (48.89%) and 23 females (51.11%). Using the Pearson chi-square test to assess the association between the sex of the patient and the presence of ED lesions, the P-value was .316 (at a degree of freedom of 1), which is >.05, which means no statistically significant association with an almost equal sex distribution. Bilateral lesions were seen in 20 patients (44.44%), while 19 patients (42.23%) had only right sided lesion and 6 patients (13.33%) had only left side lesion. The total number of elastofibroma lesions in the 45 patients was 65. By counting the lesions on the right and left sides, the number of lesions on the right side was 39 (60% of the 65 lesions, 86.67% of the patients had lesions on the right side whether having contralateral lesion or not), while 26 lesions were left sided (40% of the 65 lesions, 57.78% of the patients had lesions on the left side whether having contralateral lesion or not; Tables 3 and 4).

Among the morbidities that were documented in the patients’ medica records at time of imaging, malignancy was the most common, observed in 23 patients (51.11%), followed by hypertension in 11 patients (24.44%) and chest infections in 8 patients (17.78%). Other conditions included hiatal hernia (4 cases, 8.89%), pleural effusion (4 cases, 8.89%), diabetes mellitus (4 cases, 8.89%), and gallstones (2 cases, 4.44%; Table 2).

The diseases listed in the table mostly reflect the clinical indications or morbidities existing with conditions that prompted CT scan acquisition rather than diseases that are truly associated with ED.

The crosstabulation and chi-square test were used to investigate the association between the sex and the laterality of ED in the positive cases (right side, left side or bilateral; Table 3).

The Pearson chi-square test was applied to assess the association between the sex and the laterality of the lesion. A significant association was found between sex and lesion laterality (P = .017), with males predominantly presenting with right sided lesions and females more commonly exhibiting bilateral lesions. The absence of statistical significance in the linear-by-linear association (P = .226) suggests the relationship does not follow a simple linear trend (Table 4).

3.4. Assessment of radiologists’ diagnostic performance in detecting ED

A random convenient sample of 168 radiologists-specialists and radiology residents – were assessed for their ability to identify ED, they were categorized by age, sex, professional level, and imaging impressions (Table 5). Regarding age distribution, the majority (35.71%) were between 30 and 40 years old, followed by 32.14% who were younger than 30. Fewer radiologists fell into the 40 to 50 age range (17.86%) or older than 50 (10.71%), while 3.57% did not report their age. Among the participants’ sex, males constituted 53.57%, while females made up 42.86%. A small percentage (3.57%) did not report their sex. When analyzing the level in radiology whether residents or radiologists, residents represented more than half of the sample (57.14%). Specialists accounted for 39.29%, while 3.57% of participants did not specify their professional role. while specialists accounted for 39.29%. Again, 3.57% did not specify their professional role. In terms of diagnostic accuracy for ED, only 11.90% of responses correctly identified the lesion as ED. The most frequent mislabeling was mass or tumor (42.27%), followed by muscle (26.19%). Other misdiagnoses included bone lesion (3.57%), while 16.07% of cases had no clear diagnosis.

4. Discussion

ED is a benign, slowly growing, fibroelastic pseudotumor that predominantly affects the sub-or periscapular region. It is usually seen between the latissimus dorsi and serratus anterior muscles.^[23]^

Although initially considered rare, recent studies indicate that its prevalence is higher than previously assumed, particularly in elderly patients undergoing imaging for unrelated conditions. The prevalence of ED in this study was estimated to be 2.25%, which is consistent with what has been previously published with a range of 0.8%^[12]^ to 2.73%.^[11,14,15]^ In addition, all patients with ED in the current study were over the age of 50 years which agrees with previously published work that found ED to occur primarily in middle-aged and elderly individuals, usually after the age of 50 years.^[12,24,25]^

The prevalence of incidentally found ED in a study involving the CT scans of 4335 elderly Saudi patients was 0.8% (36 patients). The study also showed female predominance, where 77.8% of cases were in females while 22.2% in males, with an average age of 76.6 years. Additionally, 30.56% of cases were bilateral.^[12]^ Another study revealed a 2% prevalence of ED when investigated 258 CT scans for elderly patients whose average age was 71 years.^[13]^

The bilateral occurrence of ED as reported in the literature was in the range of 10% to 66%, which could support the hypothesis that chronic mechanical friction plays a role in its pathogenesis.^[20,24]^ The bilaterality in this study was 44.4%, which is within the published range.

A retrospective CT study in Turkey analyzed 8378 chest CT scans identified 87 patients with ED (1.03%), with no sex predilection. None of the cases were correctly diagnosed in the initial radiologic reports. This highlights a significant gap in radiologists’ awareness of ED’s imaging features. The study also found that bilateral ED was present in 31% of cases, further supporting its characteristic bilaterality.^[14]^ Our study didn’t show sex predilection, which is in agreement with what has been published previously.^[14]^ However, different literature reviews showed that the condition exhibits a female predominance, likely related to chronic mechanical stress and repetitive upper limb movements, which are proposed as etiological factors.^[12,26]^ A possible justification of having different sex distribution in some previous studies could be due to the heterogeneity of the original samples, with more females amongst the study population leading to more female with ED cases. Nevertheless, the analysis of sex distribution of the original sample was not involved in most of the studies.

While many patients remain asymptomatic, those who do experience symptoms typically report pain, discomfort, and a snapping or clicking sensation of the scapula, particularly during shoulder movements. Given the frequent incidental discovery of ED, it is imperative that radiologists are able to recognize its characteristic imaging features to avoid unnecessary biopsy and surgeries.^[5,24]^ Accurate radiologic identification of ED is essential to prevent misdiagnosis as a malignant soft tissue tumor. The lesion’s ill-defined, infiltrative nature often mimics sarcomas, soft tissue metastases, or lipomatous tumors, leading to unnecessary diagnostic workups.^[5]^ A thorough understanding of modality-specific imaging characteristics can significantly improve diagnostic accuracy. CT is widely used for evaluating soft tissue masses, and in ED, it typically reveals an ill-defined, heterogeneous soft tissue mass with interspersed fat streaks, producing the classic “striped” or “layered” pattern. This characteristic appearance is key to differentiating ED from malignant tumors, which often exhibit irregular margins, necrotic areas, and invasion of adjacent structures.^[4,9]^

In our study, only 11.90% (20/168) of radiologists correctly identified the lesion as ED. The most frequent mislabeling was mass or tumor (42.27%), followed by muscle (26.19%). Other misdiagnoses included bone lesion (3.57%), while 16.07% of cases had no clear diagnosis. This highlights the importance of improving radiologists’ awareness of the radiological features of ED to avoid unnecessary further interventions. A study by Naylor et al reviewed 21 elastofibroma images and showed that only 4 of these lesions were diagnosed as elastofibroma by the reporting radiologists.^[5]^ A recent paper published in 2024 indicated that most lesions are asymptomatic and incidentally diagnosed during imaging, which confirms the importance of following the characteristic imaging features.^[27]^

In cases that need confirmation or exclusion, MRI is considered the gold standard for diagnosing ED, offering superior soft tissue contrast and fat characterization. On T1-weighted MRI sequences, ED appears isointense to skeletal muscle, while on T2-weighted images, it exhibits a fasciculated appearance with alternating high-intensity fatty streaks.^[4,5]^ These features help distinguish ED from soft tissue sarcomas, which generally demonstrate hyperintensity on T2-weighted images, prominent contrast enhancement, and restricted diffusion.^[28]^ Ultrasound (US) is a cost-effective and accessible first-line modality in the assessment of soft tissue lesions, though it has limited specificity for deep-seated tumors like ED. ED typically appears as a hypoechoic lesion with alternating hyperechoic linear streaks, corresponding to fat and fibrous tissue.^[19]^ However, due to its deep location beneath the scapula, ultrasound often fails to fully characterize ED, necessitating CT or MRI for definitive evaluation.^[4]^

A promising, available MRI sequence is the diffusion weighted images that can help in differentiating the benign elastofibroma from malignant lesions and eventually preventing unnecessary surgery in some cases.^[28]^

FDG-PET/CT, widely used in oncologic imaging, has shown that ED can exhibit mild to moderate FDG uptake, leading to false-positive findings in cancer patients. A study of 10,261 PET/CT scans found 75 incidental cases of ED, with FDG uptake ranging from mild (SUV < 2) to moderate (SUV 2–5). While FDG uptake in malignant tumors is generally higher, radiologists must be cautious to avoid mistaking the benign ED for metastatic disease.^[20]^ Onishi et al noted that bilateral involvement further supports an ED diagnosis, as malignant tumors are rarely symmetrical. This reinforces the importance of integrating clinical history, imaging characteristics, and multimodal assessment to prevent unnecessary interventions.^[4,16]^

The presence of ED is sometimes described as coexisting with certain comorbidities; possibly due to the presence of underlying diseases warranting imaging that leads to incidentally discovering these lesions. Familial occurrence was suggested by some authors,^[4]^ but this needs confirmation by screening family lines and can lead to findings associated with other conditions with similar genetic predisposition. Repetitive mechanical friction at the site of the lesion can have a causative association and can justify association with certain activities and works.^[29]^ Most cases of ED were described in elderly patients, which can be the interpretation of coincidence with other age-related conditions, as well as cancers that occur in older age group.^[17]^ Symptoms related to ED can overlap with symptoms of other health conditions such as shoulder pain and heaviness, which affect the diagnosis and management of both conditions if necessary.^[30]^

Comorbidities found among ED patients in the current study included malignancy, which was the most common, observed in 23 patients (51.11%), followed by hypertension in 11 patients (24.44%) and chest infections in 8 patients (17.78%). Other conditions included hiatal hernia, pleural effusion diabetes mellitus, and gallstones. As in other studies, ED is usually incidentally discovered during imaging for other unrelated conditions.^[31]^ And so far, it is thought that there are no definite specific comorbidities associated directly with ED other than overlapping with age-related comorbidities.

4.1. Limitations of the study

The study was conducted at a single center, so generalizability to other populations may be limited. However, the fact that the center is a tertiary referral center covering the Northern Jordanian region and the inclusion of large sample size can help mitigate this concern.

There was limited clinical data regarding the risk factors such as occupation or physical activity, which may confound associations with sex or age. Also, the absence of histopathological results could introduce misdiagnosis bias, although 2 experienced radiologists screened and examined the scans according to the distinctive radiological features of elastofibroma.

Although considering the relation between handedness and lesion laterality could provide valuable data about the proposed pathophysiology of ED, the retrospective nature that was based on hospital records limited the ability to obtain data on patient handedness that was not routinely documented and therefore was unavailable for analysis.

The retrospective design and the potential bias in radiologists’ selection is another limitation (the approach of radiologists’ selection facilitated broad access and protected participant confidentiality, but at the same time it may have introduced selection bias).

5. Conclusion

Radiologic imaging plays a pivotal role in diagnosing ED, with MRI being the most reliable modality. Recognizing its typical imaging patterns in a typical location across different techniques is essential to differentiate it from malignancies, reducing the need for invasive procedures, as conservative approach is generally preferred in its management, with surgical intervention reserved for symptomatic cases. This can suggest increasing awareness of ED and familiarity with its imaging characteristics among radiologists and clinicians during teaching and clinical rounds as a trial to have more accurate diagnoses and better patient outcomes with significant reduction of unnecessary surgeries or biopsies.

Author contributions

Conceptualization: Asma’a Al-Mnayyis.

**Data ** Asma’a Al-Mnayyis, Mohammed Alorjani, Naser Obeidat, Amani Khasawneh.

**Formal ** Asma’a Al-Mnayyis, Mohammed Alorjani, Naser Obeidat.

Investigation: Asma’a Al-Mnayyis, Mohammed Alorjani.

Methodology: Asma’a Al-Mnayyis, Mohammed Alorjani, Naser Obeidat, Amani Khasawneh.

**Project ** Asma’a Al-Mnayyis, Mohammed Alorjani.

Resources: Asma’a Al-Mnayyis, Mohammed Alorjani, Naser Obeidat.

Software: Asma’a Al-Mnayyis, Naser Obeidat.

Supervision: Asma’a Al-Mnayyis, Amani Khasawneh.

Validation: Asma’a Al-Mnayyis, Naser Obeidat.

**Writing – original ** Asma’a Al-Mnayyis, Mohammed Alorjani, Naser Obeidat, Amani Khasawneh.

**Writing – review & ** Asma’a Al-Mnayyis, Mohammed Alorjani, Naser Obeidat, Amani Khasawneh.