Background: Surgery has been considered the cornerstone in the management of endometrial cancer, especially in its early stages. The use of minimally invasive surgeries in patients with endometrial cancers has been widely adopted worldwide. In this study, we discuss the outcomes of type I endometrial cancer patients who underwent laparoscopic hysterectomy at our center. Results: The patients were categorized into two groups: open surgery group (59 patients) and laparoscopy group (60 patients). There was no significant difference between both groups as regards the epidemiologic and clinicopathologic parameters. There was no statistical difference between the two groups in the FIGO stage (International Federation of Gynecology and Obstetrics). Operative time was significantly longer in the laparoscopy group compared to the open surgery group (p < 0.0001). No significant difference was found between both groups as regards the type of operation and blood loss. The rate of intraoperative complications was nearly similar in both groups. There was no significant statistical difference between the numbers of lymph node yield in both groups. Conclusion: The results in this study support the use of laparoscopy in early stage type I endometrial cancers without compromising the oncological outcomes regarding the disease-free and overall survival. We encourage further prospective multicenter randomized trials to consolidate these results.
Introduction: Proper design of the operative plan for patients with ovarian masses is a must to avoid unnecessary surgical steps, the need for another surgery or empirical chemotherapy. We investigated the role of frozen section examination in this design. Methods: This was a prospective study in which 64 complex adnexal masses with normal tumor markers underwent frozen section examination. The patients were divided into two parallel groups: group A in which the decision whether to proceed for complete staging or not was built on the result of the examination, and group B in which the patients underwent panhysterectomy at baseline regardless of their frozen section examination result. Postoperative stay, estimated blood loss and the incidence of complications were compared. Results: When comparing the two groups, including patients with tumors that turned out to be benign, there were no significant differences in postoperative complications, but there were for the operative time (60 vs. 120 minutes, p = 0.004) and blood loss, which were significantly lower in group A (50 vs. 100 mL, p = 0.001), and hospital stay, which was statistically insignificantly shorter than in group B (1 day vs. 2 days, p = 0.062). The sensitivity of frozen section examination for benign, borderline, and malignant ovarian masses was 91.9%, 76.9%, 53.3%, respectively, while the specificity was 85.2%, 87.5%, 95.9% and the overall diagnostic accuracy was 89.6%, 85.2%, 85.9%, respectively. Conclusion: The use of frozen section examination in the assessment of complex ovarian masses in patients with normal tumor markers offers an acceptable accuracy with a significant decrease of the operative time, blood loss as well as hospital stay.
Ovarian cancer, like breast cancer, may either develop spontaneously or as a result of a family history. BRCA1 and BRCA2 mutations significantly increase the risk of both cancers at all ages. It is estimated that 3–5% of women are BRCA mutation carriers. BRCA1 mutation carriers have a 65% risk of breast cancer and 39% risk of ovarian cancer. These risks are lower among BRCA2 mutation carriers, i.e. 45% and 11% for breast and ovarian cancer, respectively. In breast and ovarian cancer with BRCA mutations, blocking the function of poly(ADP-ribose) polymerase (PARP) enzymes, including PARP1 and PARP2, causes an accumulation of DNA damage that ultimately leads to cancer cell death. Based on this mechanism, PARP inhibitors have been used in the treatment of hereditary neoplasms, in which the proper functioning of DNA damage repair systems is disturbed. In clinical trials to date, PARP inhibitors significantly extended the progression-free survival in patients with confirmed BRCA mutations. Similar results have been obtained for patients without confirmed genetic background. Currently, PARP inhibitors are increasingly approved for use in the treatment of ovarian and breast cancer. From May 2021, the Ministry of Health has reimbursed maintenance therapy with PARP inhibitors in patients with known BRCA mutation status.
Lymphoepithelioma-like carcinoma (LELC) of the uterine cervix is a rare type of cervical cancer. The etiopathogenesis of cervical LELC involves consideration of the human papillomavirus (HPV) and Epstein–Barr virus infection. We present the case of a 57-year-old female diagnosed with a unique HPV-59 with the absence of Epstein–Barr virus, which is characteristic for European women. The treatment included a radical hysterectomy with nerve-sparing radical hysterectomy, which has not been used in patients with LELC so far. Complementary treatment included combined radiotherapy and cisplatin infusion.
Magnetic resonance imaging-guided radiotherapy can accurately irradiate moving targets such as cervical cancer. An 82-year-old woman with locally advanced cervical cancer was referred for palliative radiotherapy. She had refused chemotherapy and brachytherapy, so she was treated with external beam radiotherapy to control her uterine bleeding and to alleviate pubic pain. Since her cervical cancer had no metastases, and she was expected to survive for a long time, curative doses of radiation (70–80 Gy/28 fractions) were administered by magnetic resonance imaging-guided planned adaptive intensity-modulated radiation therapy. Six months after intensity-modulated radiation therapy, the tumor disappeared without adverse events, and her symptoms were relieved. To the best of our knowledge, this is the first report of locally advanced cervical cancer treated with high-dose magnetic resonance imaging-guided adaptive intensity-modulated radiation therapy.
Objective: In this study, we aimed to determine the learning curve for liver wedge resection performed as part of cytoreductive surgery in advanced ovarian malignant tumors. Materials and methods: This was a retrospective analysis of 120 women diagnosed with stage IIIC ovarian cancer according to the International Federation of Gynecology and Obstetrics (FIGO) classification: 22 underwent liver wedge resection as part of cytoreductive surgery (Group A), while 98 did not require liver surgery (Group B). In the study, the t-Student test was used for variables with normal distribution and the Mann−Whitney U test was utilized for increment and abnormally distributed variables. The variables categorized were shown as a number of cases (n) and a percentage (%), and compared using the chi-square test, with a p-value <0.05 considered significant. A cumulative sum control chart (CUSUM) method was used to investigate the learning curves in both groups and the entire cohort. Results: There were no significant differences in the operating time, intraoperative blood loss, postoperative hospitalization or minor and severe adverse effects between the Groups A and B. The operative time, total blood loss, and incidence of adverse effects showed a similar learning curve for Group B and the entire cohort. Conclusion: It is safe and feasible for gynecologic oncologists to perform wedge liver resections as part of cytoreductive surgery in women with advanced ovarian tumors.
Background: Epithelial ovarian cancer is increasingly often diagnosed in young females who wish to preserve their fertility. Fertilitypreserving surgeries, where conservation of the uterus and contralateral ovary was performed, might be beneficial for patients with stage I epithelial ovarian cancer, but their safety is still controversial. In the present study, we aimed to compare radical surgery and fertility-saving surgery in females with stage IA–C epithelial ovarian cancer for recurrence and survival rates, as well as to evaluate reproductive and obstetric outcomes for stage I epithelial ovarian cancer females who were managed with fertility-saving surgery. Materials and methods: We prospectively identified 60 patients aged ≤40 years who were diagnosed with stage I epithelial ovarian cancer. The patients in the fertility-preservation group underwent salpingo-oophorectomy on the side of the affected ovary in addition to incisional biopsy or wedge excision of the ovary on the other side. The patients in the radical surgery group underwent total hysterectomy and bilateral salpingo-oophorectomy. We followed up all patients for 5 years to assess their reproductive and oncological outcomes. Results: Patients in the fertility preservation surgery group were significantly younger (30 ± 4 versus 35 ± 5 years) (p < 0.001), their tumor sizes were smaller (3.4 ± 1.3 versus 6.0 ± 2.6 cm) (p < 0.001), of lower grade (p = 0.011), earlier stage (p < 0.001) and had more mucinous histology than patients in the radical surgery group. There were no statistically significant differences between both groups regarding tumor recurrence or survival rates. Of 25 patients who underwent fertility preservation surgery, 18 (72%) attempted to conceive. A total of 15/18 (83%) pregnancies were recorded, including 13 live births, 1 miscarriage, and 1 intrauterine fetal death. Conclusion: Fertility-sparing surgery could be an adequate alternative to radical surgery for young females with stage I epithelial ovarian cancer.
Nerve-sparing surgery is currently a very important topic in gynecologic oncology. In this review, it is shown that radical hysterectomy is not the only operation where the nerve-sparing technique can be used. Most surgical procedures in modern gynecologic oncology should spare the autonomic nerve structures. The review includes recently published articles precisely describing the nerve-sparing techniques in paraaortic and pelvic lymphadenectomy, and the modern approach to radical nerve-sparing hysterectomy. It has been shown in the literature that the quality of life of patients is directly dependent on the operation technique and its extension. As mentioned above, the nerve-sparing technique needs to be used not only in surgical procedures for cervical cancer, but more extensively also for endometrial and ovarian cancers. Modern techniques demonstrate that such an operation can be suitable both for the radicality and improved quality of life. Results of such operations are comparable to the old – not nerve-sparing techniques – both in terms of progression-free survival and overall survival. Nerve-sparing surgery in gynecologic oncology is our future. Better quality of life and greater patient satisfaction should be our goals. Studies are needed for better examination and comparison of the presented systematic nerve-sparing operations of lymphadenectomy in ovarian and endometrial cancers, and also combined with nerve-sparing radical hysterectomy.
Objective: The purpose of this study was to evaluate short-term oncological and perioperative outcomes of using Pfannenstiel incision for the surgical staging of endometrial carcinoma. Methods: This was a retrospective cohort study. All patients with endometrial carcinoma referred to the Department of Surgical Oncology, South Egypt Cancer Institute, for surgical staging between January 1, 2014, and July 1, 2016, were enrolled. The patients were grouped according to the type of surgical incision either through Pfannenstiel incision or midline incision, and the groups were compared. Demographic, clinical, operative, and short-term oncological features were analyzed. Results: A total number of 117 patients were recruited, of which 45 patients had Pfannenstiel incision, and 72 patients had midline incision. The clinical and pathological features of patients in both groups were similar. The operative outcomes showed no significant difference between the groups (p > 0.1). Postoperatively, the Pfannenstiel incision group had a statistically significant lower rate of complications compared to the midline incision group (15.5% vs. 38.9%, p = 0.02). The short-term oncological outcomes in the form of total procured lymph nodes or para-aortic lymph nodes were not statistically different (p > 0.1). Conclusion: Pfannenstiel incision can be safely performed for the surgical staging of endometrial cancer with acceptable oncological outcomes compared to the midline incision.
Objective: In this study, we aimed to identify the prognostic factors of survival and recurrence in ovarian and uterine serous cancer patients. Materials and methods: This was a retrospective study conducted at Tepecik Research and Education Hospital, İzmir, Turkey, between January 2002 and January 2019. The medical files of 2,027 endometrial and 821 ovarian patients who underwent examination for endometrial cancer and epithelial ovarian cancer were examined retrospectively by the same author. The data of eligible 385 and 49 patients diagnosed with ovarian and uterine serous carcinoma, respectively, were identified for analysis from the hospital database. Descriptive, univariate, and multivariate Cox regression and binary logistic regression analyses of patients were performed. Results: The mean age of ovarian serous cancer patients (n = 385) was 53.9 ± 10.9 years. The mean age of uterine serous cancer patients (n = 49) was 67.2 ± 10.6 years. A total of 81 ovarian serous cancer patients (21.0%) had stage 1, while 24 (6.2%) had stage 2, and 31 (8.1%) had stage 4 disease. A total of 26 uterine serous carcinoma patients (53.1%) had stage 1 disease, 6 (12.2%) had stage 2, 10 (20.4%) had stage 3, and 7 (14.3%) had stage 4 disease. For ovarian serous patients, stage, grade, optimality, neoadjuvant chemotherapy, adjuvant chemotherapy cycle number, and recurrence had impact on both overall and disease-free survival (p < 0.05). For uterine serous cancer patients, optimality was the only prognostic factor for both survival and recurrence (p = 0.01 and p = 0.01, respectively). Conclusion: In ovarian serous cancer patients, we found that disease stage, grade, optimality, neoadjuvant chemotherapy, and adjuvant chemotherapy cycle number had impact on overall and disease-free survival in both univariate and multivariate Cox regression analysis, whereas disease stage and optimality were the only significant prognostic factors for recurrence in ovarian serous cancer patients. However, in patients with uterine serous carcinomas, optimal surgery was the only independent prognostic factor both for survival and recurrence.
Introduction: Identification and attainment of the goals of cancer patients is an important aspect of personalized treatment. Aim of the study: The study aimed to assess the following aspects in patients treated surgically for endometrial cancer: 1) level of satisfaction with hospitalization using the EORTC IN-PATSAT32 nomothetic questionnaire; 2) degree of goals attainment using the Goal Attainment Scaling (GAS) idiographic questionnaire; 3) correlation between these evaluation methods. Material and method: The study included 123 patients with endometrial cancer (FIGO I–II) treated surgically at the Department of Obstetrics and Gynecology in Rzeszów in 2012–2014. EORTC IN-PATSAT32 and GAS questionnaires were used. The collected material was analyzed using the Statistica 10.0 software. Results: The overall level of satisfaction measured with the IN-PATSAT32 scale was 72.2 ± 20.5. The technical skills were rated the highest in nurses (74.5 ± 17.6) and doctors (69.3 ± 17.8), while the lowest score was awarded for hospital assess (54.7 ± 23.3). The overall satisfaction with care was 72.2 ± 20.5. In the personalized GAS scale, the patients listed individual expectations before the surgery, assigning ranks to their importance. For most of them, it was a very high (A) or high (B) rank. The patients assigned the highest ranks to quick mobilization, success of the operation, and willingness to be healthy. The average value of the level of goal attainment on the discharge date was 63.7 ± 9.4 points. Statistically significant correlations between the questionnaires were found for the level of goal attainment and the assessment of various aspects of hospital care. Conclusions: The study proved that the EORTC IN-PATSAT32 questionnaire was correlated with GAS questionnaire, and additionally provided knowledge about individual goals of care and the degree of their attainment. The use of nomothetic and idiographic tools gives wider possibilities in the planning and implementation of personalized care.
Aim of the study: In this retrospective cohort study we have examined differences in survival profiles with respect to the body mass index in patients with mucosal melanoma on immune checkpoint inhibitor therapy. Materials and methods: The primary outcome included the association between the body mass index and overall survival in patients with metastatic mucosal melanoma. The secondary outcomes included the clinical presentation and management of vulvar and vaginal melanomas with oral and anorectal mucosal melanomas, as well as the surgical and radiological management of vulvar and vaginal melanomas. Kaplan–Meier analysis and log-rank test were used for the assessment of overall survival. Results: The results showed that patients with mucosal melanoma whose body mass index was ≥25 had better overall survival (p = 0.02). Overall survival was different between vulvar/vaginal vs. oral mucosal melanoma (p = 0.02). Overall survival was not different between vulvar/vaginal vs. anorectal melanoma (p = 0.77). Some immune toxicities were specific to patients with vulvar/vaginal melanoma. Conclusions: Obesity is associated with improved survival in patients with metastatic mucosal melanoma, although findings can be heterogeneous depending on the subtype of mucosal melanoma.
Aim:The aim of this study was to compare the effectiveness of treatment methods and to highlight treatment debates of cesarean scar pregnancy in the light of the current literature.Materials and methods: A total of 55 cesarean scar pregnancy patients from 39 English, free full-text available case reports published between year 2010 and 2020 were analyzed.The patients were treated with various treatment methods.The most commonly used methods, complications, and treatment failures were evaluated.Cases with uterine dehiscence, rupture, acute abdomen, placental abnormalities, trophoblastic diseases, heterotopic pregnancies, twin pregnancies, and emergency surgeries were excluded from the analysis.Results: Overall, 55 patients from 39 case reports were included in the analysis.Of these cases, 24 were treated with methotrexate (14 patients systemically, 9 systemically methotrexate plus local potassium chloride, 1 methotrexate plus mifepristone).Surgical management was performed in 31 patients, and involved: dilatation and suction curettage, laparoscopy, uterine artery embolization, laparotomy, hysteroscopy, high intensity focused ultrasound, bilateral uterine artery balloon catheter insertion, obliteration of the feeding artery with fibrin sealant, and cesarean section.Two of the cesarean scar pregnancies were continued and cesarean section plus hysterectomy was performed at 35 weeks gestation.Limitations of the study: Dependence of the analysis on anecdotal case reports and series is the main limitation of this study.Therefore, there is a need for larger prospective series comparing treatment options and outcomes.Another limitation that precludes us from definitive conclusions is the heterogeneity in the methods of laboratory measurements, the quality of ultrasonography equipment, and the experience of surgeons.Conclusion: In conclusion, although there has been no established consensus on the management of scar line pregnancies in the literature, current literature indicates that one size does not fit and that it is reasonable to plan the treatment according to the patients' characteristics.Ultrasonography is valuable in diagnosis and choosing a treatment modality.It is also crucial to determine the type of scar line pregnancy before planning the treatment.
Foam cell formation is a very common pathologic finding in atherosclerosis, often found in some major organs. However, the involvement of the retroperitoneal organs is very rare and foam cell formation associated with borderline ovarian tumor has not been reported. Borderline ovarian tumors are epithelial ovarian tumors with a low growth rate, low potential to invade or metastasize, and excellent prognosis. Still, a rapidly growing borderline ovarian tumor can exert pressure on the retroperitoneal organs. It may cause retroperitoneal irritation and inflammation, and form a mass lesion in adjacent organs. We report the case of a 41-year-old woman with a borderline ovarian tumor and foam cell infiltration.
Cancer is a genetic disease with the growth of tumor cells initiated and promoted by mutations in a group of genes known as drivers.This is just the beginning of the process of cancerogenesis, characterized by cellular, genetic and epigenetic alterations as well as the loss of normal cellular regulatory processes.The revelation of complexity of mechanisms underlying the Cancer-Immunity Cycle has resulted in defining immunological and histological profiles responsible for suppressing or promoting anticancer immunity.It has been observed that such profile is determined not only by intrinsic tumor properties, patients' genetics, but also such extrinsic elements as gut microbiota, the presence of infection or exposure to sunlight.The balance between these factors, known as a cancerimmune set point, is a threshold that must be exceeded for a patient to respond to immunotherapy.Among various types of cancer immunotherapy, we can distinguish an adoptive T cell transfer, checkpoint blockade and neoantigen vaccines.The genuine features of human immune system, such as specific recognition and elimination of cancer cells, adaptation to an evolving tumor and immunological memory seem to be a perfect combination to create a powerful weapon for long-term cancer control.Nevertheless, the exact understanding of immunological mechanisms in both tumor growth and cancer elimination requires more thorough studies and may lead to enhancing the efficiency of a wide variety of immunotherapeutic anticancer approaches.
The aim of this study was to review research on the role of long non-coding RNA (lncRNA) in ovarian cancer. This article analyses studies on the effect of increased lncRNA expression on the size of ovarian cancer and the incidence of metastasis. The review covers a period from October 15, 2018 to August 22, 2020, and comprises 23 studies in which a total of 1,580 women with ovarian cancer participated, and an undetermined number of control groups where healthy tissue samples were collected. A review of the studies indicates that increased lncRNA expression is associated with elevated ovarian cancer size and metastatic risk. The most studied lncRNA include HOTAIR, CCAT2, GAS5, MALAT-1, UCA1. Studies assessing the expression levels of HOTAIR lncRNA and CCAT2 in normal and cancer tissue showed varying levels of expression in studies of different authors, which indicates that the expression of the same lncRNA may vary individually or is a result of study errors.
This retrospective cohort study examined the factors for patients with metastatic vulvar and vaginal melanomas on immune checkpoint inhibitors. The study included all patients over the age of 18 who received either anti-cytotoxic T-lymphocyte-4 (anti-CTLA-4) therapy or anti-programmed cell death protein-1 (anti-PD-1) therapy at the Sunnybrook Hospital from June 2012 to December 2018. There were 11 patients with vulvar or vaginal melanoma on immune checkpoint inhibitor therapy. The main sites of metastasis included the lungs, lymph nodes, soft tissues, and liver. The majority of patients received prior radiation therapy (7/11) and prior surgical therapy (9/11). There were no differences in overall survival for vulvar or vaginal melanomas on anti-PD-1 vs. anti-CTLA-4 therapy (p > 0.05). There were no significant differences in overall survival for vulvar and vaginal vs. cutaneous melanoma (p > 0.5). There were no significant differences in overall survival in patients with vulvar and vaginal melanoma in the presence vs. absence of immune-related adverse events (p > 0.05), yet there was a significant difference in patients with cutaneous melanoma in the presence vs. absence of immune-related adverse events (p < 0.05). Knowledge of the presentation and outcome of vulvar and vaginal melanomas is important for clinical practice in gynecology.
Background:In the light of a growing interest in breast augmentation with implant devices, physicians should be aware of medium and long-term complications after such procedures.Moreover, an increased risk of breast cancer with higher mortality in the group of implant recipients is observed, which requires an implementation of accurate screening.Summary: A special approach must be considered when managing a patient with breast implants due to the possibility to encounter unexpected difficulties during the diagnostic process.Certain complications of breast augmentation require urgent diagnosis followed by adequate treatment, often including surgical management.On the other hand, a patient may report worrying symptoms which mimic those related to breast implants.Plastic surgery patients should be counseled on multiple health aspects prior to the surgery, with emphasis on the oncological risk.Regular breast check-ups are necessary among women with breast implants since proper exposition of breast tissue may be problematic.Key messages: Proper oncological vigilance is needed as adequate imaging of augmented breasts might be compromised.A decreased survival of breast cancer patients with breast implants compared with non-augmented women is observed.A holistic approach towards the patient with breast implants helps to mitigate the risk of overlooking important symptoms.
Objective: Gestational trophoblastic disease is a term that encompasses a spectrum of disorders all arising from the placenta. Human chorionic gonadotropin (hCG) hormone has an essential role in the diagnosis and management of gestational trophoblastic neoplasia. Measuring beta-hCG (B-hCG) levels is the only standard method of monitoring treatment response in patients on chemotherapy. Serial B-hCG levels are also helpful in defining the suitable approach and the dosage of chemotherapeutic drugs. Unfortunately, this marker may not be helpful in some cases. Therefore, the present study was conducted to determine the results of the ratio of B-hCG and hyperglycosylated human chorionic gonadotropin (H-hCG) in patients with gestational trophoblastic neoplasia. Materials and methods: This was a cross-sectional study in 22 patients with gestational trophoblastic neoplasia who were referred to an oncology clinic of an academic hospital of Mashhad University of Medical Sciences in Iran from December 2017 to May 2018. Inclusion criteria were plateau level of B-hCG (during 4 weeks) or persistent low level of hCG. After ruling out other etiologies, H-hCG level was measured and the H-hCG/total hCG ratio was evaluated. If the proportion was more than 20%, active gestational trophoblastic neoplasia was diagnosed, and if it was less than 20%, quiescent gestational trophoblastic neoplasia was diagnosed. In patients with active gestational trophoblastic neoplasia, interventional procedures involved a change in the dose intensity or chemotherapy or proposing a surgery. However, only serial follow-up was recommended in patients with quiescent gestational trophoblastic neoplasia. Then, the patients were followed during the therapy and the condition of patients was followed and recorded. Results: The mean age of patients was 31.36 ± 8.01 years. Hydatidiform mole was the most common diagnosis, accounting for approximately 64% (14) of patients. A total of 81% of patients were undergoing chemotherapy. The interval time between the onset of chemotherapy until plateau or persistent low level of hCG was 11.26 ± 4.03 weeks. The mean B-hCG level was 36.6 mIU/mL and the mean H-hCG/total hCG ratio was 6.24%. This proportion was less than 20% in 82% of patients. Among these patients, 14 patients (77.8%) had spontaneously normalized levels of B-hCG during a 6-month follow-up. Two cases underwent chemotherapy due to increased B-hCG. Other patients are still under follow-up without disease progression. Among 4 patients with a H-hCG/total hCG ratio >20%, hysterectomy was recommended to one patient duo to multiparity and the fact that the tumor was localized in the uterus. In the other patients, an increase in the dose of methotrexate or a change of chemotherapy regimen was performed, which caused a decrease in B-hCG level to normal. All patients are still under follow-up without disease progression. Conclusion: The data in this study suggests the use of H-hCG as a tumor marker in patients with persistent low level of B-hCG, which is useful to distinguish between quiescence gestational trophoblastic neoplasia, which does not need treatment, from active gestational trophoblastic neoplasia. However, further studies with larger sample size are needed to confirm and generalize the above findings. Keywords: gestational trophoblastic
Introduction: Episiotomy scar endometriosis is an extremely rare entity and often causes diagnostic uncertainty.Case report: We report a case of perineal swelling and cyclical pain following obstetric delivery with episiotomy.Magnetic resonance imaging revealed possible episiotomy scar endometriosis confined to the perineum.Wide surgical excision was performed and the histopathological report confirmed the diagnosis.No recurrence was noted after the surgery.Conclusion: Episiotomy scar endometriosis should be considered whenever a woman with previous episiotomy presents with cyclical pain or a nodule in the perineum.Magnetic resonance imaging can assist with the diagnosis and wide excision remains the best treatment option for this condition.
