Assuntos
COVID-19 , Trombose , Genitália , Humanos , Necrose , RNA Mensageiro , SARS-CoV-2 , Trombose/etiologia , VacinaçãoAssuntos
Escleroderma Sistêmico , Dermatopatias , Biomarcadores , Proteínas de Choque Térmico HSP27 , Proteínas de Choque Térmico , Humanos , Chaperonas Moleculares , Escleroderma Sistêmico/diagnóstico , Escleroderma Sistêmico/patologia , Esclerose/patologia , Pele/patologia , Dermatopatias/patologiaAssuntos
Doenças Pulmonares Intersticiais/diagnóstico por imagem , Miosite/diagnóstico , Esclerodermia Difusa/imunologia , Doença Aguda , Idoso , Anticorpos Anticitoplasma de Neutrófilos/imunologia , Anticorpos Antinucleares/imunologia , Autoanticorpos/imunologia , DNA Topoisomerases Tipo I , Progressão da Doença , Eletromiografia , Feminino , Humanos , Doenças Pulmonares Intersticiais/complicações , Doenças Pulmonares Intersticiais/imunologia , Doenças Pulmonares Intersticiais/fisiopatologia , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Miosite/complicações , Miosite/imunologia , Proteínas Nucleares/imunologia , Ribonucleoproteína Nuclear Pequena U1/imunologia , Esclerodermia Difusa/complicações , Tomografia Computadorizada por Raios XAssuntos
Esclerodermia Difusa/sangue , Esclerodermia Limitada/sangue , Pele/patologia , beta-Defensinas/sangue , Estudos de Casos e Controles , Fibrose , Humanos , Esclerodermia Difusa/complicações , Esclerodermia Difusa/patologia , Esclerodermia Limitada/complicações , Esclerodermia Limitada/patologia , Telangiectasia/sangue , Telangiectasia/etiologiaRESUMO
BACKGROUND: Trappin-2/pre-elafin is an endogenous inhibitor of human neutrophil elastase involved in inflammation, innate immunity and vascular remodelling, which consist of the complex pathological process of systemic sclerosis (SSc). OBJECTIVES: To clarify the potential role of trappin-2 in SSc. METHODS: Serum trappin-2 levels were determined by enzyme-linked immunosorbent assay in 51 SSc and 18 healthy subjects. Trappin-2 expression was evaluated in SSc lesional skin and cultured endothelial cells treated with FLI1 siRNA by immunohistochemistry, reverse transcription-real-time PCR and/or immunoblotting. Friend leukaemia virus integration 1 (Fli1) binding to the PI3 promoter was assessed by chromatin immunoprecipitation. RESULTS: Since serum trappin-2 levels inversely correlated with estimated glomerular filtration rate in SSc patients with renal dysfunction, SSc patients with normal renal function were analysed. Although serum trappin-2 levels were comparable between diffuse cutaneous SSc, limited cutaneous SSc and control subjects, the prevalence of digital ulcers or elevated right ventricular systolic pressure (RVSP) was significantly higher in SSc patients with elevated serum trappin-2 levels than in those with normal levels. Furthermore, serum trappin-2 levels were significantly increased in SSc patients with digital ulcers or elevated RVSP compared to those without. Moreover, serum trappin-2 levels positively correlated with RVSP values in SSc patients. Importantly, trappin-2 expression was enhanced in small vessels of SSc lesional skin. In cultured endothelial cells, trappin-2 expression was elevated by gene silencing of FLI1 at mRNA and protein levels and Fli1 occupied the PI3 promoter. CONCLUSIONS: Endothelial trappin-2 up-regulation partially due to Fli1 deficiency can be associated with the development of SSc vasculopathy.
Assuntos
Elafina/sangue , Escleroderma Sistêmico/sangue , Úlcera Cutânea/etiologia , Disfunção Ventricular Direita/etiologia , Idoso , Pressão Sanguínea , Vasos Sanguíneos/metabolismo , Estudos de Casos e Controles , Células Cultivadas , Células Endoteliais , Feminino , Inativação Gênica , Humanos , Masculino , Pessoa de Meia-Idade , Proteína Proto-Oncogênica c-fli-1/genética , Escleroderma Sistêmico/complicações , Escleroderma Sistêmico/genética , Pele/irrigação sanguínea , Úlcera Cutânea/sangue , Sístole , Regulação para Cima , Disfunção Ventricular Direita/sangueRESUMO
BACKGROUND: Antimicrobial peptides have attracted much attention as a member of disease-associated molecules in systemic sclerosis (SSc), which is pathologically characterized by immune abnormalities, vasculopathy and tissue fibrosis. OBJECTIVE: To investigate the potential contribution of one of the antimicrobial peptide psoriasin to the development of SSc. METHODS: Psoriasin expression in the skin samples and sera derived from SSc patients and its correlation with clinical parameters were analysed. Psoriasin expression was evaluated by immunohistochemistry with skin samples from SSc patients and healthy controls. Serum levels of psoriasin were determined by enzyme-linked immunosorbent assay in 51 SSc patients and 19 healthy controls and assessed for the association with clinical symptoms. RESULTS: The expression of psoriasin was elevated in the epidermis of SSc lesional skin. Serum psoriasin levels were higher in SSc patients, especially in diffuse cutaneous SSc patients with disease duration of <6 years, than in healthy controls. With respect to clinical association, SSc patients with interstitial lung disease, telangiectasia and pitting scars had significantly augmented levels of serum psoriasin than those without each of these symptoms. In the subgroup of patients with interstitial lung disease, the elevation of serum psoriasin levels was associated with higher ground-glass opacity scores. Furthermore, serum psoriasin levels were decreased after the treatment with intravenous cyclophosphamide pulse as compared to baseline values. CONCLUSION: Our findings indicate a possible contribution of psoriasin to the development of clinical symptoms associated with vascular and epithelial abnormalities and inflammation in SSc, further supporting the roles of antimicrobial peptides in the SSc pathogenesis.
Assuntos
Cicatriz/sangue , Doenças Pulmonares Intersticiais/sangue , Proteína A7 Ligante de Cálcio S100/sangue , Escleroderma Sistêmico/sangue , Telangiectasia/sangue , Adulto , Idoso , Estudos de Casos e Controles , Cicatriz/etiologia , Ciclofosfamida/uso terapêutico , Feminino , Humanos , Imunossupressores/uso terapêutico , Doenças Pulmonares Intersticiais/diagnóstico por imagem , Doenças Pulmonares Intersticiais/etiologia , Masculino , Pessoa de Meia-Idade , Radiografia Torácica , Proteína A7 Ligante de Cálcio S100/metabolismo , Escleroderma Sistêmico/complicações , Escleroderma Sistêmico/tratamento farmacológico , Escleroderma Sistêmico/metabolismo , Pele/metabolismo , Telangiectasia/etiologiaRESUMO
BACKGROUND: Interleukin (IL)-25 is a member of the IL-17 family, which can promote and augment T-helper (Th) type 2 responses. The expression of IL-25 and its cognate receptor, IL-25 receptor (IL-25R), is upregulated and correlated with disease activity in Th2-associated diseases. OBJECTIVES: To examine the expression and function of IL-25 in cutaneous T-cell lymphoma (CTCL). METHODS: Expression and location of IL-25 in lesional skin was investigated with immunohistochemistry. The effect of various cytokines on IL-25 production from normal human epidermal keratinocytes was assessed by quantitative reverse-transcription real-time polymerase chain reaction. Serum IL-25 levels were measured by enzyme-linked immunosorbent assay. The direct effect of IL-25 on tumour cells was also examined using CTCL cell lines and peripheral blood mononuclear cells in patients with Sézary syndrome. RESULTS: IL-25 expression was increased in epidermal keratinocytes in lesional skin of CTCL. Th2 cytokines, IL-4 and IL-13, and periostin induced IL-25 expression by normal human epidermal keratinocytes. Serum IL-25 levels were increased in patients with advanced CTCL and correlated with serum lactate dehydrogenase levels. MyLa cells expressed IL-25R and its expression was augmented by stimulation with IL-25. IL-25 enhanced IL-13 production from MyLa cells via phosphorylation of signal transducer and activator of transcription 6. Peripheral blood mononuclear cells from one patient with Sézary syndrome expressed IL-25R and showed increase of IL-13 production by IL-25. CONCLUSIONS: Th2 cytokines highly expressed in CTCL lesional skin induce IL-25 production by epidermal keratinocytes, which may, in turn, lead to formation of a Th2-dominant microenvironment through the direct induction of IL-13 by tumour cells.
Assuntos
Interleucina-17/fisiologia , Linfoma Cutâneo de Células T/imunologia , Células Th2/imunologia , Microambiente Tumoral/imunologia , Linhagem Celular , Progressão da Doença , Feminino , Humanos , Interleucina-13/biossíntese , Interleucina-17/metabolismo , Queratinócitos/imunologia , Leucócitos Mononucleares/metabolismo , Masculino , Pessoa de Meia-Idade , Fosforilação/imunologia , Receptores de Interleucina/imunologia , Fator de Transcrição STAT6/metabolismo , Regulação para Cima/imunologiaRESUMO
Single-cell analysis is of increasing importance in many fields, but is challenging due to the ultra-small volumes (picoliters) of single cells. Indeed, analysis of a specific analyte might require the analysis of a single molecule or several molecules. Analytical processes usually include sampling, chemical processing, and detection. Although several papers have reported chemical processing and detection methods for single cells, a sampling method compatible with maintaining the viability of a single cell during sampling has yet to be developed. Here, we propose a femtoliter sampling method from a living single cell using micro/nanofluidic device technology. The sampling of 39 fL of cytoplasm from a single human aortic endothelial cell was demonstrated and its viability after sampling was confirmed.
Assuntos
Citoplasma/química , Células Endoteliais/citologia , Técnicas Analíticas Microfluídicas , Nanotecnologia , Análise de Célula Única , Aorta/citologia , Células Cultivadas , HumanosAssuntos
Fatores Imunológicos/uso terapêutico , Doenças Pulmonares Intersticiais/tratamento farmacológico , Rituximab/uso terapêutico , Escleroderma Sistêmico/complicações , Feminino , Glucocorticoides/uso terapêutico , Humanos , Pulmão/diagnóstico por imagem , Doenças Pulmonares Intersticiais/diagnóstico por imagem , Doenças Pulmonares Intersticiais/etiologia , Prednisolona/uso terapêutico , Tomografia Computadorizada por Raios X , Falha de Tratamento , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: LL-37 is an antimicrobial peptide with pleiotropic effects on the immune system, angiogenesis and tissue remodelling. These are cardinal pathological events in systemic sclerosis (SSc). OBJECTIVES: To elucidate the potential role of LL-37 in SSc. METHODS: The expression of target molecules was evaluated by immunostaining and quantitative reverse-transcription real-time polymerase chain reaction in human and murine skin. The mechanisms regulating LL-37 expression in endothelial cells were examined by gene silencing and chromatin immunoprecipitation. Serum LL-37 levels were determined by enzyme-linked immunosorbent assay. RESULTS: In SSc lesional skin, LL-37 expression was increased in dermal fibroblasts, perivascular inflammatory cells, keratinocytes and, particularly, dermal small vessels. Expression positively correlated with interferon-α expression, possibly reflecting LL-37-dependent induction of interferon-α. In SSc animal models, bleomycin-treated skin exhibited the expression pattern of CRAMP, a murine homologue of LL-37, similar to that of LL-37 in SSc lesional skin. Furthermore, Fli1+/- mice showed upregulated expression of CRAMP in dermal small vessels. Fli1 binding to the CAMP (LL-37 gene) promoter and Fli1 deficiency-dependent induction of LL-37 were also confirmed in human dermal microvascular endothelial cells. In the analysis of sera, patients with SSc had serum LL-37 levels significantly higher than in healthy controls. Furthermore, serum LL-37 levels positively correlated with skin score and the activity of alveolitis and were significantly elevated in patients with digital ulcers compared with those without. CONCLUSIONS: LL-37 upregulation, induced by Fli1 deficiency at least in endothelial cells, potentially contributes to the development of skin sclerosis, interstitial lung disease and digital ulcers in SSc.
Assuntos
Catelicidinas/fisiologia , Escleroderma Sistêmico/etiologia , Pele/patologia , Doenças Vasculares/etiologia , Adulto , Idoso , Animais , Peptídeos Catiônicos Antimicrobianos/metabolismo , Catelicidinas/metabolismo , Células Endoteliais/metabolismo , Feminino , Fibrose/sangue , Fibrose/etiologia , Humanos , Interferon-alfa/metabolismo , Camundongos Endogâmicos C57BL , Pessoa de Meia-Idade , Proteína Proto-Oncogênica c-fli-1/deficiência , Escleroderma Sistêmico/sangue , Regulação para Cima/fisiologia , Doenças Vasculares/sangueAssuntos
Antirreumáticos/efeitos adversos , Glomerulonefrite/etiologia , Hemorragia/etiologia , Doenças Pulmonares Intersticiais/induzido quimicamente , Pneumopatias/etiologia , Rituximab/efeitos adversos , Esclerodermia Difusa/tratamento farmacológico , Doença Aguda , Idoso , Evolução Fatal , Feminino , Humanos , Esclerodermia Difusa/complicaçõesRESUMO
BACKGROUND: Endothelial protein C receptor (EPCR), expressed predominantly on endothelial cells, plays a critical role in the regulation of the coagulation system and also mediates various cytoprotective effects by binding and activating protein C. So far, the role of EPCR has not been studied in systemic sclerosis (SSc). OBJECTIVES: To investigate the potential contribution of EPCR to the development of SSc. METHODS: EPCR expression was examined in skin samples and cultivated dermal microvascular endothelial cells by immunostaining, immunoblotting and/or quantitative reverse-transcription polymerase chain reaction. Fli1, binding to the PROCR promoter, was assessed by chromatin immunoprecipitation. Serum EPCR levels were determined by enzyme-linked immunosorbent assay in 65 patients with SSc and 20 healthy subjects. RESULTS: EPCR expression was decreased in dermal small vessels of SSc lesional skin compared with those of healthy control skin. Transcription factor Fli1, deficiency of which is implicated in SSc vasculopathy, occupied the PROCR promoter, and EPCR expression was suppressed in Fli1 small interfering RNA-treated endothelial cells and dermal small vessels of Fli1(+/-) mice. In patients with SSc, decreased serum EPCR levels were associated with diffuse skin involvement, interstitial lung disease and digital ulcers. Furthermore, serum EPCR levels inversely correlated with plasma levels of plasmin-α2-plasmin inhibitor complex (PIC). Importantly, bosentan significantly reversed circulating EPCR and PIC levels in patients with SSc, and the expression of Fli1 and EPCR in dermal small vessels was elevated in patients treated with bosentan compared with untreated patients. CONCLUSIONS: Endothelial EPCR downregulation due to Fli1 deficiency may contribute to hypercoagulation status leading to tissue fibrosis and impaired peripheral circulation in SSc.
Assuntos
Antígenos CD/fisiologia , Proteína Proto-Oncogênica c-fli-1/deficiência , Receptores de Superfície Celular/fisiologia , Escleroderma Sistêmico/etiologia , Adulto , Idoso , Análise de Variância , Animais , Bleomicina/farmacologia , Bosentana , Estudos de Casos e Controles , Células Cultivadas , Regulação para Baixo/fisiologia , Células Endoteliais/metabolismo , Receptor de Proteína C Endotelial , Antagonistas dos Receptores de Endotelina/farmacologia , Endotélio Vascular/metabolismo , Ensaio de Imunoadsorção Enzimática , Feminino , Fibrinolisina/efeitos dos fármacos , Humanos , Masculino , Camundongos , Microvasos/metabolismo , Pessoa de Meia-Idade , Escleroderma Sistêmico/sangue , Sulfonamidas/farmacologia , Trombofilia/etiologia , alfa 2-Antiplasmina/efeitos dos fármacosRESUMO
Chronic lymphocytic leukemia (CLL) can be immunosuppressive in humans and mice, and CLL cells share multiple phenotypic markers with regulatory B cells that are competent to produce interleukin (IL)-10 (B10 cells). To identify functional links between CLL cells and regulatory B10 cells, the phenotypes and abilities of leukemia cells from 93 patients with overt CLL to express IL-10 were assessed. CD5(+) CLL cells purified from 90% of the patients were IL-10-competent and secreted IL-10 following appropriate ex vivo stimulation. Serum IL-10 levels were also significantly elevated in CLL patients. IL-10-competent cell frequencies were higher among CLLs with IgV(H) mutations, and correlated positively with TCL1 expression. In the TCL1-transgenic (TCL1-Tg) mouse model of CLL, IL-10-competent B cells with the cell surface phenotype of B10 cells expanded significantly with age, preceding the development of overt, CLL-like leukemia. Malignant CLL cells in TCL1-Tg mice also shared immunoregulatory functions with mouse and human B10 cells. Serum IL-10 levels varied in TCL1-Tg mice, but in vivo low-dose lipopolysaccharide treatment induced IL-10 expression in CLL cells and high levels of serum IL-10. Thus, malignant IL-10-competent CLL cells exhibit regulatory functions comparable to normal B10 cells that may contribute to the immunosuppression observed in patients and TCL1-Tg mice.
Assuntos
Linfócitos B Reguladores/imunologia , Linfócitos B/imunologia , Interleucina-10/imunologia , Leucemia Linfocítica Crônica de Células B/imunologia , Proteínas Proto-Oncogênicas/metabolismo , Proteínas Proto-Oncogênicas/fisiologia , Animais , Linfócitos B/metabolismo , Linfócitos B/patologia , Linfócitos B Reguladores/metabolismo , Linfócitos B Reguladores/patologia , Células Cultivadas , Imunofluorescência , Humanos , Terapia de Imunossupressão , Interleucina-10/metabolismo , Leucemia Linfocítica Crônica de Células B/metabolismo , Leucemia Linfocítica Crônica de Células B/patologia , Lipopolissacarídeos/farmacologia , Camundongos , Camundongos TransgênicosRESUMO
We report a case of palmoplantar lichen planus in a 7-year-old Japanese girl with congenital deafness, who presented with erythematous eruptions and hyperkeratosis, with peeling and fissures on her soles, palms and digits. On histological examination of a skin biopsy from the lesion on her wrist, lichen planus was identified. Using computed tomography of the inner ears, bilateral cochlear dysplasia was found. The patient's DNA was sequenced; no sequence variants were detected in the GJB2 gene encoding connexin-26, but she had a missense mutation in SLC26A4 (solute carrier family 26, member 4). Mutations in SLC26A4 are known causes of hearing loss, but this is a novel mutation, which has not been reported previously. In addition, there have been no reports of cutaneous symptoms in previously reported patients with mutations in SLC26A4. To our knowledge, therefore, this is the first report of palmoplantar lichen planus associated with sensorineural deafness accompanied by a mutation in the SLC26A4 gene.
Assuntos
Dermatoses do Pé/genética , Dermatoses da Mão/genética , Perda Auditiva Neurossensorial/genética , Ceratodermia Palmar e Plantar/genética , Líquen Plano/genética , Proteínas de Membrana Transportadoras/genética , Mutação de Sentido Incorreto , Criança , Conexina 26 , Conexinas , Surdez , Feminino , Perda Auditiva Neurossensorial/congênito , Humanos , Transportadores de SulfatoRESUMO
OBJECTIVE: Radical hysterectomy (RH) is a standard treatment for locally advanced non-squamous cell carcinoma (N-SCC) of the uterine cervix, but there have been no reports on whether neoadjuvant chemotherapy (NAC) followed by radical hysterectomy could improve the outcome of patients with this disease. MATERIALS AND METHODS: This multicenter retrospective study enrolled 77 patients with Stage IB2 to IIB N-SCC of the uterine cervix. Of these, 27 patients were treated with NAC prior to radical hysterectomy (NAC group) and 50 with RH alone (RH group). The two-year recurrence-free survival (RFS) rate, progression-free survival (PFS), and overall survival (OS) were compared between the two groups. Clinical parameters such as clinical stage, histological type, and postoperative treatment were also examined between the groups. RESULTS: While the two-year RFS rates were 81.5% and 70.0% in NAC and RH groups, respectively (p = 0.27) and the median PFS was 51 months and 35 months in NAC and RH groups, respectively (p = 0.35), the median OS was 58 months and 48 months in NAC and RH groups, respectively, which was significant (p = 0.0014). The median OS of patients with mucinous adenocarcinoma in NAC group was significantly higher than that in RH group: 58 months versus 37 months (p = 0.03). CONCLUSION: NAC prior to RH may offer the prognostic advantage of patients with locally advanced N-SCC of the uterine cervix, especially mucinous adenocarcinoma.
Assuntos
Histerectomia , Neoplasias do Colo do Útero/terapia , Adulto , Idoso , Quimioterapia Adjuvante , Intervalo Livre de Doença , Feminino , Humanos , Pessoa de Meia-Idade , Terapia Neoadjuvante , Estudos Retrospectivos , Neoplasias do Colo do Útero/mortalidadeRESUMO
BACKGROUND: Previous studies suggest that CCL13 may have some role in the pathogenesis of systemic sclerosis (SSc). OBJECTIVES: To determine serum levels of CCL13 and its clinical associations in patients with SSc. METHODS: Serum CCL13 levels were examined by enzyme-linked immunosorbent assay in 80 patients with SSc, 20 patients with systemic lupus erythematosus (SLE), 20 patients with dermatomyositis (DM), 29 patients with atopic dermatitis (AD) and 50 healthy individuals. RESULTS: Mean + or - SD serum CCL13 levels were elevated in patients with SSc (81.3 + or - 55.8 pg mL(-1)) compared with healthy controls (15.0 + or - 9.9 pg mL(-1); P < 0.001) and patients with SLE (22.0 + or - 6.9 pg mL(-1); P < 0.001), DM (24.4 + or - 36.1 pg mL(-1); P < 0.001) and AD (18.0 + or - 6.4 pg mL(-1); P < 0.001). Among patients with SSc, there were no differences in serum CCL13 levels between limited cutaneous SSc and diffuse cutaneous SSc. In a longitudinal study, CCL13 levels were generally unchanged during the follow-up. CONCLUSIONS: Serum CCL13 was specifically increased in patients with SSc, but not in patients with SLE, DM or AD or in healthy controls. CCL13 could be a promising serological marker for SSc.
Assuntos
Dermatite Atópica/sangue , Dermatomiosite/sangue , Lúpus Eritematoso Sistêmico/sangue , Proteínas Quimioatraentes de Monócitos/sangue , Escleroderma Sistêmico/sangue , Adulto , Povo Asiático , Biomarcadores/sangue , Estudos de Casos e Controles , Dermatite Atópica/imunologia , Dermatomiosite/imunologia , Ensaio de Imunoadsorção Enzimática , Feminino , Humanos , Estudos Longitudinais , Lúpus Eritematoso Sistêmico/imunologia , Masculino , Pessoa de Meia-Idade , Escleroderma Sistêmico/imunologia , Índice de Gravidade de Doença , Estatística como Assunto , Estatísticas não ParamétricasAssuntos
Agranulocitose/etiologia , Linfo-Histiocitose Hemofagocítica/complicações , Linfo-Histiocitose Hemofagocítica/terapia , Plasmaferese , Doença de Still de Início Tardio/etiologia , Adulto , Agranulocitose/diagnóstico , Citocinas/sangue , Feminino , Humanos , Linfo-Histiocitose Hemofagocítica/imunologia , Doença de Still de Início Tardio/diagnósticoRESUMO
Clear cell carcinoma (CCC) of the ovary has been recognized to show resistance to anticancer agents in the first-line chemotherapy. Our aim was to evaluate the effect of second-line chemotherapy in a retrospective study. A total of 75 patients diagnosed with CCC and treated between 1992 and 2002 in collaborating hospitals were reviewed. Criteria for the patients' enrollment were 1) diagnosis of pure-type CCC at the initial operation, 2) treatment after one systemic postoperative chemotherapy, 3) measurable recurrent or refractory tumor, 4) at least two cycles of second-line chemotherapy and assessable for the response, and 5) adequate clinical information. Regimens of first-line chemotherapy were conventional platinum-based therapy in 33 cases, paclitaxel plus platinum in 24 cases, irinotecan plus platinum in 9 cases, and irinotecan plus mitomycin C in 7 cases. Treatment-free periods were more than 6 months in 24 cases (group A) and less than 6 months in 51 cases (group B). In group A, response was observed in two cases (8%): one with conventional platinum therapy and another with irinotecan plus platinum. In group B, three cases (6%) responded: two with platinum plus etoposide and one case with irinotecan plus platinum. Median overall survival was 16 months in group A and 7 months in group B (P = 0.04). These findings suggest recurrent or resistant CCC is extremely chemoresistant, and there is only small benefit of long treatment-free period in CCC patients. Another strategy including molecular-targeting therapy is warranted for the treatment of recurrent or refractory CCC.