Von Willebrand factor in the rat kidney: its localization and the effects of its in vivo interaction with specific antibodies

Antiendothelial cell antibodies and increased von Willebrand factor (vWF) levels are observed in many renal diseases. We studied renal morphology after administration of rabbit anti-human factor VIII-von Willebrand factor (FVIII-vWFc) gamma-globulin (IgG) in rats. Isolated perfusion of normal rat kidney with the antibodies disclosed rabbit IgG along glomerular endothelium and in mesangial areas. Systemic administration resulted in an identical antibody distribution. C3 deposits and few electron dense deposits were transiently noted. After 1 week the mesangial deposition of rabbit IgG had increased significantly, most likely reflecting increased release of vWF by the endothelium. Thereafter, the deposits gradually relocated into mesangial stalk and into the glomerular vascular pole, and they had vanished after 6 weeks. Except for a mild influx of leukocytes, no renal injury occurred. In conclusion, although FVIII-vWFc antibodies cause mesangial immune deposits, antibodies against other endothelial antigens are apparently needed to inflict renal damage.

[Histological and radiobiological study on adult cases with ataxia telangiectasia]

Ataxia telangiectasia (AT) is a hereditary disease that involves both the immune and nervous system; its pathogenesis is believed to be due to disturbances in DNA repair system. Because children are usually affected, reports concerning adult patients are rare. In the present study, we performed comprehensive clinical, histological, and radiobiological examinations on two adult female siblings, currently 23 and 19 years old. The initial symptom was an ataxic gait, which began in the elder sister at the age of 20 and the younger sister at the age of 18. Both had mild telangiectasia in the bulbar conjunctiva and auricula. The neurological manifestations of both were gaze nystagmus, cerebellar ataxia, hyporeflexia, and vibratory sensation disturbance. Only the elder sister showed stocking type sensory disturbance. The MRI of both patients revealed cerebellar atrophy, especially in vermis. After either X-ray irradiation or bleomycin treatment, fibroblast survival curve showed a marked, dose-dependent declined in both patients compared with normal controls. Similar patterns were observed in both patients. After bleomycin treatment, no differences in the survival ratio of cultured fibroblasts could be found between these adult patients and those observed in younger children with classic AT. Biopsied sural nerves showed a decrease in the number of large myelinated fibers, with a few myelinated axons having relatively thin myelin. There were severe atrophic changes, with regenerative myelinated fibers in the elder sister. In conclusion, both adult patients with delayed onset AT displayed similar bleomycin hypersensitivity in fibroblasts as would be expected in children with AT. Radiobiological examinations and sural nerve biopsy suggest that both disturbed cellular regeneration and atrophic process may play a role in the neural involvement in this disease.

Octreotide decreases canine gastric mucosal blood flow: a controlled assessment by endoscopic reflectance spectrophotometry

The aim of this study was to evaluate the effects of octreotide, a long-acting somatostatin analogue, on canine gastric mucosal blood flow and hemodynamics. We hypothesized that octreotide might decrease gastric mucosal blood flow without causing adverse hemodynamic effects. Two groups of dogs were anesthetized (six normal dogs and six dogs with prehepatic portal hypertension), and each dog was administered intravenous octreotide, normal saline solution, and vasopressin for 30 minutes on separate days in a blinded, randomized fashion. Vasopressin was included as treatment for a positive control. Gastric mucosal blood flow was assessed at the fundus, corpus, and antrum by endoscopic reflectance spectrophotometry. A femoral arterial catheter monitored systemic blood pressure and heart rate. Treatment responses for all observations were calculated for each dog as a percentage of baseline values. For mucosal blood flow, treatment responses did not differ significantly over time or between animal group or gastric location. Octreotide significantly decreased indices of hemoglobin concentration (-19%, p = 0.01) and oxygen saturation (-17%, p = 0.0002) compared to saline (-9% and -7%, respectively). The mean arterial pressure was increased after octreotide compared to saline (+23% versus +7%, p = 0.01), but octrotide had no effect on heart rate (+2% versus +1%). Vasopressin also decreased the indices of hemoglobin concentration (-34%) and oxygen saturation (-82%) significantly more than saline (p = 0.001). Vasopressin increased mean arterial pressure (+55%), but also caused reflex bradycardia (-22%) significantly more than saline (p = 0.001). We conclude that octreotide decreases canine gastric mucosal blood flow and appears to cause minimal hemodynamic changes.

Characterization of two novel polysaccharides having immunological activities from the root of Panax ginseng

Two acidic polysaccharides, called ginsenan S-IA and ginsenan S-IIA, were isolated from the root of Panax ginseng C. A. Meyer. They were homogeneous on electrophoresis and gel chromatography, and their molecular masses were estimated to be 5.6 x 10(4) and 1.0 x 10(5), respectively. Ginsenan S-IA is composed of L-arabinose: D-galactose: D-galacturonic acid in the molar ratio of 8:8:1, and ginsenan S-IIA is composed of L-arabinose: D-galactose: D-glucose: D-galacturonic acid in the molar ratio of 15:10:2:5, in addition to small amounts of O-acetyl groups. About a half (ginsenan S-IA) and about a quarter (ginsenan S-IIA) of the hexuronic acid residues exist as methyl esters. Reduction of carboxyl groups, methylation analysis, nuclear magnetic resonance and periodate oxidation studies indicated that their structural features include mainly alpha-1,5-linked L-arabino-beta-3,6-branched D-galactan type structural units. Both polysaccharides showed remarkable reticuloendothelial system-potentiating activity in a carbon clearance test and pronounced anti-complementary activity. These substances are the first examples having a relatively high content of both alpha-3,5-branched L-arabinose and beta-1,4-linked D-galactose units among the acidic arabinogalactans with activities on phagocytosis and anti-complement.

Predictability of operative results of cervical compression myelopathy based on preoperative computed tomographic myelography

The transverse area and flattening ratio of the spinal cord were determined with preoperative computed tomographic myelography in 103 patients with cervical compression myelopathy: cervical spondylotic myelopathy (n = 44); ossification of the posterior longitudinal ligament (n = 39); and cervical disc herniation (n = 20). With these values and other clinical items (eg, age, duration of symptoms, preoperative severity), a linear model to predict postoperative recovery was attempted by multiple regression analysis. In cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament, the transverse area of the spinal cord and the duration of symptoms were accepted as effective explanatory variables to predict recovery. In cervical disc herniation, regardless of the transverse area or duration, the recovery was good, and pathologic state was considered essentially different.

Idiopathic spinal cord herniation. Report of two cases and review of the literature

The authors experienced unique cases of spinal cord herniation. Only eight cases of spinal cord herniation have been reported formerly. The authors report two cases of spinal cord herniation accompanied with double structure of dura mater (duplicated dura mater). The causes of their condition are discussed in this report.

Neutral proteinases in human intervertebral disc. Role in degeneration and probable origin

Neutral proteinases were partially purified from human intervertebral disc by extraction with guanidine hydrochloride followed by Sephadex G-75 column chromatography. They showed gelatinolytic and elastolytic activities at neutral pH. The apparent molecular weights of these enzymes were 70 KD and 25 KD, the former being the complexed form of the latter. The sensitivity to various synthetic inhibitors indicated these enzymes to be serine elastases. Furthermore, they were considered to be leukocyte elastases because anti-leukocyte elastase antibody inhibited the proteinase activity of these enzymes. Proteinase activity was not detected in normal discs, except for some slight activity in the end-plate. In contrast, the degenerated discs showed high activity, especially in the nucleus pulposus and end-plate. Similar high levels of proteinase activity were found in the vertebral body adjacent to normal as well as degenerated discs. These findings suggest that leukocyte elastase, which is normally present in the vertebral body, flows into and degrades the matrix of the intervertebral disc under pathologic conditions.

Decrease in deoxyribonucleotide triphosphate pools and induction of alkaline-labile sites in mouse bone marrow cells by multiple treatments with methotrexate

Methotrexate (MTX), an inhibitor of dihydrofolate reductase (DHFR), slightly induced micronuclei in bone marrow and peripheral blood cells, and this induction was enhanced by multiple treatments with the drug. Furthermore, we have suggested that the multiple-dose effect on the induction of micronuclei by MTX might be explained by intracellular accumulation of the drug, resulting in an enhancement of DHFR inhibition. An imbalance or decrease in the deoxyribonucleotide (dNTP) pool would be generated by this enzyme inhibition. Therefore, we attempted to determine the level of the dNTP pool in mouse bone marrow cells. The levels of three dNTPs (dTTP, dATP, dGTP) as determined by HPLC were only 1/10-1/40 of the levels previously found in mammalian cell lines, but dCTP levels could not be determined precisely because they approached the limits of detectability. The levels of dTTP, dATP and dGTP in mouse bone marrow cells 3 h after four injections of MTX (4 mg/kg/day) decreased to 21.2%, 47.0% and 38.1%, respectively, of those in the control group. The level of dTTP 3 h after four injections of 100 mg/kg of the drug decreased to almost 0%. The results of alkaline elution assays suggested that alkaline-labile sites were generated in mouse bone marrow cells 6 h after four injections of MTX (4 mg/kg). These findings suggest that the multiple-dose effects of MTX on micronucleus induction in mouse bone marrow cells may be explained by the decrease in the dNTP pool and subsequent generation of alkaline-labile sites (possibly apurinic/apyrimidinic sites).

Combination chemotherapy with 254-S, ifosfamide, and peplomycin for advanced or recurrent cervical cancer

BACKGROUND

Based on the fact that combination chemotherapy with cisplatin, ifosfamide, and bleomycin generated a 69% response rate in patients with recurrent cervical cancer; that 254-S (a cisplatin analogue) monotherapy generated a 46.3% response rate for cervical cancer, which was higher than those generated by cisplatin and carboplatin in historic comparison; and that peplomycin is a bleomycin analogue with improved pulmonary toxic effects, a combination regimen with 254-S, ifosfamide, and peplomycin was evaluated in an animal experiment and a clinical study in patients with advanced or recurrent cervical cancer with an expectation that the regimen might show a higher efficacy than 254-S monotherapy and the combination regimen including cisplatin.

METHODS

In the clinical testing, 254-S was administered intravenously (IV) at 80-100 mg/m2, ifosfamide was administered IV at 1500 mg/patient for 5 days, and peplomycin was administered intramuscularly at 5 mg/patient for 6 days. This treatment was repeated every 4 weeks.

RESULTS

As a result, this regimen showed additive or synergistic antitumor effects in mice receiving B16 melanoma transplants. In the clinical study, 83.8% and 60.9% response rates were obtained in 37 previously untreated patients with Stage III or IV cervical cancer and 23 with recurrent cervical cancer, respectively. The dose-limiting factor was bone marrow toxic effects, which were tolerable. The other toxic effects were mild, and there were no deaths.

CONCLUSIONS

From these results, this combination regimen was thought worthy of evaluation in a Phase III comparative study in patients with advanced or recurrent cervical cancer.

[A field assessment of a community 'rehabilitation class' for home handicapped persons--focusing on participant social network]

The purpose of this study is to evaluate a community 'Rehabilitation class' for its effectiveness. A function of the 'Rehabilitation class' is the expansion of a participant's social network, and the following hypothesis was formulated: the reciprocal relationships of participant and class or staff members bring about psychological effectiveness and a change of their awareness, resulting in the expansion of social networks. Actual class activity, psychological aspects and social networks of twenty-six participants and twenty care takers, who responded to a questionnaire survey, were examined with respect to the above hypothesis. Those reporting having changed were compared to those reporting no change. The results were as follows: (1) Class activity was directed at developing relationships among participants, and while most of them were changed positively, it appeared that staff members were not sufficiently involved. (2) There were 23 participants in the 'changed' group. Most of their care takers and family were changed positively. Eleven reported receiving significant emotional support from other 'Rehabilitation class' members, and therefore their social networks appeared to have expanded generally. (3) The 'non changed' group consisted of 3 participants whose social networks did not appear to have expanded. (4) Social networks outside the home were not expanded for all participants, probably due to their reported receiving little social support from others outside family members, and because they had few social roles outside the home. Based on the above results, it is concluded that effective classes involve participants individually, and encourage the independent activity of participants, and that it is necessary to have networking with other organizations in community, and the 'Rehabilitation class' should be provided to smaller local regions.

Immunohistochemical type distinction of alpha-fetoprotein in various alpha-fetoprotein-secreting tumors

In order to clarify the histogenesis of alpha-fetoprotein (AFP)-secreting tumor tissues, formalin-fixed, paraffin-embedded serial sections of 148 tumors in various organs were examined by the peroxidase-antiperoxidase method for AFP, and paradoxical concanavalin A staining. Yolk sac-type AFP was found in yolk sac tumors, embryonal carcinomas, solid teratomas, (yolk sac) endodermal cell tumors, adenocarcinomas (stomach, ovary or lung) and metastatic liver cancers. Hepatic-type AFP was demonstrated in hepatocellular carcinomas, hepatoblastomas, solid teratomas and a stomach cancer. Yolk sac-type AFP was observed in the neighboring liver cells of metastatic liver cancers without relation to the type of AFP in primary cancers. The results from serum analyses of preoperative tumor-bearing patients (68 cases) were coincident with those from immunohistochemical stainings.

Accumulation of thallium-201 in medullary thyroid cancer with negative serum calcitonin and carcinoembryonic antigens: a case report

Thallium-201 (201Tl) scintigraphy has been used in the evaluation of thyroid neoplasm. Even though several authors have shown the usefulness of 201Tl scintigraphy in evaluating recurrent tumor of medullary thyroid cancer, the number of reports on primary thyroid cancer is limited. We presented a case of medullary thyroid cancer which showed 201Tl uptake in both early and delayed scans. This case had normal serum levels of calcitonin and carcinoembryonic antigen.

Characterization of two acidic polysaccharides having immunological activities from the root of Panax ginseng

Two acidic polysaccharides, named ginsenan PA and ginsenan PB, were isolated from the root of Panax ginseng C. A. Meyer. They were homogeneous on electrophoresis and gel chromatography, and their molecular masses were estimated to be 1.6 x 10(5) and 5.5 x 10(4), respectively. They are composed of L-arabinose: D-galactose: L-rhamnose: D-galacturonic acid: D-glucuronic acid in the molar ratios of 11:22:1:6:1 (ginsenan PA) and 3:7:2:8:1 (ginsenan PB), in addition to small amounts of O-acetyl groups. Almost all (ginsenan PA) and part (ginsenan PB) of the hexuronic acid residues exist as methyl esters. Reduction of carboxyl groups, methylation analysis, nuclear magnetic resonance and periodate oxidation studies indicated that their structural features include mainly both alpha-arabino-beta-3,6-galactan type and rhamnogalacturonan type structural units. Both polysaccharides showed remarkable reticuloendothelial system-potentiating activity in a carbon clearance test, pronounced anti-complementary activity and alkaline phosphatase-inducing activity in a dose dependent manner.

[Sensitivity test for anti-tumor agents-3. MTT assay and its clinical effect]

MTT assay, a sensitivity test of anti-tumor agents was performed, and its clinical usefulness, was discussed. In 15 surgical specimens, the cell suspensions were prepared aseptically, and divided into three processing; namely, Papanicolaou (Pap) smears to confirm the malignant cells, MTT assay, and cell cultures in chamber slides. MTT assay was evaluated only when tumor cells in the chamber slide were observed 50% or more by Pap staining. Drugs judged to be effective were applied for patients, resulting in 64.2% of predictive accuracy in the sensitivity. Conclusions; 1) MTT assay was developed for sensitivity test of anti-tumor agents, 2) Strict assessment was carried out by the confirmation of cancer cells using chamber slides, 3) On clinical usefulness, predictability for the sensitivity was 64.2%, that for resistance was 100%, and over all predictability was 66.7% 4) MTT assay was useful for the determination of effective and for elimination of ineffective drugs.

Influence of fibril length upon ePTFE graft healing and host modification of the implant

Influence of fibril length (porosity) upon synthetic vascular graft healing has not been investigated in detail. The purpose of this study was to determine the dependence of neoendothelial healing, cellular response, and biocompatibility on the fibril length of expanded polytetrafluoroethylene (ePTFE) grafts with an internal diameter of 1.5 mm. ePTFE grafts of different fibril length, 20, 40, 60, and 90 microns, were implanted into the abdominal aorta of rats (n = 5 for each group). After 5 weeks, the implants were harvested and examined for neointimal and pseudointimal coverage by light microscopy and SEM. The hydroxyproline content of the implants was measured, and the distribution of collagen types was examined. The neointimal and pseudointimal coverage was related to the fibril length, and the neoendothelial healing was better on 60-microns and 90-microns grafts than on 20-microns and 40-microns grafts. The amount of hydroxyproline was also related to the fibril length, however, no significant difference could be observed between 60-microns and 90-microns grafts. Collagen types I and III were almost identically located in the middle portion of the implants. Our results demonstrate that the fibril length of ePTFE grafts affected neoendothelial healing and its affinity to collagen.

A clinical study of degenerative spondylolisthesis. Radiographic analysis and choice of treatment

Surgical treatment of degenerative spondylolisthesis in 27 patients by means of anterior lumbar interbody fusion and in 14 patients by means of posterior decompression yielded average degrees of recovery of 77% and 56%, respectively. Preoperative analysis of myelograms, and computed tomographies after myelography indicated that anterior shifting of the inferior articular process of the slipping vertebra was the main factor responsible for compression of the nervous tissue in the early stages of degenerative spondylolisthesis. Patients in these stages should be treated by anterior lumbar interbody fusion. In the later stages of degenerative spondylolisthesis, osteophytes on the superior articular processes of the lower vertebra were an additional factor in compression, and patients should be treated by posterior decompression. Computed tomographies after myelography provided the key images for identifying pathologic processes in degenerative spondylolisthesis and selecting appropriate surgical procedures.

Spontaneous fracture of the odontoid process in rheumatoid arthritis

Six cases of spontaneous fracture of the odontoid process in rheumatoid arthritis are presented. Fifty-one patients with atlantoaxial subluxation in rheumatoid arthritis underwent surgery between 1981 and 1990. This included six patients (in 10%) who had subluxation accompanied by fracture of the odontoid without apparent trauma. The mean patient age was 58 years and all had a long history of rheumatoid arthritis. No trauma was considered to be the cause of the fracture. This is a fracture caused by erosion and osteoporosis of the odontoid process due to rheumatoid synovitis, aging and steroid therapy. In addition, another cause is a dynamic load produced from the instability accompanying atlantoaxial subluxation working on the odontoid in cervical extension. It is important remember that the odontoid process is susceptible to spontaneous fracture.

Mechanism of induction of micronuclei and chromosome aberrations in mouse bone marrow by multiple treatments of methotrexate

Methotrexate (MTX), an inhibitor of dihydrofolate reductase (DHFR), slightly induced micronuclei and this induction of micronuclei was enhanced by multiple treatments with the drug (Yamamoto et al., 1981; Hayashi et al., 1984; CSGMT/JEM.MMS, 1990). More micronuclei and chromosomal aberrations in mouse bone marrow cells were induced by multiple than by single treatment. The MTX level in mouse plasma and bone marrow showed little (or no) differences between single and quadruple treatments several hours after the injection(s). On the other hand, the DHFR activity in bone marrow cells 3 h after one and four injections was decreased to approximately 38 and 0%, respectively, of that in non-treated mice. Furthermore, the intracellular MTX level in the bone marrow cells (but not in total bone marrow) after four injections was about 10-fold higher than that after one injection. The amount of MTX bound to protein 3 h after four injections, as assayed by gel filtration (Sephadex G-25), was approximately 8-fold greater than after one injection. Therefore, the multiple-dose effects of MTX on the induction of micronuclei and chromosomal aberrations may be explained by the intracellular accumulation of MTX resulting in an enhancement of enzyme inhibition.

[The effect of elastase on aminonucleoside nephrosis--on renal vascular system]

This study was performed to investigated the relationship between cross sectional areas of glomerular arterioles and glomerular volume in rats with puromycin aminonucleoside (PAN)-induced nephrosis, which is an experimental model of glomerular sclerosis. We also evaluated the effect of an anti-arteriosclerotic agent, elastase on these parameters. Six-week-old male Sprague-Dawley rats were divided into 3 groups; control, PAN-treated (70 mg/kg i.p.), or PAN+elastase-treated (5 mg/kg/day i. m.) group. After 12 weeks of experimental period, microvascular cast of the kidney was prepared, and the cross sectional areas of afferent and efferent arterioles as well as glomerular volume were measured using scanning electron microscopy. In the juxtamedullary glomeruli with minor abnormalities, the efferent arteriole was narrower in PAN-treated rats than in the control rats and the elastase-treatment partially corrected it (control 55.7, PAN 35.9, PAN+elastase 43.7 x 10 microns 2). On the other hand, the cross sectional area of afferent arteriole was not different among the 3 groups. In glomeruli showing sclerosis, the cross sectional area of efferent arteriole correlated positively with the glomerular volume. There results suggest that constriction of the efferent arterioles contributes to the development of glomerular sclerosis in PAN-induced nephrosis. In addition, elastase possibly inhibits this process and thereby protect glomeruli from sclerosis.

[A case report of poststernotomy mediastinitis treated with the pectoralis major muscle flap after protracted wound irrigation]

A 8-year-old boy developed mediastinitis after direct closure of atrial septal defect. Methicillin-resistant Staphylococcus aureus (MRSA) was detected from the wound. Intermittent wound irrigation with povidone-iodine solution and vancomycin solution was protracted for two months. After the remission of MRSA infection, implantation of pectoralis major muscle flap was performed. Without recurrence of infection the wound was healed completely. Although pectoralis major muscle flap is an effective method of choice for mediastinitis, an appropriate timing of enforcing this method should be investigated hereafter.

[The clinical and pharmacokinetic evaluation of two-route chemotherapy with cisplatin and sodium thiosulfate in combination with angiotensin II]

Thirty-six courses of chemotherapy with cisplatin (CDDP) and sodium thiosulfate (STS) were performed in 31 patients with gynecologic cancer 2 weeks after operation under the hypertensive condition induced by angiotensin II (AT-II). One hundred-fifty mg of CDDP/body was intraperitoneally administered while the usual systolic blood pressure was increased to 130-140% by AT-II. The hypertension was maintained for 15 minutes after finishing CDDP infusion, then 8g of STS was intravenously infused immediately after the cessation of AT-II. The urinary Pt level measured 15 minutes after finishing CDDP infusion was extremely low at 1.37 +/- 0.47 micrograms/ml, in spite of the significantly high levels of plasma total Pt (7.83 +/- 0.85 micrograms/ml) and filtrable Pt (4.02 +/- 0.55 micrograms/ml). This suggests that, during renal vasoconstriction induced by AT-II, the renal blood flow as well as renal uptake of CDDP was decreased. Plasma filtrable Pt levels were measured at 15, 30, 60 and 120 minutes after intraperitoneal administration of CDDP. At 15 and 30 minutes a significantly higher blood concentration was found than in the control group (p less than 0.05). However, CDDP-induced toxicities of the bone marrow, liver, kidney and alimentary tract were not increased. The extreme vasoconstriction in the kidneys and other organs induced by AT-II might have protected these organs from the toxicities of CDDP despite the fact that STS infusion was delayed by 15 minutes after CDDP infusion. STS infused immediately after the cessation of AT-II could neutralize the CDDP preventing the occurrence of toxicities.(ABSTRACT TRUNCATED AT 250 WORDS)

[Combination chemotherapy with 254-S, ifosfamide and peplomycin for advanced or recurrent cervical cancer]

From favorable results with 254-S, a new cisplatin analogue, single administration, we have conducted a clinical study to investigate the efficacy of combination of 254-S, ifosfamide and peplomycin, each of which has a different dose limiting factor. A total of 45 patients, including 22 patients with stage III and IV cervical cancer and 23 cases with recurrent cervical cancer, were treated with at least two courses of 254-S (100mg/m2, iv. Day 1), ifosfamide (1,500mg/body, iv. Day 1-5) and peplomycin (5mg/body, im. Day 1-6), and tumor response was evaluated clinically and by CT scanning. The response rate obtained in patients with advanced disease was 81.8% (PR = 17, CR = 1) and that in cases with recurrence was 60.9% (PR = 12, CR = 2). Myelosuppression was the dose limiting factor. In the 121 courses, grade 3 and 4 of leucopenia and thrombocytopenia were observed with an incidence of 44% and 32%, respectively and DIC occurred in 3 cases with poor PS though they recovered after reducing the 254-S dose to 80 mg/m2. The other toxicities were mild except for alopecia. Anaphylaxia was observed in a case at the second administration though the patient recovered in 15 minutes. There was no death. As to prognosis, a significant prolongation of survival period was observed in recurrent cases and 4 cases are alive (NED) after one and a half year. In the advanced cases, until now 3 cases of stage IV have died from the disease. We have concluded that this regimen is effective as a neoadjuvant chemotherapy for advanced cervical cancer and useful for the treatment of recurrent cervical cancer.