1
|
Zhou H, Wang F, Niu T. Prediction of prognosis and immunotherapy response of amino acid metabolism genes in acute myeloid leukemia. Front Nutr 2022; 9:1056648. [PMID: 36618700 PMCID: PMC9815546 DOI: 10.3389/fnut.2022.1056648] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
Background Amino acid (AA) metabolism plays a crucial role in cancer. However, its role in acute myeloid leukemia (AML) is still unavailable. We screened out AA metabolic genes, which related to prognosis, and analyzed their correlation with tumor immune microenvironment in AML. Methods We evaluated 472 amino acid metabolism-related genes in 132 AML patients. The predictive risk model was developed according to differentially expressed genes, univariate Cox and LASSO analyses. We validated the risk signature by survival analysis and independence tests. Single-sample gene set enrichment analysis (ssGSEA), tumor immune microenvironment (TME), tumor mutation burden (TMB), functional enrichment, and the IC50 of drugs were assessed to explore the correlations among the risk model, immunity, and drug sensitivity of AML. Results Six amino acid metabolism-related genes were confirmed to develop the risk model, including TRH, HNMT, TFEB, SDSL, SLC43A2, and SFXN3. The high-risk subgroup had an immune "hot" phenotype and was related to a poor prognosis. The high-risk group was also associated with more activity of immune cells, such as Tregs, had higher expression of some immune checkpoints, including PD1 and CTLA4, and might be more susceptible to immunotherapy. Xenobiotic metabolism, the reactive oxygen species (ROS) pathway, fatty acid metabolism, JAK/STAT3, and the inflammatory response were active in the high-risk subgroup. Furthermore, the high-risk subgroup was sensitive to sorafenib, selumetinib, and entospletinib. ssGSEA discovered that the processes of glutamine, arginine, tryptophan, cysteine, histidine, L-serine, isoleucine, threonine, tyrosine, and L-phenylalanine metabolism were more active in the high-risk subgroup. Conclusion This study revealed that AA metabolism-related genes were correlated with the immune microenvironment of AML patients and could predict the prognosis and immunotherapy response of AML patients.
Collapse
Affiliation(s)
- Hui Zhou
- Department of Hematology and Research Laboratory of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fengjuan Wang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ting Niu
- Department of Hematology and Research Laboratory of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China,*Correspondence: Ting Niu,
| |
Collapse
|
2
|
Rutella S, Vadakekolathu J, Mazziotta F, Reeder S, Yau TO, Mukhopadhyay R, Dickins B, Altmann H, Kramer M, Knaus HA, Blazar BR, Radojcic V, Zeidner JF, Arruda A, Wang B, Abbas HA, Minden MD, Tasian SK, Bornhäuser M, Gojo I, Luznik L. Immune dysfunction signatures predict outcomes and define checkpoint blockade-unresponsive microenvironments in acute myeloid leukemia. J Clin Invest 2022; 132:e159579. [PMID: 36099049 PMCID: PMC9621145 DOI: 10.1172/jci159579] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 09/06/2022] [Indexed: 01/12/2023] Open
Abstract
BackgroundImmune exhaustion and senescence are dominant dysfunctional states of effector T cells and major hurdles for the success of cancer immunotherapy. In the current study, we characterized how acute myeloid leukemia (AML) promotes the generation of senescent-like CD8+ T cells and whether they have prognostic relevance.METHODSWe analyzed NanoString, bulk RNA-Seq and single-cell RNA-Seq data from independent clinical cohorts comprising 1,896 patients treated with chemotherapy and/or immune checkpoint blockade (ICB).ResultsWe show that senescent-like bone marrow CD8+ T cells were impaired in killing autologous AML blasts and that their proportion negatively correlated with overall survival (OS). We defined what we believe to be new immune effector dysfunction (IED) signatures using 2 gene expression profiling platforms and reported that IED scores correlated with adverse-risk molecular lesions, stemness, and poor outcomes; these scores were a more powerful predictor of OS than 2017-ELN risk or leukemia stem cell (LSC17) scores. IED expression signatures also identified an ICB-unresponsive tumor microenvironment and predicted significantly shorter OS.ConclusionThe IED scores provided improved AML-risk stratification and could facilitate the delivery of personalized immunotherapies to patients who are most likely to benefit.TRIAL REGISTRATIONClinicalTrials.gov; NCT02845297.FUNDINGJohn and Lucille van Geest Foundation, Nottingham Trent University's Health & Wellbeing Strategic Research Theme, NIH/NCI P01CA225618, Genentech-imCORE ML40354, Qatar National Research Fund (NPRP8-2297-3-494).
Collapse
Affiliation(s)
- Sergio Rutella
- John van Geest Cancer Research Centre, Nottingham Trent University, Nottingham, United Kingdom
| | - Jayakumar Vadakekolathu
- John van Geest Cancer Research Centre, Nottingham Trent University, Nottingham, United Kingdom
| | - Francesco Mazziotta
- Department of Oncology and Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stephen Reeder
- John van Geest Cancer Research Centre, Nottingham Trent University, Nottingham, United Kingdom
| | - Tung-On Yau
- John van Geest Cancer Research Centre, Nottingham Trent University, Nottingham, United Kingdom
| | - Rupkatha Mukhopadhyay
- Department of Oncology and Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Benjamin Dickins
- John van Geest Cancer Research Centre, Nottingham Trent University, Nottingham, United Kingdom
| | - Heidi Altmann
- Department of Medicine, Universitätsklinikum Carl Gustav Carus, Technische Universität (TU) Dresden, Dresden, Germany
| | - Michael Kramer
- Department of Medicine, Universitätsklinikum Carl Gustav Carus, Technische Universität (TU) Dresden, Dresden, Germany
| | - Hanna A. Knaus
- Department of Oncology and Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - Bruce R. Blazar
- Masonic Cancer Center and Department of Pediatrics, Division of Blood & Marrow Transplant and Cellular Therapy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Vedran Radojcic
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Joshua F. Zeidner
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Andrea Arruda
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Bofei Wang
- Department of Leukemia, Division of Cancer Medicine and
| | - Hussein A. Abbas
- Department of Leukemia, Division of Cancer Medicine and
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark D. Minden
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Sarah K. Tasian
- Department of Pediatrics, Division of Oncology and Centre for Childhood Cancer Research, Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Martin Bornhäuser
- Department of Medicine, Universitätsklinikum Carl Gustav Carus, Technische Universität (TU) Dresden, Dresden, Germany
- National Center for Tumor Diseases and German Cancer Consortium, Partner Site Dresden, Dresden, Germany
- German Cancer Research Centre, Heidelberg, Germany
| | - Ivana Gojo
- Department of Oncology and Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Leo Luznik
- Department of Oncology and Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
3
|
Vadakekolathu J, Minden MD, Hood T, Church SE, Reeder S, Altmann H, Sullivan AH, Viboch EJ, Patel T, Ibrahimova N, Warren SE, Arruda A, Liang Y, Smith TH, Foulds GA, Bailey MD, Gowen-MacDonald J, Muth J, Schmitz M, Cesano A, Pockley AG, Valk PJM, Löwenberg B, Bornhäuser M, Tasian SK, Rettig MP, Davidson-Moncada JK, DiPersio JF, Rutella S. Immune landscapes predict chemotherapy resistance and immunotherapy response in acute myeloid leukemia. Sci Transl Med 2021; 12:12/546/eaaz0463. [PMID: 32493790 DOI: 10.1126/scitranslmed.aaz0463] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 01/20/2020] [Accepted: 04/21/2020] [Indexed: 01/13/2023]
Abstract
Acute myeloid leukemia (AML) is a molecularly and clinically heterogeneous hematological malignancy. Although immunotherapy may be an attractive modality to exploit in patients with AML, the ability to predict the groups of patients and the types of cancer that will respond to immune targeting remains limited. This study dissected the complexity of the immune architecture of AML at high resolution and assessed its influence on therapeutic response. Using 442 primary bone marrow samples from three independent cohorts of children and adults with AML, we defined immune-infiltrated and immune-depleted disease classes and revealed critical differences in immune gene expression across age groups and molecular disease subtypes. Interferon (IFN)-γ-related mRNA profiles were predictive for both chemotherapy resistance and response of primary refractory/relapsed AML to flotetuzumab immunotherapy. Our compendium of microenvironmental gene and protein profiles provides insights into the immuno-biology of AML and could inform the delivery of personalized immunotherapies to IFN-γ-dominant AML subtypes.
Collapse
Affiliation(s)
| | - Mark D Minden
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada
| | - Tressa Hood
- NanoString Technologies Inc., Seattle, WA 98109, USA
| | | | - Stephen Reeder
- John van Geest Cancer Research Centre, Nottingham Trent University, Nottingham NG11 8NS, UK
| | - Heidi Altmann
- Department of Medicine, Universitätsklinikum Carl Gustav Carus, 01307 Dresden, Germany
| | | | | | - Tasleema Patel
- Department of Pediatrics, Division of Oncology and Centre for Childhood Cancer Research, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, PA 19104, USA
| | - Narmin Ibrahimova
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada
| | | | - Andrea Arruda
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada
| | - Yan Liang
- NanoString Technologies Inc., Seattle, WA 98109, USA
| | | | - Gemma A Foulds
- John van Geest Cancer Research Centre, Nottingham Trent University, Nottingham NG11 8NS, UK
| | | | | | - John Muth
- MacroGenics Inc., Rockville, MD 20850, USA
| | - Marc Schmitz
- Institute of Immunology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | | | - A Graham Pockley
- John van Geest Cancer Research Centre, Nottingham Trent University, Nottingham NG11 8NS, UK.,Centre for Health, Ageing and Understanding Disease (CHAUD), Nottingham Trent University, Nottingham NG11 8NS, UK
| | - Peter J M Valk
- Department of Hematology, Erasmus University Medical Centre, 3000CA Rotterdam, Netherlands
| | - Bob Löwenberg
- Department of Hematology, Erasmus University Medical Centre, 3000CA Rotterdam, Netherlands
| | - Martin Bornhäuser
- Department of Medicine, Universitätsklinikum Carl Gustav Carus, 01307 Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany.,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Sarah K Tasian
- Department of Pediatrics, Division of Oncology and Centre for Childhood Cancer Research, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, PA 19104, USA
| | - Michael P Rettig
- Division of Oncology, Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO 63110, USA
| | | | - John F DiPersio
- Division of Oncology, Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Sergio Rutella
- John van Geest Cancer Research Centre, Nottingham Trent University, Nottingham NG11 8NS, UK. .,Centre for Health, Ageing and Understanding Disease (CHAUD), Nottingham Trent University, Nottingham NG11 8NS, UK
| |
Collapse
|
4
|
Alves R, McArdle SEB, Vadakekolathu J, Gonçalves AC, Freitas-Tavares P, Pereira A, Almeida AM, Sarmento-Ribeiro AB, Rutella S. Flow cytometry and targeted immune transcriptomics identify distinct profiles in patients with chronic myeloid leukemia receiving tyrosine kinase inhibitors with or without interferon-α. J Transl Med 2020; 18:2. [PMID: 31900171 PMCID: PMC6941328 DOI: 10.1186/s12967-019-02194-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/23/2019] [Indexed: 01/10/2023] Open
Abstract
Background Tumor cells have evolved complex strategies to escape immune surveillance, a process which involves NK cells and T lymphocytes, and various immunological factors. Indeed, tumor cells recruit immunosuppressive cells [including regulatory T-cells (Treg), myeloid-derived suppressor cells (MDSC)] and express factors such as PD-L1. Molecularly targeted therapies, such as imatinib, have off-target effects that may influence immune function. Imatinib has been shown to modulate multiple cell types involved in anti-cancer immune surveillance, with potentially detrimental or favorable outcomes. Imatinib and other tyrosine kinase inhibitors (TKIs) in chronic myeloid leukemia (CML) have dramatically changed disease course. Our study aimed to characterize the different populations of the immune system in patients with CML affected by their treatment. Methods Forty-one patients with CML [33 treated with TKIs and 8 with TKIs plus interferon (IFN)-α] and 20 controls were enrolled in the present study. Peripheral blood populations of the immune system [referred to as the overview of immune system (OVIS) panel, Treg cells and MDSCs] and PD-1 expression were evaluated by flow cytometry. The immunological profile was assessed using the mRNA Pan-Cancer Immune Profiling Panel and a NanoString nCounter FLEX platform. Results Patients receiving combination therapy (TKIs + IFN-α) had lower numbers of lymphocytes, particularly T cells [838/µL (95% CI 594–1182)] compared with healthy controls [1500/µL (95% CI 1207 – 1865), p = 0.017]. These patients also had a higher percentage of Treg (9.1%) and CD4+PD-1+ cells (1.65%) compared with controls [Treg (6.1%) and CD4+/PD-1+(0.8%); p ≤ 0.05]. Moreover, patients treated with TKIs had more Mo-MDSCs (12.7%) whereas those treated with TKIs + IFN-α had more Gr-MDSC (21.3%) compared to controls [Mo-MDSC (11.4%) and Gr-MDSC (8.48%); p ≤ 0.05]. CD56bright NK cells, a cell subset endowed with immune-regulatory properties, were increased in patients receiving TKIs plus IFN-α compared with those treated with TKIs alone. Interestingly, serum IL-21 was significantly lower in the TKIs plus IFN-α cohort. Within the group of patients treated with TKI monotherapy, we observed that individuals receiving 2nd generation TKIs had lower percentages of CD4+ Treg (3.63%) and Gr-MDSC (4.2%) compared to patients under imatinib treatment (CD4+ Treg 6.18% and Gr-MDSC 8.2%), but higher levels of PD-1-co-expressing CD4+ cells (1.92%). Conclusions Our results suggest that TKIs in combination with IFN-α may promote an enhanced immune suppressive state.
Collapse
Affiliation(s)
- Raquel Alves
- Laboratory of Oncobiology and Hematology and University Clinic of Hematology/Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR) - Group of Environment Genetics and Oncobiology (CIMAGO), FMUC, Coimbra, Portugal.,Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Coimbra, Portugal
| | - Stephanie E B McArdle
- John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, Clifton Campus, Nottingham, NG11 8NS, UK
| | - Jayakumar Vadakekolathu
- John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, Clifton Campus, Nottingham, NG11 8NS, UK
| | - Ana Cristina Gonçalves
- Laboratory of Oncobiology and Hematology and University Clinic of Hematology/Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR) - Group of Environment Genetics and Oncobiology (CIMAGO), FMUC, Coimbra, Portugal.,Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Coimbra, Portugal
| | - Paulo Freitas-Tavares
- Clinical Hematology Department, Centro Hospitalar Universitário de Coimbra (CHUC), Coimbra, Portugal
| | - Amélia Pereira
- Coimbra Institute for Clinical and Biomedical Research (iCBR) - Group of Environment Genetics and Oncobiology (CIMAGO), FMUC, Coimbra, Portugal.,Internal Medicine Service, Hospital Distrital da Figueira da Foz (HDFF), Figueira da Foz, Portugal
| | - Antonio M Almeida
- Hospital da Luz, Lisbon, Portugal.,CIIS (Centro de Investigação Interdisciplinar em Saúde, Universidade Católica Portuguesa de Lisboa), Lisbon, Portugal
| | - Ana Bela Sarmento-Ribeiro
- Laboratory of Oncobiology and Hematology and University Clinic of Hematology/Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR) - Group of Environment Genetics and Oncobiology (CIMAGO), FMUC, Coimbra, Portugal.,Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Coimbra, Portugal.,Clinical Hematology Department, Centro Hospitalar Universitário de Coimbra (CHUC), Coimbra, Portugal
| | - Sergio Rutella
- John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, Clifton Campus, Nottingham, NG11 8NS, UK. .,Centre for Health, Ageing and Understanding Disease (CHAUD), School of Science and Technology, Nottingham Trent University, Nottingham, UK.
| |
Collapse
|
5
|
Abstract
Modern management of acute myeloid leukaemia (AML) relies on the integration of phenotypic and genetic data to assign classification, establish prognosis, enhance monitoring and guide treatment. The prism through which we can now disperse a patient's leukaemia, interpret and apply our understanding has fundamentally changed since the completion of the first whole-genome sequencing (WGS) of an AML patient in 2008 and where possible, many clinicians would now prefer to delay treatment decisions until the karyotype and genetic status of a new patient is known. The success of global sequencing initiatives such as The Cancer Genome Atlas (TCGA) have brought us significantly closer to cataloguing the full spectrum of coding mutations involved in human malignancy. Indeed, genetic capability has raced ahead of our capacity to apply much of this knowledge into clinical practice and we are in the peculiar position of having routine access to genetic information on an individual patient's leukaemia that cannot be reliably interpreted or utilised. This is a measure of how rapid the progress has been, and this rate of change is likely to continue into the foreseeable future as research intensifies on the non-coding genome and the epigenome, as we scrutinise disease at a single cell level, and as initiatives like Beat AML and the Harmony Alliance progress. In this review, we will examine how interrogation of the coding genome is revolutionising our understanding of AML and improving our ability to underscore differences between paediatric and adult onset, sporadic and inherited forms of disease. We will look at how this knowledge is informing improvements in outcome prediction and the development of novel treatments, bringing us a step closer to personalised therapy for myeloid malignancy.
Collapse
Affiliation(s)
- Sarah Charrot
- Centre for Haemato-oncology, Barts Cancer Institute, QMUL, London, UK
| | - Hannah Armes
- Centre for Haemato-oncology, Barts Cancer Institute, QMUL, London, UK
| | - Ana Rio-Machin
- Centre for Haemato-oncology, Barts Cancer Institute, QMUL, London, UK
| | - Jude Fitzgibbon
- Centre for Haemato-oncology, Barts Cancer Institute, QMUL, London, UK
| |
Collapse
|
6
|
Davidson-Moncada J, Viboch E, Church SE, Warren SE, Rutella S. Dissecting the Immune Landscape of Acute Myeloid Leukemia. Biomedicines 2018; 6:E110. [PMID: 30477280 PMCID: PMC6316310 DOI: 10.3390/biomedicines6040110] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/19/2018] [Accepted: 11/21/2018] [Indexed: 01/05/2023] Open
Abstract
Acute myeloid leukemia (AML) is a molecularly heterogeneous hematological malignancy with variable response to treatment. Recurring cytogenetic abnormalities and molecular lesions identify AML patient subgroups with different survival probabilities; however, 50⁻70% of AML cases harbor either normal or risk-indeterminate karyotypes. The discovery of better biomarkers of clinical success and failure is therefore necessary to inform tailored therapeutic decisions. Harnessing the immune system against cancer with programmed death-1 (PD-1)-directed immune checkpoint blockade (ICB) and other immunotherapy agents is an effective therapeutic option for several advanced malignancies. However, durable responses have been observed in only a minority of patients, highlighting the need to gain insights into the molecular features that predict response and to also develop more effective and rational combination therapies that address mechanisms of immune evasion and resistance. We will review the state of knowledge of the immune landscape of AML and identify the broad opportunity to further explore this incompletely characterized space. Multiplexed, spatially-resolved immunohistochemistry, flow cytometry/mass cytometry, proteomic and transcriptomic approaches are advancing our understanding of the complexity of AML-immune interactions and are expected to support the design and expedite the delivery of personalized immunotherapy clinical trials.
Collapse
Affiliation(s)
| | - Elena Viboch
- NanoString Technologies Inc., Seattle, WA 98109, USA.
| | | | | | - Sergio Rutella
- John van Geest Cancer Research Center, School of Science and Technology, Nottingham Trent University, Nottingham NG11 8NS, UK.
| |
Collapse
|