1
|
Hydatidiform mole in Duhok, Iraq: Frequency, types and histopathological diagnostic features. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.663841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
2
|
Verri D, Pasciuto T, Epstein E, Fruscio R, Mascilini F, Moro F, Scambia G, Valentin L, Testa AC. GestaTIonal TrophoblAstic NeoplasIa Ultrasound assessMent: TITANIUM study. Int J Gynecol Cancer 2019; 29:1216-1220. [DOI: 10.1136/ijgc-2019-000434] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2019] [Indexed: 11/03/2022] Open
Abstract
BackgroundThere are limited data on ultrasound morphologic features of gestational trophoblastic neoplasia. A predictive model to determine predictors of response to therapy would be ideal in the management of patients with this rare disease.Primary Objectives and Study HypothesisTITANIUM is a prospective, multicenter, observational study aiming to describe ultrasound features of gestational trophoblastic neoplasia and to investigate the role of ultrasound in identifying patients at high risk of resistance to single-drug therapy. The study hypothesis is that ultrasound could improve the International Federation of Gynecology and Obstetrics (FIGO) scoring system for early identification of patients predisposed to single-drug resistance.Trial Design and Major Inclusion/Exclusion CriteriaPatients eligible have a diagnosis of gestational trophoblastic neoplasia according to FIGO or the criteria set by Charing Cross Hospital, London, UK. At diagnosis, patients are classified as low-risk (score 0–6) or high-risk (score >6) according to the FIGO risk scoring system, and a baseline ultrasound scan is performed. Patients receive treatment according to local protocol at each institution. Follow-up ultrasound examinations are performed at 1, 4, 10, 16, and 22 months after start of chemotherapy, and at each scan, serum human chorionic gonadotropin (hCG) level, and chemotherapy treatment, if any, are recorded.Primary EndpointsOur aims are to define ultrasound features of gestational trophoblastic neoplasia and to develop a predictive model of resistance to single-drug therapy in low-risk patients.Sample SizeThe sample size was calculated assuming that 70% of patients with gestational trophoblastic neoplasia are at low risk, and estimating the rate of resistance to single-drug therapy in this group to be 40%. Assuming a dropout rate of 10%, we should recruit at least 120 patients. With this sample size, we can attempt to create a mathematical model with three variables (either two ultrasound parameters in addition to the risk score or three ultrasound variables statistically significant at univariate analysis) to predict resistance to single-drug therapy in low-risk patients.Estimated Dates for Completing Accrual and Presenting ResultsThe accrual started in February 2019. Additional referral centers for gestational trophoblastic disease, with similar ultrasound expertise, are welcome to participate in the study. Enrollment should be completed by December 2021, and analysis will be conducted in December 2023.Trial RegistrationThe study received the Ethical Committee approval of the Coordinator Center (Rome) in January 2019 (Protocol No. 0004668/19).
Collapse
|
3
|
Lima LDLA, Parente RCM, Maestá I, Amim Junior J, de Rezende Filho JF, Montenegro CAB, Braga A. Clinical and radiological correlations in patients with gestational trophoblastic disease. Radiol Bras 2016; 49:241-250. [PMID: 27777478 PMCID: PMC5073391 DOI: 10.1590/0100-3984.2015.0073] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Gestational trophoblastic disease is an abnormality of pregnancy that encompasses
a group of diseases that differ from each other in their propensity for
regression, invasion, metastasis, and recurrence. In the past, it was common for
patients with molar pregnancy to present with marked symptoms: copious bleeding;
theca lutein cysts; uterus larger than appropriate for gestational age; early
preeclampsia; hyperemesis gravidarum; and hyperthyroidism. Currently, with early
diagnosis made by ultrasound, most patients are diagnosed while the disease is
still in the asymptomatic phase. In cases of progression to trophoblastic
neoplasia, staging-typically with Doppler flow studies of the pelvis and chest
X-ray, although occasionally with computed tomography or magnetic resonance
imaging-is critical to the choice of an appropriate antineoplastic therapy
regimen. Because it is an unusual and serious disease that affects women of
reproductive age, as well as because its appropriate treatment results in high
cure rates, it is crucial that radiologists be familiar with gestational
trophoblastic disease, in order to facilitate its early diagnosis and to ensure
appropriate follow-up imaging.
Collapse
Affiliation(s)
- Lana de Lourdes Aguiar Lima
- Master's Student in the Perinatal Health Program at the Faculdade de Medicina da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | | | - Izildinha Maestá
- PhD, Adjunct Professor of Obstetrics at the Faculdade de Medicina da Universidade Estadual Paulista "Júlio de Mesquita Filho" (Unesp), Botucatu, SP, Brazil
| | - Joffre Amim Junior
- PhD, Associate Professor of Obstetrics at the Faculdade de Medicina da Universidade Federal do Rio de Janeiro (UFRJ), Director of the Maternidade Escola da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Jorge Fonte de Rezende Filho
- PhD, Full Professor of Obstetrics at the Faculdade de Medicina da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Carlos Antonio Barbosa Montenegro
- PhD, Full Member Emeritus of the Academia Nacional de Medicina, Full Professor of Obstetrics at the Faculdade de Medicina da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Antônio Braga
- PhD, Adjunct Professor of Obstetrics at the Faculdade de Medicina da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, and at the Faculdade de Medicina da Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil
| |
Collapse
|
4
|
Alazzam M, Tidy J, Osborne R, Coleman R, Hancock BW, Lawrie TA. Chemotherapy for resistant or recurrent gestational trophoblastic neoplasia. Cochrane Database Syst Rev 2016; 2016:CD008891. [PMID: 26760424 PMCID: PMC6768657 DOI: 10.1002/14651858.cd008891.pub3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Gestational trophoblastic neoplasia (GTN) is a highly curable group of pregnancy-related tumours; however, approximately 25% of GTN tumours will be resistant to, or will relapse after, initial chemotherapy. These resistant and relapsed lesions will require salvage chemotherapy with or without surgery. Various salvage regimens are used worldwide. It is unclear which regimens are the most effective and the least toxic. OBJECTIVES To determine which chemotherapy regimen/s for the treatment of resistant or relapsed GTN is/are the most effective and the least toxic. SEARCH METHODS We searched the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 4), MEDLINE and EMBASE up to October 2011. In addition, we handsearched the relevant society conference proceedings and study reference lists. For the updated review, we searched Cochrane Group Specialised Register, CENTRAL, MEDLINE and EMBASE to 16 Novemeber 2015. In addition, we searched online clinical trial registries for ongoing trials. SELECTION CRITERIA Only randomised controlled trials (RCTs) were included. DATA COLLECTION AND ANALYSIS We designed a data extraction form and planned to use random-effects methods in Review Manager 5.1 for meta-analyses. MAIN RESULTS The search identified no RCTs; therefore we were unable to perform any meta-analyses. AUTHORS' CONCLUSIONS RCTs in GTN are scarce owing to the low prevalence of this disease and its highly chemosensitive nature. As chemotherapeutic agents may be associated with substantial side effects, the ideal treatment should achieve maximum efficacy with minimal side effects. For methotrexate-resistant or recurrent low-risk GTN, a common practice is to use sequential five-day dactinomycin, followed by MAC (methotrexate, dactinomycin, cyclophosphamide) or EMA/CO (etoposide, methotrexate, dactinomycin, cyclophosphamide, vinblastine) if further salvage therapy is required. However, five-day dactinomycin is associated with more side effects than pulsed dactinomycin, therefore an RCT comparing the relative efficacy and safety of these two regimens in the context of failed primary methotrexate treatment is desirable.For high-risk GTN, EMA/CO is the most commonly used first-line therapy, with platinum-etoposide combinations, particularly EMA/EP (etoposide, methotrexate, dactinomycin/etoposide, cisplatin), being favoured as salvage therapy. Alternatives, including TP/TE (paclitaxel, cisplatin/ paclitaxel, etoposide), BEP (bleomycin, etoposide, cisplatin), FAEV (floxuridine, dactinomycin, etoposide, vincristine) and FA (5-fluorouracil (5-FU), dactinomycin), may be as effective as EMA/EP and associated with fewer side effects; however, this is not clear from the available evidence and needs testing in well-designed RCTs. In the UK, an RCT comparing interventions for resistant/recurrent GTN will be very challenging owing to the small numbers of patients with this scenario. International multicentre collaboration is therefore needed to provide the high-quality evidence required to determine which salvage regimen/s have the best effectiveness-to-toxicity ratio in low- and high-risk disease. Future research should include economic evaluations and long-term surveillance for secondary neoplasms.
Collapse
Affiliation(s)
- Mo'iad Alazzam
- Beacon HospitalGynaecological Oncology DivisionSandyfordDublinIreland18
| | - John Tidy
- Sheffield Teaching Hospitals Foundation NHS TrustObstetrics & GynaecologyRoyal Hallamshire HospitalGlossop RoadSheffieldUKS10 2JF
| | - Raymond Osborne
- Toronto‐Sunnybrook Regional Cancer CentreDivision of Gynecology‐Oncology2075 Bayview AveTorontoONCanadaM4N 3M5
| | - Robert Coleman
- Sheffield UniversitySchool of Medicine and Biomedical SciencesWestern BankSheffieldUKS10 2TN
| | - Barry W Hancock
- Sheffield UniversitySchool of Medicine and Biomedical SciencesWestern BankSheffieldUKS10 2TN
| | - Theresa A Lawrie
- 1st Floor Education Centre, Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupCombe ParkBathUKBA1 3NG
| | | |
Collapse
|
5
|
Gvinianidze L, Panagiotopoulos N, Woo WL, Borg E, Lawrence D. The challenging management of lung choriocarcinoma. J Thorac Dis 2014; 6:E220-2. [PMID: 25364535 DOI: 10.3978/j.issn.2072-1439.2014.09.18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 08/24/2014] [Indexed: 11/14/2022]
Abstract
The purpose of this paper is to highlight the existence and the management of lung choriocarcinoma (CCA), a rare category of lung tumors. We present a 42-year-old female that presented to our department with a PET positive lesion in the left upper lobe and a history of pregnancy 6 months prior to onset of symptoms. CT guided biopsy was inconclusive for diagnosis and the patient underwent a left thoracotomy and lingula sparing upper lobectomy. Histology revealed CCA of the lung and subsequently blood results confirmed the elevated b-HCG. CCA of the lung is a clinical entity that should be considered in the differential diagnosis of lung lesions in women after pregnancy.
Collapse
Affiliation(s)
- Lasha Gvinianidze
- 1 Department of Cardiothoracic Surgery, The Heart Hospital, University College London Hospitals (UCLH), London, UK ; 2 Department of Histopathology, University College London Hospitals (UCLH), London, UK
| | - Nikolaos Panagiotopoulos
- 1 Department of Cardiothoracic Surgery, The Heart Hospital, University College London Hospitals (UCLH), London, UK ; 2 Department of Histopathology, University College London Hospitals (UCLH), London, UK
| | - Wen Ling Woo
- 1 Department of Cardiothoracic Surgery, The Heart Hospital, University College London Hospitals (UCLH), London, UK ; 2 Department of Histopathology, University College London Hospitals (UCLH), London, UK
| | - Elaine Borg
- 1 Department of Cardiothoracic Surgery, The Heart Hospital, University College London Hospitals (UCLH), London, UK ; 2 Department of Histopathology, University College London Hospitals (UCLH), London, UK
| | - David Lawrence
- 1 Department of Cardiothoracic Surgery, The Heart Hospital, University College London Hospitals (UCLH), London, UK ; 2 Department of Histopathology, University College London Hospitals (UCLH), London, UK
| |
Collapse
|
6
|
Manu V, Pillai AK, Kumar S, Chouhan A. Placental site trophoblastic tumor with metastasis - A case report. Med J Armed Forces India 2014; 69:68-70. [PMID: 24532939 DOI: 10.1016/j.mjafi.2012.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 01/15/2012] [Indexed: 11/19/2022] Open
Affiliation(s)
- V Manu
- Associate Professor, Department of Pathology, AFMC, Pune 411040, India
| | - A K Pillai
- Classified Specialist (Gyanecology & Obstetrics), INHS Asvini, Colaba, Mumbai 400005, India
| | - Sushil Kumar
- Additional DGMS (Navy), IHQ (N), MOD, Sena Bhawan, New Delhi 110011, India
| | - A Chouhan
- MO Specialist (Gyanecology & Obstetrics), INHS Jeevanti, Naval Base, Goa, India
| |
Collapse
|
7
|
Seckl MJ, Sebire NJ, Fisher RA, Golfier F, Massuger L, Sessa C. Gestational trophoblastic disease: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2013; 24 Suppl 6:vi39-50. [PMID: 23999759 DOI: 10.1093/annonc/mdt345] [Citation(s) in RCA: 206] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
|
8
|
Deng L, Zhang J, Wu T, Lawrie TA. Combination chemotherapy for primary treatment of high-risk gestational trophoblastic tumour. Cochrane Database Syst Rev 2013:CD005196. [PMID: 23440800 DOI: 10.1002/14651858.cd005196.pub4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND This is an update of the original review that was published in The Cochrane Database of Systematic Reviews, 2009, Issue 2. Gestational trophoblastic neoplasia (GTN) are malignant disorders of the placenta that include invasive hydatidiform mole, choriocarcinoma, placental-site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT). Choriocarcinoma and invasive hydatidiform mole respond well to chemotherapy: low-risk tumours are treated with single-agent chemotherapy (e.g. methotrexate or actinomycin D), whereas high-risk tumours are treated with combination chemotherapy (e.g. EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine)). Various drug combinations may be used for high-risk tumours; however, the comparative efficacy and safety of these regimens is not clear. OBJECTIVES To determine the efficacy and safety of combination chemotherapy in treating high-risk GTN. SEARCH METHODS For the original review, we searched the Cochrane Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL; Issue 2, 2008), MEDLINE, EMBASE and CBM in May 2008. For the updated review, we searched Cochrane Group Specialised Register, CENTRAL, MEDLINE and EMBASE to September 2012. In addition, we searched online clinical trial registries for ongoing trials. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing first-line combination chemotherapy interventions in women with high-risk GTN. DATA COLLECTION AND ANALYSIS Two review authors independently collected data using a data extraction form. Meta-analysis could not be performed as we included only one study. MAIN RESULTS We included one RCT of 42 women with high-risk GTN who were randomised to MAC (methotrexate, actinomycin D and chlorambucil) or the modified CHAMOCA regimen (cyclophosphamide, hydroxyurea, actinomycin D, methotrexate, doxorubicin, melphalan and vincristine). There were no statistically significant differences in efficacy of the two regimens; however women in the MAC group experienced statistically significantly less toxicity overall and less haematological toxicity than women in the CHAMOCA group. During the study period, six women in the CHAMOCA group died compared with one in the MAC group. This study was stopped early due to unacceptable levels of toxicity in the CHAMOCA group. We identified no RCTs comparing EMA/CO with MAC or other chemotherapy regimens. AUTHORS' CONCLUSIONS CHAMOCA is not recommended for GTN treatment as it is more toxic and not more effective than MAC. EMA/CO is currently the most widely used first-line combination chemotherapy for high-risk GTN, although this regimen has not been rigorously compared to other combinations such as MAC or FAV in RCTs. Other regimens may be associated with less acute toxicity than EMA/CO; however, proper evaluation of these combinations in high-quality RCTs that include long-term surveillance for secondary cancers is required. We acknowledge that, given the low incidence of GTN, RCTs in this field are difficult to conduct, hence multicentre collaboration is necessary.
Collapse
Affiliation(s)
- Linyu Deng
- National Key Laboratory of Biotherapy and Cancer Centre,West ChinaHospital, Sichuan University, Chengdu, China
| | | | | | | |
Collapse
|
9
|
Alazzam M, Tidy J, Osborne R, Coleman R, Hancock BW, Lawrie TA. Chemotherapy for resistant or recurrent gestational trophoblastic neoplasia. Cochrane Database Syst Rev 2012; 12:CD008891. [PMID: 23235667 DOI: 10.1002/14651858.cd008891.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Gestational trophoblastic neoplasia (GTN) is a highly curable group of pregnancy-related tumours; however, approximately 25% of GTN tumours will be resistant to, or will relapse after, initial chemotherapy. These resistant and relapsed lesions will require salvage chemotherapy with or without surgery. Various salvage regimens are used worldwide. It is unclear which regimens are the most effective and the least toxic. OBJECTIVES To determine which chemotherapy regimen/s for the treatment of resistant or relapsed GTN is/are the most effective and the least toxic. SEARCH METHODS We searched the Cochrane Gynaecological Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 4), MEDLINE and EMBASE up to October 2011. In addition, we handsearched the relevant society conference proceedings and study reference lists. SELECTION CRITERIA Only randomised controlled trials (RCTs) were included. DATA COLLECTION AND ANALYSIS We designed a data extraction form and planned to use random-effects methods in Review Manager 5.1 for meta-analyses. MAIN RESULTS The search identified no RCTs; therefore we were unable to perform any meta-analyses. AUTHORS' CONCLUSIONS RCTs in GTN are scarce owing to the low prevalence of this disease and its highly chemosensitive nature. As chemotherapeutic agents may be associated with substantial side effects, the ideal treatment should achieve maximum efficacy with minimal side effects. For methotrexate-resistant or recurrent low-risk GTN, a common practice is to use sequential five-day dactinomycin, followed by MAC (methotrexate, dactinomycin, cyclophosphamide) or EMA/CO (etoposide, methotrexate, dactinomycin, cyclophosphamide, vinblastine) if further salvage therapy is required. However, five-day dactinomycin is associated with more side effects than pulsed dactinomycin, therefore an RCT comparing the relative efficacy and safety of these two regimens in the context of failed primary methotrexate treatment is desirable.For high-risk GTN, EMA/CO is the most commonly used first-line therapy, with platinum-etoposide combinations, particularly EMA/EP (etoposide, methotrexate, dactinomycin/etoposide, cisplatin), being favoured as salvage therapy. Alternatives, including TP/TE (paclitaxel, cisplatin/ paclitaxel, etoposide), BEP (bleomycin, etoposide, cisplatin), FAEV (floxuridine, dactinomycin, etoposide, vincristine) and FA (5-fluorouracil (5-FU), dactinomycin), may be as effective as EMA/EP and associated with fewer side effects; however, this is not clear from the available evidence and needs testing in well-designed RCTs. In the UK, an RCT comparing interventions for resistant/recurrent GTN will be very challenging owing to the small numbers of patients with this scenario. International multicentre collaboration is therefore needed to provide the high-quality evidence required to determine which salvage regimen/s have the best effectiveness-to-toxicity ratio in low- and high-risk disease. Future research should include economic evaluations and long-term surveillance for secondary neoplasms.
Collapse
Affiliation(s)
- Mo'iad Alazzam
- Department of Gynaecology, The Galway Clinic, Doughiska, Galway, Ireland.
| | | | | | | | | | | |
Collapse
|
10
|
Skubisz MM, Tong S. The evolution of methotrexate as a treatment for ectopic pregnancy and gestational trophoblastic neoplasia: a review. ISRN OBSTETRICS AND GYNECOLOGY 2012; 2012:637094. [PMID: 22462004 PMCID: PMC3302016 DOI: 10.5402/2012/637094] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 12/05/2011] [Indexed: 12/01/2022]
Abstract
Methotrexate was developed in 1949 as a synthetic folic acid analogue to compete with folic acid and thus interfere with cell replication. While initially developed as a potential treatment for acute lymphoblastic leukaemia, a serendipitous observation led to methotrexate's use to effect the dramatic cure of a case of advanced choriocarcinoma. This prompted the exploration for the potential of methotrexate to treat other conditions involving disordered trophoblastic tissue. Methotrexate has subsequently revolutionized the treatment of two pregnancy-related conditions—gestational trophoblastic neoplasia and ectopic pregnancy. This article reviews the development of modern treatment protocols that use methotrexate to medically treat these two important gynaecological conditions.
Collapse
Affiliation(s)
- Monika M Skubisz
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, Heidelberg, 3084 VIC, Australia
| | | |
Collapse
|
11
|
|
12
|
Abstract
Gestational trophoblastic disease encompasses a range of pregnancy-related disorders, consisting of the premalignant disorders of complete and partial hydatidiform mole, and the malignant disorders of invasive mole, choriocarcinoma, and the rare placental-site trophoblastic tumour. These malignant forms are termed gestational trophoblastic tumours or neoplasia. Improvements in management and follow-up protocols mean that overall cure rates can exceed 98% with fertility retention, whereas most women would have died from malignant disease 60 years ago. This success can be explained by the development of effective treatments, the use of human chorionic gonadotropin as a biomarker, and centralisation of care. We summarise strategies for management of gestational trophoblastic disease and address some of the controversies and future research directions.
Collapse
Affiliation(s)
- Michael J Seckl
- Department of Cancer Medicine, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, London, UK.
| | | | | |
Collapse
|