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Ryšánková K, Gumulec J, Grepl M, Krhut J. Acquired haemophilia as a complicating factor in treatment of non-muscle invasive bladder cancer: A case report. World J Clin Cases 2023; 11:5338-5343. [PMID: 37621596 PMCID: PMC10445081 DOI: 10.12998/wjcc.v11.i22.5338] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/16/2023] [Accepted: 06/26/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Acquired haemophilia (AH) is a serious autoimmune haematological disease caused by the production of auto-antibodies against coagulation factor VIII. In some patients, AH is associated with a concomitant malignancy. In case of surgical intervention, AH poses a high risk of life-threatening bleeding. CASE SUMMARY A 60-year-old female patient with multiple recurrences of non-muscle invasive bladder cancer underwent transurethral tumour resection. A severe haematuria developed postoperatively warranting two endoscopic revisions; however, no clear source of bleeding was identified in the bladder. Subsequent haematological examination established a diagnosis of AH. Treatment with factor VIII inhibitor bypass activity and immunosuppressive therapy was initiated immediately. The patient responded well to the therapy and was discharged from the hospital 21 d after the primary surgery. At the 38-mo follow-up, both AH and bladder cancer remained in complete remission. CONCLUSION AH is a rare, life-threatening haematological disease. AH should be considered in patients with persistent severe haematuria or other bleeding symptoms, especially if combined with isolated activated partial thromboplastin time prolongation.
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Affiliation(s)
- Kateřina Ryšánková
- Department of Urology, University Hospital Ostrava, Ostrava 70852, Czech Republic
- Department of Surgical Studies, Faculty of Medicine, Ostrava University, Ostrava 70300, Czech Republic
| | - Jaromír Gumulec
- Department of Haematooncology, University Hospital Ostrava, Ostrava 70852, Czech Republic
- Department of Internal Medicine, Faculty of Medicine, Ostrava University, Ostrava 70300, Czech Republic
| | - Michal Grepl
- Department of Urology, University Hospital Ostrava, Ostrava 70852, Czech Republic
- Department of Surgical Studies, Faculty of Medicine, Ostrava University, Ostrava 70300, Czech Republic
| | - Jan Krhut
- Department of Urology, University Hospital Ostrava, Ostrava 70852, Czech Republic
- Department of Surgical Studies, Faculty of Medicine, Ostrava University, Ostrava 70300, Czech Republic
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Ryšánková K, Gumulec J, Grepl M, Krhut J. Acquired haemophilia as a complicating factor in treatment of non-muscle invasive bladder cancer: A case report. World J Clin Cases 2023; 11:5332-5337. [DOI: 10.12998/wjcc.v11.i22.5332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/16/2023] [Accepted: 06/26/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Acquired haemophilia (AH) is a serious autoimmune haematological disease caused by the production of auto-antibodies against coagulation factor VIII. In some patients, AH is associated with a concomitant malignancy. In case of surgical intervention, AH poses a high risk of life-threatening bleeding.
CASE SUMMARY A 60-year-old female patient with multiple recurrences of non-muscle invasive bladder cancer underwent transurethral tumour resection. A severe haematuria developed postoperatively warranting two endoscopic revisions; however, no clear source of bleeding was identified in the bladder. Subsequent haematological examination established a diagnosis of AH. Treatment with factor VIII inhibitor bypass activity and immunosuppressive therapy was initiated immediately. The patient responded well to the therapy and was discharged from the hospital 21 d after the primary surgery. At the 38-mo follow-up, both AH and bladder cancer remained in complete remission.
CONCLUSION AH is a rare, life-threatening haematological disease. AH should be considered in patients with persistent severe haematuria or other bleeding symptoms, especially if combined with isolated activated partial thromboplastin time prolongation.
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Affiliation(s)
- Kateřina Ryšánková
- Department of Urology, University Hospital Ostrava, Ostrava 70852, Czech Republic
- Department of Surgical Studies, Faculty of Medicine, Ostrava University, Ostrava 70300, Czech Republic
| | - Jaromír Gumulec
- Department of Haematooncology, University Hospital Ostrava, Ostrava 70852, Czech Republic
- Department of Internal Medicine, Faculty of Medicine, Ostrava University, Ostrava 70300, Czech Republic
| | - Michal Grepl
- Department of Urology, University Hospital Ostrava, Ostrava 70852, Czech Republic
- Department of Surgical Studies, Faculty of Medicine, Ostrava University, Ostrava 70300, Czech Republic
| | - Jan Krhut
- Department of Urology, University Hospital Ostrava, Ostrava 70852, Czech Republic
- Department of Surgical Studies, Faculty of Medicine, Ostrava University, Ostrava 70300, Czech Republic
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Krašek V, Kotnik A, Zavrtanik H, Klen J, Zver S. Acquired haemophilia in patients with malignant disease: A case report. World J Clin Cases 2021; 9:2409-2418. [PMID: 33869621 PMCID: PMC8026824 DOI: 10.12998/wjcc.v9.i10.2409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/04/2021] [Accepted: 01/26/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acquired haemophilia is a rare coagulation disorder characterized by autoantibodies against coagulation factor VIII leading to severe and potentially life-threatening haemorrhages. The underlying disorder causing the development of an autoimmune phenomenon is not always known, but 10%-15% could be linked to malignancies. Patients with cancer who require surgical resection represent a treatment challenge not solely due to increased risk of bleeding but also due to adverse events of immunosuppressive therapy.
CASE SUMMARY We present the case of a 67-year-old man with non-metastatic adenocarcinoma of the distal bile duct who developed concomitant acquired haemophilia a month after having been diagnosed with malignant disease. Haemostasis was established with recombinant activated factor VII, and immunosuppressive therapy was started immediately. An extensive surgical procedure was performed in order to remove the cancer and, therefore, eliminate the inhibitory autoantibodies. Due to a complicated postoperative course, relatively short period of treatment and likelihood of micrometastases, no improvement in the patient’s status was observed. Diagnosis and treatment of acquired haemophilia as well as other coagulation disorders in patients with cancer are discussed.
CONCLUSION Prompt diagnosis of acquired haemophilia is required in order to start appropriate treatment and reduce mortality. Among patients with cancer, other causes of abnormal bleeding related to malignancy should be considered.
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Affiliation(s)
- Veronika Krašek
- Medical Faculty, University of Ljubljana, Ljubljana 1000, Slovenia
| | - Aleša Kotnik
- Medical Faculty, University of Ljubljana, Ljubljana 1000, Slovenia
| | - Hana Zavrtanik
- Medical Faculty, University of Ljubljana, Ljubljana 1000, Slovenia
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
| | - Jasna Klen
- Medical Faculty, University of Ljubljana, Ljubljana 1000, Slovenia
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
| | - Samo Zver
- Medical Faculty, University of Ljubljana, Ljubljana 1000, Slovenia
- Department of Hematology, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
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Taza F, Suleman N, Paz R, Haas C. Acquired Hemophilia A and urothelial carcinoma. J Community Hosp Intern Med Perspect 2021; 11:89-93. [PMID: 33552425 PMCID: PMC7850392 DOI: 10.1080/20009666.2020.1836726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Acquired Hemophilia A (AHA) is a rare entity, resulting from the production of autoantibodies against Factor VIII of the coagulation cascade. These autoantibodies may develop in response to autoimmune conditions, drugs, neoplastic diseases, and pregnancy. Diagnosis involves clinical presentation, mucocutaneous or intramuscular bleeding, and laboratory findings, such as prolonged activated partial thromboplastin time, decreased levels of Factor VIII, and the presence of Factor VIII autoantibodies. The etiology is diverse, with a variety of underlying culprits. Malignancy-associated AHA has been associated with approximately 15% of cases. Urothelial malignancy-mediated AHA is exceedingly rare, with only two previously published reports. The management of AHA includes stabilization and control of bleeding via the use of hemostatic agents, and elimination of the inhibitor with immunosuppressive therapy. Here, we report a case of AHA secondary to urothelial malignancy and review the pathobiology and pathogenesis of Hemophilia A and AHA.
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Affiliation(s)
- Fadi Taza
- Department of Medicine, MedStar Health Internal Medicine Residency Program, Baltimore, MD, USA
| | - Nawar Suleman
- Department of Medicine, MedStar Health Internal Medicine Residency Program, Baltimore, MD, USA
| | - Robert Paz
- Department of Medicine, MedStar Health Hospitalist Program, Baltimore, MD, USA
| | - Christopher Haas
- Department of Medicine, MedStar Health Internal Medicine Residency Program, Baltimore, MD, USA.,Georgetown University Medical Center, Washington, DC, USA
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Napolitano M, Siragusa S, Mancuso S, Kessler CM. Acquired haemophilia in cancer: A systematic and critical literature review. Haemophilia 2017; 24:43-56. [PMID: 28960809 DOI: 10.1111/hae.13355] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 12/12/2022]
Abstract
AIM There is a paucity of data on the clinical presentation and management of cancer patients with acquired haemophilia (AH), we here report a systematic literature review on acquired haemophilia in the context of cancer. METHODS Treatment outcomes of AH were defined as complete response (CR), partial response (PR) or no response (NR), based on inhibitor eradication, coagulation factor VIII levels and bleeding control. Reported deaths were either related to cancer or bleeding. RESULTS Overall, 105 cases were collected and analyzed according to classification of cancer and efficacy of treatments for inhibitor and malignancy. The mean age was 68 years for both males (range 37-86 years) and females (range 43-89 years), 39 patients were female subjects and 66 were males. A solid cancer was diagnosed in 60 subjects, while 45 patients suffered a haematological malignancy. Solid cancers affected mainly males; however, the incidence of solid tumours vs haematological malignancies was not statistically significant (P = .09). Not all patients were treated for their underlying cancer, bleeding and/or inhibitor, in two cases outcome is unavailable. CR was reported in 62.1% (64/103) cases, PR in 9.7% (10/103) cases, NR with or without death was reported in 28.1% (29/103) cases. CONCLUSION CR was best achieved when successful and complete elimination of autoantibodies occurred contemporaneously with the successful treatment of the underlying malignancy. In some cases, recurrent autoantibodies were harbingers of relapsed cancer. Type of cancer, inhibitor titer, treatments administered for bleeding control and inhibitor eradication did not significantly affect clinical outcome of analyzed cases.
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Affiliation(s)
- M Napolitano
- Hematology Unit, Thrombosis and Hemostasis Reference Regional Center, Università degli studi di Palermo, Palermo, Italy
| | - S Siragusa
- Hematology Unit, Thrombosis and Hemostasis Reference Regional Center, Università degli studi di Palermo, Palermo, Italy
| | - S Mancuso
- Hematology Unit, Thrombosis and Hemostasis Reference Regional Center, Università degli studi di Palermo, Palermo, Italy
| | - C M Kessler
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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Sato K, Tsukada N, Inamura J, Kon M, Ito S, Hirai K, Hosoki T. A case of acquired haemophilia A complicated by peritonitis after distal gastrectomy. Haemophilia 2016; 22:e469-71. [PMID: 27457489 DOI: 10.1111/hae.13039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2016] [Indexed: 11/30/2022]
Affiliation(s)
- K Sato
- Department of Hematology/Oncology, Asahikawa Kosei Hospital, Asahikawa, Japan.
| | - N Tsukada
- Department of Hematology/Oncology, Asahikawa Kosei Hospital, Asahikawa, Japan
| | - J Inamura
- Department of Hematology/Oncology, Asahikawa Kosei Hospital, Asahikawa, Japan
| | - M Kon
- Department of Clinical Laboratory, Asahikawa Kosei Hospital, Asahikawa, Hokkaido, Japan
| | - S Ito
- Department of Oncology for Local Community Cooperation, Asahikawa Medical University Hospital, Asahikawa, Hokkaido, Japan
| | - K Hirai
- Department of Hematology/Gastroenterology, Harada Hospital, Asahikawa, Hokkaido, Japan
| | - T Hosoki
- Department of Hematology/Oncology, Asahikawa Kosei Hospital, Asahikawa, Japan
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Management of postoperative hemorrhage associated with factor VIII inhibitor: report of a case. Surg Today 2012; 43:1058-61. [PMID: 22886607 DOI: 10.1007/s00595-012-0286-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2012] [Accepted: 04/09/2012] [Indexed: 10/28/2022]
Abstract
This report presents a case that was successfully treated for acquired factor VIII inhibitor after extensive visceral surgery. A 71-year-old male who underwent surgery for bile duct cancer had active bleeding in the abdominal drainage tube on postoperative day (POD) 5, and prolonged activated partial thromboplastin time (aPTT) was detected (83.1 s) on POD 7. An extensive coagulation work-up revealed factor VIII deficiency (1 %), and a diagnosis of an acquired factor VIII deficiency was established when a factor VIII inhibitor of 8 Bethesda units was demonstrated. The patient was treated with activated prothrombin complex concentrate (aPCCs) and bloody discharge was stopped within 3 days. Inhibitor elimination was started using prednisolone on POD 20; rituximab, was administered on POD 74 and 81. Factor VIII inhibitor had disappeared by POD 124, and factor VIII (72 %) and aPTT recovered to 45.9 s. This case report demonstrated the efficacy of aPCCs and rituximab in the treatment of acquired hemophilia associated with visceral surgery.
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Reitter S, Knoebl P, Pabinger I, Lechner K. Postoperative paraneoplastic factor VIII auto-antibodies in patients with solid tumours. Haemophilia 2011; 17:e889-94. [PMID: 21457407 DOI: 10.1111/j.1365-2516.2011.02522.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Paraneoplastic FVIII antibodies may occur concurrent with the diagnosis or at various times after diagnosis and treatment of cancer. Between 2002 and 2009, we observed two patients with acquired haemophilia A due to an FVIII auto-antibody, which appeared 4 and 5 months after uncomplicated cancer surgery. We aimed to evaluate if such an association of cancer surgery and FVIII antibody formation has been observed previously. We retrieved all published case reports of cancer-associated FVIII auto-antibodies from PubMed for the period 1950-2010. The search in the literature revealed 13 patients in whom a FVIII inhibitor developed after uncomplicated surgery for cancer and a bleeding-free time interval of up to 6 months; 11/15 patients had abdominal cancers (five colon cancer, four pancreatic cancer, gastric cancer and choledochus carcinoma one each). The median time period between surgery and antibody detection was 3 months (1 week-6 months). In most cases, the antibody titre was low (median: 14 BU mL⁻¹, range: 1.7-64 BU mL⁻¹). Immunosuppressive treatment was successful in most of the cases - nine of the treated patients reached a sustained CR of the antibody after a median time of 3 months. Postoperative paraneoplastic FVIII inhibitors may be regarded as a special, not yet recognized subgroup of acquired FVIII antibodies. They share some characteristics with postpartum FVIII inhibitors with regard to the latency period between the triggering event and the appearance of the antibody, and between the usually low antibody titres and their good response to immunosuppressive treatment.
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Affiliation(s)
- S Reitter
- Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Appelmann I, Biermann C, Hartig I, Berdel WE, Mesters R. Acquired haemophilia in a patient with discoid lupus. Ann Hematol 2010; 90:119-20. [PMID: 20467746 DOI: 10.1007/s00277-010-0972-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 04/19/2010] [Indexed: 11/29/2022]
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The severity of trauma determines the immune response to PF4/heparin and the frequency of heparin-induced thrombocytopenia. Blood 2009; 115:1797-803. [PMID: 19965682 DOI: 10.1182/blood-2009-07-231506] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Heparin can induce heparin-induced thrombocytopenia (HIT). The combined effect of type of surgery (major vs minor) and heparin on this prothrombotic immune reaction to platelet factor 4 (PF4)/heparin was analyzed. In a randomized, double-blind study, trauma patients receiving low-molecular-weight (LMWH) or unfractionated heparin (UFH) for thrombosis prophylaxis were assessed for PF4/heparin-antibody seroconversion, HIT, and thrombosis according to type of surgery. The risk for seroconversion was higher than major versus minor surgery odds ratio, 7.98 [95% confidence interval, 2.06-31.00], P = .003, controlled for potential confounders, as was the risk for HIT (2.2% [95% confidence interval, 0.3%-4.1%] vs 0.0%, P = .010). During LMWH compared with UFH thromboprophylaxis, HIT (1 of 298 vs 4 of 316; P = .370) and PF4/heparin seroconversion (1.7% vs 6.6%; P = .002) were less frequent, driven by differences in patients undergoing major surgery (incidence of HIT: LMWH 0.8% vs UFH 4.0%; P = .180; seroconversion rates: 4.0% vs 17.0%; P = .001). After minor surgery, no case of HIT occurred. The severity of trauma and the need for major surgery strongly influence the risk of an anti-PF4/heparin immune response, which is then increased by UFH. In major trauma certoparin may be safer than UFH because it induces HIT-antibody seroconversion, and the corresponding risk of HIT, less frequently.
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Hémophilie A acquise précédant l’apparition d’un cancer : quelles explorations et quelle surveillance ? Rev Med Interne 2009; 30:630-3. [DOI: 10.1016/j.revmed.2008.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 07/25/2008] [Accepted: 09/03/2008] [Indexed: 11/19/2022]
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Sumner MJ, Geldziler BD, Pedersen M, Seremetis S. Treatment of acquired haemophilia with recombinant activated FVII: a critical appraisal. Haemophilia 2007; 13:451-61. [PMID: 17880429 DOI: 10.1111/j.1365-2516.2007.01474.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Acquired haemophilia is a rare bleeding disorder usually caused by the spontaneous formation of inhibitory antibodies to coagulation FVIII. The disease occurs most commonly in the elderly, and although acquired haemophilia may be associated with a variety of underlying conditions, up to 50% of reported cases are idiopathic. Treatment options have traditionally involved human FVIII or FIX replacement therapy (if the inhibitor titre allows), porcine FVIII or the use of activated pro-thrombin complex concentrates. Recombinant activated coagulation FVII (rFVIIa) was available on an emergency and compassionate use basis from 1988 to 1999 at sites in Europe and North America. It has been registered in Europe for use in treating acquired haemophilia since 1996 and has recently been licensed for this indication in the United States. By directly activating FX on the surface of activated platelets at the site of injury (thereby bypassing FVIII and FIX), rFVIIa can circumvent the actions of inhibitory antibodies present in acquired haemophilia patients. This paper provides an overview of experiences with rFVIIa for the treatment of acquired haemophilia from the NovoSeven compassionate and emergency use programmes (1989-1999), the Hemophilia and Thrombosis Research Society Registry, and independent published reports from January 1999 to September 2005. rFVIIa has been reported to provide safe and effective haemostasis as a first line therapy in patients of all ages for a variety of surgical and non-surgical bleeding situations.
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Affiliation(s)
- M J Sumner
- Novo Nordisk Inc., 100 College Road West, Princeton, NJ 08540, USA.
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Schoenmakers SHHF, Brüggemann LW, Groot AP, Maijs S, Reitsma PH, Spek CA. Role of coagulation FVIII in septic peritonitis assessed in hemophilic mice. J Thromb Haemost 2005; 3:2738-44. [PMID: 16359511 DOI: 10.1111/j.1538-7836.2005.01649.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inhibition of blood coagulation appears to be an important therapeutic strategy to improve the outcome in sepsis. However, the beneficial effect of anticoagulant treatment in sepsis is solely based on experimental data using inhibitors of the extrinsic coagulant pathway. The role of the intrinsic pathway of coagulation in the pathogenesis of sepsis has not been explored yet. OBJECTIVE In the current study, we contribute to determine the role of factor (F)VIII, the key player of the intrinsic coagulant pathway, on host defense against peritonitis. METHOD Hemizygous FVIII-deficient mice and their wild-type littermates were challenged with 1 x 10(4) bacteria in a septic peritonitis model. RESULTS The intraperitoneal injection of Escherichia coli led to growth and dissemination of bacteria and provoked an inflammatory response as evident from elevated cytokine levels, increased cell influx into tissues, liver necrosis, and endothelialitis resulting in mortality. The FVIII-deficient genotype slightly reduced bacterial outgrowth but had no effect on markers of inflammation and/or survival. In addition, FVIII-deficient mice showed profound activation of coagulation, thereby improving the hemophilic phenotype of FVIII-deficient mice. CONCLUSION FVIII deficiency slightly modifies host defense in septic peritonitis in mice, but does not influence the final outcome of peritonitis. Therefore, we question the importance of the intrinsic coagulant pathway during sepsis.
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Affiliation(s)
- S H H F Schoenmakers
- Laboratory for Experimental Internal Medicine, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
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