Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell...

46
Cell Cycle – Control of Cell Proliferation Ludger Hengst Sektion für Medizinische Biochemie - Biozentrum - Medizinische Universität Innsbruck

Transcript of Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell...

Page 1: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Cell Cycle – Control of Cell Proliferation Ludger Hengst

Sektion für Medizinische Biochemie - Biozentrum - Medizinische Universität Innsbruck

Page 2: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

1 fertilized egg !! !! ! !100 000 000 000 000 cells �

Cell cycle – control of cell proliferation Ludger Hengst

Biozentrum - Medizinische Biochemie - Medizinische Universität Innsbruck

In Adults: ! ≈4.000.000 cell divisions / sec.�

Page 3: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

1.   Principles of the cell cycle �

Cell Cycle Checkpoints�

2.  The restriction point�

3.   CDKs – central cell cycle regulators�

4.   CDK inhibitors�

5.   The retinoblastoma protein�

6.   The RB-E2F pathway�

Page 4: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

1.  Duplication of the genome!

2.  Separation of the duplicated genetic material (and other cellular compounds) into two daughter cells"

Central Aims of the Cell Cycle

Page 5: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Four Cell Cycle Phases �

M

Mitosis and Cytokinesis"

S

DNA Synthesis

G1

G2

Gap-phase 1"

Gap-phase 2"

Page 6: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

M

S

G1

G2

Principles of the eucaryotic cell cycle:

1.  One and only one replication of the entire genome per cell cycle

2.  Initiation of a subsequent cell cycle phase requires proper termination of the preceding phase

Page 7: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

M

S

G1

G2 G0

Restriction point"

G0-phase

Page 8: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Why seperate cell cycle phases?

The temporal separation of DNA replikation and mitosis permits the incorporation of control mechanisms in the eucaryotic cell cycle. These control mechanisms are called!Checkpoints.

Page 9: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Checkpoint: a process within the cell cycle, which controls the transition ! from one cell cycle state into the next state

!! - Checkpoints secure e.g. that DNA replication is completed ! before mitosis can be initiated.

!! - Checkpoints secure genomic stability by arresting cell ! cycle progression upon DNA damage.!

Checkpoints

Page 10: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

G1/S Checkpoint"

√ size ? "

√ DNA damage ?"

G2 / M Checkpoint"√ DNA replicated?"

√ DNA damage?"

Spindel Checkpoint"√ all chromosomes attached to the spindle ?"

G1

G0

S

M

G2

Important Checkpoints

√ mitogens anti-mitogenic signals ?""√ differentiation - signals ?"

Page 11: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

1.  Restrict cell divisions to precisely the required numbers, e.g. induced divisions after wounding or cell death�"- Avoids hypo- and hyperproliferation�

�2.  Warrant one, and only one DNA replication of all regions of

the genome per cell cycle. �"- Avoids genetic instability�

�3.  Precise segregation of the genome into both daughter cells.�

"- Avoids genetic instability��4. "Prevention of replication or segregation of damaged DNA �

"- Avoids the multiplication of damaged DNA

Important aims of cell cycle control mechanisms: �

Page 12: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Consequences of misregulated cell cycle control: �Genetic instability of tumor cells

Aneuploidy : abnormal number of chromosomes (extra or missing)

Chromosomal translocations: Rearrangements of chromosome parts between nonhomologues chromosomes

1

3

14

Page 13: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Length of cell cycle phases"

Duplication of bacteria:"

Eucaryotes:"Early frog embryo cells " 30 minYeast " " " 1.5 - 3 hCells in the epithelium of the small intestine " 12 h"Proliferating mammalian cells18-24 h"Fibroblasts in culture " 20 h"Human liver cells " " 1 year"

E. coli: 20 - 25 min"

M

G1"

G2"

S

1 h"

6-12 h"

6-8 h"

2-4 h"

Page 14: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

1.   Principles of the cell cycle �

2.  The restriction point�

3.   CDKs – central cell cycle regulators�

4.   CDK inhibitors�

5.   The retinoblastoma protein�

6.   The RB-E2F pathway�

Page 15: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

G1

G0

S

M

G2

Restriction Point"

The Cell Cycle �

Mitosis and cytokinesis"

DNA-Synthesis

Mitogens ?"Antimitogens ?"

Growth factors ?"Differentiation signals ?"

Exit from the cell cycle:"- senescence - terminal differentiation- quiescence""G0-phase / quiescence:"-  no cell divisions"-  no DNA-replikation"- can persist hours, days or years"

Page 16: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Cell Fusions

Rao, P.N. & Johnson, R.T. (1970). Mammalian Cell Fusion: Studies on the Regulation of DNA Synthesis and Mitosis. Nature 225, 159-164. Johnson, R.T. & Rao, P.N. (1970). Mammalian Cell Fusion: Induction of Premature Chromosome Condensation in Interphase Nuclei. Nature 226, 717-722.

Page 17: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Fusion of G1, S or G2 cells with mitotic cells leads to nuclear envelope breakdown and DNA condensation in the heterocaryon.!!Mitotic cells contain a factor (“MPF” - Mitosis promoting factor) which can induce mitosis in cells of other cell cycle phases.!

Rao, P.N. & Johnson, R.T. (1970). Mammalian cell fusion: studies on the regulation of DNA synthesis and mitosis.Nature 225, 159-164. Johnson, R.T. & Rao, P.N. (1970). Mammalian cell fusion: induction of premature chromosome condensation in interphase nuclei.Nature 226,

717-722.

Heterocaryon experiments"

G1, S or G2

+ M M

Page 18: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Fusion of G1 cells with S-phase cells results in heterocaryons, in which the G1 nuclei initiate DNA replikation. S-phase cells only initiate mitosis after completion of DNA!replication in G1 cells.!!S-phase cells contain a factor which can initiate DNA replication in G1 cells. Checkpoints prevent “premature” entry into mitosis before S-phase is completed in both nuclei.

Rao, P.N. & Johnson, R.T. (1970). Mammalian cell fusion: studies on the regulation of DNA synthesis and mitosis.Nature 225, 159-164. Johnson, R.T. & Rao, P.N. (1970). Mammalian cell fusion: induction of premature chromosome condensation in interphase nuclei.Nature 226,

717-722.

Heterocaryon experiments"

G1, S or G2

+ M

G1

+

S S

M

Page 19: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Rao, P.N. & Johnson, R.T. (1970). Mammalian cell fusion: studies on the regulation of DNA synthesis and mitosis.Nature 225, 159-164. Johnson, R.T. & Rao, P.N. (1970). Mammalian cell fusion: induction of premature chromosome condensation in interphase nuclei.Nature 226,

717-722.

Heterocaryon experiments"

G1, S or G2

+ M

G1

+

S S

S

+

G2 no DNA synthesis in the G2 nucleus, delayed entry into mitosis

M

G2 nuclei do not re-initiate DNA replication!Existence of a “licensing system”, which labels replicated DNA

and prevents re-replication.

Page 20: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

1.   Principles of the cell cycle �

2.  The restriction point�

3.   CDKs – central cell cycle regulators�

4.   CDK inhibitors�

5.   The retinoblastoma protein�

6.   The RB-E2F pathway�

Page 21: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

The Nobel Prize in Physiology or Medicine 2001 "for their discoveries of key regulators of the cell cycle"

R. Tim Hunt

Fission yeast

Sir Paul M. Nurse

Sea Urchin

Leland H. Hartwell

Bakers yeast

The Cell Cycle Engine�

Page 22: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Cyclin A (N-term.)

Cdk2

Cdk

Cyclin

The Cell Cycle Engine: Cyclin-Dependent Kinases�

Page 23: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

time!

rel. Cdk-kinase activity

Cell Cycle Transitions are driven by the oscillating Activity� of Cyclin-Dependent Kinases (CDKs) �

G1-phase kinase! S-phase kinase! M-phase kinase!

G 1 S G 2 M

Page 24: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

G1

G0

S

M

G2

Cdk2 Cyc E

Cdk2 Cyc A

Cdk1 Cyc A

Cdk1 Cyc B

Cdk4 Cyc D

Restriction Point"

The Cell Cycle Engine: Cyclin-Dependent Kinases�

Page 25: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

inactive! inactive! inactive!active!

Assembly factors ?spontanious"

CAK"KAP!

Wee1 / Myt1"Cdc25!

Cdk

Cyclin

Cdk

Cyclin

Cdk

Cyclin

Cdk

Cyclin

P"P"P"P"

Kinases"Phosphatases!

CDKs are regulated by activating and inhibitory phosphorylations �

Page 26: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

1.   Principles of the cell cycle �

2.  The restriction point�

3.   CDKs – central cell cycle regulators�

4.   CDK inhibitors�

5.   The retinoblastoma protein�

6.   The RB-E2F pathway�

Page 27: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

M

G2

S

G1

G1 arrest"(Lovastatin; TGF-β)"

Molecular Brakes: CDK Inhibitor Proteins �

G1

G2 S

M

100!

75!

50!

25!

0!

% E-

kina

se a

ctiv

ity!

Cdk

Cyclin p27

Hengst et al., PNAS 1994!

Page 28: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Mechanism of CDK inhibition by p27 �

Cyclin A

Cdk2

p27

Page 29: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Cyclin A Cdk2

p27Kip1 Cdk

Cyclin p27

Mechanism of CDK inhibition by p27 �

Page 30: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

ATP"p27"

Page 31: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Lacy et al., Nature Structural & Molecular Biology. 2004

Cip/Kip Inhibitors are Intrinsically Unstructured Proteins (IUPs)!

Page 32: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

p27 198 AA

CDK inhibitory domain

p21 p27 p57

22 30 40 50 60 70 80 90 PCGSK ACR R LFGPVD S E Q L S R D SDALM A GCIQ E ARE R W N F D F VTET PL E-- G DFA W ER V RGLG L P KL Y LPTGP EHPKP S ACR N LFGPVD H E E L T R DL EKHC RDMEE AS Q RK W N F D F Q NHK PL E-- G KYE W Q E V EKG SL P EF Y YRPPR VLVRT S ACR S LFGPVD H E E L G R E L RMRA A ELNA E D Q N R W D F N F Q QDV PL RGP G RLQ W M E V DSE S V P AF Y RET-V

p57

Cyclin binding domain CDK binding domain

316 AA

p21 164 AA

The Cip/Kip-Family of CDK Inhibitors

Cdk

Cyclin p27

Linker helix

Page 33: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Two Families of CDK Inhibitors �

Cdk p16

Ink4 family!(Inhibitor of Cdk4)!

p15, p16, p18, p19 (Ink4 a-d)!!-  specific for cyclin D / CDK4,6!-  bind the CDK subunit!-  ankyrin repeat structure!!

Cdk

Cyclin p27

Cip/Kip family (Cdk interacting protein;!Kinase inhibitory protein)!

p21, p27, p57 (Cip1, Kip1, Kip2)!!-  bind to a broad spectrum of CDK/ cyclins!-  bind the CDK / cyclin complex!-  conserved N-terminal CDK- inhibitory domain!-  may act as actvators for cyclin D/Cdk4,6 !

Page 34: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Cdk6

p16Ink4a

INK4 CDK4,6 Inhibitors�

Cdk4 p16

Cyclin D

Page 35: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

What are critical CDK substrates at the G1/S transition ? �

Page 36: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

1.   Principles of the cell cycle �

2.  The restriction point�

3.   CDKs – central cell cycle regulators�

4.   CDK inhibitors�

5.   The retinoblastoma protein�

6.   The RB-E2F pathway�

Page 37: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Rb

The CDK substrat retinoblastom protein (Rb) is a central cell cycle regulator

E1A G1

G0

S

M

G2

-  Retinoblastoma is a rapidly developing childhood cancer (1/20.000) arising from immature retinal cells -  The Rb protein is a tumor suppressor protein; 45% of the patients carry a heterozygous mutation in Rb1 -  Children with (heteroygous) mutations in Rb frequently develop tumours in other tissues (Knudsons two-hit hypothesis) -  Viral oncoproteins like E1A and HPV E7 bind Rb and induce cell division in cultured cells

Page 38: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Rb binds E2F and inhibits cell cycle progression

Rb E2F

E2F binding site

inactive

Rb

E2F binding site

E2F

active

E1A

Page 39: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Phosphorylation of Rb releases E2F

inactive

P

CDK

Rb E2F

E2F binding site

P Rb

E2F binding site

E2F

active

Page 40: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

1.   Principles of the cell cycle �

2.  The restriction point�

3.   CDKs – central cell cycle regulators�

4.   CDK inhibitors�

5.   The retinoblastoma protein�

6.   The RB-E2F pathway�

Page 41: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Rb E2F

mitogens

P

Mitogen induced expression and activation of cyclin D/ CDK initiates cell cycle progression

G1

G0

S

M

G2

Cdk2 Cyc E

Cdk2 Cyc A

Cdk1 Cyc A

Cdk4 Cyc D

P

Cdk4 Cyc D

Cdk2 Cyc E

mitogen independent

Page 42: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

CDK inhibitors prevent CDK activation

Rb E2F

G1

G0

S

M

G2

Cdk2 Cyc E

Cdk4 Cyc D

p16 p15

p18 p19

p27 p57

p21

Cdk4

STOP

Page 43: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

The Rb pathway during the G0/G1/S transition"

S-Phase Cell

S G0/G1

p27

Antimitogens

Cdk4,6 p16

Antimitogens

Page 44: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

E2Fs Rb

HDAC

Cdk4,6

Cdc37

p27 degradation

P

S-Phase Cell

S

Cdk2 Cyc E

Cdk4,6 p27

Cyc D

Cdk2 Cyc E

p27

HDAC

E2Fs Rb P

P P

Cyclin E DHFR DNA Pol.α

G1

Cyclin A Cdk1

E2Fs

P

P Rb P

P P

P P

Cyc D

Mitogens

Cdk4,6 p16

Antimitogens

Antimitogens

Der Rb Signalweg des G0/G1/S Übergangs"

Page 45: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Head and neck!

Prostate!

Lung! Melanoma!

Gastrointestinal!

Breast!

Liver!Pancreas!

Bladder! Bone (osteosarcoma)!

Bone marrow (leukemia)!

Lymphoma!

p130"

p130" p130"

p16"

p16"

p16"

p15"

p15"

p15"

D1"

Pituitary!

Testis/Ovary!

p16"

D2"

Cdk6"

Cdk6"

D1"

D1"

D1"

p16"

p16"

p130"

D1"

Cdk4"p16"

p16"

D1"D3"

p16"

Cdk4"

p16"D1"

Cdk4" D1"

D1"

Cdk4" p16"

D1"

Cdk4" D1" p16"

pRb"E1"

p27"

p27"

p27"

p27" E1"

E1"

E1"p27"

E1"p27"

p27"

E1" p27"

E1" p27"

Cdk4"Cdk2"D2"

Other Sarcomas!p16"

Endometrium!p130"Cdk4"

p27"D1"

E1"

Glioma/blastoma!Cdk4"Cdk6"E1" p16"p15"

70%

> 80%

> 90%

> 80% > 90%

> 90%

> 80%

> 90%

> 90%

D2" D3" E1"> 90%

20%

> 80%

> 80%

p16" > 80%

E1"70%

Cdk4" E1"90%

> 90%

pRb"

pRb"

pRb"

pRb"

pRb"

pRb"

pRb"

pRb"

pRb"

pRb"

p27"

p27"

D1"

p27"

E1"

p16"

p27"

p27"

*

*

*

* *

*

*

*

*

*

*

* *

*

*

Cdk2"

*

Cdk4"p15"

* * * * *

* * D1"

* *

E1"

* *

* *

D3"

*

* *

*

pRb"D1"p16"

* * *

Cancer is a disease of the cell cycle �

From: Malumbres and Barbarcid: Nature Reviews Cancer (01). Vol1, 222

Page 46: Cell Cycle – Control of Cell Proliferation...1 fertilized egg ! ! !!100 000 000 000 000 cells Cell cycle – control of cell proliferation Ludger Hengst Biozentrum - Medizinische

Questions ��

???"