Prostate HEALTH W H AT YO U N E E D TO K N OW TO M A IN TA IN G O O D P RO S TATE H E A LTH Your Prostate Health P roblems with the prostate (a gland in the male reproductive system) become more common as a man ages. These problems include prostate cancer, a common cancer in men. This cancer can often be cured or controlled, especially if it is found and treated early. Screening tests help detect prostate cancer before it causes any symptoms. Prostate Cancer Cancer is an uncontrolled growth of abnormal cells. These cells form in one area and can spread through the body. Prostate cancer causes no symptoms in its early stages. In fact, urinary problems are more likely to be symptoms of another condition. The things that can increase a man’s chance of developing prostate cancer are called risk factors. These include: •Age. The risk of developing prostate cancer increases as you grow older. 2 Screening for prostate cancer is done with a physical exam and blood tests. These tests can help determine whether it is likely that you have cancer. The American Urological Association recommends that men with risk factors begin yearly screening at age 40. Men with no risk factors are offered yearly screening at age 50. Understanding the Prostate T Risk Factors for Prostate Cancer This booklet is not intended as a substitute for professional medical care. Only your doctor can diagnose and treat a medical problem. ©2012 Krames StayWell, LLC. www.kramesstaywell.com 800-333-3032 All rights reserved. Made in the USA. Customized for sanofi-aventis U.S. Screening for Cancer •Family history. If your father or brother has had prostate cancer, your risk of developing it is higher. •Race. African American men are more likely than other men to develop prostate cancer. They are also more likely to die of prostate cancer than other men with this disease. he prostate gland is part of the male reproductive system. As a man ages, his prostate changes. Noncancerous (benign) enlargements often form. And cancerous growths (malignant tumors) can also develop inside the prostate. What Is the Prostate? The prostate is normally about the size and shape of a walnut. It’s located below the bladder. It surrounds the urethra (the tube that carries urine and semen out of the body). The function of the prostate is to produce a fluid. This fluid mixes with fluid from the seminal vesicles and sperm from the testicles to form semen. The testicles also make hormones called androgens (such as testosterone). These hormones help the prostate to function. Lymph node Bladder Pubic bone Penis Rectum Seminal vesicle Prostate Urethra Testicle 3 W ith age, the prostate changes. The prostate may become enlarged, a condition called BPH (benign prostatic hyperplasia), or it may become inflamed, a condition called prostatitis. Unfortunately, cancer of the prostate is also common. Unlike BPH and prostatitis, cancer can grow and spread beyond the prostate, threatening health and life. The Changing Prostate Seminal vesicle Nerve Urethra Benign enlargement (BPH) Normal prostate tissue 4 Normal cells are well organized. Cells of about the same size are arranged in regular patterns. New cells form at about the same rate as old cells die. Cancerous tumor Cancer cells are not well organized. Cells may vary in size and shape. Cancer cells keep multiplying to form more abnormal cells. Prostate Cancer Cancer develops as cells in the body change abnormally. •Atypical cells (prostatic intraepithelial neoplasia, or PIN). Some cells don’t appear normal, but they are not cancer. These cells may indicate that cancer is present or is likely to form. •Cancer. Abnormal cells form a tumor (a lump of cells that grow uncontrolled). Cancer may or may not produce symptoms. Some tumors can be felt during a physical exam, others can’t. •Cancer spread. Prostate cancer may spread to nearby organs. In some cases, the cancer spreads further, to bones or organs in distant parts of the body. This is called metastasis. BPH BPH (benign prostatic hyperplasia) develops when changing hormone levels cause the prostate to grow larger. This often begins around age 50. Excess tissue can block the urethra, making it harder for urine to flow. The enlarged prostate can also press on the bladder, so you may need to urinate more often. Other symptoms include straining during urination, a weak urine stream, and feeling that the bladder isn’t emptying all the way. Thickened bladder wall Excess tissue How BPH Affects the Bladder Pushing to urinate through a narrowed urethra can cause the bladder walls to thicken or stretch out of shape. A stretched bladder may have problems emptying all the way. If the bladder doesn’t empty, infections or bladder stones can occur. Also, the kidneys can’t drain properly into a bladder that doesn’t empty completely. If not treated, this can lead to kidney failure. Pressure from urine buildup can also cause leaking of urine (called overflow incontinence). Prostatitis Prostatitis is an infection or inflammation that causes the prostate to become painful and swollen. This narrows the urethra and can block the bladder neck. Prostatitis can cause a burning sensation during urination. You may also feel pressure or pain in the genital area. In some cases, prostatitis can cause fever and chills, and can make you very sick. Prostatitis is most common in younger men. Inflamed tissue 5 T Understanding The Screening Process o evaluate the problem, your doctor will ask questions about the urinary symptoms you’ve been having. He or she will also examine the prostate and order tests. Tests help find the cause of your symptoms. They also help rule out other health problems that can cause urinary symptoms. Who Should Be Screened? The American Cancer Society recommends yearly screening if you are over 50. African American men or men with a family history of prostate problems may need to start screening at a younger age. Talk to your doctor about when you should start screening, and be sure to review the pros and cons of yearly screening on page 9 of this booklet. Your evaluation will start with a health history and DRE (digital rectal exam). •During the DRE, your doctor will insert a lubricated gloved finger into the rectum to feel 6 the prostate’s size, shape, and texture. Your doctor may also gently massage the prostate. This causes a few drops of fluid to come out through the urethra. The fluid is collected and checked for signs of prostatitis. A DRE may cause a little discomfort, but it takes less than a minute. Prostate specific antigen (PSA) is a chemical made by prostate tissue. The PSA level (amount of PSA in the blood) is tested to evaluate a man’s risk of prostate cancer. In general, a high or rising PSA level may mean an increased cancer risk. PSA testing is also used to evaluate the success of cancer treatments. For example, a falling PSA level can mean that treatment is working. Keep in mind that PSA levels can vary for many reasons. Discuss your PSA test results with your doctor and ask what they mean for your situation. Evaluating the PSA A high or rising PSA level suggests that prostate cancer may have formed. A lower PSA level indicates that cancer is less likely. In addition to the PSA level, your doctor may look at: •The ratio of free PSA (PSA that is not bound to a certain protein in the blood) to total PSA. •The PSA velocity (how fast the PSA level is rising). •The PSA density (the relation of the PSA level to the size of the prostate). Health History and Exam •During the health history, you will be asked about your health and your symptoms. Tell your doctor if you take any prescription or overthe-counter medications, supplements, or herbs. The PSA Test Rectum A DRE lets your doctor feel for changes in the prostate. Factors That Affect PSA Many factors can affect PSA levels. Some, such as age, BPH, and prostate cancer, are ongoing. Others, such as prostatitis or recent sexual activity, have only a temporary effect on PSA. Your healthcare provider can explain how these factors may affect the timing of the PSA test and your results. Further Testing Abnormalities found with DRE may not be tumors. And a high PSA level doesn’t always mean cancer. More tests may need to be done. After looking at the results of your screening tests, your doctor may recommend other tests. 7 To Screen or Not to Screen? Core Needle Biopsy S I f the results of your exam and tests lead your doctor to suspect cancer, tissue samples will be taken from the prostate (a core needle biopsy). This can provide more information about prostate cells. What to Consider Making a choice about whether to screen depends on how you feel about the pros and cons of screening: Taking Tissue Samples The procedure takes about 20 minutes. Before it starts, you may be given an enema to clear the bowels. When the procedure begins: •You will be given antibiotics to prevent infection. •You may be given a sedative, local anesthetic, or pain medication. •A small probe is then inserted into the rectum as you lie on your side. An image of your prostate can then be seen on a video monitor. This is called a transrectal ultrasound (TRUS). Risks and Complications of Core Needle Biopsy • Infection • Blood in urine, stool, or semen hould you be screened yearly for prostate problems, even if you have no symptoms? Experts disagree. Below are some factors to think about as you make a decision. •With this image as a guide, your doctor uses a thin needle to remove tiny tissue samples from several sites in the prostate. Pros Cons •Many experts believe that screening saves lives. Prostate cancer is the second leading cause of cancer death in men. Screening is the best way to find prostate cancer in its early stages. •Screening tests show how likely cancer is. But they are not perfect. So some of the biopsies done based on these tests will be unnecessary. Doing a biopsy has risks, such as bleeding and infection. •When found early, prostate cancer can nearly always be successfully treated. When it is found at a more advanced stage, the outlook often is not as good. •Prostate cancers are often slow-growing. Many never become life-threatening and never need treatment. If you find out you have cancer, you may feel you need to treat it, even if tests show that it’s not a dangerous cancer. Prostate cancer treatments have side effects that can affect quality of life, such as incontinence and erectile dysfunction. •The side effects of prostate cancer therapies are often temporary and can be treated. Weighing Your Options Before making a decision about screening, talk to your doctor. Ask any questions you have about testing. Talking to your partner, friends, or family members may also be helpful. Things to consider include: •Whether you have risk factors. •Your age, overall health, and life expectancy. •Your feelings about treatment. If you found out that you had prostate cancer, would you want to have it treated? 8 9 Your Diagnosis: What Happens Next? Y our doctor will form a diagnosis based on your health history, DRE, and test results. Your treatment options depend on the severity of your symptoms and their underlying cause. Work with your doctor to choose the best treatment plan for your needs. Thinking About Your Treatment Options There are many ways to treat prostate cancer. Treatments include surgery, radiation, and medications. In some cases, watchful waiting (monitoring the cancer without treating it) is a choice. The treatment your healthcare team will suggest depends on many factors. These include your age, your overall health, how fast the cancer is growing, and whether it has spread. Discuss your options with your healthcare team. ❑ Diagnosis of BPH There are a number of treatments for BPH. One or more may be chosen based on how much your symptoms affect your daily life. Your treatment plan may include behavioral changes, such as changing your diet, medication, or surgery. ❑ Diagnosis of Prostatitis Some cases of prostatitis are caused by bacterial infection. These cases are treated with antibiotic pills, which are taken for up to 3 months. Other cases of prostatitis require different medications or treatments. Your doctor will tell you more. He or she may also suggest ways to relieve your symptoms, such as relaxing during urination and taking warm baths. ❑ Diagnosis of Cancer Many treatments for prostate cancer are available. Which one will be most effective depends on many factors, including your age, overall health, and biopsy results. First, tests will be done to learn more about the cancer. This helps determine the best treatment. In many cases, prostate cancer can be cured or controlled. Although prostate cancer is common in older men, most men don’t die of it. 10 Your Healthcare Team The team of professionals who will assist in your care may include: •A urologist, a doctor who treats and performs surgery on the urinary system and the male reproductive system. •A radiation oncologist, a doctor who uses radiation to treat cancer. •A medical oncologist, a doctor who treats cancer with medications. •A nurse practitioner, who may perform exams and manage follow-up care. •Your primary care physician, who refers you to the appropriate specialists. He or she also monitors your overall health. 11 T Evaluating the Cancer o form your treatment plan, your healthcare team must learn more about your cancer. What do the cancer cells look like? Has the cancer spread beyond the prostate? Cells removed during biopsy will be viewed under the microscope. Treatment will depend on how the cells look (grade) and where they are located (stage). The Gleason Score Often there is more than one cancer grade within a tumor. The two most common grades found in the tumor are added together to get the Gleason score (or sum), a number between 2 and 10. 12 Grading the Cancer Staging the Cancer Choosing the Best Treatment A cancer is graded using tissue removed during a biopsy. A pathologist (a doctor who identifies diseases by studying cells and tissues) looks at this tissue under a microscope. He or she then determines the cancer’s grade, from 1 to 5. Low-grade cancers are similar to normal tissue. High-grade cancers differ from normal tissue in the way cells are organized, and in cell size and shape. The higher the grade, the faster the cancer is likely to be growing. The pathologist will give a report to your urologist. Your urologist will assign your cancer a stage based on PSA, DRE, and imaging tests. Lower-stage cancers are confined to the prostate. Higher-stage cancers have spread from the prostate to nearby organs, bone, or other body tissues. Knowing the cancer’s grade and stage helps with forming a treatment plan. Your plan may be based on: Grade 1 or 2 Seen under a microscope, grade 1 or 2 cells are abnormal but still appear to be organized in rings. This may indicate a slowgrowing cancer. Stage T1: A tumor that is completely inside the prostate. It can’t be felt during DRE. Grade 3 or 4 Grade 3 or 4 cells vary more in size and shape. Fewer rings are visible. These cancer cells may grow more rapidly. Grade 5 Grade 5 cells don’t form rings. They vary even more in size and shape than lower-grade cells. This indicates a fast-growing cancer. Stage T2: A tumor that can be felt during DRE but is still completely inside the prostate. Cancer Stage T3 or T4: Cancer that has spread to the outside of the prostate or to the seminal vesicles. Stage N+, M+: Cancer that has spread to the lymph nodes (N+), or to the bones or other organs (M+). • Watchful waiting. Depending on the cancer’s grade and stage, your age, and your overall health, you may not need treatment. Your PSA will be monitored, and you’ll have frequent follow-up exams to watch for changes. • Treating to cure. Low- or mid-stage cancer can often be cured with surgery or radiation. • Treating to control. High-grade or high-stage cancer often can’t be cured but may be controlled using surgery, radiation, hormone therapy, or chemotherapy. 13 Radiation Therapy R adiation therapy is used to destroy cancer cells. Cancer cells continue to die for months after the therapy ends. Radiation (x-rays) can be delivered from outside the body, or from material placed inside the prostate. Radiation therapy also damages some normal cells. This damage causes side effects, which can be controlled. Risks and Complications of External Radiation • Mild to moderate diarrhea • Frequent urination, possibly with a burning feeling • Erectile dysfunction • Some loss of pubic hair • Fatigue • Bloating or gas pains • Bleeding or scarring of the bladder or rectum • Urinary retention • Irritation or inflammation of the rectum with diarrhea, an urgent need to pass stool, or rectal discomfort 14 Targeting Cancer Cells from Inside the Body Interstitial brachytherapy is radiation treatment done from inside the body. “Seeds” (tiny pieces of radioactive material) are implanted into the prostate. These seeds may be either permanent or temporary. •Permanent seeds release decreasing amounts of radiation over a period of months. You can most likely go home soon after the seeds are implanted. Targeting Cancer Cells From Outside the Body •Temporary seeds release a single high dose of radiation. They are implanted and removed. You may stay in the hospital for a day or more after the first dose. One or more doses may be given during the next day. Radioactive seeds Radioactive “seeds” are implanted throughout the prostate. External-beam radiation is done using a machine that sends beams of radiation from outside your body to the cancer. Before, During, and After Treatment •Before treatment. Your radiation oncologist designs your treatment plan. This may include hormone therapy to shrink the prostate. The radiation therapy team locates the exact areas that will be treated. •During treatment. You are given anesthesia to keep you free from pain during the procedure. Needles are then inserted behind the scrotum. These needles are used to implant the seeds. The procedure takes about 1 to 2 hours. •During treatment. A radiation therapist positions you on a table. Radiation is aimed at the tumor from different angles. Each treatment lasts a few minutes. It is done once a day, 5 days a week, for 5 to 7 weeks. •After each treatment. You will most likely be able to follow your normal routine. Discuss with your team how to manage side effects of treatment. •Before treatment. You may be given hormone therapy to shrink the prostate. Ultrasound or a CT scan is then used to map the size and shape of the prostate. •After treatment. Soon after treatment, you can resume normal activities. Your healthcare team will help you to manage any side effects. With permanent seeds, you may need to restrict contact with young children and pregnant women for a period of time. Discuss these precautions with your healthcare team. Risks and Complications of Interstitial Brachytherapy • Erectile dysfunction • Incontinence • Frequent urination, possibly with a burning feeling • Pain in the perineal region • Bleeding or inflammation of the bladder or rectum • Urinary obstruction 15 Removing the Prostate R adical (total) prostatectomy is surgery to remove the entire prostate. It may be done if diagnostic tests show that the cancer is confined to the prostate. The surgery will be performed in one of four ways. Your healthcare team will help you decide which one might be best for you. The prostate, Seminal vesicle the seminal vesicles, and a portion of the urethra are removed. Radical Prostatectomy •You will be given medication that blocks pain. This is called anesthesia. •During surgery, one or several cuts are made. This will depend on the kind of prostatectomy performed. •The urologist may remove and check the lymph nodes near the prostate to see if the cancer has spread. If the cancer has spread, the urologist may decide not to remove the prostate. Urethra Prostate Bladder •The prostate, the seminal vesicles, and a portion of the urethra will then be removed. •Nerve-sparing techniques may be used to help preserve erectile function (the ability to achieve and maintain an erection). Balloon Catheter Urethra Risks and Complications of Prostatectomy 16 • Erectile dysfunction (difficulty achieving or maintaining an erection) • Incontinence (loss of bladder control) • Infection • Excessive bleeding • Difficulty urinating • Pneumonia • Blood clots • Bowel perforation The urethra is reattached to the bladder. A catheter is inserted to drain urine while you heal. A balloon holds the catheter in place. The Techniques Open Surgery Open surgery may be performed through an incision in the abdomen. This is known as the retropubic approach. It is the open surgery most commonly performed. The other open surgery technique is called the perineal approach. This is done through an incision behind the scrotum. Laparoscopic Surgery During laparoscopic surgery, several incisions are made in the abdomen. These are smaller than the one made in open surgery. Long, thin tools are placed inside each incision. These tools include: •Laparoscope. This is a long, thin tube with a video camera inside. The camera sends images to a video screen next to the operating table. This allows the surgeon a clear view of the area around your prostate. •Surgical tools allow the surgeon to remove the prostate and seminal vesicles, stanch bleeding, and sew wounds closed. •Graspers to grasp fat, tissue, or the prostate. Robot-assisted Surgery With robot-assisted surgery, which is also known as Da Vinci surgery, four robotic arms are stationed beside the operating table. These arms hold the surgical instruments. The surgeon sits at a computer console away from the operating table. The console gives the surgeon a larger, three-dimensional view of the surgery site. This view is not attainable with the other techniques. From the console, the surgeon controls the robotic arms. They are thought to allow for more precise movement. Other advantages of Da Vinci surgery are that it may cause less blood loss and allow for a quicker recovery. 17 Your Surgical Experience Y our surgeon will give you detailed instructions on preparing for surgery. After surgery, you’ll be told how to care for yourself at home as you recover. Be sure to ask any questions you have about the procedure and recovery. After Surgery •You may have to stay in bed for a while after surgery. But you'll be encouraged to walk as soon as you can. This will help prevent blood clots from forming in your legs. You'll also be shown exercises that help keep your blood flowing while you're in bed. •Urine will drain through the catheter into a sterile bag. The urine may be bloody or cloudy at first. •You may be able to have a regular diet 24 hours after surgery. •You may return home in 1 to 3 days. Before surgery, you may donate blood to be used in case you need a blood transfusion. Before Surgery •Lab tests. Your surgeon may instruct you to have these done before surgery. •Medications. Your surgeon will tell you which medications you shouldn't take in the weeks before surgery. These tend to be medications that thin the blood. •Bowel prep. This may include a laxative the day before surgery and an enema the morning of surgery. Preparing the bowels for surgery is important because it decreases their size. This allows your surgeon to see more of the surgery site. It also decreases the chance of infection if the bowel were to be nicked during 18 surgery (Note: This is uncommon). •Fasting. You'll be asked not to eat or drink after midnight the night before surgery. •You will discuss anesthesia with the anesthesiologist. You might be given local anesthesia. This means the area around the surgery site will be numb, but you'll be awake. Or, you may be given general anesthesia. This means you'll be asleep during the procedure. •Medications to control pain will be prescribed. Catheter bag •The catheter will be left in place when you go home. You’ll be given instructions on how to manage it. •The catheter and stitches will be removed at a follow-up visit. This is often 1 to 2 weeks after surgery. At this point in your recovery, you may be able to partake in activities you did before surgery. But don't push yourself too hard. Try to avoid strenuous activity even after your catheter is removed. Walking as soon as possible after surgery helps prevent blood clots in your legs. •Bladder control often takes a few weeks to several months to return. Improvement can continue for up to a year. Call Your Doctor If • You have fever or chills. • An incision is draining or increasingly painful or red. • Your leg or ankle begins to swell. • Urine isn’t draining from the catheter. • You can’t urinate after the catheter has been removed. 19 Controlling Spread and Symptoms C ancer that has spread beyond the prostate can often be treated. Hormone therapy can slow the growth and spread of the cancer. Chemotherapy may help relieve symptoms and control the cancer. Cancer pain can be managed with medications. Chemotherapy (chemo) uses medications to destroy cancer cells anywhere in the body. Chemo may be given by pill, injection, or IV infusion (through a tube placed in a vein). It may slow the growth of cancer, and may relieve pain and other symptoms. Chemotherapy is given in cycles so your body has a chance to recover. Your doctor will determine how you receive chemo and for how long. Hormone Therapy Before treatment Testosterone can cause cancer cells to grow. Treatments can include: Since chemotherapy can affect your blood cells, your doctor is likely to order blood tests. It is important to carefully follow instructions you are given before treatment. Always tell your healthcare team which medications you are taking, including herbal medicines or supplements. Make sure you contact your medical team if you have any questions. •Luteinizing hormone-releasing hormone (LHRH) agonists. These medications reduce the amount of testosterone made by the testicles. LHRH agonists are injected monthly every 2, 3, 4, or 6 months. •Antiandrogens. These medications block the body’s ability to use testosterone. They are given by pill. •Orchiectomy. This surgery removes the testicles, the main source of testosterone. Pain Control Prostate cancer that has spread may cause pain. This pain can be treated. Pain medications can improve your quality of life. Using them can relieve stress, helping you to better withstand the cancer. Discuss the side effects of these medications, and any other concerns you have, with your doctor. 20 Chemotherapy Risks and Complications of Hormone Therapy • Hot flashes • Breast enlargement or tenderness • Sexual dysfunction • Osteoporosis (bone loss) • Diarrhea • Loss of energy During treatment Each chemotherapy session may take an hour or more. Most chemotherapy medications are given intravenously, through a needle inserted into a vein. Your dose will depend on your weight and height, plus other factors. There may be a few medications given together. And the schedule may vary to ensure you’re getting the most effective treatment possible. After treatment Your progress will be monitored, and you may be given medications to take at home after your treatments. After chemotherapy you may experience side effects, but most are temporary and your body will recover once the treatment finishes. Because your immune system is not as strong as normal, you should try to avoid contact with people who have infections. Also, you shouldn’t get any new immunizations for several months. Risks and Complications of Chemotherapy • Infection • Hair loss • Fatigue • Muscle Pain • Diarrhea • Nausea/Vomiting 21 Living Your Life N o matter what type of treatment you choose, life with prostate cancer can be a challenge. Your goal should be to live as normal a life as possible. Your healthcare team can help you to cope with any physical and emotional issues that result from treatment. The support of your family and friends can help, too. Dietary Changes Eating smart can result in better overall health. Fish high in omega-3 may help protect against prostate cancer. Try to eat 5 to 9 servings of fruit and vegetables daily. Tomatoes, and products containing cooked tomatoes such as pizza, have been linked to a reduction in prostate cancer. You should work to eliminate dairy and meats from your diet. Avoid tobacco products and excessive alcohol. Choosing organic produce and drinking 3 to 5 cups of decaffeinated green tea daily are good ideas, too. Exercise Exercise can result in better prostate health. Try exercising 30 minutes or longer at least three times weekly. Find an exercise that works for you. Good choices include walking or hiking outdoors, jogging, bicycling, and swimming. It’s also a good idea to practice stress reduction and relaxation techniques. The Future 22 Sexuality Urinary Problems Treatment for prostate cancer may affect your sexuality. It can result in erectile dysfunction or a lowered sex drive. Often, these problems can be treated. Ask your urologist for help. And talk to your partner about ways to nurture your relationship so that it will be satisfying for both of you. Incontinence or other urinary problems can occur due to treatment for prostate cancer. Effective treatments exist for most urinary problems. Talk to your urologist or radiation oncologist about what may help you. During and after treatment, your urologist will monitor your prostate health. Your healthcare team will also help you control any ongoing symptoms resulting from treatment. Keep in mind that each man responds differently to prostate cancer treatment. Continue working with your team throughout treatment. Mention any concerns you have, and be sure to get your questions answered. Above all, think about how best to live your life. Prostate cancer may or may not shorten your life. But living life to the fullest is a good goal for anyone. 23 Reaching Out for Support Cancer Information Service (National Cancer Institute) 800-422-6237 www.cancer.gov/cancertopics/types/prostate American Cancer Society 800-227-2345 | www.cancer.org Us TOO International, Inc. (Prostate cancer support groups) 800-808-7866 | www.ustoo.org H aving prostate cancer can be hard to cope with. But you don’t have to keep your feelings to yourself. Talk with friends and family. Try a prostate cancer support group. Sharing your concerns can help you get the emotional support you need. Check out the resources on this page for more information. www.kramesstaywell.com 800.333.3032 Compliments of 65662US.LEU.12.03.003 1204
© Copyright 2024