Blocking MMP-12-modulated epithelial-mesenchymal transition by repurposing penfluridol restrains lung adenocarcinoma metastasis via uPA/uPAR/TGF-β/Akt pathway.


Journal

Cellular oncology (Dordrecht)
ISSN: 2211-3436
Titre abrégé: Cell Oncol (Dordr)
Pays: Netherlands
ID NLM: 101552938

Informations de publication

Date de publication:
Oct 2021
Historique:
received: 11 11 2020
accepted: 11 06 2021
pubmed: 29 7 2021
medline: 8 2 2022
entrez: 28 7 2021
Statut: ppublish

Résumé

Metastasis of lung adenocarcinoma (LADC) is a crucial factor determining patient survival. Repurposing of the antipsychotic agent penfluridol has been found to be effective in the inhibition of growth of various cancers. As yet, however, the anti-metastatic effect of penfluridol on LADC has rarely been investigated. Herein, we addressed the therapeutic potential of penfluridol on the invasion/metastasis of LADC cells harboring different epidermal growth factor receptor (EGFR) mutation statuses. MTS viability, transwell migration and invasion, and tumor endothelium adhesion assays were employed to determine cytotoxic and anti-metastatic effects of penfluridol on LADC cells. Protease array, Western blot, immunohistochemistry (IHC), immunofluorescence (IF) staining, and expression knockdown by shRNA or exogenous overexpression by DNA plasmid transfection were performed to explore the underlying mechanisms, both in vitro and in vivo. We found that nontoxic concentrations of penfluridol reduced the migration, invasion and adhesion of LADC cells. Protease array screening identified matrix metalloproteinase-12 (MMP-12) as a potential target of penfluridol to modulate the motility and adhesion of LADC cells. In addition, we found that MMP-12 exhibited the most significantly adverse prognostic effect in LADC among 39 cancer types. Mechanistic investigations revealed that penfluridol inhibited the urokinase plasminogen activator (uPA)/uPA receptor/transforming growth factor-β/Akt axis to downregulate MMP-12 expression and, subsequently, reverse MMP-12-induced epithelial-mesenchymal transition (EMT). Subsequent analysis of clinical LADC samples revealed a positive correlation between MMP12 and mesenchymal-related gene expression levels. A lower survival rate was found in LADC patients with a SNAl1 Our results indicate that MMP-12 may serve as a useful biomarker for predicting LADC progression and as a promising penfluridol target for treating metastatic LADC.

Identifiants

pubmed: 34319576
doi: 10.1007/s13402-021-00620-1
pii: 10.1007/s13402-021-00620-1
doi:

Substances chimiques

Proteins 0
Receptors, Urokinase Plasminogen Activator 0
Transforming Growth Factor beta 0
Penfluridol 25TLU22Q8H
Proto-Oncogene Proteins c-akt EC 2.7.11.1
Urokinase-Type Plasminogen Activator EC 3.4.21.73
Matrix Metalloproteinase 12 EC 3.4.24.65

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

1087-1103

Subventions

Organisme : Taipei Medical University
ID : 110-eva-14

Informations de copyright

© 2021. Springer Nature Switzerland AG.

Références

B.Y. Wang, J.Y. Huang, C.Y. Cheng, C.H. Lin, J. Ko, Y.P. Liaw, Lung cancer and prognosis in taiwan: a population-based cancer registry. J. Thorac. Oncol. 8, 1128–1135 (2013)
pubmed: 23945383 doi: 10.1097/JTO.0b013e31829ceba4
D.M. Jackman, Y. Zhang, C. Dalby, T. Nguyen, J. Nagle, C.A. Lydon, M.S. Rabin, K.K. McNiff, B. Fraile, J.O. Jacobson, Cost and survival analysis before and after implementation of Dana-Farber clinical pathways for patients with stage IV non-small-cell lung cancer. J. Oncol. Pract. 13, e346–e352 (2017)
pubmed: 28260402 doi: 10.1200/JOP.2017.021741
L. Qiao, J. Wang, G. Long, Y. Jiang, Sequential treatment of tyrosine kinase inhibitor and platinum-based doublet chemotherapy on EGFR mutant non-small cell lung cancer: a meta-analysis of randomized controlled clinical trials. Onco. Targets Ther. 10, 1279–1284 (2017)
pubmed: 28280362 pmcid: 5338926 doi: 10.2147/OTT.S128187
S. Brassart-Pasco, S. Brezillon, B. Brassart, L. Ramont, J.B. Oudart, J.C. Monboisse, Tumor microenvironment: Extracellular matrix alterations influence tumor progression. Front. Oncol. 10, 397 (2020)
pubmed: 32351878 pmcid: 7174611 doi: 10.3389/fonc.2020.00397
S Blanco-Prieto, L Barcia-Castro, M Paez, FJ de la Cadena, L Rodriguez-Berrocal, MI Vazquez-Iglesias, A Botana-Rial, L Fernandez-Villar, De Chiara, Relevance of matrix metalloproteases in non-small cell lung cancer diagnosis. BMC Cancer 17, 823 (2017)
pubmed: 29207990 pmcid: 5718060 doi: 10.1186/s12885-017-3842-z
S.D. Shapiro, D.K. Kobayashi, T.J. Ley, Cloning and characterization of a unique elastolytic metalloproteinase produced by human alveolar macrophages. J. Biol. Chem. 268, 23824–23829 (1993)
pubmed: 8226919 doi: 10.1016/S0021-9258(20)80459-1
P Qu, H Du, X Wang, C Yan, Matrix metalloproteinase 12 overexpression in lung epithelial cells plays a key role in emphysema to lung bronchioalveolar adenocarcinoma transition. Cancer Res. 69, 7252–7261 (2009)
pubmed: 19706765 pmcid: 2753283 doi: 10.1158/0008-5472.CAN-09-0577
P Qu, C Yan, H Du, Matrix metalloproteinase 12 overexpression in myeloid lineage cells plays a key role in modulating myelopoiesis, immune suppression, and lung tumorigenesis. Blood 117, 4476–4489 (2011)
pubmed: 21378275 pmcid: 3099569 doi: 10.1182/blood-2010-07-298380
H.S. Hofmann, G. Hansen, G. Richter, C. Taege, A. Simm, R.E. Silber, S. Burdach, Matrix metalloproteinase-12 expression correlates with local recurrence and metastatic disease in non-small cell lung cancer patients. Clin. Cancer Res. 11, 1086–1092 (2005)
pubmed: 15709175
F.Z. Lv, J.L. Wang, Y. Wu, H.F. Chen, X.Y. Shen, Knockdown of MMP12 inhibits the growth and invasion of lung adenocarcinoma cells. Int. J. Immunopathol. Pharmacol. 28, 77–84 (2015)
pubmed: 25816409 doi: 10.1177/0394632015572557
NH Cho, KP Hong, SH Hong, S Kang, KY Chung, SH Cho, MMP expression profiling in recurred stage IB lung cancer. Oncogene 23, 845–851 (2004)
pubmed: 14647437 doi: 10.1038/sj.onc.1207140
V Mittal, Epithelial mesenchymal transition in aggressive lung cancers. Adv. Exp. Med. Biol. 890, 37–56 (2016)
pubmed: 26703798 doi: 10.1007/978-3-319-24932-2_3
M.L. Stallings-Mann, J. Waldmann, Y. Zhang, E. Miller, M.L. Gauthier, D.W. Visscher, G.P. Downey, E.S. Radisky, A.P. Fields, D.C. Radisky, Matrix metalloproteinase induction of Rac1b, a key effector of lung cancer progression. Sci. Transl. Med. 4, 142ra195 (2012)
doi: 10.1126/scitranslmed.3004062
S Singhal, J Mehta, R Desikan, D Ayers, P Roberson, P Eddlemon, N Munshi, E Anaissie, C Wilson, M Dhodapkar, J Zeddis, B Barlogie, Antitumor activity of thalidomide in refractory multiple myeloma. N. Engl. J. Med. 341, 1565–1571 (1999)
pubmed: 10564685 doi: 10.1056/NEJM199911183412102
MJ Thun, SJ Henley, C Patrono, Nonsteroidal anti-inflammatory drugs as anticancer agents: mechanistic, pharmacologic, and clinical issues. J. Natl. Cancer Inst. 94, 252–266 (2002)
pubmed: 11854387 doi: 10.1093/jnci/94.4.252
V. Shafiei-Irannejad, N. Samadi, R. Salehi, B. Yousefi, N. Zarghami, New insights into antidiabetic drugs: Possible applications in cancer treatment. Chem. Biol. Drug Des. 90, 1056–1066 (2017)
pubmed: 28456998 doi: 10.1111/cbdd.13013
F.H. Chou, K.Y. Tsai, C.Y. Su, C.C. Lee, The incidence and relative risk factors for developing cancer among patients with schizophrenia: a nine-year follow-up study. Schizophr. Res. 129, 97–103 (2011)
pubmed: 21458957 doi: 10.1016/j.schres.2011.02.018
B.G. Soares, M.S. Lima, Penfluridol for schizophrenia. Cochrane Database Syst. Rev. Cd002923 (2006)
V. Shaw, S. Srivastava, S.K. Srivastava, Repurposing antipsychotics of the diphenylbutylpiperidine class for cancer therapy. Semin. Cancer Biol. 68, 75–83 (2021)
N.M. Tuan, C.H. Lee, Penfluridol as a candidate of drug repurposing for anticancer agent. Molecules 24, 3659 (2019)
WY Hung, JH Chang, Y Cheng, GZ Cheng, HC Huang, M Hsiao, CL Chung, WJ Lee, MH Chien, Autophagosome accumulation-mediated ATP energy deprivation induced by penfluridol triggers nonapoptotic cell death of lung cancer via activating unfolded protein response. Cell Death Dis. 10, 538 (2019)
pubmed: 31308361 pmcid: 6629704 doi: 10.1038/s41419-019-1785-9
A Ranjan, P Gupta, SK Srivastava, Penfluridol: an antipsychotic agent suppresses metastatic tumor growth in triple-negative breast cancer by inhibiting integrin signaling axis. Cancer Res. 76, 877–890 (2016)
pubmed: 26627008 doi: 10.1158/0008-5472.CAN-15-1233
H Kim, K Chong, BK Ryu, KJ Park, MO Yu, J Lee, S Chung, S Choi, MJ Park, YG Chung, SH Kang, Repurposing penfluridol in combination with temozolomide for the treatment of glioblastoma. Cancers 11, 1310 (2019)
pmcid: 6770574 doi: 10.3390/cancers11091310
YH Yu, HA Chen, PS Chen, YJ Cheng, WH Hsu, YW Chang, YH Chen, Y Jan, M Hsiao, TY Chang, YH Liu, YM Jeng, CH Wu, MT Huang, YH Su, MC Hung, MH Chien, CY Chen, ML Kuo, JL Su, MiR-520h-mediated FOXC2 regulation is critical for inhibition of lung cancer progression by resveratrol. Oncogene 32, 431–443 (2013)
pubmed: 22410781 doi: 10.1038/onc.2012.74
Y.W. Lin, L.M. Lee, W.J. Lee, C.Y. Chu, P. Tan, Y.C. Yang, W.Y. Chen, S.F. Yang, M. Hsiao, M.H. Chien, Melatonin inhibits MMP-9 transactivation and renal cell carcinoma metastasis by suppressing Akt-MAPKs pathway and NF-κB DNA-binding activity. J. Pineal. Res. 60, 277–290 (2016)
pubmed: 26732239 doi: 10.1111/jpi.12308
MH Chien, WJ Lee, YC Yang, P Tan, KF Pan, YC Liu, HC Tsai, CH Hsu, YC Wen, M Hsiao, Hua, N-alpha-acetyltransferase 10 protein promotes metastasis by stabilizing matrix metalloproteinase-2 protein in human osteosarcomas. Cancer Lett. 433, 86–98 (2018)
pubmed: 29960050 doi: 10.1016/j.canlet.2018.06.033
F.A. Venning, L. Wullkopf, J.T. Erler, Targeting ECM disrupts cancer progression. Front. Oncol. 5, 224 (2015)
pubmed: 26539408 pmcid: 4611145 doi: 10.3389/fonc.2015.00224
C. Gialeli, A.D. Theocharis, N.K. Karamanos, Roles of matrix metalloproteinases in cancer progression and their pharmacological targeting. FEBS J 278, 16–27 (2011)
pubmed: 21087457 doi: 10.1111/j.1742-4658.2010.07919.x
A.J. Gentles, A.M. Newman, C.L. Liu, S.V. Bratman, W. Feng, D. Kim, V.S. Nair, Y. Xu, A. Khuong, C.D. Hoang, M. Diehn, R.B. West, S.K. Plevritis, A.A. Alizadeh, The prognostic landscape of genes and infiltrating immune cells across human cancers. Nat. Med. 21, 938–945 (2015)
pubmed: 26193342 pmcid: 4852857 doi: 10.1038/nm.3909
JF Santibanez, H Obradovic, T Kukolj, J Krstic, Transforming growth factor-beta, matrix metalloproteinases, and urokinase-type plasminogen activator interaction in the cancer epithelial to mesenchymal transition. Dev. Dyn. 247, 382–395 (2018)
pubmed: 28722327 doi: 10.1002/dvdy.24554
SL Raza, LC Nehring, SD Shapiro, LA Cornelius, Proteinase-activated receptor-1 regulation of macrophage elastase (MMP-12) secretion by serine proteinases. J. Biol. Chem. 275, 41243–41250 (2000)
pubmed: 10993890 doi: 10.1074/jbc.M005788200
G Qin, M Luo, J Chen, Y Dang, G Chen, L Li, J Zeng, Y Lu, J Yang, Reciprocal activation between MMP-8 and TGF-beta1 stimulates EMT and malignant progression of hepatocellular carcinoma. Cancer Lett. 374, 85–95 (2016)
pubmed: 26872724 doi: 10.1016/j.canlet.2016.02.001
X. Zhu, L. Wang, B. Zhang, J. Li, X. Dou, R.C. Zhao, TGF-beta1-induced PI3K/Akt/NF-kappaB/MMP9 signalling pathway is activated in Philadelphia chromosome-positive chronic myeloid leukaemia hemangioblasts. J. Biochem. 149, 405–414 (2011)
pubmed: 21288887 doi: 10.1093/jb/mvr016
L.J. Talbot, S.D. Bhattacharya, P.C. Kuo, Epithelial-mesenchymal transition, the tumor microenvironment, and metastatic behavior of epithelial malignancies. Int. J. Biochem. Mol. Biol. 3, 117–136 (2012)
pubmed: 22773954 pmcid: 3388731
LM Machesky, Lamellipodia and filopodia in metastasis and invasion. FEBS Lett. 582, 2102–2111 (2008)
pubmed: 18396168 doi: 10.1016/j.febslet.2008.03.039
J. Dong, B. Zhai, W. Sun, F. Hu, H. Cheng, J. Xu, Activation of phosphatidylinositol 3-kinase/AKT/snail signaling pathway contributes to epithelial-mesenchymal transition-induced multi-drug resistance to sorafenib in hepatocellular carcinoma cells. PLoS One 12, e0185088 (2017)
pubmed: 28934275 pmcid: 5608310 doi: 10.1371/journal.pone.0185088
C. Scheau, I.A. Badarau, R. Costache, C. Caruntu, G.L. Mihai, A.C. Didilescu, C. Constantin, M. Neagu, The role of matrix metalloproteinases in the epithelial-mesenchymal transition of hepatocellular carcinoma. Anal. Cell Pathol. (Amst.) 2019, 9423907 (2019)
SA Illman, K Lehti, J Keski-Oja, J Lohi, Epilysin (MMP-28) induces TGF-beta mediated epithelial to mesenchymal transition in lung carcinoma cells. J. Cell Sci. 119, 3856–3865 (2006)
pubmed: 16940349 doi: 10.1242/jcs.03157
J. Cathcart, A. Pulkoski-Gross, J. Cao, Targeting matrix metalloproteinases in cancer: Bringing new life to old ideas. Genes Dis. 2, 26–34 (2015)
pubmed: 26097889 pmcid: 4474140 doi: 10.1016/j.gendis.2014.12.002
G.J. Boelen, L. Boute, J. d’Hoop, M. EzEldeen, I. Lambrichts, G. Opdenakker, Matrix metalloproteinases and inhibitors in dentistry. Clin. Oral. Investig. 23, 2823–2835 (2019)
pubmed: 31093743 doi: 10.1007/s00784-019-02915-y
W. Xu, Z. Yang, N. Lu, A new role for the PI3K/Akt signaling pathway in the epithelial-mesenchymal transition. Cell Adh. Migr. 9, 317–324 (2015)
pubmed: 26241004 pmcid: 4594353 doi: 10.1080/19336918.2015.1016686
S Julien, I Puig, E Caretti, J Bonaventure, L Nelles, F van Roy, C Dargemont, AG de Herreros, A Bellacosa, L Larue, Activation of NF-kappaB by Akt upregulates Snail expression and induces epithelium mesenchyme transition. Oncogene 26, 7445–7456 (2007)
pubmed: 17563753 doi: 10.1038/sj.onc.1210546
A. Miyoshi, Y. Kitajima, K. Sumi, K. Sato, A. Hagiwara, Y. Koga, K. Miyazaki, Snail and SIP1 increase cancer invasion by upregulating MMP family in hepatocellular carcinoma cells. Br. J. Cancer 90, 1265–1273 (2004)
pubmed: 15026811 pmcid: 2409652 doi: 10.1038/sj.bjc.6601685
K. Yokoyama, N. Kamata, R. Fujimoto, S. Tsutsumi, M. Tomonari, M. Taki, H. Hosokawa, M. Nagayama, Increased invasion and matrix metalloproteinase-2 expression by Snail-induced mesenchymal transition in squamous cell carcinomas. Int. J. Oncol. 22, 891–898 (2003)
pubmed: 12632084
J.H. Chang, C.W. Cheng, Y.C. Yang, W.S. Chen, W.Y. Hung, J.M. Chow, P.S. Chen, M. Hsiao, W.J. Lee, M.H. Chien, Downregulating CD26/DPPIV by apigenin modulates the interplay between Akt and Snail/Slug signaling to restrain metastasis of lung cancer with multiple EGFR statuses. J. Exp. Clin. Cancer Res. 37, 199 (2018)
pubmed: 30134935 pmcid: 6104010 doi: 10.1186/s13046-018-0869-1
J.H. Chang, S.L. Lai, W.S. Chen, W.Y. Hung, J.M. Chow, M. Hsiao, W.J. Lee, M.H. Chien, Quercetin suppresses the metastatic ability of lung cancer through inhibiting Snail-dependent Akt activation and Snail-independent ADAM9 expression pathways. Biochim. Biophys. Acta Mol. Cell Res. 1864, 1746–1758 (2017)
pubmed: 28648644 doi: 10.1016/j.bbamcr.2017.06.017
X. Xiao, Z. He, W. Cao, F. Cai, L. Zhang, Q. Huang, C. Fan, C. Duan, X. Wang, J. Wang, Y. Liu, Oridonin inhibits gefitinib-resistant lung cancer cells by suppressing EGFR/ERK/MMP-12 and CIP2A/Akt signaling pathways. Int. J. Oncol. 48, 2608–2618 (2016)
pubmed: 27082429 doi: 10.3892/ijo.2016.3488
L Wu, A Tanimoto, Y Murata, T Sasaguri, J Fan, Y Sasaguri, T Watanabe, Matrix metalloproteinase-12 gene expression in human vascular smooth muscle cells. Genes Cells 8, 225–234 (2003)
pubmed: 12622720 doi: 10.1046/j.1365-2443.2003.00628.x
L Li, L Qi, Z Liang, W Song, Y Liu, Y Wang, B Sun, B Zhang, W Cao, Transforming growth factor-β1 induces EMT by the transactivation of epidermal growth factor signaling through HA/CD44 in lung and breast cancer cells. Int. J. Mol. Med. 36, 113–122 (2015)
pubmed: 26005723 pmcid: 4494581 doi: 10.3892/ijmm.2015.2222
S. Mazhar, S.E. Taylor, J. Sangodkar, G. Narla, Targeting PP2A in cancer: Combination therapies. Biochim. Biophys. Acta Mol. Cell Res. 1866, 51–63 (2019)
pubmed: 30401535 doi: 10.1016/j.bbamcr.2018.08.020
S.Y. Wu, Y.C. Wen, C.C. Ku, Y.C. Yang, J.M. Chow, S.F. Yang, W.J. Lee, M.H. Chien, Penfluridol triggers cytoprotective autophagy and cellular apoptosis through ROS induction and activation of the PP2A-modulated MAPK pathway in acute myeloid leukemia with different FLT3 statuses. J. Biomed. Sci. 26, 63 (2019)
pubmed: 31470848 pmcid: 6717358 doi: 10.1186/s12929-019-0557-2
E Hedrick, X Li, S Safe, Penfluridol represses integrin expression in breast cancer through induction of reactive oxygen species and downregulation of Sp transcription factors. Mol. Cancer Ther. 16, 205–216 (2017)
pubmed: 27811009 doi: 10.1158/1535-7163.MCT-16-0451

Auteurs

Wen-Yueh Hung (WY)

Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, 250 Wu-Hsing Street, 11031, Taipei, Taiwan.

Wei-Jiunn Lee (WJ)

Department of Medical Education and Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
Department of Urology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.

Guo-Zhou Cheng (GZ)

Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, 250 Wu-Hsing Street, 11031, Taipei, Taiwan.

Ching-Han Tsai (CH)

Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, 250 Wu-Hsing Street, 11031, Taipei, Taiwan.

Yi-Chieh Yang (YC)

Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, 250 Wu-Hsing Street, 11031, Taipei, Taiwan.
Department of Medical Research, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan.

Tsung-Ching Lai (TC)

Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Hsing Long Road, Section 3, Taipei, 11696, Taiwan.

Ji-Qing Chen (JQ)

Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, 250 Wu-Hsing Street, 11031, Taipei, Taiwan.
Department of Cancer Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.

Chi-Li Chung (CL)

School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan.
Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan.

Jer-Hwa Chang (JH)

Department of Medical Education and Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan. m102094030@tmu.edu.tw.
Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Hsing Long Road, Section 3, Taipei, 11696, Taiwan. m102094030@tmu.edu.tw.
School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan. m102094030@tmu.edu.tw.
Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan. m102094030@tmu.edu.tw.

Ming-Hsien Chien (MH)

Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, 250 Wu-Hsing Street, 11031, Taipei, Taiwan. mhchien1976@gmail.com.
Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan. mhchien1976@gmail.com.
TMU Research Center of Cancer Translational Medicine, Taipei Medical University, Taipei, Taiwan. mhchien1976@gmail.com.
Traditional Herbal Medicine Research Center, Taipei Medical University Hospital, Taipei, Taiwan. mhchien1976@gmail.com.

Articles similaires

[Redispensing of expensive oral anticancer medicines: a practical application].

Lisanne N van Merendonk, Kübra Akgöl, Bastiaan Nuijen
1.00
Humans Antineoplastic Agents Administration, Oral Drug Costs Counterfeit Drugs

Smoking Cessation and Incident Cardiovascular Disease.

Jun Hwan Cho, Seung Yong Shin, Hoseob Kim et al.
1.00
Humans Male Smoking Cessation Cardiovascular Diseases Female
Humans United States Aged Cross-Sectional Studies Medicare Part C
1.00
Humans Yoga Low Back Pain Female Male

Classifications MeSH