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Eine Sicherheits- und Wirksamkeitsstudie zur Bewertung von CTX001 bei Patienten mit schwerer Sichelzellanämie

21. August 2026 aktualisiert von: Vertex Pharmaceuticals Incorporated

Eine Phase-1/2/3-Studie zur Bewertung der Sicherheit und Wirksamkeit einer Einzeldosis autologer CRISPR-Cas9-modifizierter CD34+-humaner hämatopoetischer Stamm- und Vorläuferzellen (CTX001) bei Patienten mit schwerer Sichelzellanämie

Dies ist eine einarmige, unverblindete Phase-1/2/3-Einzeldosisstudie an mehreren Standorten bei Patienten mit schwerer Sichelzellanämie (SCD). Die Studie wird die Sicherheit und Wirksamkeit von autologen CRISPR-Cas9-modifizierten CD34+ menschlichen hämatopoetischen Stamm- und Vorläuferzellen (hHSPCs) unter Verwendung von CTX001 bewerten.

Studienübersicht

Status

Abgeschlossen

Intervention / Behandlung

Studientyp

Interventionell

Einschreibung (Tatsächlich)

63

Phase

  • Phase 2
  • Phase 3

Kontakte und Standorte

Dieser Abschnitt enthält die Kontaktdaten derjenigen, die die Studie durchführen, und Informationen darüber, wo diese Studie durchgeführt wird.

Studienorte

      • Brussels, Belgien
        • Hopital Universitaire des Enfants Reine Fabiola (HUDERF)
      • Düsseldorf, Deutschland
        • University Hospital Duesseldorf
      • Regensburg, Deutschland
        • Regensburg University Hospital, Clinic and Polyclinic for Paediatric and Adolescent Medicine, Paediatric Haemotology, Oncology and Stem Cell Transplantation
      • Paris, Frankreich
        • Hôpital Necker Enfants malades
      • Rome, Italien
        • Dipartimento di Onco-Ematologia e Terapia Cellulare e Genica Ospedale Pediatrico Bambino Gesu - IRCCS
      • Toronto, Kanada
        • The Hospital for Sick Children
    • California
      • Palo Alto, California, Vereinigte Staaten, 94304
        • Lucile Packard Children's Hospital of Stanford University
    • Illinois
      • Chicago, Illinois, Vereinigte Staaten, 60611
        • Ann & Robert Lurie Children's Hospital of Chicago
      • Chicago, Illinois, Vereinigte Staaten, 60612
        • University of Illinois at Chicago Hospitals and Health Systems
    • New York
      • New York, New York, Vereinigte Staaten, 10032
        • Columbia University Medical Center (21+ years)
      • New York, New York, Vereinigte Staaten, 10032
        • Columbia University Medical Center (≤21 years)
    • Pennsylvania
      • Philadelphia, Pennsylvania, Vereinigte Staaten, 19104
        • Children's Hospital of Philadelphia
    • Tennessee
      • Memphis, Tennessee, Vereinigte Staaten, 38105
        • St. Jude Children's Research Hospital
      • Nashville, Tennessee, Vereinigte Staaten, 37203
        • The Children's Hospital at TriStar Centennial Medical Center/ Sarah Cannon Center for Blood Cancers
    • Texas
      • San Antonio, Texas, Vereinigte Staaten, 78229
        • Methodist Children's Hospital/Texas Transplant Institute
      • London, Vereinigtes Königreich
        • Imperial College Healthcare NHS Trust, Hammersmith Hospital
      • London, Vereinigtes Königreich
        • Royal London and St Bartholomew's Hospital, Pathology and Pharmacy Building

Teilnahmekriterien

Forscher suchen nach Personen, die einer bestimmten Beschreibung entsprechen, die als Auswahlkriterien bezeichnet werden. Einige Beispiele für diese Kriterien sind der allgemeine Gesundheitszustand einer Person oder frühere Behandlungen.

Zulassungskriterien

Studienberechtigtes Alter

12 Jahre bis 35 Jahre (Kind, Erwachsene)

Akzeptiert gesunde Freiwillige

Nein

Beschreibung

Wichtige Einschlusskriterien:

  • Diagnose einer schweren Sichelzellanämie wie definiert durch:
  • Dokumentierter Genotyp der schweren Sichelzellanämie
  • Vorgeschichte von mindestens zwei schweren vasookklusiven Krisenereignissen pro Jahr in den letzten zwei Jahren vor der Einschreibung
  • Geeignet für eine autologe Stammzelltransplantation nach Einschätzung des Ermittlers

Wichtige Ausschlusskriterien:

  • Ein verfügbarer 10/10-Human-Leukozyten-Antigen (HLA)-abgestimmter verwandter Spender
  • Vorherige hämatopoetische Stammzelltransplantation (HSCT)
  • Klinisch signifikante und aktive bakterielle, virale, pilzliche oder parasitäre Infektion

Andere im Protokoll definierte Einschluss-/Ausschlusskriterien können gelten

Studienplan

Dieser Abschnitt enthält Einzelheiten zum Studienplan, einschließlich des Studiendesigns und der Messung der Studieninhalte.

Wie ist die Studie aufgebaut?

Designdetails

  • Hauptzweck: Behandlung
  • Zuteilung: N / A
  • Interventionsmodell: Einzelgruppenzuweisung
  • Maskierung: Keine (Offenes Etikett)

Waffen und Interventionen

Teilnehmergruppe / Arm
Intervention / Behandlung
Experimental: Exa-cel
Exa-cel (autologous CD34+ hHSPCs modified with CRISPR-Cas9 at the erythroid lineage-specific enhancer of the BCL11A gene). Participants received a single infusion of exa-cel through a central venous catheter on Day 1.
Administered by IV infusion following myeloablative conditioning with busulfan.
Andere Namen:
  • Exagamglogene autotemcel
  • CTX001

Was misst die Studie?

Primäre Ergebnismessungen

Ergebnis Maßnahme
Maßnahmenbeschreibung
Zeitfenster
Percentage of Participants Who Have Not Experienced Any Severe Vaso-occlusive Crisis (VOC) for at Least 12 Consecutive Months (VF12) After Exa-cel Infusion
Zeitfenster: From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
A VOC is a condition of SCD characterized by vaso-occlusion presenting as recurrent pain episodes. The percentage of participants who remain VOC free after achieving VF12 were data reported in the outcome measure.
From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Percentage of Participants Who Achieve Neutrophil Engraftment
Zeitfenster: Up to 24 months post exa-cel infusion.
Neutrophil engraftment is defined as the first day of 3 consecutive measurements of absolute neutrophil count (ANC)≥500/μL on 3 different days, within 42 days after exa-cel infusion without the use of unmodified CD34+ cells after reaching the nadir, defined as ANC <500/µL.
Up to 24 months post exa-cel infusion.
Time to Neutrophil Engraftment for Participants Who Achieve Neutrophil Engraftment
Zeitfenster: Up to 24 months post exa-cel infusion.
Neutrophil engraftment is defined as the first day of 3 consecutive measurements of absolute neutrophil count (ANC)≥500/μL on 3 different days, without use of the unmodified CD34+ cells after reaching the nadir, defined as ANC<500/μL. Time to neutrophil engraftment was calculated by the neutrophil engraftment date subtract exa-cel infusion date +1.
Up to 24 months post exa-cel infusion.
Time to Platelet Engraftment for Participants Who Achieve Platelet Engraftment
Zeitfenster: From Exa-cel infusion up to 2 years after exa-cel infusion
Platelet engraftment is defined as the first day of 3 consecutive measurements of unsupported (no platelet transfusions for the last 7 days) platelet ≥50,000/μL on 3 different days after Exa-cel infusion. For participants discharged early day 7 after the last platelet transfusion will be the day of platelet engraftment, as long as 3 subsequent and consecutive unsupported measurements on 3 different days are >50,000/μL. For participants who have been discharged prior to platelet engraftment, it is recommended to collect blood every 2 to 3 days to obtain an accurate assessment of platelet engraftment. Time to platelet engraftment was defined as first of 3 consecutive measurements on 3 different days with platelet ≥50 × 109/L without a platelet transfusion for 7 consecutive days.
From Exa-cel infusion up to 2 years after exa-cel infusion
Safety and Tolerability as Assessed by Number of Participants With Treatment-Emergent Adverse Events (TEAEs) and Serious Adverse Events (SAEs)
Zeitfenster: From receiving exa-cel infusion up to 2 years
From receiving exa-cel infusion up to 2 years
Transplant-related Mortality (TRM) Within 100 Days After Exa-cel Infusion
Zeitfenster: Within 100 days after exa-cel infusion
The transplant-related mortality is defined as death related to Busulfan and/or exa-cel infusion. The number and proportion of TRM participants who have died within 100 days, or with at least 100 days post exa-cel infusion.
Within 100 days after exa-cel infusion
Transplant-related Mortality Within 12 Months Post Exa-cel Infusion
Zeitfenster: Within 12 months post exa-cel infusion
The transplant-related mortality is defined as death related to Busulfan and/or exa-cel infusion. The number and proportion of TRM within 12 months will be summarized for participants who have died within 12 months, or with at least 12 months post exa-cel infusion.
Within 12 months post exa-cel infusion
All-cause Mortality
Zeitfenster: From exa-cel infusion up to 2 years
All-cause mortality from exa-cel infusion up to 2 years
From exa-cel infusion up to 2 years

Sekundäre Ergebnismessungen

Ergebnis Maßnahme
Maßnahmenbeschreibung
Zeitfenster
Percentage of Participants Free From Inpatient Hospitalization for Severe VOCs Sustained for at Least 12 Months (HF12)
Zeitfenster: From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
The HF12 means Free from inpatient hospitalization for severe vaso-occlusive crises (VOCs) and sustained for at least 12 months after exa-cel infusion.
From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Relative Reduction From Baseline in Annualized Rate of Severe VOCs for Participants Who do Not Achieve VF12 up to 24 Months After Exa-cel Infusion
Zeitfenster: From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
The VF12 defines absence of any severe vaso-occlusive crises (VOCs) for at least 12 consecutive months after exa-cel infusion. Only severe VOCs adjudicated by an outcome measure adjudication committee as meeting the protocol definition of severe VOCs were included in the analysis. Relative reduction from baseline was calculated as 100 % × (Baseline value - post-baseline value) / Baseline value. Annualized rate is calculated by the Total number of events/number of years.
From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Percentage of Participants With at Least 90% Relative Reduction From Baseline in Annualized Rate of Severe VOCs for Participants Who do Not Achieve VF12 up to 24 Months After Exa-cel Infusion
Zeitfenster: From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Percentage of participants with at least 90% relative reduction from baseline was reported. The percentages were calculated relative to the number of participants who did not achieve VF12.
From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Percentage of Participants With at Least 80% Relative Reduction From Baseline in Annualized Rate of Severe VOCs for Participants Who do Not Achieve VF12 up to 24 Months After Exa-cel Infusion
Zeitfenster: From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Percentage of participants with at least 80% relative reduction from baseline was reported. The percentages were calculated relative to the number of participants who did not achieve VF12.
From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Percentage of Participants With at Least 75% Relative Reduction From Baseline in Annualized Rate of Severe VOCs for Participants Who do Not Achieve VF12 up to 24 Months After Exa-cel Infusion
Zeitfenster: From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Percentage of participants with at least 75% relative reduction from baseline was reported. The percentages were calculated relative to the number of participants who did not achieve VF12.
From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Percentage of Participants With at Least 50% Relative Reduction From Baseline in Annualized Rate of Severe VOCs for Participants Who do Not Achieve VF12 up to 24 Months After Exa-cel Infusion
Zeitfenster: From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Percentage of participants with at least 50% relative reduction from baseline was reported. The percentages were calculated relative to the number of participants who did not achieve VF12.
From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Duration of Severe VOC Free in Participant Who Have Achieved VF12
Zeitfenster: From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
The VF12 means the absence of any severe VOC for at least 12 consecutive months after exa-cel infusion. The evaluation of the severe VOC free duration in participants who achieved VF12 started 60 days after the last RBC transfusion for post transplant support or SCD management.
From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Relative Reduction From Baseline in Annualized Rate of Inpatient Hospitalizations for Severe VOCs Up to 24 Months After Exa-cel Infusion
Zeitfenster: From 60 days after last RBC transfusion up to 2 years after exa-cel infusion

The HF12 means Free from inpatient hospitalization for severe vaso-occlusive crises (VOCs) and sustained for at least 12 months after exa-cel infusion. Relative reduction from baseline is calculated as 100% × (Baseline value - post-baseline value) / Baseline value. Annualized rate is calculated by the Total number of events/number of years.

Only severe VOCs adjudicated by an outcome measure adjudication committee as meeting the protocol definition of severe VOCs are included in the analysis.

From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Relative Reduction From Baseline in Annualized Duration of Hospitalization for Severe VOCs Who Did Not Achieve HF12 Up to 24 Months After Exa-cel Infusion
Zeitfenster: From 60 days after last RBC transfusion up to 2 years after exa-cel infusion

The HF12 means Free from inpatient hospitalization for severe vaso-occlusive crises (VOCs) and sustained for at least 12 months after exa-cel infusion. Relative reduction from baseline is calculated as 100% × (Baseline value - post-baseline value) / Baseline value. Annualized rate is calculated by the Total number of events/number of years.

Only severe VOCs adjudicated by an outcome measure adjudication committee as meeting the protocol definition of severe VOCs are included in the analysis.

From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Percentage of Participants With Sustained Fetal Hemoglobin (HbF) Greater Than or Equal to (≥) 20% for at Least 3 Months
Zeitfenster: From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
The HbF evaluation started 60 days after the last RBC transfusion for post transplant support or SCD management. The last RBC transfusion refers to that in the period of the initial RBC transfusions for post transplant support or SCD management.
From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Percentage of Participants With Sustained HbF ≥ 20% for at Least 6 Months
Zeitfenster: From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
The HbF evaluation started 60 days after the last RBC transfusion for post transplant support or SCD management. The last RBC transfusion refers to that in the period of the initial RBC transfusions for post transplant support or SCD management.
From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Percentage of Participants With Sustained HbF ≥20% for at Least 12 Months
Zeitfenster: From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
The HbF evaluation started 60 days after the last RBC transfusion for post transplant support or SCD management. The last RBC transfusion refers to that in the period of the initial RBC transfusions for post transplant support or SCD management.
From 60 days after last RBC transfusion up to 2 years after exa-cel infusion
Number of Annualized Red Blood Cells (RBC) Units Transfused After Exa-cel Infusion
Zeitfenster: 2 years after exa-cel infusion
The evaluation of the number of annualized RBC units transfused after exa-cel infusion started 12 months after exa-cel infusion.
2 years after exa-cel infusion
Participants With Relative Reduction From Baseline in Number of Annualized Units of Red Blood Cells Transfused
Zeitfenster: 2 years after exa-cel infusion
Relative reduction from baseline = 100% × (Baseline value - post baseline value)/Baseline value. The evaluation of the number of annualized RBC units transfused after exa-cel infusion started 12 months after exa-cel infusion.
2 years after exa-cel infusion
Total Fetal Hemoglobin (HbF) Concentration Over Time
Zeitfenster: 2 years after exa-cel infusion
2 years after exa-cel infusion
Total Hemoglobin (Hb) Concentration Over Time
Zeitfenster: 2 years after exa-cel infusion
2 years after exa-cel infusion
Change From Baseline in Reticulocyte Count Over Time
Zeitfenster: 2 years after exa-cel infusion
2 years after exa-cel infusion
Change From Baseline in Indirect Bilirubin Over Time
Zeitfenster: 2 years after exa-cel infusion
2 years after exa-cel infusion
Percentage of Participants With Detectable Haptoglobin Over Time
Zeitfenster: 2 years after exa-cel infusion
2 years after exa-cel infusion
Percentage of Participants With Lactate Dehydrogenase (LDH) Level <300 Units Per Liter (U/L) Over Time
Zeitfenster: 2 years after exa-cel infusion
2 years after exa-cel infusion
Percentage of Alleles With Intended Genetic Modification Present in Peripheral Blood Leukocytes Over Time
Zeitfenster: 2 years after exa-cel infusion
2 years after exa-cel infusion
Percentage of Alleles With Intended Genetic Modification Present in CD34+ Cells of Bone Marrow Over Time
Zeitfenster: 2 years after exa-cel infusion
2 years after exa-cel infusion
Change in Patient-reported Outcome (PRO) Over Time Assessed Using on a 11-point Numerical Rating Scale [NRS]) for Participants ≥12 and <18 Years of Age
Zeitfenster: 2 years after exa-cel infusion
The 11-point pain numerical rating scale (NRS) is used to measures pain intensity on a 1-dimensional score ranging from 0 (no pain) to 10 (worst possible pain).
2 years after exa-cel infusion
Change in Patient-reported Outcome (PRO) Over Time Assessed Using on a 11-point Numerical Rating Scale [NRS]) for Participants ≥18 and ≤35 Years of Age
Zeitfenster: 2 years after exa-cel infusion
The 11 point pain numerical rating scale (NRS) is used to measures pain intensity on a 1 dimensional score ranging from 0 (no pain) to 10 (worst possible pain).
2 years after exa-cel infusion
Change in PRO Over Time Assessed Using EuroQol Quality of Life Scale (EQ-5D-Y)Visual Analogue Scale (VAS) for Participants ≥12 and <18 Years of Age
Zeitfenster: 2 years after exa-cel infusion
The EQ-5D VAS is a version of the EQ-5D designed for children and adolescents S). The EQ VAS records the subject's self-rated health on a 100-point VAS scale that ranged from 0 (worst imaginable health) to 100 (best imaginable health) points.
2 years after exa-cel infusion
Change in PRO Over Time Assessed Using EuroQol Quality of Life Scale (EQ-5D-5L) for Participants ≥18 and ≤35 Years of Age
Zeitfenster: 2 years after exa-cel infusion
The EQ-5D VAS is a version of the EQ-5D designed for children and adolescents S). The EQ VAS records the subject's self-rated health on a 100-point VAS scale that ranged from 0 (worst imaginable health) to 100 (best imaginable health) points.
2 years after exa-cel infusion
Change in PRO Over Time Assessed Using Functional Assessment of Cancer Therapy-bone Marrow Transplant (FACT-BMT) Score for Participants ≥18 and ≤35 Years of Age
Zeitfenster: 2 years after exa-cel infusion
The Functional Assessment of Cancer Therapy-Bone Marrow Transplant scale (FACT-BMT) is a quality of life instrument that assesses the effects of bone marrow transplantation (BMT) on a patient's physical, social/family, emotional, and functional well-being while taking into consideration BMT-specific concerns. The assessment has different questions, each scored on a Likert scale from 0-4. The overall score is computed by adding scores of the questions and falls in the range 0-148, with higher scores indicating higher levels of overall well-being.
2 years after exa-cel infusion
Change in PRO Over Time Assessed Using Adult Sickle Cell Quality of Life Measurement System (ASCQ-Me) Score on Different Domains for Participants ≥18 and ≤35 Years of Age
Zeitfenster: 2 years after exa-cel infusion
ASCQ-Me is a disease-specific HRQoL questionnaire for adults with sickle cell disease that assesses Emotional Impact, Pain Impact, Social Functioning Impact, Stiffness Impact, Sleep Impact, Pain Episode Frequency, and Pain Episode Severity. Domain scores are reported as T-scores standardized to a reference population where mean = 50, and SD = 10. A change of approximately 5 points (1/2 SD) is considered clinically meaningful. An increase of 5 points indicates improvement for the impact domains, whereas a decrease of 5 points indicates improvement for the Pain Episode Frequency and Pain Episode Severity domains. For impact domain items higher score indicates better HRQoL and lower disease burden. For Pain items lower score indicates a better outcome. Scores are interpreted relative to the reference population mean of 50, taking into account the direction of scoring for each domain.
2 years after exa-cel infusion
Change in PRO Over Time Assessed Using Pediatric Quality of Life Inventory (PedsQL) for Participants Greater Than or Equal to (≥) 12 and Less Than (<) 18 Years of Age
Zeitfenster: 2 years after Exa-cel infusion
PedsQL scores were used to assess quality of life of participants. It is a standardized, generic instrument for measuring health related quality of life (HRQoL) in children and adolescents. It includes different domains (Psychosocial health, physical functioning, emotional functioning, social functioning, and school functioning). When completing the PedsQL questionnaires, respondents were asked to provide a response on a 5-point scale ranging from 0 (never a problem) to 4 (almost always a problem). Responses were then transformed to a 0 to 100 score, with higher scores reflecting better quality of life.
2 years after Exa-cel infusion
Change in PRO Over Time Assessed Using Pediatric Quality of Life Inventory (PedsQL) Sickle Cell Disease Module (SCD) for Participants Greater Than or Equal to (≥) 12 and Less Than (<) 18 Years of Age
Zeitfenster: 2 years after exa-cel infusion
The PedsQL Sickle Cell Disease Module (PedsQL SCD) is a disease-specific module of the PedsQL. The tool measures self-reported health-related quality of life in participants with SCD across 9 domains: pain and hurt, pain impact, pain management (mgmt), worry I, worry II, emotions, treatment, communication I, and communication II. When completing the PedsQL SCD Module questionnaires, respondents were asked to provide a response on a 5-point scale ranging from 0 (never a problem) to 4 (almost always a problem). Responses were then transformed to a 0 to 100 score, with higher scores reflecting better quality of life.
2 years after exa-cel infusion

Mitarbeiter und Ermittler

Hier finden Sie Personen und Organisationen, die an dieser Studie beteiligt sind.

Publikationen und hilfreiche Links

Die Bereitstellung dieser Publikationen erfolgt freiwillig durch die für die Eingabe von Informationen über die Studie verantwortliche Person. Diese können sich auf alles beziehen, was mit dem Studium zu tun hat.

Allgemeine Veröffentlichungen

Studienaufzeichnungsdaten

Diese Daten verfolgen den Fortschritt der Übermittlung von Studienaufzeichnungen und zusammenfassenden Ergebnissen an ClinicalTrials.gov. Studienaufzeichnungen und gemeldete Ergebnisse werden von der National Library of Medicine (NLM) überprüft, um sicherzustellen, dass sie bestimmten Qualitätskontrollstandards entsprechen, bevor sie auf der öffentlichen Website veröffentlicht werden.

Haupttermine studieren

Studienbeginn (Tatsächlich)

27. November 2018

Primärer Abschluss (Tatsächlich)

7. Juli 2025

Studienabschluss (Tatsächlich)

7. Juli 2025

Studienanmeldedaten

Zuerst eingereicht

9. November 2018

Zuerst eingereicht, das die QC-Kriterien erfüllt hat

15. November 2018

Zuerst gepostet (Tatsächlich)

19. November 2018

Studienaufzeichnungsaktualisierungen

Letztes Update gepostet (Tatsächlich)

16. September 2026

Letztes eingereichtes Update, das die QC-Kriterien erfüllt

21. August 2026

Zuletzt verifiziert

1. August 2026

Mehr Informationen

Begriffe im Zusammenhang mit dieser Studie

Plan für individuelle Teilnehmerdaten (IPD)

Planen Sie, individuelle Teilnehmerdaten (IPD) zu teilen?

NEIN

Arzneimittel- und Geräteinformationen, Studienunterlagen

Studiert ein von der US-amerikanischen FDA reguliertes Arzneimittelprodukt

Ja

Studiert ein von der US-amerikanischen FDA reguliertes Geräteprodukt

Nein

Produkt, das in den USA hergestellt und aus den USA exportiert wird

Ja

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