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Shillong: Cement company Lafarge has come under pressure to wind up operations in Meghalaya, with over a dozen NGOs alleging that its operations are 'illegal and destructive´.
Vowing to struggle against the foray of the company, the NGOs have asked Chief Minister Donkupar Roy to stop all operations of Lafarge.
"Lafarge operations are illegal and destructive and can have long term implications for the people of Meghalaya and the region in having control over their land and using the natural resources sustainably," a statement issued by the NGOs today said.
Over 10 NGOs, including student organisations and environmental bodies, held a meeting here yesterday and formed a Joint Action Committee against alienation of tribal lands.
"Lafarge has resulted in massive violation of customary, state, national and international policies of development banks and given rise to conflict related to land rights," the statement said.
Alleging that the cement company has negotiated low royalties for limestone mining and that too with false land owners, the NGOs, led by social activist Rev PB Basiawmoit, said the activities of the company has also had a serious impact on the environment.
Charging the company with recruiting labourers from outside at low wages, the NGOs urged the Chief Minister to stop single window clearances and illegal permissions for sale of indigenous land.
They also threatened to launch a vigorous agitation if their demands were not fulfilled.


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England call-up three players ahead of ABs test
England have called up Tom Biggs (Bath), Freddie Burns (Gloucester) and Nick Wood (Gloucester) to their training squad ahead of Saturday's test against New Zealand at Twickenham (3.30am NZ time Sunday).
Biggs replaces Ugo Monye, who remains at Harlequins for treatment on a calf injury; Burns comes in for Toby Flood (toe); and Nick Wood is temporary cover for Alex Cobisiero (knee) as Saxons props Matt Mullan and Nathan Catt are injured along with Joe Marler.
Thirty-four players in total reported to the team base of Pennyhill Park to start preparations for a game England needs to win to avoid a 'Sanzar sweep' of three straight defeats in the autumn internationals.
"Tom is next in line from the Saxons and we are looking forward to getting a look at him," said England coach Stuart Lancaster.
"Freddie has been in for two of the last three weeks so we know what he can bring and Nick Wood will provide cover as we manage Alex's knee at the start of the week.
"Toby Flood's toe has been re-examined and there is no bone broken but we will need to see how it settles down over the next 24 hours."
England squad: Forwards: Mouritz Botha (Saracens), Dan Cole (Leicester Tigers), Alex Corbisiero (London Irish), James Haskell (London Wasps), Phil Dowson (Northampton Saints), Dylan Hartley (Northampton Saints), Tom Johnson (Exeter Chiefs), Courtney Lawes (Northampton Saints), Ben Morgan (Gloucester Rugby), Tom Palmer (London Wasps), Geoff Parling (Leicester Tigers), David Paice (London Irish), Chris Robshaw (Harlequins, capt), George Robson (Harlequins), Mako Vunipola (Saracens), Thomas Waldrom (Leicester Tigers), David Wilson (Bath Rugby), Nick Wood (Gloucester Rugby), Tom Wood (Northampton Saints), Tom Youngs (Leicester Tigers). Backs: Chris Ashton (Saracens), Brad Barritt (Saracens), Tom Biggs (Bath Rugby), Mike Brown (Harlequins), Freddie Burns (Gloucester Rugby), Danny Care (Harlequins), Lee Dickson (Northampton Saints), Owen Farrell (Saracens), Toby Flood (Leicester Tigers), Alex Goode (Saracens), Jonathan Joseph (London Irish), Charlie Sharples (Gloucester Rugby), Manusamoa Tuilagi (Leicester Tigers), Ben Youngs (Leicester Tigers).
Fairfax Media

subset: commoncrawl


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Winnie Harlow – Toronto, Ontario
Winnie is a supermodel, spokesperson, and activist. She has a skin condition called vitiligo, which makes her beauty incredibly unique. You can spot her in Beyoncé's Lemonade video.
Zoe Colivas – Toronto, Ontario
Zoe has walked for all the big designers, and it's easy to see why – brow game strong. Very strong.
Daria Werbowy – Toronto, Ontario
Daria won a modelling competition when she was just 14 years old, and her career skyrocketed. With campaigns for brands like Hermes and YSL, she was named one of Forbes' highest earning models.
Jessica Stam - Kincardine, Ontario
Jess is famous for her "doll face". After being discovered at a coffee shop as a teen, her career totally took off!
Irina Lazareanu - Montreal, Quebec
Irina's rock n' roll look have made her stand out from the pack. Born in Romania and raised in Montreal, she studied ballet before becoming a model. Oh, and she's Karl Lagerfeld's muse... nbd.
Linda Evangelista - St. Catharines, Ontario
Linda is one of the original glamazons of the 80's! She's had a super glam fashion career, and is known by every designer and photographer for being able to pull off any look.
Yasmin Warsame - Toronto, Ontario
Raised in Somalia, Yasmin moved to Toronto at 15 years old. She found her place in the modelling industry in the late 90's, and since has worked for everyone - from luxury designers to GAP. So stunning!
Coca Rocha - Toronto, Ontario
Coco has been the face of Chanel, Dior, Versace.. everything! She's become a household name, and she's a Canadian sweetheart.
Stacey McKenzie - Toronto, Ontario
Jamaican-born and Canadian-raised, Stacey is the queen of "unconventional beauty". At just 6 years old, trying on her mom's heels, she dreamed of becoming a top model. Now, she's not only a role model but a modelling coach, too!
Heather Marks - Calgary, Alberta
Heather grew up a total tomboy - playing soccer and snowboarding. She never dreamed that at 15 years old, she'd book Vogue Italia. Not bad for a first photo shoot.
Xo, Ardene
Xo, Ardene


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ASU Beebe selectivity
Think about what career is best suited for you, and where you want to study. Request more information now.
Think about what career is best suited for you, and where you want to study. Request more information now.
Think about what career is best suited for you, and where you want to study. Request more information now.
Get the facts about ASU Beebe selectivity, and registering for elective discussion sections and seminars. Which college degrees give you the best chances of finding employment after graduation? Concentrating on ASU Beebe selectivity, for example, may give you an advantage in corporate recruiting being conducted on-campus. Check with the admissions office for course registration deadlines, and college degree program requirements. Please use the form above to request admissions info for ASU Beebe.
The US News & World Report rankings are based on data which US News collects, either from an annual survey, or from the school's website. Critics charge that US News & World Report changes its grading methodology every other year so that their college rankings will change of necessity. Forbes Magazine also publishes college rankings & school listings. Although best known for their Forbes 400 list, the Forbes college rankings have been getting a lot of attention.
If you are interested in military service, the Reserve Officers Training Corps (ROTC) program will pay for your college tuition as well as provide a small stipend, as long as you're attending school full-time. There is no fixed military commitment for the first year, allowing you to enroll in ROTC on a trial basis. If you then choose to commit to a military career, ROTC scholarships pay for almost all tuition and fees, and textbook costs, for up to four years of college. Beyond major requirements within the admissions department, you may consider McCallie School specifications for complementary electives to your primary course of study.
Retention Specialist (Grant Funded)
San Mateo County Community College District
San Mateo County Community College District values the principles of diversity and equity. Exchanges information with students, faculty, and staff.
6 days ago Academic Program Manager
Towson University
Prior experience in college or university Admissions and/or Academic Program Advising preferred. Participate in high school college fairs.
6 days ago Secretarial Assistant 1
Ramapo College of New Jersey
The College also offers eight graduate programs as well as articulated programs with Rutgers, The State University of New Jersey, New York Chiropractic College.
3 days ago Senior Office Assistant - Admissions & Registrar
Tarrant County College
Experience in fast-paced, high volume college admissions office. Associate's degree or 60 college hours. Supports the values of the College.
4 days ago Outreach Specialist
Tarleton State University
Admissions Counselor II. Coordinates independent visits with community college students and community college personnel.
2 hours ago


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The home of the Swaledale & Arkengarthdale Local History Group
Breaking news
Our next meeting will be Thursday 12th October 2017, 4.15pm, Buck Hotel, Reeth. Notes of the June meeting may be downloaded here
The 1927 'Dictionary of Occupational Terms' is online at http://doot.spub.co.uk – with an index and a Google custom search. Which industry employed 'back end girls' ?!
Hugh Toller's paper on the Roman Rd from Bainbridge to Barnard Castle across Swaledale is here ; a tribute to a man who made a great contribution to our understanding of Roman roads, amongst other things, but died recently.
Healaugh & Muker Manor Books A-E covering 1686-1753 transcribed by Tim Bagenal now online at http://www.swaag.org
'Tales from the Reeth Workhouse' is downloadable from the blog.
The Swaledale Big Dig final report is available to download here ; it is around 23Mb. The Big Dig was supported by the Heritage Lottery Fund.


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What We Do
Continuing Education Centre - Bo
Continuing Education Centre - Bonthe
Continuing Education Centre - Makeni
Continuing Education Centre - Pujehun
Continuing Education Centre - Mile 91
Ceramic Centre - Waterloo
Our classes take place within the communities mentioned above. Learning takes place three hours a day leaving the rest of the day for the participants to engage in other economical activities.
The Sierra Leone Adult Education Association (SLADEA) was established in September 1978. It is a non-governmental organisation (NGO) and currently has 13 branches spread across the country's four administrative regions.
With our educational programmes we impart:
Our non-formal education programmes offer flexible access to basic education for disadvantaged children, youth and adults unable to participate in formal schooling either due to poverty or cultural and other social barriers.
With our non-formal education programmes we create educational opportunities for our less fortunate compatriots that provide them with a second chance. We provide out-of-school children and youth with access to a structured learning environment, reinforce their self-esteem and help them find ways to become self-reliant.
In many cases our programmes serve adults as a bridge to improve their academic skills to the point where they can re-enter formal schools.
Our adult education activities aim to increase our adult learners' general and academic insight and skills and improve their ability and desire to take responsibility for their own lives and to take an active part in society. Our programmes include broad skills development, which has tremendous impact on social development.
We see non-formal education as an integral part of a lifelong learning concept that ensures that adults acquire and maintain the skills, abilities and dispositions needed to adapt to a continuously changing environment and society.
We also cooperate with organisations and agencies active in the area adult education, providing training and monitoring their classes. There is an increasing need in Sierra Leone for tailor-made functional literacy classes.
To ensure that learners are provided with the highest possible standard of adult education services, we regularly monitor and supervise our teaching staff.
Sierra Leone's education system is divided into four stages; six years of primary education, three years of junior secondary education , four years of either senior secondary education or technical vocational education and four years of university or other tertiary education.
"A significant percentage of 6 to 16-year-olds is not attending school and there is a high rate of school drop-outs. With a population growth rate of approximately 2.6 % a year, the literacy rate cannot improve significantly without a massive and urgent intervention by the government" (New Education Policy).


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Product 23/58
Impressive Tree of Life Necklace Pendant with a beautiful blue Turquoise background with an ornate Sterling Silver Tree to the foreground - a really stunning tree of life jewelry piece that makes a striking Tree of Life necklace with the complimentary silver chain provided.
Pendant Size: 30mm (1 1/4") height and 23mm width (7/8") (38mm height inc bail)
● Material: 925 Sterling Silver Pendant and Tree, background is reconstituted Turquoise
*reconstituted Turquoise means genuine gemstone crushed into a powder and mixed with resin to make it easier to make certain shapes.
This necklace pendant is also available in a smaller 20mm size
- with your Tree of Life Pendant purchase you will receive a FREE Silver Chain 45cm (18") so that you can wear this pendant as a Tree of Life Necklace straight out of the box. (this free chain is silver plated) - the woven silk necklace cord (if shown in images) is not included however can be purchased separately along with a range of Sterling Silver Chains and Necklace Cords here in our Silver Chains and Necklace Cords section.
about Images if Gemstones are included in the pendant: the type of light, intensity and angle of light at a given time can produce slight variations in color particularly of natural gemstones - images were taken indoors using natural light.
Matching Tree of Life Earrings and Rings: some of our pendant designs have matching earrings and/or rings - take a look in the relevant sections of our menu, Tree of Life Earrings and Tree of Life Rings.
Our Quality: all of our Tree of Life Pendants are of the highest quality available which is consistent with our aim to offer the very best value for money for all of our Tree of Life Jewelry range.
The Tree of Life as a symbol has been adorned in one form or another for thousands of years with the Tree of Life Necklace having endured as the most common form of jewelry worn throughout the ages
The Tree of Life has been symbolized in many forms across many cultures and religions for centuries and is probably one of the most universal icons for this reason. It is seen in ancient drawings and texts in many religions including Christian, Jewish, Buddhist and the Celts with the commonly referred to Celtic Tree of Life. Digs of Ancient sites has found examples of Tree of Life pendants on necklace cords and other jewelry in bronze and stone.
Aside from religious meaning the Tree of Life symbol has meaning for many in the way of family bonds and a sense of one with nature, you can read more here about the Tree of Life Meaning. The wearing of a Tree of Life necklace today is more commonly for expressing belief in the strength of family, depicted as the roots being family roots or heritage, the trunk being the strength and support for the branches which are the members of the family.
You can also find excellent information about the Tree of Life in all its applications here on this blog Tree of Life Meaning
Cleaning your Tree of Life jewelry: take a look at our Jewelry Cleaning Products section and consider adding a quality Polishing Cloth to your purchase to keep your Tree of Life jewelry clean and brilliantly shiny.
follow these links for more tree of life jewellery including .... Tree of Life Necklaces ... Chiming Tree of Life Necklaces ... Tree of Life Jewellery ... Unique Tree of Life Necklace designs - you may even wish to compliment your necklace with a Tree of Life Bracelet.
This product was added to our catalog on Friday 20 September, 2013.


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Child protection laws passed
New laws to protect children from family violence have been passed unanimously by Parliament.
Justice Minister Simon Power said that in the 2009/10 year there were 3867 domestic violence cases in the Family Court, which each involved at least one child.
''Children are our most vulnerable members of society and deserve special protection,'' he said after the Child and Family Protection Bill had passed its third reading.
''The bill focuses on keeping children safe where there have been instances of family violence in the home, and improves the responsiveness of the Family Court to those victims.''
The legislation makes it clear that protecting children from all forms of violence - a principle of the Care of Children Act 2004 - includes protection from psychological abuse and direct and indirect abuse.
It will avoid any opportunity for a lapse between a temporary order and a final protection order coming into effect which could have resulted in a victim having no protection, and makes it easier to obtain protection for children at risk of unlawful removal from New Zealand.
The bill also creates a new offence in the Adoption Act 1955 for improper inducement of consent to an adoption, punishable by up to seven years' imprisonment.
Mr Power said he was working on other measures to improve the justice system for those who found themselves in it through no fault of their own.
Those measures included making offending against a child a specific aggravating factor at sentencing and rolling out 13 new services and entitlements for victims of crime, he said.


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This eLearning activity is broken down into two different sections focusing on how to build a medical educator portfolio. Throughout these two sections faculty share practical tips and offer hands-on activities to guide interested faculty through the process of creating, using, and refining an educator portfolio. Several templates are provided to assist with the process.
Learning Objectives:
- Describe what is an educator portfolio
- List and apply the components of an educator portfolio
- Describe scholarship and criteria for scholarship
- Identify and develop effective documentation of teaching effectiveness, excellence, and scholarship
- Apply strategies and resources to effectively assemble and maintain an Educator Portfolio
- Write an effective personal statement/self-description
Continuing Education Credit
2 Credit/Points are available for participation in this course. Certificated and credit types available include:
- AMA PRA Category 1 Credits™
- Certificate of Participation may be used to confer credit; however, all final decisions regarding the awarding of credits will be made by the licensing organization to which the credits are submitted.
- Certificate of Completion may be used to document participation, but no credit will be conferred.
Important Notes
- This course expires on December 11, 2019. Participants must complete all necessary course components by this date to receive credit.


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We were looking for something close to home for a Staycation and found this property in Sebring, FL. We stayed in a studio rental on the second floor. No elevator for those who may need one. Somewhat dated, it was clean, well stocked, and a...More
Getting you more information on this room
Getting you more information on this room
"We enjoyed the ground level with it's easy access, but the second floor units would also be a good choice."
"First floor Unit 21...has nice view of golf course from lanai and window facing the lake. Great location!"
"All rooms face the lake; there is no elevator for 2nd floor access"


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|30 Dec 2014
Windows 7 Home Premium x64
Flashing Afterglow headset, no clue why? Does anyone know?
If a moderator could make sure this goes to the right topic section, that'd be great, as I don't know if this applies here.
I own a Afterglow wired headset that works for consoles and PC. When the USB is plugged in, it's supposed to just stay glowing blue. However, it started doing something randomly while plugged into my PC that I've never seen before. The sounds till came through perfectly fine as well. I have a link to a youtube video to show what I mean.
|My System Specs
|30 Dec 2014
win 7 64 bit
make sure setup correctly Afterglow Wired Headset - PC Setup - YouTube
|My System Specs
|Thread Tools
|Similar help and support threads
Will a Headset microphone still work if I cut it off the Headset?
I have a almost broken headset, but the microphone still works fine, The microphone is connected on the wire right before the headset, Its not actually touching the headset itself. Would this microphone still work if the headset was cut off? Sorry but I can't manage to take a photo but
|Hardware & Devices
No Clue.
Hello! I got this Bsod prob. I have no clue what to do. :/ I Got the .rar file you asked for. Im not generaly stupid. THX ^^
|BSOD Help and Support
have not got a clue
constant bsods and no clue as to what to do. here is the Who Crashed report, System Information (local) computer name: PCBOOS-PC windows version: Windows 7 Service Pack 1, 6.1, build: 7601 windows dir: C:\Windows CPU: AuthenticAMD AMD Athlon(tm) 64 X2 Dual Core Processor 5200+ AMD586, level:...
|BSOD Help and Support
I have no clue what to do, HELP.
I have the zip file, I hope that helps. I really need this fixed guys, all help is appreciated. My basics are: Acer Aspire 5551 AMD Turion II p520 Dual Core Proc, 2.30GHz RAM 4g 64 bit operation. Windows 7 home premium
|BSOD Help and Support
Anyone have a clue as to what's going on?
Ok, more weirdness. So far I installed my graphics driver, miro, vlc, flash & java. I made a windows restore point after each program. I then restarted my computer and it would boot, went back to loading and got the message that some hardware change had effected windows from starting and gave me...
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Blazin Roxx Quilted Paisley Wallet
Blazin Roxx
- Blazin Roxx Quilted Paisley Wallet
- Item # 2581D9
$17.97 Final Price
49% Total Savings
Additional Information
Features & Description
- A bold wallet by Blazin Roxx!
- Faux leather construction
- Floral paisley design in bright colors with a quilted look accents front
- Faux black tooled leather trim
- Clear sparkling rhinestones accent edges
- Detachable & adjustable chin cord
- Detachable wristlet for easy carrying
Update your handbag essentials with a new Blazin Roxx wallet. This faux leather wallet features an ample amount of storage for credit cards, cash and coins. Stylish wallet measures approximately 8" x 4" x 2". Imported.


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March Madness!
Hang on for a minute...we're trying to find some more stories you might like.
Email This Story
Losing a lot of money or winning big, a time of basketball miracles and where legends are born.
It's March Madness and it begins on March 14, 2017 and ends on April 3, 2017.
Everyone thinks that their brackets are all perfect and nothing can go wrong with it, until the team that you thought would win it all loses in the first round.
It starts with 68 teams, and at the end there can only be one winner. There are no second chances, and if the team loses one game, they're out for the season.
Some of the most heartbreaking moments are when your team loses by a buzzer beater and you betted half of your money.
Many bandwagon fans just choose the teams with the players ranked high in the next year's NBA draft, or the highest seeds, and they are often wrong.
The weeks before, many arguments start about who is going to win and who is going to make it farther than they were expected to reach.
When asked who was going to win, Mohamed Hassan said, "UCLA is going to win because Lonzo Ball is one of the best point guards in college basketball."


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2 Day 14 pass limited load Florida Middle Grounds 10/13/2017
This trip is a limited passenger trip that departs at 8 pm and returns two days later between 4 and 8 pm. The price includes all meals and beverages, live and dead bait, tackle, ice and cleaning your catch. The ride Book Now →


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Dim the lights and start carving those Jack-o'-lanterns, HBO Now is featuring a creepy collection of horror films this October. Of course, there's plenty of non-genre fare for the easily scared, including Brad Pitt and Angelina Jolie's last movie as a married couple.
Both the original and extended edition remake of Poltergeist will be available on the streaming service, alongside the gritty zombie flick 28 Days Later, I Am Legend, Jeepers Creepers, An American Haunting and John Carpenter's Ghost of Mars.
More recent theatrical releases, including the fourth wall-breaking Deadpool, Joy, and Gods of Egypt join the mix to satisfy the comic book and fantasy crowds.
Jolie's By the Sea premieres at the end of the month.
Projects levaing HBO Now include several comedies, such as Soapdish, 27 Dresses, Dumb and Dumber To and Pitch Perfect 2.
The highly anticipated premiere of Westworld, HBO's new original series, will also lead the pack at the beginning of the month. See the full list of new and leaving programs below.
New Original Programming:
Westworld, Series Premiere (Oct. 2)
Class Divide (Oct. 3)
Divorce, Series Premiere (Oct. 9)
Insecure, Series Premiere (Oct. 9)
VICE News Tonight (Oct. 10)
Magnifica '70, Season 2 Premiere (Oct. 17)
Tracey Ullman's Show, Series Premiere (Oct. 28)
Sesame Street — Halloween Episode (Oct. 29)
Season Finales
High Maintenance, Season 1 (Oct. 21)
Theatrical Premieres:
Cop Car, 2015 (Oct. 1)
Deadpool, 2016 (Oct. 1)
Ride Along 2, 2016 (Oct. 8)
By the Sea, 2015 (Oct. 13)
Joy, 2015 (Oct. 15)
Mr. Right, 2015 (Oct. 18)
Gods of Egypt, 2016 (Oct. 22)
Poltergeist (Extended Edition), 2015 (Oct. 29)
Living Legend, 2015
Por amor en el caserio (AKA For Love in El Caserio), 2014
Embarazados (AKA We are Pregnant), 2016
Starting October 1:
28 Days Later, 2002
An American Haunting (Extended Cut), 2005
Balls of Fury, 2007
Bride Wars, 2009
Cast Away, 2000
Cocktail, 1988
The Cowboy Way, 1994
Crocodile Dundee in Los Angeles, 2001
Demolition Man, 1993
Drumline, 2002
Eastern Promises, 2007
I Am Legend (Extended Cut), 2007
Jeepers Creepers, 2001
The Jewel of the Nile, 1985
John Carpenter's Ghost of Mars, 2001
A Kid in King Arthur's Court, 1995
The Kingdom, 2007
The Place Beyond the Pines, 2012
Poltergeist, 1982
Repo Man, 1984
Romancing the Stone, 1984
Spider-Man, 2002
Spider-Man 2, 2004
We Were Soldiers, 2002
The Wedding Singer, 1998
Ending October 30:
Lucy, 2014
Ending October 31:
27 Dresses, 2008
28 Weeks Later, 2007
The Best Little Whorehouse in Texas, 1982
Cheech & Chong's Next Movie, 1980
Dressed to Kill, 1980
Dumb and Dumber To, 2014
Fantastic Four: Rise of the Silver Surfer, 2007
Friday Night Lights, 2004
Happy Feet, 2006
Inherent Vice, 2014
Juno, 2007
Me and Earl and the Dying Girl, 2015
Mean Streets, 1973
Pitch Perfect 2, 2015
Soapdish, 1991
Spy, 2015
Sudden Death, 1995
The Theory of Everything, 2015
Vacation, 2015
We Are Your Friends, 2015
Wild Wild West, 1999
Windtalkers, 2002


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Truck Accident Lawyers and Law Firms in Bethany, OK
Truck Accident Lawyers
Cunningham & Mears
Oklahoma City, Oklahoma Personal Injury Attorneys(405) 232-1212 or (888) 799-1212
Cunningham and Mears in Oklahoma City handles personal injury cases. The firm believes that clients should return to how they were before the accident as much as possible. The staff helps clients find medical providers and work with the clients on how to proceed with the case.
Law Firm's Overview VideosFree ConsultationContingency Fee
Mazaheri Law Firm, PLLC
Oklahoma City Full-Service Law Firm(405) 414-2222
Mazaheri Law Firm, PLLC is a multiethnic, bilingual law firm located in Oklahoma City, Oklahoma and providing a variety of legal services. Practice areas encompass family law such as divorce and child-related issues; employment law including discrimination, wage claims, whistleblower...
Law Firm's Overview VideosContingency FeeCredit Cards
Amanda R. Everett, P.C.
Oklahoma Criminal Defense, Family & Personal Injury Attorneys(405) 698-3307
Amanda R. Everett, P.C. is located in Norman, Oklahoma. It is our firm belief that everyone deserves representation, regardless of resources. Amanda R. Everett, P.C. is committed to providing high quality legal services for those facing criminal charges, family issues or have been...
Law Firm's Overview Free ConsultationContingency Fee
Ryan Bisher Ryan & Simons
Oklahoma City Personal Injury Attorneys(405) 528-4567 or (800) 725-2222
Ryan Bisher Ryan & Simons in Oklahoma, OK, specializes in personal injury cases. For more than 30 years, the firm has helped people with claims for Social Security disability, automobile and trucking accidents, wrongful deaths, insurance bad faith, medical malpractice, and on-the-job...
Law Firm's Overview VideosFree ConsultationContingency Fee
Denker & Butler, PLLC
Wills, Probate, Divorce and Family Lawyers in Oklahoma City(405) 563-7151
Denker & Butler, P.L.L.C., is more than just a law firm. After years of experience, we don't just practice one area of law. We cover multiple areas across the entire state of Oklahoma. We strive to prove that we are the experienced, efficient and knowledgeable legal representation...
Law Firm's Overview Free Consultation
Stephens, Anderson & Cummings, LLP
Personal Injury Lawyers in Oklahoma City, OK(405) 946-0900 or (877) 920-9009
Stephens, Anderson & Cummings, LLP, based in Fort Worth, Texas, provides a broad range of legal services to clients throughout the region. Our practice focuses on personal injury, including auto and truck accidents, motorcycle and bicycle accidents, pedestrian injuries, boating accidents,...
Law Firm's Overview VideosFree ConsultationContingency Fee
Hasbrook & Hasbrook
Oklahoma City, OK Personal Injury, Employment and Insurance Law Firm(405) 235-1551
Hasbrook & Hasbrook is a personal injury firm located in Oklahoma City, Oklahoma and serving clients throughout the state. Our practice areas encompass car and 18-wheeler accidents, motorcycle and bicycle accidents, nursing home abuse and neglect, dog bites, workplace accidents,...
Law Firm's Overview Free Consultation
Abel Law Firm
Oklahoma Personal Injury Lawyers(405) 239-7046 or (800) 739-2235
Abel Law Firm is a personal injury firm located in Oklahoma City and serves clients throughout Broken Arrow, Enid, Moore, Norman, and Tulsa. Our practice areas encompass vehicle accidents, medical negligence, construction accidents, nursing home neglect, product and premises liability,...
Law Firm's Overview Free Consultation
Law Offices of Dan Davis
Oklahoma City Personal Injury Attorney(405) 531-9983
The Law Offices of Dan Davis represents injury victims in Oklahoma. Backed by nearly 30 years of experience, the firm handles cases involving auto accidents, trucking accidents, motorcycle accidents, wrongful death, Social Security Disability, medical malpractice, and more.
Law Firm's Overview Free Consultation
Atkins & Markoff
Oklahoma Personal Injury, Criminal, and Family Law Firm(405) 607-8757
Atkins & Markoff is a top-tier legal practice that has been providing Oklahomans with unsurpassed representation and client-focused service since 1997. Highly accomplished and genuinely compassionate, our Oklahoma lawyers are equipped with more than 100 combined years of experience....
Law Firm's Overview
Brown & Gould, PLLC
Oklahoma City Civil Litigation Attorneys(405) 235-4500 or (877) 886-3377
Brown and Gould PLLC in Oklahoma City, OK, focuses on business law, corporate law, employment law and medical malpractice. Regardless of the issue, the firm provides high-quality legal advice to clients. The firm fights for clients' rights and protect their future throughout the...
Law Firm's Overview
Burch, George & Germany, PC
Oklahoma City Personal Injury Lawyers(405) 239-7711
Burch, George & Germany, PC has given over 15 years of dedicated legal expertise and expert knowledge to Oklahoma residents suffering from the aftermath of an auto accident. The firm's committed team of four tireless attorneys has devoted the majority of its practice to the research,...
Law Firm's Overview VideosFree ConsultationContingency FeeCredit Cards
Cain Law Office
Truck Accident and Personal Injury Law Firm in Oklahoma City, Oklahoma(405) 519-6263
Monty L. Cain, P.C. provides superior legal representation to individuals and families throughout the Oklahoma City area in a comprehensive array of personal injury matters. We have assisted the victims of automobile accidents, trucking accidents, wrongful death, nursing home negligence,...
Law Firm's Overview Free Consultation
Clark & Mitchell, PC
Medical Malpractice Attorneys in Oklahoma City(405) 235-8488 or (888) 725-9056
Clark and Mitchell Law is based in Oklahoma City, Oklahoma and specializes in auto accidents, insurance bad faith and medical malpractice. If you have been the victim of injustice in Oklahoma City and the surrounding areas, Clark and Mitchell Law are here to help you recover compensation...
Law Firm's Overview Free ConsultationContingency Fee
Dawkins, Litton & Gowens PLLC
Oklahoma City Personal Injury Lawyers(405) 254-8461 or (866) 439-5849
At Dawkins, Litton & Gowens PLLC, we offer client-centered service in the areas of personal injury and workers' compensation. Our commitment is to helping working people and their families obtain the financial recovery they need to move forward. From our offices in Oklahoma, we serve...
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Hornbeek Vitali & Braun, PLLC
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Shelton Walkley Mackey
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Beeler, Walsh & Walsh, PLLCOklahoma City, OK - Law Firm near Bethany
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text:
Pharmaceutical compositions of 4-hydroxy tamoxifen, particularly
compositions suitable for percutaneous administration, are useful
in methods for treating and preventing breast cancer. When percutaneously
administered to a patient's breasts, 4-hydroxy tamoxifen concentrates
locally, and exerts an anti-estrogenic effect. In patients with
breast cancer, this effect reduces tumor tissue proliferation. In
patients at risk for developing breast cancer, the anti-estrogenic
effect prevents breast tumor formation.
What is claimed is:
1. A method of treatment, comprising administering 4-hydroxy tamoxifen
to a patient having breast cancer.
2. A method according to claim 1, wherein said 4-hydroxy tamoxifen
is administered percutaneously.
3. A method according to claim 2, wherein said 4-hydroxy tamoxifen
is in a vehicle containing a penetration enhancer.
4. A method according to claim 2, wherein about 0.25 to 2.0 mg/breast
of said 4-hydroxy tamoxifen is administered to said patient per
5. A method according to claim 2, wherein about 0.5 to 1.0 mg/breast
of said 4-hydroxy tamoxifen is administered to said patient per
6. A method according to claim 2, wherein about 0.25 mg/breast
of said 4-hydroxy tamoxifen is administered to said patient per
7. A method according to claim 2, wherein about 0.5 mg/breast of
said 4-hydroxy tamoxifen is administered to said patient per day.
8. A method according to claim 2, wherein about 0.75 mg/breast
of said 4-hydroxy tamoxifen is administered to said patient per
9. A method according to claim 2, wherein about 1.0 mg/breast of
said 4-hydroxy tamoxifen is administered to said patient per day.
10. A method according to claim 2, wherein said 4-hydroxy tamoxifen
is formulated in a hydroalcoholic gel.
11. A method according to claim 10, wherein said hydroalcoholic
gel comprises ethyl alcohol, isopropyl myristate, and hydroxypropylcellulose.
12. A method according to claim 2, wherein said 4-hydroxy tamoxifen
is formulated in an alcoholic solution.
13. A method according to claim 1, wherein said breast cancer is
estrogen receptor-positive.
14. A method of preventing breast cancer, comprising administering
4-hydroxy tamoxifen to a patient at risk for developing breast cancer.
15. A method according to claim 14, wherein said 4-hydroxy tamoxifen
is administered percutaneously.
16. A method according to claim 15, wherein said 4-hydroxy tamoxifen
is in a vehicle containing a penetration enhancer.
17. A method according to claim 15, wherein about 0.25 to 2.0 mg/breast
of said 4-hydroxy tamoxifen is administered to said patient per
18. A method according to claim 15, wherein about 0.5 to 1.0 mg/breast
of said 4-hydroxy tamoxifen is administered to said patient per
19. A method according to claim 15, wherein about 0.25 mg/breast
of said 4-hydroxy tamoxifen is administered to said patient per
20. A method according to claim 15, wherein about 0.5 mg/breast
of said 4-hydroxy tamoxifen is administered to said patient per
21. A method according to claim 15, wherein about 0.75 mg/breast
of said 4-hydroxy tamoxifen is administered to said patient per
22. A method according to claim 15, wherein about 1.0 mg/breast
of said 4-hydroxy tamoxifen is administered to said patient per
23. A method according to claim 15, wherein said 4-hydroxy tamoxifen
is formulated in a hydroalcoholic gel.
24. A method according to claim 23, wherein said hydroalcoholic
gel comprises ethyl alcohol, isopropyl myristate, and hydroxypropylcellulose.
25. A method according to claim 15, wherein said 4-hydroxy tamoxifen
is formulated in an alcoholic solution.
26. A pharmaceutical composition for percutaneous administration
comprising 4-hydroxy tamoxifen and at least one penetration enhancer.
27. A composition according to claim 26, wherein said pharmaceutical
composition is a hydroalcoholic gel, a hydroalcoholic solution,
a patch, an ointment, a cream, an emulsion (lotion), a powder or
an oil.
28. A composition according to claim 26, wherein the pharmaceutical
composition is a hydroalcoholic composition containing a penetration
enhancer, an aqueous vehicle, an alcoholic vehicle and a gelling
29. A composition according to claim 28, wherein the pharmaceutical
composition comprises also a neutralizing agent.
30. A composition according to claim 28, wherein the penetration
enhancer comprises at least a fatty acid ester.
31. A composition according to claim 28, wherein said pharmaceutical
composition comprises: a) about 0.01% to 0.1% by weight of 4-hydroxy
tamoxifen, b) about 0.5% to 2% by weight of isopropyl myristate,
c) about 65% to 75% by weight of alcohol, d) about 20% to 35% by
weight of aqueous vehicule, e) about 1.0% to 5% by weight of gelling
agent, wherein the percentage of components are weight to weight
of the composition.
32. A composition according to claim 31, wherein the 4-hydroxy
tamoxifen constitutes about 0.01%, 0.02%, 0.03%, 0.04%, 0.05%, 0.06%,
0.07%, 0.08%, 0.09%, or 0.10% by weight of the composition.
33. A composition according to claim 31, wherein the isopropyl
myristate constitutes about 0.5%, 0.6%, 0.7%, 0.8%, 0.9%, 1.0%,
1.1%, 1.2%, 1.3%, 1.4%, 1.5%, 1.6%, 1.7%, 1.8%, 1.9% or 2.0% by
weight of the composition.
34. A composition according to claim 31, wherein the alcohol is
ethanol or isopropanol, and constitutes about 65% to 75% by weight
of the composition.
35. A composition according to claim 31, wherein the aqueous vehicle
is a phosphate buffered solution, and constitutes about 25% to 35%
by weight of the composition.
36. A composition according to claim 31, wherein the gelling agent
is a polyacrylic acid, hydroxypropylcellulose or other cellulose
derivative, and constitutes about 1.0% to 5% by weight of the composition.
37. A composition according to claim 31, which further comprises
a neutralizing agent selected in the group consisting of sodium
hydroxide, ammonium hydroxide, potassium hydroxide, arginine, aminomethylpropanol
and tromethamine, which neutralizing agent constitutes about 0.1%
to 5% by weight of the composition.
38. A composition according to claim 31, which is packaged in a
unit dose packet or in a multiple dose container with a metered
[0001] The present invention relates to the treatment and prevention
of breast cancer with 4-hydroxy tamoxifen (4-OHT).
[0002] Breast cancer constitutes a significant health problem for
women in the United States and throughout the world. Despite advances
in detection and treatment of the disease, breast cancer remains
the second leading cause of cancer-related deaths in women, affecting
more than 180,000 women in the United States alone each year. For
women in North America, the life-time odds of getting breast cancer
are one in eight.
[0003] No universally successful method for preventing or treating
breast cancer currently exists. Management of the disease relies
on a combination of early diagnosis (through routine breast screening
procedures) and aggressive treatment, which may include one or more
of a variety of treatments such as surgery, radiotherapy, chemotherapy
and hormone therapy. These therapies are dangerous, toxic, costly,
and often ineffective, especially in the treatment of metastatic
[0004] The most commonly prescribed hormonal medication for breast
cancer is tamoxifen. It works by blocking the effects of estrogen,
which promotes the growth of breast cancer cells. As a treatment
for breast cancer, tamoxifen slows or stops the growth of cancer
cells that are already present in the body, and helps prevent recurrences
and the development of new cancers. Taking tamoxifen for 5 years
reduces the risk of recurrence by about half in patients with estrogen
receptor positive cancers. Tamoxifen also decreases the incidence
of breast cancer involving the opposite breast (contralateral) in
both premenopausal and postmenopausal women. Moreover, tamoxifen
has recently been found to reduce the incidence of breast cancer
in women at high risk of developing this disease.
[0005] In spite of its benefits, tamoxifen has significant drawbacks.
Its action potentially impacts on every estrogen receptor bearing
cell in the body, and, as both an agonist and antagonist, tamoxifen
provokes a wide range of systemic effects. These effects increase
the risk of endometrial cancer, endometrial hyperplasia and polyps,
deep vein thrombosis and pulmonary embolism, changes in liver enzyme
levels, and ocular toxicities, including cataracts. Additionally,
patients treated with oral tamoxifen reported having hot flashes,
vaginal discharge, depression, amenorrhea, and nausea (Ibis, 2002;
Fentiman 1986, 1988, 1989).
[0006] Due to tamoxifen's drawbacks, some cancer researchers have
proposed using 4-hydroxy tamoxifen, a metabolite of tamoxifen, for
breast cancer. In in vitro studies, 4-hydroxy tamoxifen inhibits
the growth of both normal and cancerous breast cells (Nomura, 1985;
Malet, 1988, 2002; Charlier, 1995). Additionally, transdermally
delivered 4-hydroxy tamoxifen exhibits an anti-tumor effect on human
breast tumors grown subcutaneously in mice (U.S. Pat. No. 5,904,930).
[0007] Limited experiments in humans have shown that percutaneously
administered 4-hydroxy tamoxifen can concentrate in local breast
tumors, with very little systemic distribution (Mauvais-Jarvis,
1986). However, the most extended reported study of this sort, in
which patients were treated for three weeks, showed that breast
tissue concentrations of 4-hydroxy tamoxifen administered percutaneously
remained lower than those observed after oral tamoxifen treatment
(Pujol, 1995). Accordingly, the researchers concluded that they
could not propose percutaneous 4-hydroxy tamoxifen as an alternative
tamoxifen treatment.
[0008] Importantly, none of the reported studies regarding 4-hydroxy
tamoxifen in humans has evaluated an anti-tumor effect. This failure
leaves wide open the most important question--whether percutaneously
administered 4-hydroxy tamoxifen actually exerts any effect on breast
cancer in humans. Therefore, a strong need still exists for breast
cancer treatments and prophylactics that provoke few systemic side
[0009] The present invention includes a method of treating breast
cancer by administering 4-hydroxy tamoxifen. This treatment approach,
preferably implemented topically, effectively reduces tumor tissue
proliferation and results in lower plasma drug levels than oral
[0010] The present invention also includes a method of preventing
breast cancer by administering 4-hydroxy tamoxifen. As with the
treatment approach, the prophylactic approach also is preferably
implemented topically.
[0011] For purposes of prophylaxis or treatment, 4-hydroxy tamoxifen
may be administered by any means that delivers it to estrogen receptor-bearing
cells in vivo. As noted, it is preferable that the administration
be done percutaneously (topically), to avoid the first-pass effect
and related liver metabolism of the 4-hydroxy tamoxifen. For percutaneous
administration, 4-hydroxy tamoxifen may be applied to any skin surface.
Application to the breasts is advantageous because 4-hydroxy tamoxifen
tends to concentrate in local subcutaneous tissues with estrogen
receptors when administered percutaneously.
[0012] A broad range of topical formulations are suitable for performing
the invention, but hydroalcoholic solutions and hydroalcoholic gels
are preferred. The concentration of 4-hydroxy tamoxifen in these
formulations may vary, but a dose should result in local 4-hydroxy
tamoxifen tissue concentrations that effectively oppose estrogenic
driven effects.
[0013] FIG. 1 illustrates the metabolism of tamoxifen.
[0014] FIG. 2 illustrates the mean plasma concentration of 4-hydroxy
tamoxifen in healthy women following cutaneous administration.
[0015] FIG. 3 illustrates the concentration of 4-hydroxy tamoxifen
in tissues, according to mode of administration and dosage. Panel
A shows the concentration of 4-hydroxy tamoxifen in tumor tissues.
Panel B shows the concentration of 4-hydroxy tamoxifen in plasma.
[0016] An important aspect of the present invention is the surprising
discovery that 4-hydroxy tamoxifen, when administered percutaneously,
is effective not only in treating but also in preventing breast
cancer. Moreover, percutaneously administered 4-hydroxy tamoxifen
results in lower plasma levels of the drug than the standard dose
of oral tamoxifen, which translates to fewer adverse side effects.
Accordingly, percutaneous 4-hydroxy tamoxifen is an alternative
to tamoxifen for both treatment and prophylaxis in this context.
[0017] The inventors have performed the first study to demonstrate
that 4-hydroxy tamoxifen reduces breast tumor proliferation in vivo
in humans (see Example 4, below). In brief, they administered 4-hydroxy
tamoxifen gel percutaneously to human patients diagnosed with estrogen
receptor positive breast cancer. After only 2-3 weeks of administration,
the inventors observed dose-related reductions in tumor tissue proliferation
indexes, with the highest dose (2.0 mg/day) showing approximate
equivalence to a standard dose of oral tamoxifen. The tumor tissue
proliferation indexes evaluated were Ki67 (Gerdes 1984; Schluter
1993) and Proliferating Cell Nuclear Antigen (PCNA) (Waseem, 1990).
Although percutaneous 4-hydroxy tamoxifen gel and oral tamoxifen
were equivalent in reducing tumor tissue proliferation, 4-hydroxy
tamoxifen plasma levels were consistently lower in patients receiving
4-hydroxy tamoxifen gel.
[0018] The compound 4-hydroxy tamoxifen, or 1-[4-(2-N-dimethylaminoethoxy)-
phenyl]-1-(4-hydroxyphenyl)-2-phenylbut-1-ene, constitutes an active
metabolite of the well characterized anti-estrogen compound, tamoxifen.
Due to the presence of a double bond between two carbon atoms, 4-hydroxy
tamoxifen exists in two stereoisomeric forms. According to the medical
and biochemical literature, isomeric forms of 4-hydroxy tamoxifen
are commonly designated as cis and trans isomers. From a purely
chemical perspective, however, this designation is not strictly
accurate because each double bonded carbon atom does not contain
an identical chemical group. Therefore, it is more appropriate to
refer to the isomers as E (the so-called cis form) and Z (the so-called
trans form) configurations. Both the E and Z isomers of 4-hydroxy
tamoxifen, either alone or in combination, are useful according
to the present invention. The Z isomer is preferred, however, because
it is more active than the E isomer.
[0019] 4-Hydroxy tamoxifen acts as a selective estrogen receptor
modulator (SERM) that exhibits tissue-specificity for estrogen receptive
tissues. In breast tissue, it functions as an estrogen antagonist.
Studies have shown that 4-hydroxy tamoxifen can regulate the transcriptional
activity of estrogen-related receptors, which may contribute to
its tissue-specific activity. In vitro, 4-hydroxy tamoxifen exhibits
more potency than tamoxifen, as measured by binding affinity to
estrogen receptors, or ERs, and a binding affinity similar to estradiol
for estrogen receptors (Robertson et al., 1982; Kuiper et al., 1997).
Z-4-hydroxy tamoxifen inhibits the growth in culture of normal human
epithelial breast cells 100 fold more than Z-tamoxifen (Malet et
al., 1988).
[0020] Although 4-hydroxy tamoxifen is a tamoxifen metabolite,
its usefulness for breast cancer is not presaged by previous experience
with tamoxifen itself. Tamoxifen is extensively metabolized in humans,
as shown in FIG. 1. Thus, its action in vivo is the net result of
individual actions by the parent compound and its metabolite compounds
competing for the occupation of receptors within target tissues.
For example, see Jordan, 1982. Each of these compounds manifests
different and unpredictable biological activities in different cells,
determined in part by each compound's individual effect on estrogen
receptor conformation. That is, estrogen receptor binding of each
compound generates a unique receptor-ligand conformation that recruits
different cofactors, and results in varying pharmacologies for the
different compounds (Wijayaratne et al., 1999; Giambiagi et al.,
[0021] Several examples of these varying effects have been documented.
For instance, tamoxifen but not 4-hydroxy tamoxifen is a potent
rat liver carcinogen. (Carthew et al., 2001; Sauvez et al., 1999).
Additionally, tamoxifen but not 4-hydroxy tamoxifen reportedly initiates
apoptosis in p53(-) normal human mammary epithelial cells (Dietze
et al., 2001). By contrast, 4-hydroxy tamoxifen exhibits a significant
inhibitory effect on estrone sulphatase activity in mammary cancer
cell lines, while tamoxifen has little or no effect in this regard
(Chetrite et al., 1993).
[0022] Previous studies with 4-hydroxy tamoxifen also did not predict
its effectiveness for breast cancer treatment and prevention. The
ability of any drug to inhibit tumor cell growth in vitro or in
a xenograft assay is a crude indicator of how the drug might act
in humans (Gura, 1997). Cell culture, an artificial environment,
provides no information regarding how a drug acts in a complete
biological system, and animals often do not process drugs the same
way as humans. Moreover, previous human studies with 4-hydroxy tamoxifen
only evaluated drug delivery, and provided no information regarding
the drug's effect on breast tumors. By contrast, experiments performed
by the present inventors have surprisingly shown that 4-hydroxy
tamoxifen, administered percutaneously, causes dose-related reductions
in tumor tissue proliferation indexes.
[0023] Methods for preparing 4-hydroxy tamoxifen are well known.
For example, U.S. Pat. No. 4,919,937 describes a synthesis, derived
from Robertson and Katzenellenbogen, 1982, that occurs in stages:
[0024] Stage 1--Reaction between 4-(.beta.-dimethylaminoethoxy)-.alpha.-et-
hyldeoxybenzoin and p-(2-tetrahydropyranyloxy)phenylmagnesium bromide;
[0025] Stage 2--Separately from stage 1, formation of 1-(4-hydroxyphenyl)-2-phenyl-1-butanone
by hydroxylation of 1,2-diphenyl-1-butanone;
[0026] Stage 3--Reaction between the products of stages 1 and 2
to form 1-(4-dimethylaminoethoxyphenyl)-1-[p-2-tetrahydropyranyloxy)phenyl]-2-phe-
[0027] Stage 4--Dehydration with methanol/hydrochloric acid produces
but-1-ene=4-OH-tamoxifen, a mixture of E and Z isomers;
[0028] Stage 5--Separation of the E and Z isomers by chromatography
and crystallization to constant specific activity.
[0029] According to the present invention, 4-hydroxy tamoxifen
may be administered to a patient diagnosed with breast cancer. The
cancer preferably will be estrogen receptor positive, as it is believed
that 4-hydroxy tamoxifen primarily exerts its effect by acting on
estrogen receptors. Additionally, it is preferred that the breast
cancer be localized to the breast. For example, a primary breast
tumor and/or a metastatic tumor solely located in the breast may
be treated by topical administration. Breast cancer tumors at other
locations that are accessible to topically administered 4-hydroxy
tamoxifen also may be treated in this manner, however.
[0030] The present invention also contemplates administration of
4-hydroxy tamoxifen prophylactically, to a patient at increased
risk for developing breast cancer. Many risk factors for breast
cancer are well established. For instance, family history of breast
cancer, personal history of breast cancer, previous breast biopsy
detection of proliferative breast disease such as atypical hyperplasia,
and previous breast irradiation all place a patient at an elevated
risk for developing breast cancer. Particular genetic risk factors
include BRCA1, BRCA2, ATM, CHEK-2 and p53 mutations. Certain lifestyle-related
risk factors for women include delayed childbirth until after age
30, long-term use of oral contraceptives, and long-term use of hormone
replacement therapy. A skilled medical practitioner can evaluate
these and other risk factors to determine whether a patient will
benefit from prophylactic use of 4-hydroxy tamoxifen. In making
such an assessment, a practitioner may employ the Gail model.
[0031] 4-Hydroxy tamoxifen is particularly useful for preventing
breast cancer in pre-menopausal women. In this population, an anti-estrogen
must compete with high amounts of circulating estrogen to occupy
estrogen receptors. Because 4-hydroxy tamoxifen has 100 fold more
affinity for estrogen receptors than tamoxifen, it is better able
to compete for the receptors at low doses. The ability to use a
low dose holds particular importance in a prophylactic context,
where a patient's exposure to the drug is long-term and side effects
are less tolerable.
[0032] Pursuant to the present invention, 4-hydroxy tamoxifen may
be administered in any dosage form and via any system that delivers
the active compound to breast and/or tumor estrogen receptors in
vivo. Preferably, the 4-hydroxy tamoxifen is delivered by "percutaneous
administration," a phrase that denotes any mode of delivering
a drug from the surface of a patient's skin, through the stratum
corneum, epidermis, and dermis layers, and into the microcirculation.
This is typically accomplished by diffusion down a concentration
gradient. The diffusion may occur via intracellular penetration
(through the cells), intercellular penetration (between the cells),
transappendageal penetration (through the hair follicles, sweat,
and sebaceous glands), or any combination of these.
[0033] Percutaneous administration of 4-hydroxy tamoxifen offers
several advantages. First, it avoids the hepatic metabolism that
occurs subsequent to oral administration (Mauvais-Jarvis et al.,
1986). Second, percutaneous administration significantly reduces
systemic drug exposure, and the attendant risks from non-specifically
activating estrogen receptors throughout the body; this, because
topical 4-hydroxy tamoxifen is absorbed primarily into local tissues.
In particular, when 4-hydroxy tamoxifen is percutaneously applied
to breasts, high concentrations accumulate in the breast tissue,
presumably due to many estrogen receptors therein, without creating
a high plasma concentration (Mauvais-Jarvis et al., supra). Pursuant
to the present invention, therefore, 4-hydroxy tamoxifen may be
applied to any skin surface, but preferably to one or both breasts.
[0034] Although the invention is not constrained to any particular
theory, clinically significant side effects of anti-estrogen agents
occur when the agents displace estradiol in non-target tissues.
Because 4-hydroxy tamoxifen and estradiol have similar binding affinities
for estrogen receptors, a competition between them for receptor
binding would be approximately equal when the concentration of each
compound approximates that of the other. If the 4-hydroxy tamoxifen
concentration exceeds the estradiol concentration, the former will
be bound preferentially to the estrogen receptors, and vice versa.
[0035] Accordingly, doses of 4-hydroxy tamoxifen that result in
plasma concentrations less than about 80 pg/mL, or the mean estradiol
concentration in normal premenopausal women, are preferred. More
preferably, doses of 4-hydroxy tamoxifen will result in plasma concentrations
less than about 50 pg/mL. The daily doses to be administered can
initially be estimated based upon the absorption coefficients of
4-hydroxy tamoxifen, the breast tissue concentration that is desired,
and the plasma concentration that should not be exceeded. Of course,
the initial dose may be optimized in each patient, depending on
individual responses.
[0036] As noted above, by targeting 4-hydroxy tamoxifen to breast
tissue, high concentrations can be achieved in that tissue without
simultaneously raising 4-hydroxy tamoxifen plasma levels to a point
where significant systemic competition for estradiol receptors occurs.
At a percutaneous dose of 1 mg/breast/day, 4-hydroxy tamoxifen concentration
in breast tissue exceeds normal estradiol concentrations in breast
tissue by a factor of 4. (Barrat et al., 1990; Pujol et al., supra).
Moreover, 4-hydroxy tamoxifen applied in this manner reaches concentrations
in breast tissue that are an order of magnitude higher than concentrations
in plasma, i.e., 10:1. By contrast, the breast tissue to plasma
ratio of 4-hydroxy tamoxifen following oral administration of tamoxifen
is about 5:1.
[0037] In a percutaneous formulation, doses on the order of 0.25-2.0
mg/breast/day of 4-hydroxy tamoxifen should achieve the desired
result, with doses of about 0.5-1.0 mg/breast/day being preferred.
In particular embodiments, the dosage is about 0.5, 0.75 or 1.0
mg/breast/day of 4-hydroxy tamoxifen.
[0038] Percutaneous administration can be accomplished mainly in
two different ways: (i) by mixing a therapeutically active compound
or its non-toxic pharmaceutically acceptable salt with suitable
pharmaceutical carriers and, optionally, penetration enhancers to
form ointments, emulsions, lotions, solutions, creams, gels or the
like, where an amount of said preparation is applied onto a certain
area of the skin, or (ii) by incorporating the therapeutically active
substance into patches or transdermal delivery systems according
to known technology.
[0039] The effectiveness of percutaneous drug administration depends
on many factors, including drug concentration, surface area of application,
time and duration of application, skin hydration, physicochemical
properties of the drug, and partitioning of the drug between the
formulation and the skin. Drug formulations intended for percutaneous
use take advantage of these factors to achieve optimal delivery.
Such formulations often comprise penetration enhancers that improve
percutaneous absorption by reducing the resistance of the stratum
corneum by reversibly altering its physiochemical properties, changing
hydration in the stratum corneum, acting as co-solvent, or changing
the organization of lipids and proteins in the intercellular spaces.
Such enhancers of percutaneous absorption include surfactants, DMSO,
alcohol, acetone, propyleneglycol, polyethylene glycol, fatty acids
or fatty alcohols and their derivatives, hydroxyacids, pyrrolidones,
urea, essential oils, and mixtures thereof. In addition to chemical
enhancers, physical methods can increase percutaneous absorption.
For example, occlusive bandages induce hydration of the skin. Other
physical methods include iontophoresis and sonophoresis, which use
electrical fields and high-frequency ultrasound, respectively, to
enhance absorption of drugs that are poorly absorbed due to their
size and ionic characteristics.
[0040] The many factors and methods relating to percutaneous drug
delivery are reviewed in REMINGTON: THE SCIENCE AND PRACTICE OF
PHARMACY, Alfonso R. Gennaro (Lippincott Williams & Wilkins,
2000), at pages 836-58, and in PERCUTANEOUS ABSORPTION: DRUGS COSMETICS
MECHANISMS METHODOLOGY, Bronaugh and Maibach (Marcel Dekker, 1999).
As these publications evidence, those in the pharmaceutical field
can manipulate the various factors and methods to achieve efficacious
percutaneous delivery.
[0041] 4-Hydroxy tamoxifen is a large and very lipophilic molecule;
hence, without assistance from penetration enhancers it poorly penetrates
the skin. Accordingly, formulations of 4-hydroxy tamoxifen used
in the present invention preferably comprise one or more penetration
enhancers. Alcohols are preferred enhancers because 4-hydroxy tamoxifen
is soluble in alcohol. Isopropyl myristate also is a preferred enhancer.
[0042] For percutaneous administration, 4-hydroxy tamoxifen may
be delivered in an ointment, cream, gel, emulsion (lotion), powder,
oil or similar formulation. To this end, the formulation may comprise
customary excipient additives, including vegetable oils such as
almond oil, olive oil, peach kernel oil, groundnut oil, castor oil
and the like, animal oils, DMSO, fat and fat-like substances, lanolin
lipoids, phosphatides, hydrocarbons such as paraffins, petroleum
jelly, waxes, detergent emulsifying agents, lecithin, alcohols,
carotin, polyols or polyglycols such as glycerol (or glycerine),
glycerol ethers, glycols, glycol ethers, polyethylene glycol, polypropylene
glycol, non-volatile fatty alcohols, acids, esters, volatile alcoholic
compounds, urea, talc, cellulose derivatives, coloring agents, antioxidants
and preservatives.
[0043] According to the present invention, 4-hydroxy tamoxifen
also may be delivered via a transdermal patch. In one embodiment,
the patch comprises a reservoir for the 4-hydroxy tamoxifen formula.
The patch may comprise (a) a solution-impermeable backing foil,
(b) a layer-like element having a cavity, (c) a microporous or semi-permeable
membrane, (d) a self-adhesive layer, and (e) optionally, a removable
backing film. The layer-like element having a cavity may be formed
by the backing foil and the membrane. Alternatively, the patch may
comprise (a) a solution-impermeable backing foil, (b) an open-pored
foam, a closed-pore foam, a tissue-like layer or a fibrous web-like
layer as reservoir, (c) if the layer according to (b) is not self-adhesive,
a self-adhesive layer, and (d) optionally a removable backing film.
[0044] In preferred embodiments of the invention, 4-hydroxy tamoxifen
is formulated in a hydroalcoholic gel. The amount of 4-hydroxy tamoxifen
in such a gel may range from about 0.001 to about 1.0 gram of 4-hydroxy
tamoxifen per 100 grams of gel. Preferably, it ranges from about
0.01 to about 0.1 gram of 4-hydroxy tamoxifen per 100 grams of gel.
[0045] It is also preferred that 4-hydroxy tamoxifen formulations
comprise one or more fatty acid esters as a penetration enhancer.
One highly preferred example of a fatty acid ester penetration enhancer
is isopropyl myristate. When isopropyl myristate is used in a gel,
the amount may range from about 0.1 to about 5.0 grams per 100 grams
of gel. Preferably, the amount of isopropy myristate ranges from
about 0.5 to about 2.0 grams per 100 grams of gel.
[0046] 4-Hydroxy tamoxifen formulations of the invention generally
will comprise one or more nonaqueous vehicles. These vehicles should
be capable of dissolving both 4-hydroxy tamoxifen and any penetration
enhancer used. They also should have a low boiling point, preferably
less than 100.degree. C. at atmospheric pressure, to permit rapid
evaporation upon contact with the skin. Examples of suitable non-aqueous
vehicles include ethanol, isopropanol and ethyl acetate. Ethanol
and isopropanol are preferred. In particular, ethanol effectively
contributes to the percutaneous absorption of 4-hydroxy tamoxifen
by rapidly evaporating upon contact with skin. The amount of nonaqueous
vehicle in a gel formulation generally ranges between 54% and 85%
by weight, and preferably between 65% and 75.
[0047] Formulations also may comprise an aqueous vehicle, which
permits solubilization of any hydrophilic molecules in a formulation,
and also promotes diffusion of lipophilic molecules from the formulation
to the skin. An aqueous vehicle also can regulate pH. Aqueous vehicles
include alkalinizing and basic buffer solutions, including phosphate
buffered solutions (e.g., dibasic or monobasic sodium phosphate),
citrate buffered solutions (e.g., sodium citrate or potassium citrate)
and simply purified water. The amount of an aqueous vehicle preferably
ranges between 15% and 45% by weight of a gel formulation, and more
preferably between 25% and 35%.
[0048] Additionally, 4-hydroxy tamoxifen formulations may comprise
one or more gelling agents to increase the viscosity of a formulation
and/or to function as a solubilizing agent. Depending on the gelling
agent's nature, it may constitute between 0.1% and 20% by weight
of a formulation, preferably between 0.5% and 10%, and still more
preferably between 1% and 5%. Preferred gelling agents include carbomers,
cellulose derivatives, poloxamers and poloxamines. Mor particularly,
preferred gelling agents are chitosan, dextran, pectins, natural
gum and cellulose derivatives such as ethyl cellulose, hydroxypropyl
cellulose, hydroxyethyl cellulose, hydroxypropyl methyl cellulose
(HPMC), carboxymethyl cellulose (CMC), and the like. One highly
preferred gelling agent is hydroxypropyl cellulose.
[0049] When a formulation comprises a gelling agent, in particular
a non-preneutralized acrylic polymer, it may advantageously also
comprise a neutralizing agent. The neutralizing agent/gelling agent
ratio preferably is between 10:1 and 0.1:1, more preferably between
7:1 and 0.5:1, and still more preferably between 4:1 and 1:1. A
neutralizing agent should form, in the presence of the polymer,
salts that are soluble in the vehicle. A neutralizing agent also
should permit optimum swelling of polymer chains during neutralization
of charges and formation of polymer salts. Useful neutralizing agents
include sodium hydroxide, ammonium hydroxide, potassium hydroxide,
arginine, aminomethylpropanol and tromethamine. Those skilled in
the art will select a neutralizing agent according to the type of
gelling agent employed in a formulation. When cellulose derivatives
are used as gelling agents, however, no neutralizing agents are
[0050] Table 1 describes the composition of two highly preferred
4-hydroxy tamoxifen gel formulations.
1TABLE 1 Composition of 4-Hydroxy Tamoxifen Gel Formulations Quantity
per 100 g of gel 20 mg 57 mg Ingredient 4-OHT Gel 4-OHT Gel 4-Hydroxy
Tamoxifen 0.02 g 0.057 g 95% Ethyl Alcohol, EP 72 g 72 g Isopropyl
myristate, EP 1 g 1 g Hydroxypropylcellulose, EP 1.5 g 1.5 g Phosphate
Buffer (pH 7, diluted 1:4) q.s. 100 g q.s. 100 g
[0051] Reference to the following, illustrative examples will help
to provide a more complete understanding of the invention.
[0052] Demonstration of Percutaneous 4-Hydroxy Tamoxifen Delivery
[0053] Four patients with breast cancer received [.sup.3H]-4-hydroxy
tamoxifen in an alcoholic solution applied directly to the breasts
at specified intervals between 12 hours to 7 days prior to surgery
to excise diseased tissue. After surgery, both the excised tissue
and the normal breast tissue surrounding the tumor contained radioactivity
(Kuttenn et al., 1985).
[0054] In a follow-up study, 9 of 12 patients scheduled for surgical
excision of hormone-dependent breast cancer received Z-[.sup.3H]-4-hydroxy
tamoxifen (80 .mu.Ci) in a 60% alcoholic solution, and 3 patients
received Z-[.sup.3H]-tamoxifen (80 .mu.Ci) for comparison. The patients
received [.sup.3H]-labeled drug applied directly on the affected
breasts at specified intervals ranging from 12 hours to 7 days before
surgery to excise diseased tissue. Breast tissue from three regions:
the tumor, tissue immediately surrounding the tumor, and normal
tissue, was excised and immediately frozen in liquid nitrogen. Additionally,
plasma and urine samples were obtained at scheduled intervals and
frozen until analysis.
[0055] Table 2 shows results from the analyses performed. 4-Hydroxy
tamoxifen concentrated predominantly in the cytosolic and nuclear
fractions of breast tissue, where estrogen receptors are present.
In these intracellular sites, 4-hydroxy tamoxifen remained unmetabolized
except for limited isomerization from the Z to the E form. Retention
in the breast lasted approximately 4 days in the 4-hydroxy tamoxifen
group, but was shorter and far weaker in the tamoxifen group.
2TABLE 2 [.sup.3H]-4-Hydroxy Tamoxifen and Metabolites Identified
in Breast Tumor Tissue Following Percutaneous Administration of
Z-[.sup.3H]-4-Hydroxy Tamoxifen to the Affected Breast % Metabolites
in Breast Tissue Metabolites 12 hr.sup.1 24 hr 36 hr Day 4 Day 7
4-Hydroxy Tamoxifen 97 94 78 70 65 N-Desmethyl-4-Hydroxy 2 4 14
20 16 Tamoxifen Bisphenol 1 2 3 8 8 N-Desmethyl tamoxifen <1
<1 3-4 Tamoxifen <1 2 .sup.1Time after administration of Z-[.sup.3H]-4-hydroxy
[0056] The percentage of radioactivity identified as [.sup.3H]-4-hydroxy
tamoxifen in breast tissue after percutaneous administration decreased
slowly over seven days (from 97% to 65%). During this period a progressive
isomerization of the Z isomer into the E isomer occurred, with similar
percentages observed at day 7 (32% and 33%).
[0057] The radioactivity in blood due to [.sup.3H]-4-hydroxy tamoxifen
increased gradually, with a plateau from days 4 to 6. This contrasts
with [.sup.3H]-tamoxifen, which rapidly appeared in the blood, plateauing
at 2 days. At 36 hours following percutaneous [.sup.3H]-4-hydroxy
tamoxifen administration, only 0.5% of the radioactivity administered
showed in the blood.
[0058] In contrast to the near absence of 4-hydroxy tamoxifen metabolism
in the breast tissue, marked metabolism occurred in blood. In blood,
at 24 hours after administration, 68% of radioactivity represented
4-hydroxy tamoxifen, 18% represented N-desmethyl-4-hydroxy tamoxifen,
and 11% represented bisphenol.
[0059] Peak urinary elimination occurred at a later time following
percutaneous administration of 4-hydroxy tamoxifen compared to percutaneous
tamoxifen. Following application of 4-hydroxy tamoxifen, a progressive
increase of metabolites, mostly N-desmethyl-4-hydroxy tamoxifen
and bisphenol, was observed in the urine.
[0060] This example demonstrates that percutaneous application
of 4-hydroxy tamoxifen to the breasts results in a substantial and
lasting local tissue concentration of the drug, with minimal metabolism,
stable and very low plasma concentrations, and slow elimination
via the urine.
[0061] Demonstration of the Pharmacokinetics and Pharmacodynamics
of Percutaneously Administered 4-OH-Tamoxifen Compared to 20 mg
of Oral Tamoxifen
[0062] This study compared the tissue and plasma concentrations
of 4-hydroxy tamoxifen after percutaneous administration via a hydroalcoholic
gel with tissue and plasma concentrations of 4-hydroxy tamoxifen
after oral administration of tamoxifen (Pujol, 1995).
[0063] Thirty-one patients scheduled for breast cancer surgery
were randomly assigned to 1 of 5 groups. They received treatment
with either oral tamoxifen or percutaneous 4-hydroxy tamoxifen as
outlined in Table 3. Treatment was daily and lasted for 3-4 weeks
prior to surgery. The study evaluated three different doses of 4-hydroxy
tamoxifen (0.5, 1, or 2 mg/day) and two areas of application (either
to both breasts or to a large surface of skin including arms, forearms,
and shoulders). One group of patients received 20 mg/day (10 mg
b.i.d.) of oral tamoxifen (Nolvaldex.RTM.).
3TABLE 3 Treatment Groups Dose Total Daily Application mg/breast/
Dose Group N Drug Site day (mg/day) 1 6 PO tamoxifen -- -- 20.sup.a
2 6 4-OHT gel both breasts 0.25 0.5 3 5 4-OHT gel both breasts 0.50
1 4 5 4-OHT gel arms, forearms, -- 1 and shoulders 5 6 4-OHT gel
arms, forearms, -- 2.sup.b and shoulders .sup.a10 mg b.i.d. .sup.bdivided
into 2 daily applications; 1 mg in the morning and 1 mg in the evening
[0064] The 4-hydroxy tamoxifen gel (20 mg of 4-hydroxy tamoxifen/100
g of hydroalcholic gel; Besins-International Laboratories) was packaged
in a pressurized dose-metering pump that delivered 1.25 g of gel/metered
dose (i.e., 0.25 mg of 4-hydroxy tamoxifen/dose).
[0065] During surgery; two samples (1 cm.sup.3 each) of breast
tissue were excised, one tumoral and the other macroscopically normal.
They were immediately frozen in liquid nitrogen until assayed. Blood
samples were obtained on the day of and the day prior to surgery.
All tissue and plasma samples were analyzed for 4-hydroxy tamoxifen
concentration by gas chromatograph/mass spectrometry (GC-MS).
[0066] Pre and post-treatment blood samples were assayed for complete
blood counts (CBC), bilirubin, serum glutamic-pyruvic transaminase
(SGPT), serum glutamic-oxaloacetic transaminase (SGOT), alkaline
phosphatase, creatinine, estradiol, follicle-stimulating hormone
(FSH), luteinizing hormone (LH), sex hormone-binding globulin (SHBG),
cholesterol, high-density lipoprotein (HDL), low-density lipoprotein
(LDL), triglycerides, fibrinogen, and anti-thrombin III.
[0067] Table 4 below summarizes the concentration of 4-hydroxy
tamoxifen found in breast tissue and plasma. Normal and tumor breast
tissues contained similar concentrations of 4-hydroxy tamoxifen
in all five treatment groups. 4-hydroxy tamoxifen concentrated at
higher amounts in breast tissue when the gel was applied directly
to the breasts, rather than to other large skin surfaces.
4TABLE 4 Concentrations of 4-hydroxy tamoxifen Mean .+-. SD 4-hydroxy
tamoxifen (Range) Plasma Concentrations (pg/mL) Group N Day Pre-Surgery
Day of Surgery Normal Tissue (pg/g) Tumor (pg/g) 1 6 2326 .+-. 585
2317 .+-. 1098 10215 .+-. 2151 12453 .+-. 3751 (1371-2959).sup.a
(881-4176) (5873-11511) (9568-18904).sup.a 2 6 0 17 .+-. 27 353
.+-. 513 1447 .+-. 2673 (0-0).sup.a (0.sup.c-61) (0.sup.d-1317)
(0.sup.f-6889) 3 5 164 .+-. 131 62 .+-. 71 1112 .+-. 1125 1877 .+-.
2472 (29-279).sup.b (28-190) (197-2979) (345-6211) 4 5 94 .+-. 76
13 .+-. 29 140 .+-. 130 552 .+-. 357 (35-201).sup.b (0.sup.c-65)
(0.sup.e-270) (271-1150) 5 6 78 .+-. 138 73 .+-. 114 992 .+-. 2195
224 .+-. 312 (0.sup.e-284).sup.b (0.sup.c-244) (0.sup.d-5462) (0.sup.d-799)
.sup.an = 5 .sup.bn = 4 .sup.cFour patients had undetectable levels
of 4-hydroxy tamoxifen (LOQ = 20 pg/ml). .sup.dThree patients had
undetectable levels of 4-hydroxy tamoxifen. .sup.e2 patients had
undetectable levels of 4-hydroxy tamoxifen .sup.f1 patient had undetectable
levels of 4-hydroxy tamoxifen
[0068] Side effects did not pose a significant problem. Cutaneous
treatment did not cause any local irritation. One woman in Group
2 (0.5 mg/day of 4-hydroxy tamoxifen gel) reported dizzy spells,
cystitis, and mild vaginitis occurring on the seventh day of treatment.
One woman in Group 1 (oral tamoxifen) reported hot flashes and mild
vaginitis on the fifth day of treatment.
[0069] No differences existed between the pre- and post treatment
blood samples for any of the hematology or serum chemistry evaluations
in the patients who received 4-hydroxy tamoxifen gel. However, a
statistically significant decrease in anti-thrombin III and fibrinogen
and a statistically significant increase in platelet and lymphocyte
counts were observed in the oral tamoxifen group, consistent with
the biologic effects of this drug observed in other studies.
[0070] Demonstration of Tolerance and Pharmacokinetics of Percutaneously
Administered 4-OH-Tamoxifen in Healthy Women
[0071] This study demonstrates the tolerance and pharmacokinetics
of topically applied 4-hydroxy tamoxifen gel in healthy premenopausal
women, aged 18-45. Each participant applied the gel daily for the
duration of two menstrual cycles.
[0072] Three doses and two gel concentrations were tested, as summarized
in Table 5. For Groups A-C, the gel, containing 20 mg of 4-hydroxy
tamoxifen/100 g, was dispensed from a pressurized dose-metering
pump that delivered 0.25 mg of 4-hydroxy tamoxifen/dose. The study
of Group C was suspended because the quantity of gel was too large
to be applied to a single breast. Groups D and E received a more
concentrated gel that contained almost 3 times as much 4-hydroxy
tamoxifen: 57 mg of 4-hydroxy tamoxifen/100 g, or 50 mg of 4-hydroxy
tamoxifen/100 mL of gel. This more concentrated gel also was delivered
by a dose-metering pump that supplied 0.25 mg of 4-hydroxy tamoxifen/dose.
5TABLE 5 Treatment Groups Dose Gel Concentration Group N (mg/day)
(mg of 4-OHT/g of gel) Treatment A 12 0.5 20 mg/100 g 1 metered
dose/ breast/day B 8 1 20 mg/100 g 2 metered doses/ breast/day C
2 2 20 mg/100 g study was interrupted D 12 1 57 mg/100 g 2 metered
doses/ breast/day E 12 2 57 mg/100 g 4 metered doses/ breast/day
[0073] At the end of a menstrual cycle, each patient received a
single dose, after which serial blood samples were collected at
0, 0.5, 1, 1.5, 2, 3, 4, 6, 12, 18, 24, 36, 48, and 72 hours.
[0074] On the first day of the following menstruation, treatment,
which consisted of daily application of the gel over two menstrual
cycles, began. Blood samples were collected 24 hours following the
morning application of gel on days 7, 20 and 25 of the first and
second cycles. On the last day of administration, day 25 of the
second menstrual cycle, serial blood samples were collected prior
to application and at 0.5, 1, 1.5, 2, 3, 4, 6, 12, 18, 24, 36, 48,
and 72 hours after application of the gel. The samples were analyzed
for 4-hydroxy tamoxifen, estradiol, progesterone, FSH and LH.
[0075] Plasma concentrations of 4-hydroxy tamoxifen remained detectable
72 hours after the last gel application. Therefore, to ensure that
data points were obtained until 4-hydroxy tamoxifen became undetectable
in the blood, additional blood samples were collected from some
participants at intervals up to 92 days following the last application
of gel.
[0076] Table 6 displays the mean.+-.standard deviation (SD) plasma
concentrations of 4-hydroxy tamoxifen, with ranges in parentheses.
A single 0.5 mg dose did not produce detectable plasma concentrations
of 4-hydroxy tamoxifen, but 6 of 12 patients had detectable plasma
concentrations (>5 pg/mL) after a single dose of 1 mg.
6TABLE 6 Mean .+-. SD Plasma Concentrations of 4-hydroxy tamoxifen
in Healthy Women Following Daily Cutaneous Administration for Two
Menstrual Cycles Time after Mean .+-. SD (Range is indicated in
parenthesis) in pg/mL Application 0.5 mg/day 1 mg/day 1 mg/day 2
mg/day Cycle Day (hr) (n = 12).sup.1 (n = 8).sup.1 (n = 12).sup.2
(n = 12).sup.2 First 1 0 (0-17.2) (0-13.9) (0-9.5) (0-0) 7 24 6.4
Second 7 24 25.2 .+-. 16.1 17.4 .+-. 11.2 22.2 .+-. 16.4 42.2 .+-.
24.8 (6.5-61.7) (5.7-39.6) (9.0-64.4) (18.2-98.0) 20 24 15.7 .+-.
(5.4-24.8) (<LOQ-65.4) (18.7-119.7) 25 0.sup.3 10.8 .+-. 9.9
(8.0-72.1) (16.9-120.3) 0.5 10.9 .+-. 7.4 13.5 .+-. 9.1 25.9 .+-.
(7.5-67.0) (15.9-90.0) 2 11.8 .+-. 9.5 10.7 .+-. 6.9 25.1 .+-. 18.0
(16.5-92.0) 6 11.4 .+-. 8.5 10.7 .+-. 6.4 25.0 .+-. 18.2 41.0 .+-.
(8.1-57.9) (16.0-107.3) 26 24 12.4 .+-. 9.4 18.6 .+-. 14.2 26.0
(15.8-132.5) 36 10.9 .+-. 6.9 13.4 .+-. 7.5 25.7 .+-. 18.4 42.1
12.1 .+-. 6.5 12.5 .+-. 6.0 22.0 .+-. 16.0 38.1 .+-. 25.3 (4.8-26.6)
(5.6-37.8) (17.7-98.0) +5 days -- 5.8 .+-. 5.2 11.4 .+-. 8.2 20.4
.+-. 17.3 (<LOQ-12.4) (<LOQ-25.8) (9.1-71.6) +8 days <LOQ
(<LOQ-17.4) (0-14.8) 10.8 .+-. 13.4 (<LOQ-52.0) +12 days (maximum
(<LOQ-7.0) (0-<LOQ) (0-30.4) 9.09) +20 days 0 <LOQ (0-<LOQ)
(0-<LOQ) LOQ = limit of quantification (<5 pg/mL) .sup.1Gel
concentration was 20 mg of 4-hydroxy tamoxifen per 100 g of gel.
.sup.2Gel concentration was 57 mg of 4-hydroxy tamoxifen per 100
g of gel. .sup.3Timepoint 0 is 24 hours after the application on
Day 24 and prior to the final application on Day 25.
[0077] FIG. 2 shows a plasma concentration-time curve, following
the last administration on day 25 of the second menstrual cycle.
Table 7 shows mean pharmacokinetic parameters that relate to the
last administration, on day 25 of the second menstrual cycle.
7TABLE 7 Mean Pharmacokinetic Parameters of 4-hydroxy tamoxifen
in Healthy Women Following the Last Administration Mean .+-. SD
(Range is indicated in parenthesis) 0.5 mg/day 1 mg/day 1 mg/day
2 mg/day Parameter (n = 12).sup.a (n = 8).sup.a (n = 12).sup.b (n
= 12).sup.b C.sub.max 17.0 .+-. 8.5 21.0 .+-. 14.0 35.1 .+-. 22.4
51.6 .+-. 31.7 (pg/mL) (7.6-34.4) (<LOQ-40.1) (9.9-78.1) (22.1-132.5)
t.sub.max (hr) 40 .+-. 81 24 .+-. 18 12.8 .+-. 14.9 11.8 .+-. 12.3
(0.5-288) (0.5-48) (1-36) (0.5-36) t.sub.1/2 (hr) -- -- (58-118)
(49-101) AUC.sub.0-24 256.3 .+-. 205.3 300.9 .+-. 190.8 619 .+-.
466 998 .+-. 653 (pg .multidot. hr/ (24.6-651.1) (0-693.6) (187-1522)
(424-2778) mL) C.sub.av = 10.7 .+-. 8.5 12.5 .+-. 7.9 25.8 .+-.
19.4 41.6 .+-. 27.2 AUC.sub.0-24/ (1.0-27.1) (0-28.9) (7.8-63.4)
(17.7-115.8) 24 (pg/mL) T (1stC < -- 274 .+-. 141 236 .+-. 72
326 .+-. 97 LOQ) (hr) (144-480) (144-384) (192-480) .sup.aGel concentration
was 20 mg of 4-hydroxy tamoxifen per 100 g of gel. .sup.bGel concentration
was 57 mg of 4-hydroxy tamoxifen per 100 g of gel.
[0078] AUC.sub.0-24=area under the concentration-time curve for
0-24 hours; C.sub.av=Calculation of area under the curve over 24
hours (AUC.sub.0-24) divided by 24 hours; C.sub.max=maximal concentration
in plasma; t.sub.1/2=half-life; T(1 stC<LOQ)=first timepoint
at which the plasma concentration was below the limit of quantification;
t.sub.max=time of maximal concentration in plasma.
[0079] The data are consistent with a dose response across the
three doses tested (0.5, 1, and 2 mg). The more concentrated gel
was better absorbed, by approximately double, than the less concentrated
gel, based on AUC and C.sub.av.
[0080] Biological tolerance was excellent in all 36 patients. The
treatment did not affect FSH, LH, estradiol, or progesterone hormone
levels during the menstrual cycles. Moreover, echographic examination
of the ovaries at the end of treatment was normal in all patients,
showing normal sized developing follicles. One patient developed
an allergic reaction to the gel, and 10 reported facial acne (5
of which had a past history of acne).
[0081] In summary, this study indicates that the exposure to 4-hydroxy
tamoxifen after topical application increases with dose, that plasma
concentrations of 4-hydroxy tamoxifen are lower than typical estradiol
concentrations (80 pg/mL), and that there is no detectable laboratory
or clinical evidence of systemic effects.
[0082] Demonstration that Percutaneously Administered 4-Hydroxy
Tamoxifen Causes Dose-Related Reductions in Tumor Tissue Proliferation
[0083] This study demonstrates that percutaneously administered
4-hydroxy tamoxifen causes dose-related reductions in breast tumor
tissue proliferation indexes. It is the first direct comparison
of 4-hydroxy tamoxifen gel with tamoxifen and untreated controls
on biological end points of breast cancer in humans. The results
show that percutaneous administration of 4-hydroxy tamoxifen gel
for 2-3 weeks produces dose-dependent reductions in tumor tissue
proliferation indexes (Ki-67 and PCNA) in postmenopausal women scheduled
to undergo surgery for breast cancer, with approximate equivalence
between the 2.0 mg/day 4-hydroxy tamoxifen dose and 20 mg/day oral
tamoxifen. Estrogen and progesterone receptor levels did not show
dose-related reductions with 4-hydroxy tamoxifen treatment. Plasma
levels of 4-hydroxy tamoxifen were consistently higher in the oral
tamoxifen group than in the 4-hydroxy tamoxifen gel groups, and
tumor tissue concentrations of 4-hydroxy tamoxifen increased with
increasing dose of 4-hydroxy tamoxifen gel.
[0084] The present study also provides information on the biologic
processes underlying the effects of tamoxifen. The group receiving
2 mg percutaneous 4-hydroxy tamoxifen showed the same cytostatic
effect on breast cancer cell proliferation as the oral tamoxifen
group in spite of markedly lower plasma 4-hydroxy tamoxifen concentrations.
This finding shows that a major effect of tamoxifen is locally mediated
by estrogen receptors in tumor tissue.
[0085] Study Design
[0086] A randomized, open, parallel groups phase IIb study was
designed to compare the effects of three dose levels of 4-hydroxy
tamoxifen, oral tamoxifen and no treatment on markers of tumor proliferation
(Ki-67 and PCNA). Ki-67 antigen was detected by MIB1 antibody and
PCNA (Proliferative Cell Nuclear Antigen) was detected with PC-10
monoclonal antibody.
[0087] Patients
[0088] Participants in the study were postmenopausal women diagnosed
with estrogen receptor positive invasive breast cancer, as determined
by Trucut biopsy. Criteria for enrollment included age >50 years,
histologically confirmed T1 or T2 estrogen receptor positive primary
breast cancer, and fit for surgery within 1 month of the biopsy.
Patients with inflammatory cancer, known metastasis or lymph node
involvement were excluded as were patients with previous radiotherapy
or chemotherapy and ongoing hormone replacement therapy (a minimum
washout period of 8 days was observed before the Tru-cut biopsy).
Other exclusion criteria were a history of thrombophlebitis requiring
anticoagulant treatment, retinopathy, cutaneous allergy to alcohol
or mammary dermatitis contraindicating the application of a gel.
[0089] Patients were randomized to one of five treatment groups:
0.5 mg/d 4-OHT (0.5 ml gel [0.25 mg 4-OHT] applied to each breast
daily); 1.0 mg/d 4-OHT (1 ml gel [0.5 mg 4-OHT] applied to each
breast daily); 2.0 mg/d 4-OHT (2 ml gel [1.0 mg 4-OHT] applied to
each breast daily); oral tamoxifen (20 mg/d as a single dose) or
no treatment (untreated control). Patients were scheduled for tumor
resection surgery with curative intent between day 15 and day 22
after the start of treatment. On the day prior to surgery, a blood
sample was also obtained for determination of 4-OHT concentrations.
On the day of surgery, patients were reassessed for concomitant
therapy, concomitant conditions, hematology, biochemistry, plasma
4-0HT, estrone (E1), and estradiol (E2) concentrations.
[0090] Tumor Sampling
[0091] A Tru-cut/core biopsy taken at the first clinic attendance
for diagnostic purposes was used as the pre-randomization tumor
sample. A post-treatment specimen was obtained at definitive surgical
resection. All of the tissue samples were fixed in 3.7% formalin
immediately after removal, then embedded in paraffin wax for sectioning
and subsequent analysis of biological markers. Tumor extracts (before
and after treatment) were also stored in liquid nitrogen for subsequent
assay of estrogen and progesterone receptors, as well as levels
of 4-OHT.
[0092] Analysis of Tumor Marker Expression
[0093] Proliferation-associated Antigen Expression. Ki67 and Proliferating
Cell Nuclear Antigen (PCNA) labeling indices (LI) were assessed
on paraffin embedded sections of the pre- and post-treatment tissue
specimens. The Ki67 antigen was assessed using the monoclonal antibody
MIB 1 (DAKO, Denmark) as used in routine conditions in pathology.
Anti-PCNA (DAKO) completed the panel of antibodies used to analyze
proliferation in fixed tissues. Detection was made without heat
denaturation. Six serial sections were analyzed per case in order
to standardize sampling. Analysis was performed with a computer
assisted system. (Systme microphotomtrique balayage automatique;
Samba-Alcatel, Grenoble, France). For each preparation, optical
density (OD) thresholds were determined using real microscopic images
of the analyzed field as reference. Measurements of immunostaining
were performed at .times.25. Twenty fields were analyzed for each
section. Stained nuclear surface was determined (segmentation and
thresholding) and a LI scored (stained cells/counterstained elements).
OD immunostaining was expressed in arbitrary units. Control of immunostaining
quantitative analysis and reproducibility of the procedure were
performed:--by comparison to iterative measurements done on the
same preparations,--by comparison to measurements compiled on six
sequential sections of the same specimen. Evaluation of tissue variations
in immunostaining quantitative analysis was performed by comparing
the OD immunostaining measurements of 20 fields taken from nonconsecutive
sections from each specimen. The intensity of PCNA immunoreactivity
displayed by actively proliferating cells in lymph nodes (centroblasts)
served as a reference for thresholds positive staining in breast
tissues. Results were expressed as LI.
[0094] Estrogen and Progesterone Receptor Expression. Estrogen
(ER) and progesterone (PgR) receptor concentrations were assayed
in tumor tissue before and after treatment with either ligand binding
assay (LBA) using the Dextran-Coated Charcoal method (Korenman,
1974) and/or by immunohistochemical (ICH) method on paraffin-embedded
sections. The cut-off for ER positivity was more than 10 fmol/mg
measured using radioimmunoassay or more than 10% of tumoral cells
labeled by an immunoenzymatic assay (Bevitt, 1997).
[0095] 4-OHT Assay. Concentrations of 4-OHT in plasma, tumor tissue,
and normal tissue were performed using Gas Chromatography (GC) combined
with Mass Spectrometry (MS) used in the Negative Ion Chemical Ionization-mode
(NICI) (Girault, 1993). The quantification limits of the method
were 5 pg/ml for the plasma and 50 pg/g for tissue samples respectively.
Tumor extracts and normal breast tissue obtained at the time of
surgery (after treatment) were stored in liquid nitrogen until subsequent
assay of 4-OHT.
[0096] Statistical Analysis
[0097] Based on the planned sample size of 14 patients in the control
group and 42 patients (3 groups) assigned to 4-OHT gel, this study
had good power (90%) to detect a hypothesized 50% greater relative
decrease in Ki-67 labeling index in the 4-OHT group than in the
no treatment group using a two-sided test with 5% type I error.
The primary efficacy endpoint was change in tumor proliferation
marker expression. Other study variables were considered secondary
endpoints. This "per protocol" analysis included only
those who received at least 13 days of treatment, completed the
end of treatment assessment for the primary endpoint, and had no
significant protocol deviations or violations.
[0098] Treatment group comparisons were made using analysis of
variance (ANOVA). The Kruskal-Wallis test was used in cases where
the distribution of the data was non-symmetric/non-normal. Categorical
variables were analyzed using Fisher's exact test. Hypothesis testing
was conducted at the .alpha.=0.05 significance level adjusted for
multiple comparisons. Inferences fell into the following categories
for the variables measured:--testing for differences among the five
treatment groups;--examining differences among the three dose levels
of 4-OHT;--examining differences between each dose level of 4-OHT
and oral tamoxifen.
[0099] Results
[0100] Patient Characteristics. A total of 55 patients were enrolled
in the trial. Six patients were excluded from the analysis: one
(in the 4-OHT 1.0 mg/d group) withdrew her consent, one (0.5 mg/d)
was lost to follow-up, one (2.0 mg/d) was estrogen receptor negative
at the start of the study, one (0.5 mg/d) received hormone replacement
therapy, and two (0.5 and 1.0 mg/d) discontinued their treatment
after only 6 and 12 days. Therefore, a total of 49 patients were
evaluable for efficacy. Groups were well balanced with respect to
tumor size, duration of amenorrhea, and tumor grade at surgery.
Patients in the untreated control group were older than those in
the active treatment groups (Table 7).


text:
Product: Fedrigoni Freelife Series, a type of paper that is certified for a long life.
Problem: PrismPapyrus wanted to convey the availability and the characteristics of this paper to its existing and prospective clients. But they only had a budget of $1500 to do this. The limited budget put mass media out of the equation. So this is how we did it.
Solution: We sent their clients a DIY direct mailer, printed on the Fedrigoni Freelife paper, of course. It let them create little paper models of endangered species that they could put on their desks and thus preserve them for a long time. The DM did its job and conveyed the long-lasting character of the paper in the most interesting manner.
Results: There was a sharp surge in the inquiries for Fedrigoni Freelife Series and nearly 30% of those resulted in sales for PrismPapyrus.
Direct advertisment created by Eleven, India for Prism Papyrus, within the category: Office Equipment.
Founder Director: Prateek Bhardwaj
Creative Directors: Abhishek Dey, Sambit Mishra, Virendra Tivrekar
Art Directors: Virendra Tivrekar, Sanjog Karulkar
Copywriter: Saurabh Sawant
Photographer: Farzan Randelia
Illustrator: Sachin Kondhalkar
Director: Sarfaraz Patel
Brand Manager: Abbas Sikandar
Wow really a nice and effective work. Kudos fellas.
Love creating ads..
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