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• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/13—Amines
  • A61K31/135—Amines having aromatic rings, e.g. ketamine, nortriptyline
  • A61K31/138—Aryloxyalkylamines, e.g. propranolol, tamoxifen, phenoxybenzamine
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
  • A61K47/30—Macromolecular organic or inorganic compounds, e.g. inorganic polyphosphates
  • A61K47/36—Polysaccharides; Derivatives thereof, e.g. gums, starch, alginate, dextrin, hyaluronic acid, chitosan, inulin, agar or pectin
  • A61K47/38—Cellulose; Derivatives thereof
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0012—Galenical forms characterised by the site of application
  • A61K9/0014—Skin, i.e. galenical aspects of topical compositions
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/06—Ointments; Bases therefor; Other semi-solid forms, e.g. creams, sticks, gels
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P35/00—Antineoplastic agents
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P35/00—Antineoplastic agents
  • A61P35/04—Antineoplastic agents specific for metastasis
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P5/00—Drugs for disorders of the endocrine system
  • A61P5/24—Drugs for disorders of the endocrine system of the sex hormones
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P5/00—Drugs for disorders of the endocrine system
  • A61P5/24—Drugs for disorders of the endocrine system of the sex hormones
  • A61P5/30—Oestrogens
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P5/00—Drugs for disorders of the endocrine system
  • A61P5/24—Drugs for disorders of the endocrine system of the sex hormones
  • A61P5/32—Antioestrogens

Definitions

• the present invention relates to the reduction of breast density with 4-hydroxy tamoxifen (4-OHT). It also relates to improvements in mammographic sensitivity and to reductions in breast cancer risks that attend a reduction in breast density.
• the density of a patient's breast tissue depends on the relative proportions of adipose tissue (fat), connective tissue and epithelial tissue.
• Adipose tissue is the least dense of these three, while connective tissue and epithelial tissue are relatively dense.
• breast density is directly proportional with connective and epithelial tissue content.
• Overall breast composition can range from tissue composed entirely of fat, to tissue predominated by diffuse and/or nodular densities.
• breast density inversely correlates with age, postmenopausal status, number of births, and declining body weight.
• These correlations suggest that histologic changes associated with breast density are under hormonal control. Indeed, women who have dense breasts, as determined by mammography, have higher serum estrogen concentrations than women with less dense breasts.
• estrogen replacement therapy is associated with increased breast density in postmenopausal women (Leung et al., 1997; Saftlas et al., 1987; Jenks et al., 1994; Kaufman et al., 1993).
• Dense breast tissue carries at least two important health implications. First, it is one predictor of breast cancer risk (Wolfe, 1976). In fact, studies have shown that high mammographic breast density indicates a 4- to 6-fold increased risk of breast cancer (Byrne et al., 1997; Boyd et al., 1992, 1995). The association between breast density and breast cancer risk appears to stem from increased stromal and epithelial cell proliferation in dense breast tissues.
• a second important implication of dense breast tissue is that it affects mammographic sensitivity (Kerlikowske et al., 1996; Ma et al., 1992). This is critical because of current widespread reliance on mammography for cancer detection. Less dense breast tissue, which is dominated by adipose tissue, is easy to assess with mammography, while denser breast tissue is more difficult to assess. On a mammogram, denser breast tissue, such as glands and connective tissue, appears white, while fat appears black. Tumors also appear white on a mammogram. Thus, dense, but normal, breast tissue surrounding a tumor can mask the tumor's presence.
• HRT hormone replacement therapy
• This approach to reducing breast density has obvious drawbacks.
• Tamoxifen' s effects on the breast are primarily anti-estrogenic, and mammographic patterns of density appear to be altered by oral tamoxifen.
• studies have demonstrated a significant change toward a less dense mammographic pattern in the contralateral breasts of postmenopausal breast cancer patients treated with 20 mg/day tamoxifen (Atkinson et al., 1999; Brisson et al., 2000). More dramatic reductions occur in premenopausal patients, who tend to have more dense breasts (Son et al., 1999). Son et al.
• Tamoxifen has significant drawbacks in this context. Its action potentially impacts on every estrogen receptor 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 disturbances, including cataracts. Additionally, patients treated with oral tamoxifen reported having hot flashes, vaginal discharge, depression, amenorrhea, and nausea (Fentiman 1986; Fentiman 1988; Fentiman 1989; Ibis 2002).
• the present invention contemplates reducing breast density by administering 4- hydroxy tamoxifen.
• This treatment approach preferably implemented topically, improves mammographic sensitivity and reduces the risk of breast cancer. It offers several advantages over other methods for reducing breast density, such as (1) fewer systemic side effects, (2) a better safety profile, and (3) easy patient compliance.
• 4-hydroxy tamoxifen may be administered by any means that delivers it to estrogen receptors 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.
• 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.
• a broad range of topical formulations are suitable for performing the invention, but hydroalcoholic solutions and hydroalcoholic gels are preferred.
• concentration of 4- hydroxy tamoxifen in these formulations may vary, but a dose should result in local 4- hydroxy tamoxifen concentrations that effectively oppose estrogenic driven effects.
• Figure 1 illustrates the mean plasma concentration of 4-hydroxy tamoxifen in healthy women following cutaneous administration.
• an important aspect of the present invention resides in the discovery that 4- hydroxy tamoxifen effectively reduces breast density, particularly when administered percutaneously. Moreover, it has been discovered that 4-hydroxy tamoxifen provokes fewer unwanted side effects than do other methods for reducing breast density.
• Dense breast tissue is easily recognized by mammography. It appears white, whereas non-dense tissue appears dark. Dense breast tissue may be diffuse throughout the breast, or may be nodular.
• the American College of Radiology (ARC) has developed a system for classifying breast composition, based on density. Four categories exist in the system:
• Class I Class I breasts are almost entirely fatty. Mammography is very effective for this class, and is sensitive to even small tumors. Breast cancer risks are smaller for patients with such breasts.
• Class II Class II breasts contain scattered fibroglandular tissue. A minor decrease in mammographic sensitivity results in slightly higher risks for this class.
• Class III Class III breasts contain heterogenously dense tissue. There is a moderate decrease in mammographic sensitivity for this class, and more elevated breast cancer risks.
• Class IN Class IN breasts contain extremely dense tissue. There is a marked decrease in mammographic sensitivity and a higher risk for breast cancer in this class.
• the present invention is useful for reducing densities in all radiological classes. Preferably, it is applied to treating breasts in classes II-IN, and more preferably to treating breasts in classes III-IV.
• the compound 4-hydroxy tamoxifen, or l-[4-(2- ⁇ -dimethylaminoethoxy)phenyl]-l- (4-hydroxyphenyl)-2-phenylbut-l-(Z)-ene constitutes an active metabolite of the well characterized anti-estrogen compound, tamoxifen.
• the trans isomer is preferred.
• 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). Trans 4- hydroxy tamoxifen inhibits the growth in culture of normal human epithelial breast cells 100 fold more than trans-tamoxifen (Malet et al., 1988).
• SERM selective estrogen receptor modulator
• 4-hydroxy tamoxifen is a tamoxifen metabolite, its usefulness for reducing breast density is not presaged by previous experience with tamoxifen itself. Tamoxifen is extensively metabolized by cytochrome P-450 in humans. 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.
• 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, 1988).
• 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 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 ⁇ /., 1993).
• Stage 2 Separately from stage 1, formation of l-(4-hydroxyphenyl)-2-phenyl-l- butanone by hydroxylation of 1,2-diphenyl-l-butanone; Stage 3 - Reaction between the products of stages 1 and 2 to form l-(4- dimethylaminoethoxyphenyl)-l-[p-2-tetrahydropyranyloxy)phenyl]-2-phenylbutan- l-ol;
• 4-hydroxy tamoxifen may be administered in any dosage form and via any system that delivers the active compound to estrogen receptors in vivo, preferably to breast estrogen receptors.
• 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.
• Percutaneous administration of 4-hydroxy tamoxifen offers several advantages. First, it avoids the hepatic metabolism that occurs subsequent to oral administration
• 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.
• 4-hydroxy tamoxifen 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.
• 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).
• 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.
• the breast tissue to plasma ratio of 4-hydroxy tamoxifen following oral administration of tamoxifen is about 5:1.
• 1.5 mg/breast/day should achieve the desired result, with doses of about 1.0 mg/day, 1.5 mg/day and 2.0 mg/day (0.5-1.0 mg/breast/day) being preferred.
• 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.
• 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 contain 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, fatty alcohols and related molecules, pyrrolidones, urea, and essential oils.
• 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.
• 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 contain one or more penetration enhancers. Alcohols are preferred enhancers because 4-hydroxy tamoxifen is soluble in alcohol. Isopropyl myristate also is a preferred enhancer.
• 4-Hydroxy tamoxifen may be delivered in an ointment, cream, gel, emulsion (lotion), powder, oil or similar formulation.
• 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, glycerol, glycerol ethers, glycols, glycol ethers, polyethylene glycol, polypropylene glycol, non-volatile fatty alcohols, acids, esters, volatile alcoholic compounds, urea, talc, cellulose derivatives, and preservatives.
• vegetable oils such as almond oil, olive oil, peach kernel oil, groundnut oil, castor oil and the like
• animal oils DMSO
• preferred formulations contain 4-hydroxy tamoxifen in a hydroalcoholic gel.
• the amount of 4-hydroxy tamoxifen per 100 grams of gel may range from about 0.001 gram to about 1.0 gram. Preferably, it ranges from about 0.01 gram to about 0.1 gram.
• Table 1 describes the composition of two highly preferred 4- hydroxy tamoxifen gel formulations.
• 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.
• 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.
• 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 trans to the cis 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.
• the percentage of radioactivity identified as [ 3 H] -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 trans isomer into the cis isomer occurred, with similar percentages observed at day 7 (32% and 33%).
• the 4-hydroxy tamoxifen gel (20 mg of 4-hydroxy tamoxifen/100 g of hydroalcholic gel; Besins-Iscovesco 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).
• GC-MS gas chromatograph mass spectrometry
• CBC complete blood counts
• bilirubin serum glutamic-pyruvic transaminase
• SGOT serum glutamic-oxaloacetic transaminase
• alkaline phosphatase creatinine, estradiol, follicle-stimulating hormone (FSH), lutenizing hormone (LH), sex hormone-binding globulin (SHBG), cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides, fibrinogen, and anti-thrombin III.
• FSH follicle-stimulating hormone
• LH lutenizing hormone
• SHBG sex hormone-binding globulin
• cholesterol high-density lipoprotein
• LDL low-density lipoprotein
• triglycerides fibrinogen, and anti-thrombin III.
• Table 4 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.
• 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.
• 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.
• 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. 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.
• SD standard deviation
• Timepoint 0 is 24 hours after the application on Day 24 and prior to the final application on Day 25.
• Figure 1 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.
• Table 7 Mean Pharmacokinetic Parameters of 4-hydroxy tamoxifen in Healthy Women Following the Last Administration
• 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.
• Example 4 Study to Demonstrate Efficacy for Percutaneous 4-Hydroxy Tamoxifen in Reducing Mammographic Density of Breast Tissue
• the primary objective of this study is to demonstrate that 4-hydroxy tamoxifen, when administered percutaneously, effectively reduces the mammographic density of breast tissue.
• IBIS-I International Breast Cancer Intervention Study
• J ⁇ CI J ⁇ CI 86: 578-80 (1994).

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