# Patent

## Title
Medication against breast cancer and related diseases

## Abstract

The present invention relates to novel uses of a steroid compound, which specifically binds to the androgen receptor (AR) but which is not metabolized by aromatase to a process for their preparation, to pharmaceutical compositions containing them, and to the use of said compounds for the prophylaxis and/or treatment of hormone-dependent or hormone receptor regulated cancers in mammals.

## Background
This is a National Phase Application in the United States of International Patent Application No. PCT/EP2007/004221 filed May 11, 2007, which claims priority on European Patent Application No. 06 009 894.4, filed May 12, 2006 and U.S. Provisional Application No. 60/747,124, filed May 12, 2006. The entire disclosures of the above patent applications are hereby incorporated by reference.


BACKGROUND OF THE INVENTION
1. Field of the Invention
The present invention relates to novel uses of 4,17β-dihydroxyandrost-4-ene-3-one (hereinafter 4-hydroxytestosterone) and its salts and esters, to a process for their preparation, to pharmaceutical compositions containing them, and to the use of said compounds for the prophylaxis and treatment of certain diseases in mammals, in particular cancers.
2. Discussion of the Related Art
After colorectal cancer breast cancer is the most frequent cancer disease in the western world despite the fact that it affects almost exclusively women. In Germany, breast cancer amounts to about 20% of all cancer types diagnosed in women. The therapy in most of the cases consists of surgical removal of the tumour (lumpectomy) or complete removal of the affected breast if the size of the tumor prevents breast conserving therapy. In both cases the operation is followed by drug therapy. A particular complication of breast carcinomas is the high potential of metastatic spread into other organs particularly liver, brain, bones and the skin. Therefore the operation is followed by drug therapy (adjuvant therapy). This therapy is also aimed at preventing local recurrence of the disease.
If the removed tumors were exhibiting estrogen receptors, antiestrogens are used (Tamoxifen or aromatase-inhibitors. The lack of estrogen receptors leads to a postoperative drug therapy using cytostatic drugs.
Tamoxifen binds to the estrogen receptor (ER) and blocks the growth promoting effect of estrogens. Aromatase-inhibitors block the final step in the production of estrogens from androgenic precursors (c-19-steroids). They either bind irreversibly to the active site of the enzyme (aromatase-inactivators, i.e. steroidal aromatase-inhibitors: 4-hydroxyandrostenedione (Formestane=LENTARON®), or Exemestane (AROMASIN®)) or inhibit competitively the cytochrome p 450 part of the enzyme (nonsteroidal aromatase-inhibitors: Anastrozol (ARIMIDEX®) and Letrozol (FEMARA®).
If the breast cancer exhibited an overexpression of the Her2neu gene, antibodies against this cell-surface protein are given intravenously such as e.g. Trastuzumab (HERCEPTIN®).
Basic and clinical data indicate that aromatized metabolites of androgens, i.e. the estrogens, are the hormones involved in the pathogenic cellular changes associated with the growth of some hormone-dependent cancers, such as breast, endometrial and ovarian carcinomas. Aromatase has recently been recognized as an enzyme that is capable to synthesize estradiol directly in tumours.
Endogenous estrogens are ultimately formed from either androstenedione or testosterone as immediate precursors. The local production of estrogens in the breast tissue, especially in the tumour cells itself, had been regarded to be of great importance for the therapy of the disease. In this context, aromatization of the steroidic ring A performed by the enzyme aromatase, and its inhibition had been considered to play a major role in anti breast cancer approaches.
Prior to the present invention, conventional therapeutic approaches to address breast cancer in women—besides other concepts based on estrogen receptor antagonists or therapeutic antibodies—therefore focused on an aromatase-inhibiting action itself. Accordingly, steroidal substances which had been reported to be endowed with an aromatase-inhibiting action have been described, for example Δ1-testololactone [U.S. Pat. No. 2,744,120], 4-hydroxy-androst-4-ene-3,17-dione and esters thereof [see, for example, U.S. Pat. No. 4,235,893], 10-(1,2-propadienyl)-estr-4-ene-3,17-dione (U.S. Pat. No. 4,289,762], 10-(2-propynyl)-estr-4-ene-3,17-dione [J. Amer. Chem. Soc., 103, 3221 (1981) and U.S. Pat. No. 4,322,416], 19-thioandrostene derivatives (Europ. Pat. Appl. 100566), androsta-4,6-diene-3,17-dione, androsta-1,4,6-triene-3,17-dione [G.B. Pat Appl. 2,100,601A] and androsta-1,4-diene-3,17-dione [Cancer Res. (Suppl.) 42,3327 (1982)].
Clinical studies conducted with estrogen-receptor (ER) antagonists and aromatase inhibitors however showed that these compounds were not able to exert a significant and sufficient inhibitory effect on tumour proliferation and/or growth. For example, TAMOXIFEN® based therapy suffers from drawbacks such as tachyphylaxy (therapy failure) and the fact that its effects in some cells are estrogen-like (e.g. risk for thrombosis and edometrial cancer) being the reason that TAMOXIFEN® can not be administered for a period longer than 3 to 5 years. Newer drugs such as aromatase inhibitors can in principle only be used in post-menopausal women and, furthermore, are only effective on ER-positive tumours. Estrogen receptor negative tumors have a worse prognosis and can be postoperatively only treated by cytostatic drugs and in some cases by intravenously given antibodies to the Her2neu antigen. “Hormonal” treatment with selective estrogen receptor modulators (SERMs) such as tamoxifen or raloxifen or aromatase-inhibitors has proven to be ineffective. “Hormonal” treatment is lifelong and usually well tolerated. There is no “hormonal” treatment for ER-negative breast cancers so far.
It could be shown (J. Szelei et al., “Androgen-Induced Inhibition of Proliferation in Human Breast Cancer MCF7 Cells Transfected with Androgen Receptor”, Endocrinol., 138, no. 4, 1406-1412, 1997) that stable transfected cells expressing AR acquire the ability to respond to androgen by evoking an end of cellular proliferation. A more recent report (J. Ortmann et al., “Testosterone and 5α-dihydrotestosterone inhibit in vitro growth of human breast cancer cell lines”, Gynecol. Endocrinol. 2002; 16:113-120) shows that testosterone and 5α-dihydrotestosterone (DHT) can inhibit cell proliferation in certain cell lines. Testosterone itself has a similar effect. It clinical usefulness however is hampered by the fact that it undergoes rapid metabolization to either estradiol or dihydrotestosterone (DHT). The local formation of estradiol from testosterone within the breast cancer by local aromatase activity promotes cancer-growth.
On the other hand, AR itself had been regarded as a modulator of processes involved in differentiation, homeostasis, and development of male secondary characters. Thus, AR-directed treatment schemes had been focused on androgen-related diseases in men, including hypogonadism, male infertility, prostate cancer, delay of puberty, hirsutism, androgen-deficient diseases, androgen replacement in aging men, and male pattern baldness. In this context, a disclosure of U.S. Pat. No. 2,762,818A does not go beyond using 4-hydroxytestosterone and its esters, based on their androgenic and anabolic properties, to treat an androgen deficiency status itself. There was however neither a purpose nor a finding which would suggest an activity on breast cancer cells or on effects from which an efficacy against the disease conditions according to the present invention could have been deduced. Further, US2003/0229063A addresses low androgen to estrogen ratios in men (leading to endocrine disorders) and only for this purpose attempts to make use of 4-hydroxytestosterone based on an asserted aromatase-inhibiting effect alone.
In WO 2005/062760 incorporated herein in its entirety by way of reference, possible roles of androgen receptor (AR) in prostate carcinogenesis and breast cancer is discussed, and methods for breast cancer diagnosis by assaying the presence of AR are presented. However, in terms of therapeutic concepts, WO 2005/062760 is limited to control AR itself, not androgen mediated activity, in the context of mammary gland development by inhibiting AR activity.
For certain indications, the present invention now provides successful other therapeutic approaches involving androgen-receptor (AR) specific compounds that exert testosterone-like effects (in particular anabolic effects) in AR-positive cells and tissues and are not metabolized by aromatase.
SUMMARY OF THE INVENTION
According to the present invention, it was found that if a correlation between steroid compounds having specific affinity to the androgen receptor (AR) and a certain receptor status of target cells is met, a surprising efficacy for specifically devised therapeutic treatments can be achieved. Useful prophylaxis for corresponding disease conditions is likewise provided.
Thus, in an embodiment the present invention involves the use of a steroid compound, which specifically binds to the androgen receptor (AR) and preferably has a high affinity to AR but which is not metabolized by aromatase or 5-alpha reductase, for treating a patient in a therapy, or for a prophylaxis in a condition selected from the group consisting of breast cancer, endometrial carcinoma, cervix carcinoma, epithelial ovarian ovarian carcinoma, uterine (fallopian) carcinoma, benign proliferative change or alteration of the breast, fibroadenoma, macromastia (peri-postmenopausal), mastopathy, myoma, and secondary or metastatic tumors derived therefrom, and shrinking breast tissue; wherein the patient has AR positive target cells or target tissue.
In the aforementioned embodiment, the patient may have estrogen receptor (ER) positive or estrogen receptor (ER) negative target cells or target tissue.
According to another embodiment of the present invention, the same compound specifically binding to and preferably having high affinity to the androgen receptor (AR) is used in the therapy or prophylaxis of the same disease conditions, wherein however the patient has ER negative target cells or target tissue.
The concept of the present invention can be combined to provide even better therapeutic prospects, i.e. in cases where the patient has AR positive and ER negative target cells or target tissue.
If not known from other information or data, receptor status of target cells or target tissues with respect to AR and/or ER can be determined and, if desired, quantified by standard methods known to the person skilled in the art, including immunoassays involving AR- and/or ER-specific antibodies, DNA and/or RNA hybridization assays or PCR amplification tests involving AR- and/or ER-specific nucleic acid probes.
The compounds according to the invention shall be used in amounts therapeutically and/or prophylactically effective against the indicated disease conditions. “Use” according to the present invention may include method of treatment or prophylaxis of the specified compounds, or of a pharmaceutical composition containing the same as an active principle together with a suitable carrier and/or diluent, for the described indications, and it includes use in the preparation of said pharmaceutical composition.
Based on the disclosed concept of the invention, there are also provided preferred treatment or prophylaxis schemes involving the use of the compounds of the invention per se, i.e. even independently from knowing the receptor stats in advance. This is because some prior art treatment schemes of breast cancer or related diseases typically presupposed the presence of ER positive target cells. While this may be assumed for a majority of breast cancer cells, there is generally a risk of ER negative cells being present which are not susceptive for effective treatment. Further there is a general risk of formation of metastatis derived from the primary cancers especially in cases where ER negative cancer cells were not successfully treated during treatment phase. Since compounds of the present invention have been demonstrated to be active against ER negative cancer cells and tissues, new treatment modalities are opened, and they can be used with higher safety. Thus, in certain embodiments of the present invention the compounds disclosed herein are provided for medical use, independent of the receptor status, in particular:
(i) Application in a topical administration form, especially at the site of the body affected by the disease to be treated or to be of interest prophylactically. This mode of administration allows to benefit from the direct action via AR in the target cells and tissues, contrary to an effect via a decrease of gonadotropin secretion (gonadotropins may even promote cancer growth by enhancing local estrogen production also in the tumour).

(ii) Treatment or prophylaxis of postmenopausal women (which are particularly prone to hormone-dependent disorders, and therefore for prophylaxis, or treating recurrence of breast cancer; or of osteoporosis). Here again, the compounds of the present invention can exert the desired effects locally.

(iii) Use for therapeutic or prophylactic indications of, alone or in combination:

    
    
        ductal, medullary and lobular breast carcinoma (in particular contralateral breast cancer, and/or in combination with the aforementioned topical administration);
        adjuvant and in particular neoadjuvant breast cancer treatment;
        shrinking of breast cancer tissue;
        prophylaxis against recurrency or remission of breast cancer;
        skin metastases derived from breast cancer (in particular in combination with the aforementioned topical administration).
    
    


Treatment or prophylaxis of these specific indications benefit from the particular mode of activity of the compounds disclosed herein.



BRIEF DESCRIPTION OF THE DRAWINGS
FIGS. 1A, 1B and 1C, graphically depict results relating to the inhibition of MCF-7 cell proliferation for compound concentrations of 10−7 M, 10−8 M and 10−9 M of either DHT or 4-OHT, respectively, as compared with a control.



Particulars of the compounds to be used according to the invention will be described in more detail.
The steroid compounds are required not to be metabolized by aromatase or 5-alpha-reductase. Possible compounds satisfying these requirements are non-aromatizable steroidal compounds and non-steroidal compounds specifically binding to AR, respectively. Although not being bound to any theory, various circumstances detrimental to the concept of the present invention could be attributed, if the compound was aromatizable by aromatase. First, cellular mechanisms invoked by the presence of such a substrate could lead to an upregulation for enhanced expression of the aromatase enzyme and thus to an increased aromatase level at the critical target tissue site. Second, aromatization of the compound bound to steroid-receptors in the cancer could lead to a compound exhibiting estrogen-like growth promoting activities. Third the resulting compound could diminish desired activities via the AR.
Further, the compounds are required to specifically bind to AR. The compound used according to the present invention preferably has a high binding affinity to the androgen receptor (AR), i.e. having affinity specific to AR in a range of IC50≦500 nM, preferably IC50≦100 nM and more preferably IC50≦50 nM, wherein IC50 is defined as the concentration of the compound required to reduce specific binding of a reference compound, 5α-dihydrotestosterone (DHT), by 50%. The IC50—values can be determined by known methods using radioactively labelled DHT as reference compound, for example by a standard dextran-coated charcoal adsorption method as described by Raynaud et al., J. Steroid Biochem. 6, 615-622 (1975), using 1 nM reference concentrations of radiolabeled [3H]-DHT, or by similar IC50 determination methods described in the literature. Because the concentration of AR in the target cell is very low, typically in the nanomolar range approximately, differences in binding constants to the order contemplated in the present invention are significant.
In consideration of both requirements, the compounds therefore preferably share a common C-19 steroid structure, more preferably an androst-4-en-17-ol-3-one structure, wherein the structure of the compound may be further defined by a 1-en double bond and/or a substituent bonded to the 17-ol (hydroxyl) group.
In a particular embodiment of the present invention, the compound is selected from compounds having the following formula:




wherein
a, b and c respectively denote, independently from each other, a single bond or a double bond;
R1 is hydrogen or C1 to C6 alkyl;
R2 is hydrogen or OR5, wherein R5 is hydrogen or C1 to C6 straight chain or branched alkyl;
R3 is, in case of c being a single bond, hydrogen or C1 to C6 alkyl, or in case of c being a double bond, CHR5, wherein R5 is the same as defined before;
R4 is hydrogen, C1 to C6 alkyl, phenyl unsubstituted or substituted by C1 to C6 alkyl, COR6 acyl group (R6 being hydrogen; C1 to C6 straight chain or branched alkyl; phenyl or benzoyl respectively unsubstituted or substituted by C1 to C6 alkyl), or any group leading to hydroxyl upon biological metabolization or chemical deprotection;
and pharmaceutically acceptable salts thereof.
In terms of a preferable consistency of being surely not aromatized, yet ensuring strong affinity to AR, compounds are preferably selected wherein b is a double bond, R2 is hydrogen or hydroxyl and/or R3 is methylene group, and R4 is hydrogen, C1-C6 alkyl or C1-C6 acyl group. Particularly preferred are 4,17β-dihydroxyandrost-4-en-3-one (4-hydroxytestosterone) (wherein a is single bond, b is double bond, R2 is OH and R4 is hydrogen) and 17β-hydroxy-6-methylenandrost-1,4-diene (wherein a and b are double bonds, R2 and R4 respectively are hydrogen) and the corresponding esters (such as R4 denoting COR6 acyl group as defined) and salts.
Compounds of the present invention also include those which are metabolized to the above-defined compounds. For example, androst-3,17-dione structures (having 4-en- or 1,4-dien-bonds and optionally 6-methylene group) are included as progenitor compounds which upon metabolization in the body are metabolized to corresponding androst-17-ol-3-one structures.
Moreover, it preferred that compounds are used which have predominantly anabolic activities on target cells, rather than mere androgenic effects. Further preferable are compounds which also display apoptotic effects on target cells.
It has been devised that such properties can further contribute to a prophylactic and/or therapeutic efficacy against breast cancer and related disorders.
Although EP0307135A may partly disclose some compounds which may fall under the aforementioned formula, its therapeutic concept deal with aromatase inhibition alone or, if related to a possible androgenic activity, with an inhibitory effect on estrogen biosysnthesis through a decrease in gonadotropin secretion (i.e. systemic effects, necessitating actions via generative glands, ovaries, LH-associated effects and the like). The concepts of the present invention however differ, and thus compounds are selected by distinctly different selection criteria in terms of effects exerted directly at the site of interest by considerations directed to, alone or in combination, receptor status of target cells or tissues; mode of administration; patient group; and certain indicated disease or prophylactic conditions.
The compounds of the present invention exhibit androgen-receptor (AR) binding affinity. In most cells, except breast cancer cells they are capable of inducing an anabolic effect, provided they exhibit AR. In breast cancer cells they induce apoptosis. These compounds are neither substrates for nor metabolic products from aromatase and thus do not share the negative effects of substances being metabolized by aromatase. Furthermore, the compounds of the present invention are not substrates for 5α-reductase. As these substances cannot be that easily metabolised as, for example, testosterone, their inhibitory effect on the tumour cell is greatly facilitated and they additionally exert an apoptotic effect on the tumour cell itself. Therefore, these substances are presumably more efficient in the treatment of breast cancer cells than the line of currently used substances to treat both types of breast cancer. Another beneficial effect of this prophylactic or therapeutic concept is that even in estrogen receptor negative (ER-negative) tumours there is a high probability of the cells to be AR-positive and therefore even these tumours currently treated only with cytostatic drugs can be pharmacologically addressed by 4-hydroxytestosterone, thereby increasing the range of hormonal breast cancer therapy significantly.
Since the compounds of the present invention are AR specific compounds, but are not metabolized by aromatase, they can fully exert their actions and effects associated with the specifically defined therapeutic or prophylactic uses via AR. This makes the concept of the presently selected compounds distinct over the prior art.
In experiments carried out with the compounds of the present invention it could be shown that these substances had excellent skin penetration capabilities so that a sufficient tumour inhibition could be achieved by simple topic administration of e.g. an ointment, lotion or cream etc. comprising a therapeutically or prophylactically effective amount of a compound according to the present invention to an area of a patient in need of treatment. After topical administration, the compound(s) penetrate through the skin and concentrate in the fatty tissue.
In the case of breast cancer, the medicament can be applied locally to the skin, such that the preferably strongly lipophilic active compound is transdermally absorbed and thus brought locally to the intended site of action. The active compound concentrates in the periductal fatty tissue. In a long-term treatment, the fatty matter of the treated breast is markedly reduced. This reduction decreases the quantity of oestrogen-forming cells having oestrogen-forming competence. The lipophilicity and hydrophobicity of the active compound has the result that the active compound is exclusively concentrated locally in the fatty tissue and thus cannot display any significant systemic action.
According to a preferred embodiment of the present invention it is intended to apply the medicament topically immediately on or in the vicinity of the intended site of action. According to the invention, the result achieved is an adequate local active compound level in the tissue at risk (in prophylaxis) or in the diseased tissue (in therapy) without a noticeable absorption of the active compound taking place in the blood circulation. The benefit of this embodiment thus not only relies in the topical application per se, but in the local topical application in such a way that the active compound concentrates immediately in the tissue at risk and/or diseased tissue, and not indirectly via the blood circulation.
Owing to the primary target disease to be treated as described above, especially for breast cancer etc., a local topic treatment or prophylactic application is predominantely carried out with female patients and particularly on breast skin of female patients, although the same therapeutic principle applies also to male breast cancer.
If metastasizing carcinomas are also to be treated and/or prophylaxis is to be carried out against these, the medicament according to the invention can be applied topically to the intended site of action in such an amount that a noticeable absorption in the blood circulation additionally takes place and a serum level thus builds up which also transports the active compound to metastases. In this use too, a local absorption on or in the vicinity of the intended site of action, notably where metastasizing carcinomas exist, also primarily takes place.
An important advantage of the invention is the possibility of also using the medicament for breast cancer prophylaxis. A particularly advantageous possibility of employment is so-called secondary prophylaxis. In female or male patients in whom a breast cancer has been diagnosed and treated, there is a certain risk of recurrence at the same site and also a high risk of a further carcinoma in the contralateral breast. In both cases the endowment of the second cancer with ER is not predictable. The operated and the contralateral breast can then be treated prophylactically with the medicament according to the invention.
It will prevent also the appearance of a ER negative cancer (particularly common in patients suffering from a familiar predisposition for breast cancer).
In the case of so-called high-risk women, primary prophylaxis can be performed. The selection criteria which can be used for such a high-risk group are, for example, the facts that at least one female or male relative of first degree on the mother's side is or has been suffering from breast cancer on one side before the 45th year of life or bilaterally, or that on the mother's side at least one female or male relative of first degree and an additional female or male relative are or have been suffering from breast cancer.
In the majority of theses cases the underlying cause of the disease is a genetic defect in one of the two known “breast cancer genes” BRCA1 and BRCA2.
Since the local application according to a preferred embodiment of the invention virtually completely avoids possible systemic side effects of the active compound on account of its hydrophobicity and high safety profile, the indication for primary prophylaxis can be made relatively generously already in the presence of tissue having a comparatively low or average risk. Prophylaxis can be started long time before signs and symptoms of breast cancer may be occurring.
In the preferred topical administration the compound or composition according to the invention is preferably applied over a relatively long period of time (if needed up to lifelong) and application is carried out, for example, once or twice per day. Since the active substances of the invention intended to be applied topically (locally) are preferably provided in lipid-soluble form, they can easily penetrate into the fatty tissue and locally exert their prophylactic and/or therapeutic effect.
Since the active compounds administered topically according to the invention remain localized in the fatty tissue of the breast and display their intended action there on account of their lipid solubility, any possible side effects induced by systemic application are eliminated. This reduction or exclusion of side effects allows significantly wider prophylactic use. The medicament according to the invention can be applied by patients themselves and frequent visits to the doctor for this purpose are not necessary.
The advantages described above further contribute to the particular suitability of the compounds of the present invention for treating generally breast carcinoma, and more beneficially treating the same by topical administration; contralateral breast cancer; adjuvant and in particular neoadjuvant breast cancer treatment; shrinking of breast cancer tissue; prophylaxis against recurrency or remission of breast cancer; skin metastases derived from breast cancer; and the like conditions.
In particular for topic administration, a medicament formulated according to the invention preferably also contains formestane.
Formestane derivatives such as, for example, acetylated formestane (for example 4-O-acetylandrost-4-ene-3,17-dione) are likewise preferably utilizable. The acetylation of the formestane increases its hydrophilicity and thus skin penetration significantly. Since the acetyl group is hydrolysed under the conditions prevailing in the subcutaneous region after passage through the skin, the actual active compound formestane is formed again in situ. When using such an acetylated formestane, a precursor of the actual active compound penetrating better through the skin is thus applied and it has been recognized that the actual active compound is formed in situ subcutaneously from this precursor.
As a rule for topic administration, the active compounds used according to the invention are lipid-soluble and highly suitable for topical application. As already described above, the concentration in the fatty tissue of the breast avoids systemic side effects. To improve the skin penetration, substances known in the prior art which promote this can be added to the medicament according to the invention, for example Hyaluronidases, Dimethylsorbitol or DMSO (dimethyl sulphoxide).
In particular, the topic administration is mainly indicated for primary prevention (prophylaxis), secondary prevention (prophylaxis) after breast conserving therapy, accompanied by any form of adjuvant drug therapy, after operation for ‘ductal carcinoma in situ’ (DCIS, which is usually not followed by any adjuvant therapy) and prophylaxis of contralateral breast cancer.
Primary prevention relates to the prophylactic treatment of healthy individuals bearing a certain risk to develop cancer. Since the compounds and pharmaceutical compositions of the invention are not a substrate of aromatase and thus cannot be metabolized to estrogens, and are not virilizing, they can also be used in the primary prevention of breast cancer in premenopausal women. In secondary prevention, the compounds and compositions may be used alone or in combination with e.g. Tamoxifen, aromatase inhibitors, herceptine and/or cytostatic drugs, wherein any of such combinations would enlarge the spectrum of treatable cell types.
Thus, the present invention beneficially provides also a combination medication comprising, in common or separate administration forms for simultaneous or subsequent medical use, a compound of the present invention and a substance selected from the group consisting of estrogen-receptor antagonists, aromatase inhibitors different from the compounds of the invention disclosed herein, cytostatics and antibodies against Her2neu.
The concept of “combination medication” according to the present invention includes that the compound according to the invention on the one hand and the other aforementioned substance on the other hand are comprised in one common formulation or administration form, or in separate formulations or administration forms. Correspondingly, the pharmaceutical medication or preparation according to the invention may be embodied by one formulation in the form of a unit composition, or alternatively as “kit-of-part” products sharing the common purpose of being used separately, simultaneously, or sequentially.
The present invention is based on the findings that 4,178-dihydroxyandrost-4-ene-3-one (hereinafter 4-hydroxytestosterone), and compounds similar thereto in view of common structural and functional features as defined above, can successfully be used as a pharmaceutically active substance. In particular, it could be shown that pharmaceutical compositions containing a suitable carrier and/or diluent and, as an active principle, 4-hydroxytestosterone, can be used in the prophylaxis and/or treatment of breast cancer (in particular ductal, medullary and lobular breast carcinoma), endometrial carcinoma, cervix carcinoma, epithelial ovarian carcinoma, uterine (fallopian) carcinoma, benign proliferative change or alteration of the breast, fibroadenoma, macromastia (peri-postmenopausal), mastopathy, myoma, and secondary or metastatic tumors derived therefrom.
Hence, the present invention likewise provides the use of 4,17β-dihydroxyandrost-4-ene-3-one (4-hydroxytestosterone) and similar compounds as defined above in the preparation of a pharmaceutical composition for the (clinical) prophylaxis and/or treatment of the above hormone-dependent or hormone receptor regulated cancers in mammals.
In general, the compounds and pharmaceutical preparations of the invention can be administered topically, orally, rectally, parenterally (e.g. intramuscularly or by intravenous injection or infusion), and/or in the form of a depot preparation.
A particularly preferred compound of the present invention, 4-hydroxytestosterone, is disclosed in e.g. U.S. Pat. No. 2,762,818 A and commercially available (e.g. from Bulk Nutrition, Graham, N.C., USA, WINKOS GmbH D-79189 Bad Krozingen, Del.). The derivatives, in particular salts and esters of the preferred 4,17β-dihydroxyandrost-4-ene-3-one include suitable ester groups, such as straight chain, branched chain or cyclic or aromatic acyl groups like formyl, acetyl, propionyl, butyryl, pentanoyl, hexanoyl, heptanoyl and benzoyl, but are not limited thereto. The esters can be formed with the 4 and/or 17 hydroxy group, preferably with the 17 hydroxy group. Its salts and esters can also be prepared by known methods (see e.g. U.S. Pat. No. 2,762,818 A).
The compounds and pharmaceutical preparations of the invention are anabolic steroids and exert their testosterone-like effects upon binding to androgen receptors displayed in cells and tissues being AR-positive.
In view of their high therapeutic index, the compounds of the invention can be used safely in medicine. For example, the approximate acute toxicity (LD50) of the compounds of the invention in the mouse, determined by single administration of increasing doses and measured on the seventh day after the treatment was found to be negligible.
The compounds and pharmaceutical preparations or compositions of the invention can be administered in a variety of dosage forms, e.g. topically, in the form of an ointment, a cream, a lotion, a gel, a spray, or a transdermal plaster, also comprising depot dosage forms (including pellets), orally, in the form of tablets, capsules, sugar or film coated tablets, liquid solutions or suspensions: rectally, in the form of suppositories; parenterally, e.g. intramuscularly, or by intravenous injection or infusion. According to a preferred embodiment, the compounds of the invention are designed for topical administration.
The dosage depends on the age, weight, conditions of the patient and administration route; for example the dosage adopted for oral administration to adult humans may range from about 10 to about 150-1000 mg pro dose, from 1 to 5 times daily.
The invention includes pharmaceutical preparations or compositions comprising a compound of the invention in association with a pharmaceutically acceptable excipient (which can be a carrier or diluent).
The pharmaceutical compositions containing the compounds of the invention are usually prepared following conventional methods and are administered in a pharmaceutically suitable form.
For topical administration, the medicament is preferably formulated as an ointment, cream, gel, emulsion or lotion. Formulation as a powder or oil is also conceivable. Formulation bases are familiar to the person skilled in the art from the cosmetic and pharmaceutical industry and do not need to be explained here in greater detail. For example, vegetable oils and fats such as almond oil, peanut oil, olive oil, peach kernel oil, castor oil, plant extracts, ethereal oils; furthermore vegetable waxes and synthetic and animal oils, fats or waxes; lecithin, lanolin alcohols, carotene, fragrances, mono- or polyhydric alcohols, urea, preservatives and colourants etc. can be used. Formulation as an oil-in-water or water-in-oil emulsion is preferred.
The active compound content of a suitable medicament can be between 0.0001 and 20% by weight, preferably 0.6% until 10% by weight, further preferably 1 and 5% by weight, of the compound according to the invention. A customary range is 0.6 to 5% by weight.
If substances are admixed to promote skin penetration, their content, when using hyaluronidases, can be, for example, between 0.01 anti 1% by weight, preferably 0.05 anti 0.2% by weight, when using dimethylsorbitol or DMSO between 1 and 25% by weight, preferably 5 and 10% by weight
For example the solid oral forms may contain, together with the active compound, diluents, e.g. lactose, dextrose, saccharose, cellulose, corn starch or potato starch; lubricants, e.g. silica, talc, stearic acid, magnesium or calcium stearate, and/or polyethylene glycols; binding agents, e.g. starches, arabic gums, gelatine, methylcellulose, carboxymethylcellulose or polyvinyl pyrrolidone; disaggregating agents, e.g. a starch, alginic acid, alginates or sodium starch glycolate; effervescing mixtures; dyestuffs, sweeteners; wetting agents, such as lecithin, polysorbates, laurylsulphates; and, in general, non-toxic and pharmacologically inactive substances used in pharmaceutical formulations. Said pharmaceutical preparations may be manufactured in known manner, for example, by means of mixing, granulating, tabletting, sugar-coating, or film-coating processes. The liquid dispersions for oral administration may be e.g. syrups, emulsions and suspensions.
The syrups may contain as carrier, for example, saccharose or saccharose with glycerine and/or mannitol and/or sorbitol.
The suspensions and the emulsions may contain as carrier, for example, a natural gum, agar, sodium alginate, pectin, methylcellulose, carboxymethylcellulose, or polyvinyl alcohol.
The suspensions or solutions for intramuscular injections may contain, together with the active compound, a pharmaceutically acceptable carrier, e.g. sterile water, olive oil, ethyl oleate, glycols, e.g. propylene glycol, and if desired, a suitable amount of lidocaine hydrochloride.
The solutions for intravenous injections or infusions may contain as carrier, for example, sterile water or preferably they may be in the form of sterile, aqueous, isotonic saline solutions.
The suppositories may contain together with the active compound a pharmaceutically acceptable carrier, e.g. cocoa-butter, polyethylene glycol, a polyoxyethylene sorbitan fatty acid ester surfactant or lecithin.
In cases where the target tumour is estrogen-receptor (ER) positive, the compounds of the invention can also be administered together with known estrogen-receptor antagonists (such as TAMOXIFEN®) and/or known aromatase inhibitors and/or known cytostatics. Thus, a pharmaceutical composition of the invention may also comprise an effective amount of (a) known compound(s) exerting estrogen-receptor antagonistic and/or aromatase inhibitory activity (compounds different from the compounds of the invention disclosed herein) and/or cytostatic activity. According to a preferred embodiment, a combination of 4-hydroxytestosterone and a suitable cytostatic or combination of cytostatics is provided, in particular, in form of a preparation that can be administered topically (e.g. cream). Examples of suitable aromatase inhibitors are e.g. disclosed in US 2004/0018991 A1 and include steroidal aromatase inhibitors such as formestan and lentaron, exemestan, MDL 18962, 7 alpha-substituted androstenedione derivatives, ATD, 10-oxirane and 10-thiirane-substituted androgens, atamestan, etc., and non-steroidal aromatase inhibitors such as vorazol, arimidex, letrozol, fadrozol, and rogletimid. With regard to the designations of these substances as well as their availability, see for example “Red List”, Editio Cantor, Aulendorf (DE, 1999).
Examples of suitable cytostatics and cytostatic combinations include e.g. AC±T—Adriamycin (chemical name: doxorubicin) with cyclophosphamide (brand name: Cytoxan), with or without Taxol (chemical name: paclitaxel) or Taxotere (chemical name: docetaxol); CMF—cyclophosphamide, methotrexate, and fluorouracil (“5-FU” or 5-fluorouracil); CAF—cyclophosphamide, Adriamycin, and fluorouracil (“5-FU” or 5-fluorouracil); CEF—cyclophosphamide, Epirubicin (similar to Adriamycin), and fluorouracil (“5-FU” or 5-fluorouracil); FAC—fluorouracil (“5-FU” or 5-fluorouracil), Adriamycin, and cyclophosphamide.
In general, and in particular if the target tissue is estrogen-receptor negative, the compounds of the invention can also be administered together with antibodies against Her2neu such as e.g. Trastuzumab (HERCEPTIN®). Thus, a pharmaceutical composition of the invention may also comprise an effective amount of known compounds exerting antagonistic Her2neu activity.
The following examples illustrate but do not limit the invention.
Example 1
The compound of the present invention can be synthesized as follows.
In a first step, 2.5 g testosterone is dissolved in 100 ml cold MeOH. After adding 9 ml NaOH (2%) and 17 ml H2O2 (30%) the mixture is stirred for 24 h at 4° C. The resulting epoxids are precipitated with ice-water.
In a second step, 2 g of the dry epoxids are dissolved in 200 ml acetic acid containing 2% H2SO4. The solution is stirred for 4 h at room temperature. The reaction products are precipitated with ice-water.
Thereafter, the reaction products are washed with 1% NaOH solution to hydrolyse the acetyl esters. The total yield of pure 4-hydroxtestosterone is in the range of 40-50%.
Example 2
A cream for topical administration according to the invention can be formulated in conventional manner using the following amounts of ingredients. The amounts are given per 100 g of cream:
















4-hydroxy-17β-acetyl-androst-4-en-3-one
4.5 g



Cetearyl alcohol
7.5 g



Paraffin wax
3.0 g



Sodium carbomer
2.5 g



Isopropyl myristate
6.0 g



Sorbitan monostearate
1.0 g



Polysorbate 20
3.0 g



Stearyl alcohol
2.0 g



DMSO
5.0 g



Purified water qs
100.0 g 










The resulting cream can be given topically on the skin above affected breast tissue of a female or male patient.
Example 3
A gel according to the invention can be formulated in conventional manner using the following amounts of ingredients. The amounts are given per 100 g of gel:
















4-hydroxytestosterone
2.5 g



Ethanol 95. degree
70.0 g 



Carbopol 980
0.5 g



Isopropyl myristate
2.5 g



Triethanolamine
0.5 g



Purified water qs
100.0 g 










Example 4
A solution for use as a spray according to the invention is prepared in conventional manner using the following formulation. The amounts are given per 100 g of solution:
















4-hydroxytestosterone
2.5 g



Ethanol 95. degree.
70.0 g 



Isopropyl myristate
2.5 g



Purified water qs
100.0 g 










Example 5
Tablets each weighing 0.150 g and containing 25 mg of the active substance, can be manufactured as follows:










Composition (for 10000 tablets)


















4,17β-dihydroxyandrost-4-ene-3-one
250 g



Lactose
800 g



Corn starch
415 g



Talc Powder
 30 g



Magnesium stearate
 5 g










The 4,17β-dihydroxyandrost-4-ene-3-one, the lactose and half the corn starch are mixed; the mixture is then forced through a sieve of 0.5 mm mesh size. Corn starch (10 g) is suspended in warm water (90 ml) and the resulting paste is used to granulate the powder. The granulate is dried, comminuted on a sieve of 1.4 mm mesh size, then the remaining quantity of starch, talc and magnesium stearate are added, carefully mixed and processed into tablets.
Example 6
Capsules, each dosed at 0.200 g and containing 20 mg of the active substance can be prepared.










Composition for 500 capsules:


















4,17β-dihydroxyandrost-4-ene-3-one
10 g



Lactose
80 g



Corn starch
 5 g



Magnesium stearate
 5 g










This formulation is encapsulated in two-piece hard gelatine capsules and dosed at 0.200 g for each capsule.
Example 7
An ointment for topical administration according to the invention can be formulated in conventional manner using the following amounts of ingredients. The amounts are given per 100 g of ointment:
















17β-hydroxy-6-methylenandrost-1,4-diene
2.5 g



Propylene glycol
25.0 g 



Isopropyl myristate
6.0 g



Sorbitan monostearate
1.0 g



Polysorbate 80
2.0 g



Stearyl alcohol
2.0 g



Hyaluronic acid
0.1 g



Purified water qs
100.0 g 










The resulting ointment can be given topically on the skin above affected breast tissue of a female patient.
Example 8
A gel for simultaneous combination topical administration according to the invention can be formulated in conventional manner using the following amounts of ingredients. The amounts are given per 100 g of gel:
















4-hydroxytestosterone
2.75 g



Formestane
1.25 g



Ethanol 80%
10.0 g



Carbopol 934 P
 8.0 g



PEG 400
 2.5 g



urea
 3.0 g



ethyl oleate
 0.5 g



purified water to
 100 g










Example 9
Tablets for simultaneous combination medication according to the invention can be formulated according to Example 5, except that half of the amount of 4,17β-dihydroxyandrost-4-ene-3-one is replaced by Formestane.
Example 10
MCF-7 cells were grown in RPMI 1640 medium at 37° C. to a cell number of about 1*105 cells/ml. Then, in quadruple identical MCF-7 cell samples, there were added either dihydrotestosterone (DHT) or 4-hydroxytestosterone (4-OHT), to obtain different concentrations thereof, namely 10−7 M, 10−8 M or 10−9 M, and further growth of cells were determined by counting of vital cells. During the course of incubation at 37° C., cell counting were performed after 3, 6 and 9 days. For control, growth of MCF-7 cells were determined without addition of an active agent.
The results on an inhibition of MCF-7 cell proliferation are shown in FIGS. 1A, 1B and 1C for the compound concentrations of 10−7 M, 10−8 M and 10−9 M of either DHT or 4-OHT, respectively, and compared with the control. The results demonstrate a significantly enhanced inhibitory effect on MCF-7 cell proliferation in case of using the compound 4-hydroxytestosterone according to the present invention, significantly stronger than 4-dihydrotestosterone and particularly stronger than the control.
The surprisingly enhanced efficacy of 4-OHT compared to DHT can be explained by the effects, that 4-OHT can specifically bind strongly to the androgen receptor (AR) and eliciting anabolic/apoptotic effects rather than androgenic effects. DHT on the other hand preferentially evokes androgenic effects.
Example 11
Double blind clinical tests were conducted with a group of 10 female patients. In this clinical testing, particular attention was paid to hormone receptor statuses of patients' target breast cancer tissue regarding progesterone receptor (PR) and in particular regarding estrogen receptor (ER); The cancers of the patients were assumed to be predominantly androgen receptor (AR) positive. Among this group, six patients had histologically ascertained malign breast carcinoma (C. mammae). The tumors of 5 patients of this investigated sub-group were found to be progesteron receptor (PR) negative and, in particular, estrogen receptor (ER) negative (status level 0 (zero)). With respect to Her-2-neu, three patients did show a negative status, one had a moderate (level 1) and another had a strong (level 2) receptor status. In a sixth patient, the presence of a malign breast carcinoma was ascertained, but the amount of cancer tissue was too low to determine receptor status.
The remaining four patients did not show a malign disease, but appeared as having normal or mastopathic breast tissue.
All 10 female patients were topically and locally treated using 4-hydroxytestosterone as active agent, by administering of a cream as described in Example 2 locally to target skin portions of the breasts. After continuing daily topical administration once a day during an administration period of 3 months, clinical investigations on therapeutic effects were performed.
The results of the 6 patients having malign breast carcinoma are shown in the following Table 1, together with the receptor status determined for patient nos. 1 to 5.















Patient




Clinical


No.
Age
ER
PR
Her2neu
Remission







# 1
62 yrs.
0
0
0
yes


# 2
54 yrs.
0
0
1
pending


# 3
87 yrs.
0
0
0
yes


# 4
68 yrs.
0
0
2
pending


# 5
57 yrs.
0
0
0
pending


# 6
50 yrs.
&
&
&
yes









Among those women so far subjected to post-treatment investigations, three patients did show a noticeable remission of breast cancer tissues as determined by mammography.
Though receptor status of the tumor of the sixth patient of this cancer sub-group is unknown, there was also a clear clinical remission ascertained in this case.
With respect to the remaining 4 patients having non-malign disease states, it is to be noted that there is a clear tendency for tissue reduction of the apparently normal or mastopathic appearing tissues in the course of topical administration.
The results of this clinical study show two main important effects of the pharmaceutical composition according to the present invention comprising 4-hydroxytestosterone (4-OHT). Firstly, 4-OHT shows an excellent efficacy in shrinking cancerous tissues. Secondly, and still more surprisingly, even ER negative cancer cells can be effectively treated.
Taken together, the findings made in the present invention support the concept that 4-OHT can efficiently act via the AR, and that apoptosis can eventually be realized.
The findings of the present invention thereby make valuable therapeutic and/or prophylactic treatments feasible. Among other useful applications including adjuvant therapy, neoadjuvant therapy is of particular importance by making use of the substantial reduction of tumour volume to assist or enable subsequent surgical treatment schemes.
Example 12
A 42 years old patient with bilateral breast-cancer and skin metastases after surgery.was treated daily with a cream corresponding to example 2. After 4 weeks of treatment the skin metastases have disappeared.
Example 13
A 50 years old patient with large breast cancer (diameter: 12 cm) massive tumour-spread and metastatic liver disease was treated by partial tumor-resection and subsequent daily application of a cream corresponding to example 2. The patient exhibited under treatment no further tumor growth and even a reduction of nonresectable tumour-mass.
Example 14
A 74 years old patient with advanced breast cancer and tumour-spread to the lymphatics was treated daily for 10 weeks. A substantial reduction of tumor volume occurred and in the affected lymph nodes no tumor cells were present anymore.

## Claims

1. A method of treating a cancer patient in need of cancer treatment, wherein the method comprises the steps of:
identifying a patient in need of treatment, and having cancer associated with cancer tissue having androgen receptor (AR) positive target cells or target tissue and estrogen receptor (ER) negative target cells or target tissue; and
administering to the patient in need of treatment an effective amount of a steroid compound specifically binding to the androgen receptor (AR) but not metabolized by aromatase,
wherein the cancer is selected from the group consisting of breast cancer, endometrial carcinoma, cervix carcinoma, epithelial ovarian carcinoma, uterine carcinoma, endometrial carcinoma, cervix carcinoma, epithelial ovarian carcinoma, or uterine carcinoma, fibroadenoma, macromastia, mastopathy, and
wherein the steroid compound is a compound of the formula:





wherein
a, b and c respectively denote, independently from each other, a single bond or a double bond;
R1 is hydrogen or C1 to C6 alkyl;
R2 is OR5, wherein R5 is hydrogen or C1 to C6 straight chain or branched alkyl;
R3 is, in case of c being a single bond, hydrogen or C1 to C6 alkyl, or in case of c being a double bond, CHR5, wherein R5 is the same as defined before;
R4 is hydrogen, C1 to C6 alkyl, unsubstituted or C1 to C6 alkyl-substituted phenyl, COR6 acyl group; and
R6 is hydrogen, C1 to C6 straight chain or branched alkyl, phenyl or benzoyl respectively unsubstituted or substituted by C1 to C6 alkyl; or pharmaceutically acceptable salts thereof.

2. The method according to claim 1, wherein said steroid compound is administered together with (an) effective amount(s) of at least one substance selected from the group consisting of estrogen-receptor antagonists, aromatase inhibitors other than said steroid compound, cytostatics and antibodies against Her2neu.

3. The method according to claim 1, wherein the administration of the steroid compound is topical.

4. The method according to claim 1, wherein treatment conditions are selected from the following conditions alone or in combination:
contralateral breast cancer;
adjuvant or neoadjuvant breast cancer treatment;
shrinking of breast cancer tissue;
recurrency of breast cancer; and
skin metastases derived from breast cancer.

5. The method according to claim 4, wherein the steroid compound is 4,17β-dihydroxyandrost-4-ene-3-one.

6. Method according to claim 1, wherein said steroid compound is administered in a pharmaceutical composition comprising said compound as an active principle, and further a suitable carrier or diluent, or both the suitable carrier and the diluent.