British Journal of Cancer(1998) 78(Supplement 3), 35-40
`© 1998 Cancer Research Campaign
`
`Clinical studies with MTA
`
`AH Calvert1 and JM Walling2
`
`'Division of Oncology, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne, NE4 6BE, UK; 2Lilly Research Laboratories, Eli Lilly and Co.,
`Indianapolis, Indiana 46285-225, USA
`
`Summary MTA (LY231514), a multi-targeted antifolate, is a classical antifolate undergoing intracellular polyglutamation. Polyglutamated
`MTA is a potent thymidylate synthase (TS) inhibitor and inhibits other folate-dependent enzymes, including dihydrofolate reductase and
`glycinamide ribonucleotide formyl transferase. Multifocal antifolates may overcome antifolate resistance, but it is not known whether the anti(cid:173)
`tumour activity of MTA depends on its TS inhibition, its primary locus of action, or whether other loci contribute. MTA was examined in three
`phase I trials using different schedules: a 10-min i.v. infusion given once every 3 weeks, once weekly for 4 weeks every 6 weeks or daily for 5
`days every 3 weeks. Dose-limiting toxicities were neutropenia and thrombocytopenia. Other consistently seen side-effects, which were
`manageable, included mucositis, skin rashes and transient elevations of transaminases. Toxicity was highly schedule dependent: the
`recommended dose for the 3-weekly schedule (600 mg m-2) was 30 times that for the daily x 5 schedule (4 mg m-2 day-1). The 3-weekly
`dosing schedule was chosen for phase II evaluation. Phase II trials are underway to investigate the activity and toxicity of MTA in several
`tumour types, including colorectal, pancreas, breast, bladder and non-small-cell lung cancer (NSCLC) Further phase I trials will investigate
`MTA in combination with other agents, including gemcitabine, cisplatin, 5-fluorouracil and folate. Preliminary phase II trials results are
`encouraging; responses were seen in colorectal, pancreas, NSCLC and breast cancer.
`
`Keywords: LY231514; MTA; multi-targeted antifolate; antimetabolite; clinical trial
`
`The use of antimetabolites in the treatment of cancer was first
`explored in 1948 by Farber, who discovered that administration of
`aminopterin caused remission in patients suffering from leukaemia
`(Farber et al, 1948). Antimetabolites are compounds that either
`inhibit the synthesis of the precursors of DNA or, because of their
`structural similarity to the natural precursors, are incorporated into
`DNA and/or RNA, causing cell death or stasis. Antifolates can
`inhibit specifically the synthesis of the pyrimidine or purine bases
`required for DNA synthesis, as several of the enzymes required for
`the synthesis of these are folate dependent. As cancer cells are
`actively proliferating, they require large quantities of DNA and
`RNA. This makes them susceptible targets for antimetabolities, as
`interference in cell metabolism has a greater effect when rapid cell
`division is taking place. The toxic effect is directed at all prolifer(cid:173)
`ating cells, not just cancer cells, accounting for some of the side(cid:173)
`effects on the haematopoietic system and epithelial tissues that are
`often seen with anti-cancer agents.
`The pathways of folate metabolism, essential to cell reproduc(cid:173)
`tion, are shown in Figure 1. These provide many targets for inter(cid:173)
`vention. Drugs that act on dihydrofolate reductase (DHFR),
`methotrexate (reviewed by Jolivet et al, 1983) is the classical
`example, will inhibit the synthesis both of purines and of pyrim(cid:173)
`idines. Other drugs may act specifically on purine or pyrimidine
`synthesis. For example, raltitrexed acts directly on thymidylate
`synthase (TS) (Ward et al, 1992), while lometrexol (Beardsley et
`al, 1989) affects only purine synthesis by inhibiting glycinamide
`ribonucleotide formyltransferase (GARFT).
`
`Correspondence to: AH Calvert
`
`MTA
`MTA (LY231514) is a folate analogue in which the 6,6-fused
`pteridine ring system of folic acid is replaced by a pyrrolo[2,3-d](cid:173)
`pyrimidine ring (Figure 2) (Taylor et al, 1992). This compound
`emerged from Lilly's programme of synthesis of potential
`GARFT inhibitors. It was discovered that one of the enantiomers
`of racemic lometrexol was difficult to synthesize, and replacement
`of the six-membered ring with an aromatic five-membered ring
`was proposed to get around this problem. The resulting compound
`was shown to potently inhibit both DHFR and TS, as well as
`inhibiting both GARFT and aminoimidazole carboxamide ribonu(cid:173)
`cleotide formyltransferase (AICARFT) at micromolar concentra(cid:173)
`tions (Shih et al, 1997). Because of this variety of actions, it has
`been termed a multi-targeted antifolate, or MTA. It is a classical
`antifolate, which is converted to polyglutamated derivatives in the
`cell. The polyglutamated forms have been shown to have much
`greater inhibitory activity against isolated TS and GARFT than the
`parent compound, although the inhibition of DHFR was unaf(cid:173)
`fected by polyglutamation (Table 1).
`Drug resistance to antifolates arises in tumour cells through a
`variety of mechanisms (O'Connor et al, 1992; Gorlick et al, 1996).
`Antifolates with multiple modes of action have been proposed as a
`potential solution to the problem of resistance. A drug with a
`variety of mechanisms of action may continue to have anti-tumour
`activity whereas a single-activity agent might not (Calvert et al,
`1980). Although MTA has been shown to inhibit DHFR, TS and
`GARFT in vitro, it has yet to be established whether its in vivo
`activity depends only on inhibition of TS, or whether other loci are
`involved. It does appear, however, that TS inhibition will play a
`major role in the clinical activity of MTA.
`
`35
`
`Wockhardt Exhibit 1013 - 1
`
`

`
`36 AH Calvert and JM Walling
`
`Methionine
`
`dUMP
`
`dTMP _ . _ .
`
`I CYCLO I
`..
`..
`
`N10 formyl
`FH4(Glu)n
`
`DHFR
`
`DNA synthesis
`
`I GAR/AICAR I
`
`Homocysteine
`
`Purines
`
`N5methylFH4 4------- N5 formylFH4
`
`Figure 1 Folate metabolite pathways. DHFR, dihydrofolate reductase; FH4 , tetrahydrofolate; FH2, dihydrofolate; Glu. polyglutamate; CY CLO, cyclo-5, 10-
`methenyltetrahydrofolate cyclooxygenase; GAR, glycinamide ribonucleotide formyltransferase; AICAR, aminoimidazole carboxamide ribonucleotide
`formyltransferase
`
`~OH
`
`~~o
`
`OH
`
`°¥OH
`
`~~o
`
`OH
`
`Lometrexol
`
`Figure 2 Structures of lometrexol and MTA
`
`MTA has been shown to have activity against a range of human
`cell lines, including CCRF-CEM leukaemia cells, colon, renal,
`hepatoma and lung cancer (Von Hoff, 1988). In vivo activity has
`been demonstrated against a thymidine kinase-deficient murine
`lymphoma model (Schultz et al, 1996). Toxicity in mice was
`minimal (Eli Lilly and Co., personal communication) and as a
`result of its preclinical activity, MTA was selected for phase I
`clinical trials.
`
`Table 1 K, values of MTA and its polyglutamate (nM)
`
`Enzyme
`
`TS
`DHFR
`GAR FT
`
`MTA (parent compound)
`
`MTA-(glu)5
`
`109
`7.0
`9300
`
`1.3
`7.2
`65
`
`TS, thymidylate synthase; DHFR, dihydrofolate reductase; GARFT,
`glycinamide ribonucleotide formyltransferase.
`
`Phase I clinical trials of MTA: 3-weekly schedule
`
`MTA has been investigated in three dose- and schedule-finding
`phase I clinical trials. In one of these, carried out in San Antonio,
`Texas, MTA was administered once every 3 weeks as a 10-min i.v.
`infusion (Rinaldi et al, 1996). The modified continual reassess(cid:173)
`ment method (MCRM) was used (Faries, 1994), which involved
`treating only one patient at each minimally toxic dose level, but
`continuing to add patients at dose levels at which significant toxi(cid:173)
`city was observed. This method allows more patients to be treated
`with doses that are likely to be effective. Doses were in the range
`50-700 mg m-2• A summary of patient characteristics is shown in
`Table 2.
`Six patients were treated at the highest dose, at which the drug
`was found to have significant side-effects, including WHO grade 4
`neutropenia (three patients), grade 3 or 4 thrombocytopenia (three
`patients) and grade 2 mucositis (two patients). These effects were
`considered to constitute a maximum-tolerated dose (MID). The
`recommended dose for phase II trials was 600 mg m-2, and 20
`patients were treated at this level. Toxicities, summarized in Table 3,
`were mainly haematological. Thrombocytopenia and neutropenia
`
`British Journal of Cancer (1998) 78(Supplement 3), 35-40
`
`©Cancer Research Campaign 1998
`
`Wockhardt Exhibit 1013 - 2
`
`

`
`Clinical studies with MTA 37
`
`Table 2 Phase I clinical trials of MTA: patient characteristics
`
`Schedule
`
`Patients entered/evaluable
`Male/female
`Age range (median) (years)
`Performance status
`(Scale)
`Tumour site
`Colorectal
`Pancreatic
`Other
`Prior chemotherapy
`Prior radiotherapy
`
`3-Weekly
`(Day 1 every 21 days)
`
`Weeklyx4
`(Days 1, 8, 15, 21every42 days)
`
`Dailyx5
`(Days 1-5 every 21 days)
`
`37/37
`27/10
`30-74 (59)
`16/4/14
`(KPS 100/90/80)
`
`25
`3
`9
`33
`NA
`
`25/24
`11/13
`20--82 (59)
`12111/1
`(WH00/1/2)
`
`17
`0
`8
`24
`8
`
`38/37
`19/19
`33-72 (58)
`7/26/5
`(WH00/1/2)
`
`17
`4
`12
`26
`11
`
`Table3 Phase I trials: responses and toxicities (course 1)
`
`Toxicity (grade)
`
`3-Weekly (patients)
`
`Weekly x 4 (patients)
`
`Daily x 5 (patients,
`(4 mg m-2 dose)
`
`Neutropenia (314)
`Thrombocytopenia (314)
`Mucositis (1/2)
`Dermatitis (1/2)
`Anaemia (1/2)
`Nausea/vomiting (1/2)
`Transaminase elevations (1/2)
`Fatigue (1/2)
`Complete response
`Partial response
`
`Minor response
`
`4/5
`1/1
`0/2
`2110
`4/5
`312
`7/1
`8/2
`0
`2 (Pancreas)
`2 (Colorectal)
`6 (Colorectal)
`
`5/5
`1/1
`410
`1/0
`817
`9/2
`311
`10/1
`0
`0
`
`1/1
`010
`210
`
`213
`
`0
`0
`
`2 (Colorectal)
`
`2 (NSCLC, colorectal)
`
`were dose limiting, although non-haematological toxicities, such as
`fatigue, mucositis, skin rash and nausea, were also seen.
`Pharmacokinetic parameters were measured in this study
`(Woodworth et al, 1997). Plasma and urine samples were taken
`from all patients after the first course of treatment. The mean
`harmonic half-life was 5.07 h, and 78% of the drug was excreted
`unchanged in the urine. Partial responses were observed in two
`patients with colorectal cancer and two patients with pancreatic
`cancer. Three of these patients had received prior TS inhibitors
`(5-FU, FUdR or raltitrexed). Minor responses were seen in six
`patients with colorectal cancer.
`
`Weekly schedule
`
`In a second phase I study, MTA was administered on a weekly
`basis, with doses ranging from 10 to 40 mg m-2 given by 10-min
`i. v. infusion every week for 4 weeks and the cycle repeated every 6
`weeks (Rinaldi et al, 1995). Patients were included who had given
`written informed consent and met the following criteria: WHO
`performance status <3; life expectancy of more than 12 weeks;
`measurable tumour; adequate bone marrow, platelet count and
`liver function. As before, dose escalation was by the MCRM and
`commenced with 10 mg m-2•
`Of the 25 patients recruited, one was not evaluable because of a
`small bowel obstruction that developed after the first dose of
`LY231514, and the patient subsequently withdrew from the study.
`The characteristics of the remaining patients are shown in Table 2.
`
`Patients received between one and seven courses of treatment, and
`a total of 58 courses were given. Significant toxicity, mainly grade
`3 and 4 neutropenia, was seen in patients who received the
`40 mg m-2 dose and, as toxicity was minimal at the 20 mg m-2
`dose, an additional dose of 30 mg m-2 was added. Ten patients
`were treated at this level, which was determined to be the recom(cid:173)
`mended dose for phase II. Toxicities are summarized in Table 3.
`Neutropenia was dose-limiting, but non-haematological toxicities
`were mild. Two minor responses were observed, in patients with
`refractory, previously treated colorectal cancer. This schedule was
`not thought to be suitable for evaluation in a phase II setting as
`myelosuppression often precluded the administration of the third
`and fourth doses in each course.
`
`Daily schedule
`
`In the third phase I trial, carried out in the UK, 38 patients with ten
`different tumour types were given MTA on a daily basis for 5 days,
`every 3 weeks (McDonald et al, 1996). Patient characteristics are
`shown in Table 2. Doses ranged from 0.2 to 5.2 mg m-2, with the
`number of courses ranging from one to ten. Of the 38 patients
`entered, 37 were evaluable for toxicity. The main toxicities
`observed were myelosuppression and an elevation in transaminase
`levels. Significant thrombocytopenia was not seen and non(cid:173)
`haematological effects were mild. Toxicities are summarized in
`Table 3. Two patients had minor responses, one with non-small(cid:173)
`cell lung cancer (NSCLC) and the other colorectal cancer.
`
`©Cancer Research Campaign 1998
`
`British Journal of Cancer (1998) 78(Supplement 3), 35-40
`
`Wockhardt Exhibit 1013 - 3
`
`

`
`38 AH Calvert and JM Walling
`
`Table4 Phase II trials of MTA: patient characteristics and responses by tumour type
`
`Pancreas
`USA
`
`44
`18/39
`
`37-77 (60)
`7/37
`0-1
`(ECOG)
`0
`0
`
`Breast
`UK
`
`22
`18/19
`
`43-81 (54)
`
`14
`17
`
`0
`6
`
`NSCLC
`Canada
`
`NSCLC
`S.Africa/Australia
`
`Colorectal
`USA
`
`Colorectal
`Canada
`
`19
`12/15
`12/7
`(63)
`
`19
`(ECOG 0/1)
`0
`0
`
`0
`3
`
`19
`10/12
`
`0-2
`WHO
`0
`0
`
`0
`3
`
`41
`17/41
`25/16
`(59)
`
`33
`30/33
`17/16
`(68)
`
`28/11/1
`(ECOG 0/1/2)
`26
`11
`
`13/18/2
`(ECOG 0/1/2)
`9
`3
`
`1
`3
`
`1
`6
`
`Study
`
`Patients entered
`Evaluable for response/toxicity
`Male/female
`Age range (median) (years)
`Stage Ill/IV
`Performance status
`(Scale)
`Prior chemotherapy
`Prior radiotherapy
`Responses
`Complete
`Partial
`
`Phase II clinical trials
`
`Although phase II trials of MTA are still in progress, some prelim(cid:173)
`inary results are available. Phase II trials are being carried out in
`patients with solid tumours, in particular, cancers of the breast and
`pancreas, as well as colorectal and NSCL cancers. Initially, the 3-
`weekly schedule (600 mg m-2) was chosen for phase II studies
`because of the ability to give repeat doses, the convenience of the
`schedule and because partial responses were seen in the phase I
`trial using this schedule.
`In order to investigate the results seen in phase I trials in which
`partial and minor responses were seen in patients with advanced
`pancreatic cancer, a study was initiated in the USA that recruited 44
`patients with histologically confirmed, unresectable pancreatic
`cancer (Miller et al, 1997). Phase II patient characteristics are
`summarized in Table 4. MTA (600 mg m-2) was given as a 10-min
`infusion every 21 days and was generally well tolerated. Dose reduc(cid:173)
`tions were required in 17% of patients. Cutaneous toxicity, often seen
`in antifolate therapy, was the most common toxicity, occurring in
`over half of the patients, but was not life-threatening and was
`reported to be alleviated by dexamethasone. Other significant toxici(cid:173)
`ties were haematological in nature. Grade 3/4 granulocytopenia was
`seen in 42% of patients, while elevation of transaminase levels was
`seen in less than 20%. One complete response and one partial
`response have been seen in this trial, out of 18 patients who are
`evaluable at the time of writing. Another six patients have stable
`disease, an encouraging result in a disease that is generally resistant
`to treatment and in which responses tend to be infrequent.
`A study of MTA in locally advanced and metastatic breast
`cancer is ongoing (Smith et al, 1997). Of 22 patients recruited to
`this study, 19 are evaluable for toxicity and 18 for response. Grade
`3/4 thrombocytopenia and neutropenia were the major toxicities
`seen, the former in 41 % of patients and the latter in 18% of
`patients. Other toxicities observed included grade 3/4 skin reac(cid:173)
`tions in 16% of patients and grade 2/3 elevations in ALT values,
`seen in 84% of patients. Partial responses were seen in six patients,
`five of whom had previously received chemotherapy, including
`docetaxel, 5-FU and gemcitabine.
`MTA is also being studied in the treatment of NSCLC. Two trials
`are ongoing, one in Canada and the other a joint South African and
`Australian study. The first of these, an NCIC study, has enrolled 19
`patients to date, 12 of whom are evaluable for response and 15 for
`toxicity (Rusthoven et al, 1997). Patients included had histologically
`proven, stage III/IV disease and were chemonaive. As determined in
`
`the phase I trials, the starting dose for the first three patients was
`600 mg m-2, but toxicities observed at this dose led to a reduction in
`the dose to 500 mg m-2. Grade 3/4 neutropenia has been seen in 32%
`of patients, along with elevated transaminase levels; this was shown
`to be transient, as seen in trials of other antifolates, such as CB 3717
`(Calvert et al, 1986) and raltitrexed (Burris et al, 1994 ). Partial
`responses were seen in three patients, for an overall response rate of
`33%. In the second trial, 19 patients received MTA 600 mg m-2 once
`every 3 weeks (Clarke et al, 1997). Of the ten patients eligible for
`response assessment, three partial responses have been seen and the
`remaining seven patients had stable disease. The principal grade 3/4
`toxicity was neutropenia, which occurred in 42% of patients. Other
`toxicities seen included grade 3/4 rash ( 17% ), grade 3 nausea (8%)
`and grade 4 vomiting (8% ). Both these trials continue to accrue
`patients.
`Patients with metastatic colorectal cancer have also been treated
`with MTA in two phase II studies carried out in the USA (John et
`al, 1997) and Canada (Cripps et al, 1997). Prior adjuvant
`chemotherapy was allowed in the USA study, as long as patients
`had been untreated for one year before inclusion in the trial. Of the
`41 patients entered into the trial, 32 had colon cancer and nine had
`rectal cancer. All patients were evaluable for toxicity and 17 for
`response. The major grade 3/4 toxicity observed was neutropenia,
`seen in 56% of patients, while 16% and 12% of patients experi(cid:173)
`enced grade 3/4 thrombocytopenia and anaemia, respectively. Skin
`reactions were common, occurring in 69% of patients, but were
`rarely significant. A complete response was seen in one patient and
`partial responses in three others, while seven patients had stable
`disease. Of the 33 patients entered into the Canadian study, 24 were
`chemonaive. The recommended phase II dose of 600 mg m-2 was
`given to nine patients, but this was subsequently reduced to 500 mg
`m-2 in the remaining 24 patients, when several early patients expe(cid:173)
`rienced toxicities requiring dose reduction. One complete response
`and six partial responses were seen in these patients, for an overall
`response rate of 23% (95% CI 10-42%). Grade 3/4 neutropenia
`was seen in 45% of patients and grade 3/4 thrombocytopenia in
`12% of patients. Grade 3 rash was seen in 40% of patients. The
`activity of MTA in colorectal cancer demonstrated in these studies
`is to be further investigated in larger phase III studies.
`In conclusion, although these phase II results are preliminary,
`MTA appears to show promising activity in the treatment of several
`solid tumours, including breast, colorectal, pancreas and NSCL
`cancers. Further data are required before conclusions can be drawn
`regarding the absolute efficacy, but first indications are favourable.
`
`British Journal of Cancer (1998) 78(Supplement 3), 35-40
`
`©Cancer Research Campaign 1998
`
`Wockhardt Exhibit 1013 - 4
`
`

`
`THE FUTURE FOR MTA
`
`MTA is a new antifolate with a novel pharmacological profile.
`Preclinical studies have shown that it has several potential modes of
`action, including inhibition of TS, GARFf and DHFR.
`Results of single-agent phase I and II trials with MTA have
`shown that the most common toxicities, i.e. myelosuppression and
`skin reactions, were generally tolerable and manageable. The
`dose-limiting toxicities were usually haematological. Preliminary
`indications are that MTA is effective against solid tumours,
`including NSCLC, colorectal, breast and pancreatic cancers, and
`phase II trials are ongoing that will assess the efficacy of the drug
`against these specific tumours.
`The activity of MTA in NSCLC is very encouraging, given that
`there has been little activity seen for other antifolates in this
`disease. A randomized trial comparing vinorelbine with 5-FU and
`leucovorin concluded that 5-FU had negligible activity against
`NSCLC (3%) in patients with stage IV disease (Crawford et al,
`1996). Three phase II trials of edatrexate showed response rates of
`32% (Shum et al, 1988), 13% (Souhami et al, 1992) and 10% (Lee
`et al, 1990). A subsequent phase III trial in 673 patients, which
`compared edatrexate, mitomycin and vinblastine (EMV) with
`mitomycin and vinblastine (MV), failed to show improved
`survival in patients treated with EMV, although the response rate
`in the EMV arm was higher (24% compared with 16%) (Comis et
`al, 1994). Myelosuppression and stomatitis were more common in
`patients receiving the EMV combination. In a study of trime(cid:173)
`trexate, no major objective responses were seen in patients with
`stage III and IV disease (Kris et al, 1989).
`It is also possible that MTA will prove to be an effective compo(cid:173)
`nent in combination therapy and, to this end, trials are planned that
`will study the effects of the drug in combination with 5-FU or
`gemcitabine. The latter combination was suggested by research that
`has shown that pretreatment of HT29 colon carcinoma cells with
`MTA results in increased antiproliferative activity of gemcitabine
`(Tonkinson et al, 1996). A phase I trial is underway to investigate
`the combination of MTA and cisplatin in patients with solid
`tumours (Thoedtmann et al, 1997). Trials are also planned to inves(cid:173)
`tigate the effect of folates on the toxicities seen with MTA, based on
`the observation that animals given folate supplements were better
`able to tolerate treatment with MTA, with fewer side-effects
`(Worzalla et al, 1997). Trials are also planned for combinations
`with gemcitabine, irinotecan, oxaliplatin, carboplatin, doxorubicin
`and docetaxel, and the combination of MTA with radiotherapy will
`also be studied, once preclinical data have been generated.
`The effect of MTA in other cancers is also under investigation.
`Trials are underway or planned in which MTA is given to patients
`with renal, bladder, cervical and oesophageal cancers, although
`results are not yet available from these studies. Other trials are
`planned in which MTA will be used to treat patients with ovarian and
`head and neck cancers, and the results of these, and other trials
`nearing completion, are awaited with interest. Initial indications
`suggest that MTA will find a place in the anti-cancer armamentarium.
`
`ACKNOWLEDGEMENTS
`
`The authors would like to acknowledge the contribution of all the
`MTA investigators who have provided the results described in this
`manuscript,
`in particular the medical and nursing staff at
`Newcastle General Hospital: Dr M Lind, Dr N Bailey, Dr S Gokal
`and Dr A Hughes, F Chapman, M Proctor, D Simmons and A
`
`Clinical studies with MTA 39
`
`Oakley. Data management support was provided by L Robson and
`K Fishwick. We also thank Dr D Thornton, J Chick, S McCarthy
`and J Stickland of Eli Lilly and Co. for their assistance and Deirdre
`Conlon (Adelphi Communications Ltd) for assistance in the
`preparation of this manuscript.
`
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`British Journal of Cancer (1998) 78(Supplement 3), 35-40
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`Wockhardt Exhibit 1013 - 5
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`

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`40 AH Calvert and JM Walling
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`British Journal of Cancer (1998) 78(Supplement 3), 35-40
`
`©Cancer Research Campaign 1998
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`Wockhardt Exhibit 1013 - 6