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Immunology |
University Department of Medicine, Queen Elizabeth II Medical Centre, Nedlands, Western Australia, Australia 6009
| ABSTRACT |
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| INTRODUCTION |
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In general, the focus of studies investigating or manipulating the immune response against tumors has been the generation of CTLs because of the lytic nature of these cells. Yet tumor-specific CTLs can be demonstrated in the absence of in vivo effects (13) . Such contradictory evidence may simply reflect a difference between in vitro and in vivo measurements but also implies that the generation of CTLs is not the sole functional effector required for antitumor immunity. In fact, an increasing body of evidence suggests that CD4 cells can play a critical role in the eradication of tumors (14) . CD4 cells have been implicated indirectly in experiments that replace "help" by introducing IL-2 (15) . It has also been shown that tumors transduced with syngeneic class II molecules can induce protection against parental class II-negative tumors (16) .
Many of these studies have been carried out in the absence of a known tumor antigen and have therefore lacked the capacity to follow the fate of tumor-specific T cells. Even when tumor antigens are defined, it has been difficult to understand the relationship between tumors and host tumor-specific CD8 and CD4 cells because of the lack of a model in which all of these parameters can be defined, controlled, and monitored. To investigate the requirements for effective immune recognition of a solid tumor, we have generated a defined model system using a transfected antigen (influenza HA3 ) and TCR transgenic mice. HA is an ideal nominal tumor antigen because its class I and class II peptide reactivities are well defined and, importantly, anti-HA TCR transgenic mice are available with both class I and II specificities. Two lines of TCR transgenic mice, one class I restricted (CL4 mice; Ref. (17) , the other class II restricted (HNT mice; Ref. (18) , both of which recognize HA in the context of H-2d, are used in this study. The advantage of using these TCR transgenic mice is that they provide a virtually monoclonal source of cells of known specificity, where the respective roles of tumor-specific CD8 and CD4 cells can be evaluated. Thus, either in intact animals or through adoptive transfer experiments, it is possible to investigate how the frequency of tumor-specific cells influences tumor immunity and the role that specific CD4 cells play in modulating the response in the absence of direct tumor recognition. Using this new model, we show that tumor-specific CD4 cells act synergistically with limiting antitumor CTLs to prevent the growth of a solid class II- tumor.
| MATERIALS AND METHODS |
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Murine MM Tumor Cell Line.
The derivation and characterization of the AB1 murine MM cell line used in this study have been described previously (19)
. Essentially, the cells were generated by inoculating crocidolite asbestos i.p. into H-2d (BALB/c) mice, and peritoneal exudate was passaged in vitro and in vivo until stable clonal cell lines were obtained. Cell lines were maintained in RPMI 1640 (Life Technologies, Inc., Gaithersburg, MD) supplemented with 20 mM HEPES, 0.05 mM 2-mercaptoethanol, 100 units/ml penicillin (CSL, Melbourne, Victoria, Australia), 50 µg/ml gentamicin (David Bull Labs, Victoria, Australia), and 5% FCS (Life Technologies, Inc.). AB1 is class I+, class II- and poorly immunogenic (20)
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HA Transfectant Cells.
The HA gene from the Mt. Sinai strain of the PR8 influenza virus was subcloned into the ß-actin expression vector (phbApr-neo; obtained from Dr. J. Allison, University of California, Berkeley, CA). AB1 (1 x 105) cells were seeded into six-well tissue culture plates (Becton Dickinson, Lincoln Park, NJ) and cultured until 60% confluent. For each well, 5 µg of plasmid DNA and 30 µl of N-[1-(2, dioleoxyloxy) propyl]-N,N,N-trimethyl-ammonium-methylsulfate transfection reagent (Boehringer Mannheim, Mannheim, Germany) were separately diluted to 250 µl in HEPES-buffered saline (140 mM NaCl, 2 mM KCl, 10 mM Na2 HPO4, 2 mM KH2PO4, and 2 mM HEPES, pH 7.4) in sterile polystyrene tubes (Becton Dickinson). Both solutions were mixed together, incubated at room temperature for 10 min, and made up to 1 ml with Optimen (Life Technologies, Inc.). Spent media was aspirated from the cell cultures, and the transfection solution was added for 24 h. Transfected cells were selected by culturing in media containing the neomycin analogue geneticin (Life Technologies, Inc.) at a final concentration of 400 µg/ml. Cells were trypsinized, resuspended in 1 ml PBS supplemented with 5% FCS, and counted using trypan blue exclusion as a measure of cell viability. A 1-ml aliquot of cell suspension was serially diluted in media and seeded into 96-well round-bottomed plates at a concentration of 0.3 cells/well in a total volume of 200 µl/well. Cells were cultured for 710 days and examined daily for cell colony formation. Wells containing a single colony were trypsinized and subcloned into separate wells of a 24-well plate. When
70% confluent, cultures were trypsinized and seeded into 80-cm2 tissue culture flasks (Becton Dickinson, Lincoln Park, NJ) and routinely maintained in media containing 400 µg/ml G418. The level of HA expression on transfected cells was measured by FACS analysis, using the biotinylated HA-specific monoclonal antibody H18 (21)
and was originally obtained from Dr. Walter Gerhard (The Wistar Institute, Phildelphia, PA). HA transfectant clones were enriched by Dynal beading. Cells were incubated (4°C for 30 min) in 1:500 dilution of anti-HA antibody and then washed three times in media (RPMI+5% FCS) and incubated with streptavidin beads (Dynal; 4°C for 30 min). Cells were washed three times, and beaded cells were separated from the cell mix using a magnet.
Characterization of the in Vivo Growth of the Transfected Tumor.
Groups of 20 female BALB/c or/BALB/c nu/nu mice, 68 weeks of age, were inoculated s.c. with either 1 x 106 AB1-HA transfectants with relatively high HA expression (AB1-HAHI) or those with relatively low expression (AB1-HALO) and monitored for tumor growth for up to 2 months after inoculation. HNT and CL4 TCR transgenic mice were inoculated s.c. with the same lines or with parental control lines and also monitored for tumor growth for up to 2 months after inoculation. Tumors between 0.5- and 1.0-cm diameter were excised and tested for maintenance of HA expression using FACS analysis.
Winn Assay.
To evaluate antitumor activity in vivo, we used a Winn assay (22)
. Cells from the draining LNs or contralateral LNs (4 x 106) of class I-restricted CL4 TCR transgenic mice that had developed AB1-HA tumor were mixed with either AB1-HA cells or the parental AB1 tumor (1 x 105) and injected s.c. into BALB/c recipient mice, and the animals were monitored for tumor development.
In Vitro Generation of HA-specific CTLs.
Effector cells were generated by incubating spleen cells from anti-HA CL4 TCR transgenic mice with peptide (1 µg/ml) for 5 days. Target cells included MM cell lines transfected with HA, P815, a chemically induced mastocytoma in DBA/2 mice obtained from the American Type Culture Collection (Rockville, MD) and untransfected MM cell lines. Targets were labeled with 150 µCi of 51Cr for 90 min and washed four times before use. Effector cells were added to corresponding targets at varying E:T ratios and incubated at 37°C for 4 h. After incubation, the supernatants were harvested, and radioactivity was counted in a gamma counter. The mean of triplicate samples was calculated, and the percentage of specific 51Cr release was determined as follows:
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Incubation of Tumor Cells with IFN-
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Tumor cell lines were treated as monolayer cultures for 48 h with 100 units/ml of recombinant mouse IFN-
(Genzyme, Cambridge, MA) with a specific activity of 1.14 x 107 units/µg protein and washed three times in media before use in in vitro assays.
Preparation of HA-specific, Class I-restricted (CL4), and Class II-restricted (HNT) Cells for Adoptive Transfer.
LN cells were purified first over nylon wool and then depleted either of CD4 T cells (CL4 mice) or CD8 T cells (HNT and BALB/c mice). BALB/c mice were then injected with 1 x 107 cells i.v. Twenty-four h after adoptive transfer, mice were inoculated s.c. with 2 x 105 AB1-HA tumor cells.
Depletion of CD8 and CD4 T Cells.
For in vitro depletion of either CD8 T cells or CD4 T cells, nylon wool-purified T cells were exposed to a 1:3 dilution of 3.168 (anti-CD8) or RL172 (anti-CD4) supernatant in RPMI with 5% FCS for 30 min at 4°C, washed once, and then exposed to a 1:10 mixture of rabbit complement (C-six Diagnostics, Inc., Mequon, WI) in RPMI with 10% FCS for 30 min at 37°C. Cells were then washed twice, and purity was checked by FACS analysis using FITC and phycoerythrin-conjugated anti-CD8 or anti-CD4 (PharMingen, San Diego, CA). Analysis was performed on a FACScan (Becton Dickinson) using Cell Quest software.
5- (and 6-) CFSE Labeling of CL4 TCR Transgenic LN Cells.
CFSE labeling was performed as described previously ((23)
). Tumor-specific (HA-specific) LN cells, from the TCR transgenic class I-restricted CL4 mice, were resuspended in PBS at 1 x 107 cells/ml. For labeling, 2 µl of a CFSE (Molecular Probes, Eugene, Oregon) stock solution (5 mM in DMSO) were incubated with 10 ml of cells (at 107/ml) in RPMI 1640, without FCS, for 10 min at room temperature. Cells were washed through FCS four times and then resuspended in PBS before injecting 1 x 107 cells into recipients i.v. In all experiments, cells were recovered 3 days after transfer and analyzed by FACS analysis.
Proliferation Assay.
BALB/c mice were inoculated s.c. with the AB1-HAHI cells, and LN cells from CL4 and HNT mice (1 x 107 cells of each) were adoptively transferred i.v. Draining and nondraining LNs from the recipient mice were isolated 2 and 8 weeks later. Single cells suspensions were made, and each sample was divided into two, one of which was depleted of CD8 cells, and the other was depleted of CD4 cells. B cells were depleted from all samples. Cell depletions were done using the anti-CD8 or -CD4 antibodies and the B220 antibody (PharMingen), followed by magnetic bead separation using beads coated with sheep anti-rat immunoglobulin (Dynal, Oslo, Norway). Cells (1 x 105) cells were plated in triplicate in 96-well, flat-bottomed microtiter plates (Costar, Cambridge, MA) in a final volume of 200 µl of RPMI/10% FCS, plus or minus the appropriate peptide (CL4 peptide in CD4-depleted samples; HNT peptide in CD8-depleted samples). Plates were incubated for a total of 48 h, and 3H was added 1215 h before harvesting.
| RESULTS |
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40% of the experimental group rejected the tumor (Fig. 2A)
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-induced class I up-regulation on the outcome of this assay. Incubation of the MM cells with IFN-
induced an
3-fold increase in the level of surface class I expression (mean fluorescence intensity, 219286; Fig. 4B
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Tumor-specific T Cells Are Functionally Responsive ex Vivo.
CD8 and CD4 cells were purified from the LNs of tumor-bearing animals 2 and 8 weeks after the coadoptive transfer of CL4 and HNT cells into tumor-inoculated recipients. The purified cells were tested for their ability to proliferate to the class I- or class II-restricted HA peptides. Cells responding to both peptides were detected, although the number of responsive cells decreased with time (Fig. 7C)
. When nontransgenic T cells were coadoptively transferred in this system and tested for their ability to proliferate to the class I- or class II-restricted HA peptides, the response was comparable with background levels, 667 ± 48 cpm and 701 ± 182 cpm, respectively.
CD4 "Help" Does Not Potentiate CD8 Effector Cell Proliferation.
To determine whether the tumor-specific CD4 cells augmented the antitumor effects of the CD8 cells by increasing their initial in vivo expansion, CFSE-labeled CL4 cells were adoptively transferred, with or without concomitant transfer of HNT cells, into BALB/c mice that had been inoculated 14 days previously with AB1-HAHI. Three days after the adoptive transfer, the CFSE fluorescence profiles of CL4 cells, reisolated from animals in the different experimental groups, were analyzed (Fig. 8)
. CL4 cells interact with and proliferate to tumor antigen only in the LN draining the site of tumor inoculation4
(Fig. 8A)
. Nondraining LNs are not a site of tumor antigen presentation to class I-restricted T cells (Fig. 8B)
. The coadministration of HNT cells did not cause any change in the "burst" size of the CD8 cells entering the proliferative phase after antigen recognition (Fig. 8C)
because the profile of fluorescence was almost identical to that seen in Fig. 8A
. Identical results were observed in BALB/c mice inoculated with AB1-HA tumor 21 or 28 days before transfer of the T cells (data not shown).
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| DISCUSSION |
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Tumor Eradication Is Not Dependent Simply upon CD8 Effector Frequency.
The immune system may not be able to eliminate tumor cells because the rate of tumor proliferation outstrips the capacity of the immune system to respond effectively before the tumor becomes established. Thus, the inability of BALB/c mice to reject the AB1-HA tumors may simply be due to a limited frequency of CD8 effector cells. This hypothesis is supported by the results in syngeneic mice in which the precursor frequency of antitumor cells is increased by the adoptive transfer of CL4 T cells. In this case, a moderate capacity to eradicate tumors was demonstrated (40% protection). This capacity was enhanced further by using CL4 mice as tumor recipients where the number of antitumor effectors is even higher. In these mice, tumor was eradicated in 60% of recipients and was independent of the amount of antigen expressed by the tumor. But, although these data demonstrate that increased precursor frequency can increase the probability of tumor eradication, they also show that at superphysiological frequencies of precursor T cells, tumor rejection is not guaranteed.
Tolerization Does Not Explain Why a Subpopulation of CL4 TCR Transgenic Mice Fails to Reject the Tumor.
What was surprising in our experiments was that 40% of the class I-restricted TCR transgenic mice failed to eradicate tumor, although the pool of effectors was similar in the entire experimental group. It was possible that the effector cells had been tolerized due to encounter with the tumor. The lack of costimulatory molecules on the MM cells could have led to anergy induction (30)
, or if these cells had been activated, they may have been deleted through clonal exhaustion (31)
. We found no evidence for tolerization because these cells could be isolated, in normal numbers, and subsequently protect naive recipients in a Winn assay. Also, after adoptive transfer into tumor-inoculated animals, CL4 peptide-reactive cells could still be identified.
Together these data are consistent with other studies that demonstrate that class I-restricted TCR transgenic mice have limited or no antitumor effects. Using lymphocytic choriomeningitis virus as a tumor antigen in an insulinoma model, it was demonstrated that, although the transgenic cells were able to destroy cells bearing lymphocytic choriomeningitis virus antigen, the destruction was transient, and both neoplastic and normal tissue remained relatively intact (26)
. The failure to fully eradicate the tumor was not due to tolerization of the CTLs but due to a failure to sustain an effective response. In a separate model, in which
-ketogluterate dehydrogenase peptides in an Ld molecule are recognized by 2C TCR transgenic mice (32)
, it was shown that skin graft rejection could occur concomitantly with tumor engraftment, despite the presence of a shared target antigen (33)
. Again, there was no evidence for tolerance induction in the effector population. Although both these models are highly informative, they are limited by either the lack of defined class II epitopes or the use of allogeneic class I molecules, where host APC-transgenic T cell tumor antigen interactions are bypassed. As in our own model, a high precursor frequency of CTLs did not guarantee tumor eradication, and additional factors must be contributing to the variability in tumor growth.
One such factor may be the limited access of tumor-specific effectors to the tumor site (8)
. In our model, both the parental tumor line and the transfected lines show very few infiltrating lymphocytes in syngeneic recipients (34)
. Alternatively, the answer may lie in the nature of the tumor cell itself and its vulnerability as a target to CTL effectors. CTLs derived from the CL4 transgenic mice, although able to lyse standard targets, were unable to kill the AB1-HA cells unless the tumors were pretreated with IFN-
. Thus, in vivo, a large number of effectors, in addition to their lytic function, may provide a sufficient source of local IFN-
production at the tumor site to increase class I expression and promote effective CTL recognition. If such cytokine production is at a critical threshold, it is feasible that the process might not be 100% efficient, allowing tumor outgrowth in some animals. Interestingly, we have shown that the levels of IFN-
within a solid tumor fall progressively during tumor growth (35)
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A third alternative may be that tumor-specific CD4 cells can modulate CTL function and, when lacking, the destruction of tumor cells is relatively inefficient.
Tumor-specific CD4 T Cells Are Unable to Directly Eradicate Tumors.
It is essential to understand the role of tumor-specific CD4 cells in generating antitumor immunity, especially for the rational design of vaccines that may need to incorporate class II epitopes. In the past, the role of such CD4 cells has only been able to be implied by the isolation and use of long-term tumor-reactive CD4 clones, by global depletions of CD4 cells using antibody treatment, or by the ability of cytokines, such as IL-2, to enhance tumor eradication. These nonspecific approaches have led to variable results; some tumor studies have shown CD4 cells to be redundant (36)
, others have demonstrated that they are capable of direct antitumor activity (37)
, and others have shown that CD4 cells may act to suppress antitumor CD8 responses (38)
. Experiments to clarify the role of CD4 cells in tumor immunity clearly require the ability to directly identify and manipulate tumor-specific CD4 cells.
Our data demonstrate that tumor-specific class II restricted TCR transgenic mice fail to reject HA-transfected tumors and suggest that tumor-specific CD4 cells alone, even if present in large numbers, are not capable of causing tumor eradication. In the absence of class II expression on the tumor, this may not seem a surprising result but, despite the inability of the HNT cells to interact directly with the tumor cells, the AB1-HAHI line showed a significant delay in growth compared with the AB1-HALO line. This delay was clearly due to immunological events because both transfectants grew at similar rates in T cell-deficient mice. The kinetics of tumor growth correlated with the level of HA expression, suggesting that the limited effect of the specific CD4 cells in modulating tumor growth was contingent upon reaching a threshold level of antigen expression, which is in contrast to the results with tumor-specific CD8 cells (see below). That the CD4 cells recognize tumor antigen in vivo is clear from the CFSE data, which demonstrate antigen-CD4 cell interactions in the draining LNs. These data clearly imply a role for the traffic of tumor antigen via APCs. This traffic is limited to the draining LNs and occurs in the absence of metastasizing tumor or up-regulation of class II on the tumor cells.
Tumor-specific CD4 Cells Synergize with Limiting CD8 Cells to Cause Tumor Eradication.
CD4 cells are mostly considered as adjuvants to B cells and CD8 T cells through the provision of helper factors, although they have other potential roles in an immune response. In particular, CD4 cells have been shown to be the pathogenic effectors in some models of autoimmunity (39
, 40)
, including a transgenic model of diabetes, which uses the same TCR transgenic mice as in our experiments (18)
. The inability to demonstrate any direct role in the class II-restricted TCR transgenic mice and the variability of tumor growth in the class I-restricted TCR transgenics led us to investigate how CD4 cells might modulate CD8-mediated tumor eradication. We hypothesized that any effect of specific CD4 cells in our model would be more easily detected in an adoptive transfer approach using more limited numbers of CTL effectors. The addition of specific CD4 cells to the CTL pool produced 100% protection, substantially higher than in the intact CL4 transgenic mice or with either subpopulation alone. Importantly, the data also demonstrate that these CD4 cells must be tumor specific because naive BALB/c CD4 cells could not substitute for the class II-restricted TCR transgenic cells.
How Do CD4 Cells Act to Improve Tumor Eradication by CD8 Cells?
It is possible that CD4 cells may be obligatory at both the induction and effector phases of the immune response to ensure tumor eradication. CD4 cells act as helper cells for CTL function, and such a requirement for help in tumor immunity has been suggested in a number of vaccination studies in which IL-2 can replace CD4 function (15)
. CD4 cells may also augment the presentation of tumor antigens to CD8 cells by modifying the APCs (41, 42, 43)
or impairing CD8 deletion (24)
. In our tumor studies, CD4 cells did not boost the CTL response by increasing the number of CD8 cells proliferating in the draining LNs. Nor, at least up to 3 days, did their presence lead to a change in the level of Fas expression on the CD8 cells. In our model, CD4 cells are not altering CD8 fate through changes in Fas, at least at relatively early time points. Thus, CD4 cells do not seem to be potentiating tumor eradication by influencing either of these processes.
Preliminary histological data show that when tumor-specific CD4 and CD8 cells are cotransferred into tumor-inoculated animals, there is a large infiltration of both subsets within the tumor. In the absence of CD4 cell transfer, few, if any lymphocytes, infiltrate the site, none of which are CD8+. These data imply that CD4 cells influence the trafficking of CD8 cells into the tumor. Once in the tumor, both CD4 and CD8 cells could contribute to produce IFN-
, up-regulate class I, and allow CTL recognition of the target cells. This ability to modulate the tumor milieu is distinct from traditional helper functions, via IL-2, normally attributed to CD4 cells and may lead to increased tumor immunogenicity.
The data reported here establish the utility of this novel tumor model and demonstrate that the responses of both CD4 and CD8 cells can be analyzed. They also demonstrate the importance of a linkage between the CD4 and CD8 tumor-specific components of cellular immune response; specific CD4 cells activated by APCs that have processed the tumor antigen improve the capacity of limiting numbers of specific CD8 effector cells to eradicate solid tumors, either through direct help or indirectly by modifying the tumor milieu to produce up-regulation of class I, or possibly through APC modulation. This model provides an excellent basis for further dissection of the interactions that occur within the immune system to ensure tumor eradication.
| ACKNOWLEDGMENTS |
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| FOOTNOTES |
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1 This work was supported by the National Health and Medical Research Council of Australia (NH&MRC Grant 961329). A. L. M. is a recipient of the Dora Lush postgraduate scholarship (NH&MRC). ![]()
2 To whom requests for reprints should be addressed, at University Department of Medicine, Queen Elizabeth II Medical Centre, 4th Floor, G Block, Nedlands, Western Australia, Australia 6009. Phone: 618 9346 3127; Fax: 618 9346 2816; E-mail: bscott{at}cyllene.uwa.edu.au ![]()
3 The abbreviations used are: HA, hemagglutinin; MM, malignant mesothelioma; FACS, fluorescence-activated cell sorter; LN, lymph node; CFSE, 5- and 6-carboxyfluorescein diacetate succinimidyl ester; TCR, T-cell receptor; APC, antigen-presenting cell; IL, interleukin. ![]()
4 A. L. Marzo, R. A. Lake, D. Lo, L. Sherman, A. McWilliam, D. Nelson, B. W. S. Robinson, and B. Scott. Tumor antigens are constitutively presented in the draining lymph nodes, submitted for publication. ![]()
Received 10/ 5/98. Accepted 1/ 5/99.
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D. J. Nelson, S. Mukherjee, C. Bundell, S. Fisher, D. van Hagen, and B. Robinson Tumor Progression Despite Efficient Tumor Antigen Cross-Presentation and Effective "Arming" of Tumor Antigen-Specific CTL J. Immunol., May 1, 2001; 166(9): 5557 - 5566. [Abstract] [Full Text] [PDF] |
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S. C. Eck and L. A. Turka Adoptive Transfer Enables Tumor Rejection Targeted against a Self-Antigen without the Induction of Autoimmunity Cancer Res., April 1, 2001; 61(7): 3077 - 3083. [Abstract] [Full Text] |
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N. Dalyot-Herman, O. F. Bathe, and T. R. Malek Reversal of CD8+ T Cell Ignorance and Induction of Anti-Tumor Immunity by Peptide-Pulsed APC J. Immunol., December 15, 2000; 165(12): 6731 - 6737. [Abstract] [Full Text] [PDF] |
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A. L. Marzo, B. F. Kinnear, R. A. Lake, J. J. Frelinger, E. J. Collins, B. W. S. Robinson, and B. Scott Tumor-Specific CD4+ T Cells Have a Major ""Post-Licensing"" Role in CTL Mediated Anti-Tumor Immunity J. Immunol., December 1, 2000; 165(11): 6047 - 6055. [Abstract] [Full Text] [PDF] |
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D. Nelson, C. Bundell, and B. Robinson In Vivo Cross-Presentation of a Soluble Protein Antigen: Kinetics, Distribution, and Generation of Effector CTL Recognizing Dominant and Subdominant Epitopes J. Immunol., December 1, 2000; 165(11): 6123 - 6132. [Abstract] [Full Text] [PDF] |
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M. von Mehren, P. Arlen, K. Y. Tsang, A. Rogatko, N. Meropol, H. S. Cooper, M. Davey, S. McLaughlin, J. Schlom, and L. M. Weiner Pilot Study of a Dual Gene Recombinant Avipox Vaccine Containing Both Carcinoembryonic Antigen (CEA) and B7.1 Transgenes in Patients with Recurrent CEA-expressing Adenocarcinomas Clin. Cancer Res., June 1, 2000; 6(6): 2219 - 2228. [Abstract] [Full Text] |
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C. Robinson, M. Callow, S. Stevenson, B. Scott, B. W. S. Robinson, and R. A. Lake Serologic Responses in Patients with Malignant Mesothelioma . Evidence for Both Public and Private Specificities Am. J. Respir. Cell Mol. Biol., May 1, 2000; 22(5): 550 - 556. [Abstract] [Full Text] |
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