effector regulatory t cells (etregs) with a cd45ra · 5/19/2016 · author manuscript published...

1

Effector regulatory T cells reflect the equilibrium between antitumor immunity and autoimmunity in adult T cell leukemia Hiroshi Ureshino1, Takero Shindo1, Hiroyoshi Nishikawa2*, Nobukazu Watanabe3, Eri Watanabe3, Natsuko Satoh3, Kazutaka Kitaura4, 5, Hiroaki Kitamura1, Kazuko Doi6, Kotaro Nagase7, Hiromi Kimura7, Makoto Samukawa8, Susumu Kusunoki8, Masaharu Miyahara9, Tadasu Shin-I10, Ryuji Suzuki4, Shimon Sakaguchi2, Shinya Kimura1

1Department of Hematology, Respiratory Medicine and Oncology, Saga University School of Medicine, Saga, Japan; 2Experimental Immunology, World Premier International Research Center, Immunology Frontier Research Center, Osaka University, Suita, Japan; 3Laboratory of Diagnostic Medicine, Division of Stem Cell Therapy, Institute of Medical Science, The University of Tokyo, Tokyo, Japan; 4Department of Clinical Immunology, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Japan; 5Repertoire Genesis, Inc., Ibaraki, Japan; 6Department of Dermatology, Karatsu Red Cross Hospital, Karatsu, Japan;

7Department of Dermatology, Saga University School of Medicine, Saga, Japan; 8Department of Neurology, Kinki University School of Medicine, Sayama, Japan; 9Department of Internal Medicine, Karatsu Red Cross Hospital, Karatsu, Japan; 10BITS Co. Ltd., Tokyo, Japan. *Current Address: Hiroyoshi Nishikawa Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Tokyo, Japan

Running Title: Effector regulatory T cells in ATL Keywords: Regulatory T cell, antitumor immunity, autoimmunity, T cell receptor, adult T cell leukemia Financial support: None

on January 23, 2021. © 2016 American Association for Cancer Research. cancerimmunolres.aacrjournals.org Downloaded from

Author manuscripts have been peer reviewed and accepted for publication but have not yet been edited. Author Manuscript Published OnlineFirst on May 23, 2016; DOI: 10.1158/2326-6066.CIR-15-0303

http://cancerimmunolres.aacrjournals.org/

2

Correspondence to: Takero Shindo, M.D., Ph.D. 5-1-1 Nabeshima, Saga, 849-8501, Japan Phone: +81-952-34-2366; Fax: +81-952-34-2017 E-mail: [email protected] Conflicts of interest H.N. received a grant-in-aid for scientific research from Kyowa Hakko Kirin Company, Ltd., in 2011–2012. The other authors declare no conflicts of interest. Abstract word count: 190, Text word count: 1,555 Figures: 2, Supplementary figures: 2, Supplementary tables: 2




3

Abstract

The regulatory T cells (Tregs) with the most potent immunosuppressive activity are the

effector regulatory T cells (eTregs) with a CD45RA–Foxp3++CCR4+ phenotype. Adult T

cell leukemia (ATL) cells often share the Treg phenotype and also express CCR4.

Although mogamulizumab, a monoclonal antibody to CCR4, shows marked antitumor

effects against ATL and peripheral T-cell lymphoma, concerns have been raised that it

may induce severe autoimmune immunopathology by depleting eTregs. Here we

present two ATL cases that responded to mogamulizumab, but developed a severe skin

rash and autoimmune brainstem encephalitis. Deep sequencing of the TCR revealed that

ATL cells and naturally occurring Tregs within the cell population with a Treg

phenotype can be clearly distinguished according to CADM1 expression. The onset of

skin rash and brainstem encephalitis was coincident with eTreg depletion from the

peripheral blood, whereas ATL relapses were coincident with eTreg recovery. These

results imply that eTreg numbers in the peripheral blood sensitively reflect the

equilibrium between antitumor immunity and autoimmunity, and that mogamulizumab

might suppress ATL until the eTreg population recovers. Close monitoring of eTreg

numbers is crucial if we are to provide immunomodulatory treatments that target

malignancy without severe adverse events.




4

Introduction

Human regulatory T cells (Tregs) suppress immune reactions, including autoimmunity

and antitumor immunity; therefore, inhibiting Treg activity is becoming an important

focus of cancer treatment (1). Tregs are classified into several subtypes, the most

suppressive being effector Tregs (eTregs), which express a CD45RA–Foxp3++

phenotype and the chemokine receptor CCR4 (2, 3). Adult T cell leukemia (ATL) is a

therapy-resistant hematologic malignancy with a poor prognosis (4, 5). ATL occurs in

about 5% of human T-lymphotropic virus type-1 (HTLV-1) carriers, and most ATL cells

express CCR4 (6, 7). ATL cells often share the Treg phenotype, i.e.,

CD3+CD4+CD25+Foxp3+ (8, 9). Although ATL cells may be defined by their expression

of CADM1 (10, 11), the overlap and differences between Tregs and ATL cells remain

unclear.

Mogamulizumab is a defucosylated and humanized monoclonal antibody to

CCR4 that shows marked effects against ATL (12) and peripheral T cell lymphoma (13).

It works directly by depleting tumor cells and indirectly by increasing antitumor

immunity through eTreg depletion via antibody-dependent cellular cytotoxicity (ADCC)

(3). However, it sometimes causes adverse events, including a skin rash or

Stevens-Johnson syndrome (14, 15), which may be attributed to Tregs depletion.

However, the association between therapeutic effects, adverse events, and Tregs

depletion remains unclear.

Here, we report two mogamulizumab-treated ATL patients who developed

severe skin rash and brainstem encephalitis. Deep sequence analysis of the TCR




5

repertoire revealed that CADM1 expression specifies minimal residual ATL cells within

the cell population with a Treg phenotype. While the immunopathology was closely

associated with eTreg depletion, ATL relapsed as eTregs recovered. Despite the fact that

mogamulizumab suppresses ATL, it should be noted that it can induce serious

immunopathology by depleting eTregs, and that it might suppress ATL until eTreg

recovery.




6

Materials and methods

Peripheral blood mononuclear cells (PBMCs) were collected from the patients and

sorted into specific cell fractions using a FACSAria cell sorter (Becton Dickinson,

Franklin Lakes, NJ). Sequencing of the TCRα/β was performed at Repertoire Genesis

Incorporation (Osaka, Japan) using the unbiased gene amplification method with

Adaptor-Ligation PCR (Supplementary Table 1). About 103–104 valid reads were

generated (Supplementary Table 2). Bioinformatics analysis was then performed using

the repertoire analysis software, Repertoire Genesis (RG), provided by Repertoire

Genesis Incorporation (Osaka, Japan). RG assigns TRV and TRJ alleles to queries and

then generates CDR3 sequences, finally aggregating their combination patterns.

Out-of-frame sequences were excluded from the analyses. The details of these analyses

have been described previously (16). All the studies using patient samples were

performed in accordance with the guidelines set out in the Declaration of Helsinki and

were approved by the institutional review board.




7

Case presentations and results

Case 1: A 77-year-old male with acute ATL received mogamulizumab. Although

ATL cells immediately disappeared from the peripheral blood, he developed severe skin

eruptions that required long-term corticosteroid therapy. Histopathological examination

of the skin lesions revealed a marked dermal cellular infiltrate comprising mainly CD8+

T cell–dominant lymphocytes and some eosinophils, without ATL cells (Supplementary

Fig. S1A–K). A small percentage of CD3dimCD4+CADM1+CD7- cells (P3 cells) still

remained in the peripheral blood on day 234 after starting mogamulizumab (Fig. 1A).

TCRα repertoire analyses of the sorted cells revealed that these cells were exclusively

clonal ATL cells: clone 1, TRAV9-2/J31, with CDR3 sequence CAPKNNARLMF and

clone 2, TRAV13-1/J4, with CDR3 sequence CAAIPWGYNKLIF (Fig. 1A). While the

skin eruption was active, CD3+CD4+CD45RA–Foxp3++ eTregs almost disappeared (Fig.

1B and C: day 213). When the eTregs recovered, the ATL cell population

(CD4+CADM1+CD7– cells) gradually increased (Fig. 1B: days 282 and 325). The

severity of the skin eruption was closely associated with the percentage of eTregs (Fig.

1C). The eruption was mild on day 192 (%eTreg 2.12%) but became severe on day 213

(%eTreg 0.55), before resolving on day 282 (%eTreg 5.93). Notably, the percentage of

ATL cells spontaneously fluctuated from day 325 through day 438, which might reflect

transient anti-ATL immunity. However, his ATL clinically relapsed as multiple

mediastinal lymphadenopathy, which required further treatment on day 430. This time,

mogamulizumab had little effect. Following several courses of cytotoxic chemotherapy,

the patient died on day 644. Simultaneous staining for Foxp3 and CADM1 revealed that




8

the Foxp3+ cell population contained both CADM1-positive and -negative cells; the

former gradually becoming predominant during relapse (Fig. 1D). TCRα/β and CDR3

sequencing of CADM1-positive and -negative CD3+CD4+CD25++ cells collected on day

417 revealed that CADM1-positive cells exclusively contained one of the two ATL

clones (Fig. 1A and E). Though CADM1-negative cells were predominantly

TRAV9-22/J22 (Fig. 1E), they had diverse CDR3 sequences (Fig. 1E) and TRBV/J

patterns (Fig. 1F), meaning that they were not clonal. These results show that, even

among cells with the Treg phenotype, ATL and non-ATL cells can be distinguished

according to CADM1 expression.

Case 2: A 66-year-old male with acute ATL received mogamulizumab. Despite the

rapid disappearance of the ATL cells from the peripheral blood, he developed a severe

skin rash on the trunk (Fig. 2A). Skin biopsy and immunohistochemical staining

revealed both CD4 and CD8 T cell infiltration of the dermal layer, but no ATL or

Foxp3+ cells were detected (Supplementary Fig. 2A–F). At that time, Foxp3+ Tregs

(especially CD3+CD4+CD45RA–Foxp3++ eTregs) were depleted in the peripheral blood

(Fig. 2C: days 121 and 149 after mogamulizumab administration).

He also developed neurological symptoms, including ptosis, diplopia, and hearing

loss. Magnetic resonance imaging (MRI) of the brain on day 149 revealed a

high-intensity area in the brainstem on diffusion-weighted images and fluid attenuated

inversion recovery images (FLAIR) (Fig. 2B: day 149). Tests of the cerebrospinal fluid

revealed a mild increase in protein levels (62 mg/dL), but an absence of ATL cells.

Anti-ganglioside GM2 IgM was detected in the serum, and intrathecal administration of




9

methotrexate and cytarabine did not improve the neurological symptoms; therefore, he

was diagnosed with autoimmune brainstem encephalitis. After steroid pulse and

high-dose immunoglobulin therapy followed by prednisolone administration, the

neurological symptoms completely resolved and the high-intensity area on brain MRI

disappeared (Fig. 2B: day 219).

Two months later, he developed progressive drowsiness. Brain MRI revealed a

broad high-intensity area in the right frontal and temporal lobes on FLAIR; no abnormal

signals were detected in the brainstem (Fig. 2B: day 270). Steroid pulse and high-dose

immunoglobulin therapy did not improve the symptoms, and biopsy of the frontal lobe

revealed diffuse infiltration by atypical CD3+CD4+CD25+ lymphocytes (Supplementary

Fig. S2G–L) with monoclonal integration of HTLV-1; therefore, a diagnosis of ATL

with central nervous system (CNS) involvement was made. Notably, eTregs in the

peripheral blood had recovered at that time (Fig. 2C: day 275) and Foxp3+ cells were

focally detected in the brain (Supplementary Fig. 2M). The CD4+Foxp3+ T cells in

peripheral blood were negative for CADM1 (Fig. 2C: day 275), indicating that they

were not ATL cells, but naturally occurring Tregs. High-dose methotrexate/cytarabine

and mogamulizumab ameliorated the symptoms, and both the abnormality detected on

MRI and the CD4+CD45RA-Foxp3++ cells in the peripheral blood rapidly disappeared

(Fig. 2C: day 310). At the time of the study, the patient showed no signs of ATL relapse.




10

Discussion

Based on our sequencing and phenotypic analyses of these two patients over time,

we can come to some conclusions about the overlap and differences between ATL cells

with the Treg phenotype and non-leukemia “true” eTregs. As these two populations

share the same phenotype of CD3+CD4+CD25+Foxp3+, it is actually difficult to

discriminate them. Given that ATL cells share the clonal TCR rearrangements, deep

sequencing analysis of TCRα/β chains and CDR3 diversity confirmed that the

CD3+CD4+CADM1+CD7– cells were exclusively ATL cells. Among cells with the

Treg phenotype only the CADM1+ cells shared the same clonality as ATL cells. The

data suggest that ATL cells with the Treg phenotype have a different cellular origin from

that of naturally occurring Tregs, and that transition between the two subsets is unlikely.

CADM1-negative CD3+CD4+CD25+ cells appeared clonal in terms of Vα and Jα chain

combinations (TRAV9-2/J22) (Fig. 1E), but not in terms of the β chain (Fig. 1F); the

meaning of this remains unclear.

The frequency of eTregs was closely associated with adverse events and ATL

relapses. Depletion of eTregs was coincident with severe skin rash and autoimmune

brainstem encephalitis, suggesting that depletion of eTregs causes severe autoimmunity.

On the other hand, eTregs recovery was coincident with ATL relapse. In addition, at the

time case 1 relapsed, CADM1–Foxp3+ cells (naturally occurring Tregs) re-appeared first,

followed by the re-appearance of CADM1+Foxp3+ cells (ATL cells), which then

gradually became dominant (Fig. 1D). These observations raise a hypothesis that

mogamulizumab suppresses ATL until eTregs recovery, which weakens anti-ATL




11

immunity and results in relapse of ATL.

Treg deficiency induces a severe autoimmune pathology called IPEX (immune

dysregulation, polyendocrinopathy, enteropathy, and X-linked) syndrome (17, 18),

whereas abundant Tregs in tumor tissues are associated with a poor prognosis (19, 20);

however, it is unclear whether the percentage of Tregs in the peripheral blood has an

inverse impact on immunopathology (21-23). This may be because the Foxp3+ cell

population contains some non-Tregs cells (CD45RA-Foxp3dim cells) that do not have

suppressive activity (2). We found that the depletion and recovery of eTregs in the

peripheral blood, but not that of the whole Treg population, were coincident with

adverse events and ATL relapse, respectively.

In conclusion, the eTreg population reflects the equilibrium between antitumor

immunity and autoimmunity. Currently, many monoclonal antibodies that increase

antitumor immunity (including immune checkpoint blockers) are approved for clinical

use (24). Although these reagents enable deep suppression of Tregs or enhancement of

antitumor immunity, they may increase the risk of severe autoimmune disease. To

optimize the effects (and avoid serious adverse events) of the currently available

monoclonal antibodies that modulate antitumor immunity, close observation and

analyses of the correlation between eTreg numbers, antitumor immunity, and

autoimmunity are warranted.




12

Acknowledgments

We thank Dr. Ayumi Uchibori (Kyorin University) for analysis of paraneoplastic

neurological syndrome-related antibodies.




13

References

1. Nishikawa H, Sakaguchi S. Regulatory T cells in cancer immunotherapy. Curr

Opin Immunol. 2014;27:1-7.

2. Miyara M, Yoshioka Y, Kitoh A, Shima T, Wing K, Niwa A, et al. Functional

delineation and differentiation dynamics of human CD4+ T cells expressing the FoxP3

transcription factor. Immunity. 2009;30:899-911.

3. Sugiyama D, Nishikawa H, Maeda Y, Nishioka M, Tanemura A, Katayama I,

et al. Anti-CCR4 mAb selectively depletes effector-type FoxP3+CD4+ regulatory T

cells, evoking antitumor immune responses in humans. Proceedings of the National

Academy of Sciences of the United States of America. 2013;110:17945-50.

4. Tsukasaki K, Hermine O, Bazarbachi A, Ratner L, Ramos JC, Harrington W,

Jr., et al. Definition, prognostic factors, treatment, and response criteria of adult T-cell

leukemia-lymphoma: a proposal from an international consensus meeting. Journal of

clinical oncology : official journal of the American Society of Clinical Oncology.

2009;27:453-9.

5. Uchiyama T, Yodoi J, Sagawa K, Takatsuki K, Uchino H. Adult T-cell

leukemia: clinical and hematologic features of 16 cases. Blood. 1977;50:481-92.

6. Ishida T, Utsunomiya A, Iida S, Inagaki H, Takatsuka Y, Kusumoto S, et al.

Clinical significance of CCR4 expression in adult T-cell leukemia/lymphoma: its close

association with skin involvement and unfavorable outcome. Clinical cancer research :

an official journal of the American Association for Cancer Research. 2003;9:3625-34.

7. Yoshie O, Fujisawa R, Nakayama T, Harasawa H, Tago H, Izawa D, et al.




14

Frequent expression of CCR4 in adult T-cell leukemia and human T-cell leukemia virus

type 1-transformed T cells. Blood. 2002;99:1505-11.

8. Matsubara Y, Hori T, Morita R, Sakaguchi S, Uchiyama T. Delineation of

immunoregulatory properties of adult T-cell leukemia cells. International journal of

hematology. 2006;84:63-9.

9. Shimauchi T, Kabashima K, Tokura Y. Adult T-cell leukemia/lymphoma cells

from blood and skin tumors express cytotoxic T lymphocyte-associated antigen-4 and

Foxp3 but lack suppressor activity toward autologous CD8+ T cells. Cancer science.

2008;99:98-106.

10. Kobayashi S, Nakano K, Watanabe E, Ishigaki T, Ohno N, Yuji K, et al.

CADM1 expression and stepwise downregulation of CD7 are closely associated with

clonal expansion of HTLV-I-infected cells in adult t-cell leukemia/lymphoma. Clinical

cancer research : an official journal of the American Association for Cancer Research.

2014;20:2851-61.

11. Kobayashi S, Watanabe E, Ishigaki T, Ohno N, Yuji K, Nakano K, et al.

Advanced human T-cell leukemia virus type 1 carriers and early-stage indolent adult

T-cell leukemia-lymphoma are indistinguishable based on CADM1 positivity in flow

cytometry. Cancer science. 2015;106:598-603.

12. Ishida T, Joh T, Uike N, Yamamoto K, Utsunomiya A, Yoshida S, et al.

Defucosylated anti-CCR4 monoclonal antibody (KW-0761) for relapsed adult T-cell

leukemia-lymphoma: a multicenter phase II study. Journal of clinical oncology : official

journal of the American Society of Clinical Oncology. 2012;30:837-42.




15

13. Ogura M, Ishida T, Hatake K, Taniwaki M, Ando K, Tobinai K, et al.

Multicenter phase II study of mogamulizumab (KW-0761), a defucosylated anti-cc

chemokine receptor 4 antibody, in patients with relapsed peripheral T-cell lymphoma

and cutaneous T-cell lymphoma. Journal of clinical oncology : official journal of the

American Society of Clinical Oncology. 2014;32:1157-63.

14. Ishida T, Ito A, Sato F, Kusumoto S, Iida S, Inagaki H, et al. Stevens-Johnson

Syndrome associated with mogamulizumab treatment of adult T-cell leukemia /

lymphoma. Cancer science. 2013;104:647-50.

15. Yoshie O, Matsushima K. CCR4 and its ligands: from bench to bedside. Int

Immunol. 2014.

16. Kitaura K, Fujii Y, Hayasaka D, Matsutani T, Shirai K, Nagata N, et al. High

clonality of virus-specific T lymphocytes defined by TCR usage in the brains of mice

infected with West Nile virus. J Immunol. 2011;187:3919-30.

17. Chatila TA, Blaeser F, Ho N, Lederman HM, Voulgaropoulos C, Helms C, et

al. JM2, encoding a fork head-related protein, is mutated in X-linked

autoimmunity-allergic disregulation syndrome. J Clin Invest. 2000;106:R75-81.

18. Hori S, Nomura T, Sakaguchi S. Control of regulatory T cell development by

the transcription factor Foxp3. Science. 2003;299:1057-61.

19. Curiel TJ, Coukos G, Zou L, Alvarez X, Cheng P, Mottram P, et al. Specific

recruitment of regulatory T cells in ovarian carcinoma fosters immune privilege and

predicts reduced survival. Nat Med. 2004;10:942-9.

20. Ishida T, Ishii T, Inagaki A, Yano H, Komatsu H, Iida S, et al. Specific




16

recruitment of CC chemokine receptor 4-positive regulatory T cells in Hodgkin

lymphoma fosters immune privilege. Cancer Res. 2006;66:5716-22.

21. Arimoto K, Kadowaki N, Ishikawa T, Ichinohe T, Uchiyama T. FOXP3

expression in peripheral blood rapidly recovers and lacks correlation with the

occurrence of graft-versus-host disease after allogeneic stem cell transplantation.

International journal of hematology. 2007;85:154-62.

22. Clark FJ, Gregg R, Piper K, Dunnion D, Freeman L, Griffiths M, et al.

Chronic graft-versus-host disease is associated with increased numbers of peripheral

blood CD4+CD25high regulatory T cells. Blood. 2004;103:2410-6.

23. Zorn E, Kim HT, Lee SJ, Floyd BH, Litsa D, Arumugarajah S, et al. Reduced

frequency of FOXP3+ CD4+CD25+ regulatory T cells in patients with chronic

graft-versus-host disease. Blood. 2005;106:2903-11.

24. Topalian SL, Sznol M, McDermott DF, Kluger HM, Carvajal RD, Sharfman

WH, et al. Survival, durable tumor remission, and long-term safety in patients with

advanced melanoma receiving nivolumab. Journal of clinical oncology : official journal

of the American Society of Clinical Oncology. 2014;32:1020-30.




17

Abbreviations

eTreg, effector regulatory T cell

ATL, adult T cell leukemia

HTLV-1, human T-lymphotropic virus type-1

ADCC, antibody-dependent cellular cytotoxicity

FLAIR, fluid attenuated inversion recovery images

MRI, magnetic resonance imaging

IPEX; immune dysregulation, polyendocrinopathy, enteropathy, and X-linked




18

Figure legends

Figure 1. Clinical course of Case 1.

(A) TCRα V and J assignment and sequencing of the CDR3 region from whole PBMCs

on day 234 after the start of mogamulizumab therapy (upper row) and sorted cells based

on high-resolution flow cytometry (lower row). CADM1–CD7+ cells (P1: 64.9%),

CADM1dimCD7+ cells (P2: 6.0%), CADM1+CD7– cells (P3 3.9%), and CADM1dimCD7-

cells (P4 6.2%) were sorted from the total CD4+ T cell population before analysis.

Regarding TCR repertoire analysis, the upper 3D graphs show TRAV/J clones

according to their percentage, and the lower tables show the ten major clones in each

cell populations. The two columns and bars highlighted in yellow (TRAV9-2/J31) and

brown (TRAV13-1/J4) indicate ATL clones. (B) High-resolution flow cytometric

detection of eTregs (upper row: CD45RA-Foxp3++) and ATL cells (middle and lower

rows: CD3dimCADM1+CD7–) among the CD4+ T cell population in peripheral blood.

Numbers represent the percentage of eTreg cells (upper row), CD4+ T cells (middle

row), and CADM1+CD7- cells (lower row). (C) Time course of skin eruptions. (D) Flow

cytometric analysis of CADM1-positive and -negative cells within the

CD3+CD4+Foxp3+ cell population. (E and F) TCRα/β V and J assignment and

sequencing of the CDR3 region in sorted CADM1-positive and -negative cells with the

Treg phenotype (CD3+CD4+CD25+). Days are counted from start of mogamulizumab

treatment.

Figure 2. Clinical course of Case 2.




19

(A) Sequential emergence of symptoms followed by improvement: ptosis,

diplopia, hearing loss, skin rash, and drowsiness. Administration of therapeutic reagents

is also shown: mogamulizumab (Moga), prednisolone (PSL), methylprednisolone

(mPSL), intravenous immunoglobulin (IVIG), and methotrexate/cytarabine

(MTX/AraC). (B) Representative magnetic resonance images (MRI) of the brain. DW

images are shown in the upper row and FLAIR images in the lower row. The

high-intensity area in the right frontal lobe on the day 314 DW image indicates

hematoma after the biopsy. (C) The expression of CD45RA, Foxp3, CADM1, and CD7

by peripheral blood CD3+CD4+ T cells was repeatedly analyzed by flow cytometry. In

the upper row, the numbers indicate the percentage of CD45RA-Foxp3++ cells (eTregs).

In the lower row, CD7-CADM1+ cells represent ATL cells. Days are counted from start

of mogamulizumab treatment.




Published OnlineFirst May 23, 2016.Cancer Immunol Res Hiroshi Ureshino, Takero Shindo, Hiroyoshi Nishikawa, et al. antitumor immunity and autoimmunity in adult T cell leukemiaEffector regulatory T cells reflect the equilibrium between

Updated version

10.1158/2326-6066.CIR-15-0303doi:

Access the most recent version of this article at:

Material

Supplementary

http://cancerimmunolres.aacrjournals.org/content/suppl/2016/05/19/2326-6066.CIR-15-0303.DC1

Access the most recent supplemental material at:

Manuscript

Authoredited. Author manuscripts have been peer reviewed and accepted for publication but have not yet been

E-mail alerts related to this article or journal.Sign up to receive free email-alerts

Subscriptions

Reprints and

[email protected] at

To order reprints of this article or to subscribe to the journal, contact the AACR Publications

Permissions

Rightslink site. Click on "Request Permissions" which will take you to the Copyright Clearance Center's (CCC)

.http://cancerimmunolres.aacrjournals.org/content/early/2016/05/19/2326-6066.CIR-15-0303To request permission to re-use all or part of this article, use this link



http://cancerimmunolres.aacrjournals.org/lookup/doi/10.1158/2326-6066.CIR-15-0303

http://cancerimmunolres.aacrjournals.org/content/suppl/2016/05/19/2326-6066.CIR-15-0303.DC1

http://cancerimmunolres.aacrjournals.org/cgi/alerts

mailto:[email protected]

http://cancerimmunolres.aacrjournals.org/content/early/2016/05/19/2326-6066.CIR-15-0303


effector regulatory t cells (etregs) with a cd45ra · 5/19/2016 · author manuscript published...

Documents