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Published in: Cancer Immunology, Immunotherapy 9/2014

01-09-2014 | Original Article

Intrinsically de-sialylated CD103+ CD8 T cells mediate beneficial anti-glioma immune responses

Authors: Emmanuel Jouanneau, Keith L. Black, Lucia Veiga, Ryan Cordner, Shyam Goverdhana, Yuying Zhai, Xiao-xue Zhang, Akanksha Panwar, Armen Mardiros, HongQiang Wang, Ashley Gragg, Mandana Zandian, Dwain K. Irvin, Christopher J. Wheeler

Published in: Cancer Immunology, Immunotherapy | Issue 9/2014

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Abstract

Background

Cancer vaccines reproducibly cure laboratory animals and reveal encouraging trends in brain tumor (glioma) patients. Identifying parameters governing beneficial vaccine-induced responses may lead to the improvement of glioma immunotherapies. CD103+ CD8 T cells dominate post-vaccine responses in human glioma patients for unknown reasons, but may be related to recent thymic emigrant (RTE) status. Importantly, CD8 RTE metrics correlated with beneficial immune responses in vaccinated glioma patients.

Methods

We show by flow cytometry that murine and human CD103+ CD8 T cells respond better than their CD103 counterparts to tumor peptide-MHC I (pMHC I) stimulation in vitro and to tumor antigens on gliomas in vivo.

Results

Glioma responsive T cells from mice and humans both exhibited intrinsic de-sialylation-affecting CD8 beta. Modulation of CD8 T cell sialic acid with neuraminidase and ST3Gal-II revealed de-sialylation was necessary and sufficient for promiscuous binding to and stimulation by tumor pMHC I. Moreover, de-sialylated status was required for adoptive CD8 T cells and lymphocytes to decrease GL26 glioma invasiveness and increase host survival in vivo. Finally, increased tumor ST3Gal-II expression correlated with clinical vaccine failure in a meta-analysis of high-grade glioma patients.

Conclusions

Taken together, these findings suggest that de-sialylation of CD8 is required for hyper-responsiveness and beneficial anti-glioma activity by CD8 T cells. Because CD8 de-sialylation can be induced with exogenous enzymes (and appears particularly scarce on human T cells), it represents a promising target for clinical glioma vaccine improvement.
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Literature
1.
go back to reference Stupp R, Hegi ME, Gilbert MR, Chakravarti A (2007) Chemoradiotherapy in malignant glioma: standard of care and future directions. J Clin Oncol 25:4127–4136PubMedCrossRef Stupp R, Hegi ME, Gilbert MR, Chakravarti A (2007) Chemoradiotherapy in malignant glioma: standard of care and future directions. J Clin Oncol 25:4127–4136PubMedCrossRef
2.
go back to reference Yu JS, Wheeler CJ, Zeltzer PM et al (2001) Vaccination of malignant glioma patients with peptide-pulsed dendritic cells elicits systemic cytotoxicity and intracranial T-cell infiltration. Cancer Res 61:842–847PubMed Yu JS, Wheeler CJ, Zeltzer PM et al (2001) Vaccination of malignant glioma patients with peptide-pulsed dendritic cells elicits systemic cytotoxicity and intracranial T-cell infiltration. Cancer Res 61:842–847PubMed
3.
go back to reference Kikuchi T, Akasaki Y, Irie M, Homma S, Abe T, Ohno T (2001) Results of a phase I clinical trial of vaccination of glioma patients with fusions of dendritic and glioma cells. Cancer Immunol Immunother 50:337–344PubMedCrossRef Kikuchi T, Akasaki Y, Irie M, Homma S, Abe T, Ohno T (2001) Results of a phase I clinical trial of vaccination of glioma patients with fusions of dendritic and glioma cells. Cancer Immunol Immunother 50:337–344PubMedCrossRef
4.
go back to reference Yamanaka R, Abe T, Yajima N, Tsuchiya N, Homma J, Kobayashi T, Narita M, Takahashi M, Tanaka R (2003) Vaccination of recurrent glioma patients with tumour lysate-pulsed dendritic cells elicits immune responses: results of a clinical phase I/II trial. Br J Cancer 89:1172–1179PubMedCentralPubMedCrossRef Yamanaka R, Abe T, Yajima N, Tsuchiya N, Homma J, Kobayashi T, Narita M, Takahashi M, Tanaka R (2003) Vaccination of recurrent glioma patients with tumour lysate-pulsed dendritic cells elicits immune responses: results of a clinical phase I/II trial. Br J Cancer 89:1172–1179PubMedCentralPubMedCrossRef
5.
go back to reference Yu JS, Liu G, Ying H, Yong WH, Black KL, Wheeler CJ (2004) Vaccination with tumor lysate-pulsed dendritic cells elicits antigen-specific cytotoxic T cells in patients with malignant glioma. Cancer Res 64:4973–4979PubMedCrossRef Yu JS, Liu G, Ying H, Yong WH, Black KL, Wheeler CJ (2004) Vaccination with tumor lysate-pulsed dendritic cells elicits antigen-specific cytotoxic T cells in patients with malignant glioma. Cancer Res 64:4973–4979PubMedCrossRef
6.
go back to reference Kikuchi T, Akasaki Y, Abe T, Fukuda T, Saotome H, Ryan JL, Kufe DW, Ohno T (2004) Vaccination of glioma patients with fusions of dendritic and glioma cells and recombinant human interleukin 12. J Immunother 27:452–459PubMedCrossRef Kikuchi T, Akasaki Y, Abe T, Fukuda T, Saotome H, Ryan JL, Kufe DW, Ohno T (2004) Vaccination of glioma patients with fusions of dendritic and glioma cells and recombinant human interleukin 12. J Immunother 27:452–459PubMedCrossRef
7.
go back to reference Rutkowski S, De Vleeschouwer S, Kaempgen E et al (2004) Surgery and adjuvant dendritic cell-based tumour vaccination for patients with relapsed malignant glioma, a feasibility study. Br J Cancer 91:1656–1662PubMedCentralPubMed Rutkowski S, De Vleeschouwer S, Kaempgen E et al (2004) Surgery and adjuvant dendritic cell-based tumour vaccination for patients with relapsed malignant glioma, a feasibility study. Br J Cancer 91:1656–1662PubMedCentralPubMed
8.
go back to reference Yamanaka R, Homma J, Yajima N et al (2005) Clinical evaluation of dendritic cell vaccination for patients with recurrent glioma: results of a clinical phase I/II trial. Clin Cancer Res 11:4160–4167PubMedCrossRef Yamanaka R, Homma J, Yajima N et al (2005) Clinical evaluation of dendritic cell vaccination for patients with recurrent glioma: results of a clinical phase I/II trial. Clin Cancer Res 11:4160–4167PubMedCrossRef
9.
go back to reference Liau LM, Prins RM, Kiertscher SM et al (2005) Dendritic cell vaccination in glioblastoma patients induces systemic and intracranial T-cell responses modulated by the local central nervous system tumor microenvironment. Clin Cancer Res 11:5515–5525PubMedCrossRef Liau LM, Prins RM, Kiertscher SM et al (2005) Dendritic cell vaccination in glioblastoma patients induces systemic and intracranial T-cell responses modulated by the local central nervous system tumor microenvironment. Clin Cancer Res 11:5515–5525PubMedCrossRef
10.
go back to reference De Vleeschouwer S, Fieuws S, Rutkowski S et al (2008) Postoperative adjuvant dendritic cell-based immunotherapy in patients with relapsed glioblastoma multiforme. Clin Cancer Res 14:3098–3104PubMedCrossRef De Vleeschouwer S, Fieuws S, Rutkowski S et al (2008) Postoperative adjuvant dendritic cell-based immunotherapy in patients with relapsed glioblastoma multiforme. Clin Cancer Res 14:3098–3104PubMedCrossRef
11.
go back to reference Wheeler CJ, Black KL, Liu G et al (2008) Vaccination elicits correlated immune and clinical responses in glioblastoma multiforme patients. Cancer Res 68:5955–5964PubMedCrossRef Wheeler CJ, Black KL, Liu G et al (2008) Vaccination elicits correlated immune and clinical responses in glioblastoma multiforme patients. Cancer Res 68:5955–5964PubMedCrossRef
12.
go back to reference Wheeler CJ, Das A, Liu G, Yu JS, Black KL (2004) Clinical responsiveness of glioblastoma multiform to chemotherapy after vaccination. Clin Cancer Res 10:5316–5326PubMedCrossRef Wheeler CJ, Das A, Liu G, Yu JS, Black KL (2004) Clinical responsiveness of glioblastoma multiform to chemotherapy after vaccination. Clin Cancer Res 10:5316–5326PubMedCrossRef
13.
go back to reference Okada H, Kalinski P, Ueda R et al (2011) Induction of CD8+ T-cell responses against novel glioma-associated antigen peptides and clinical activity by vaccinations with α-type 1 polarized dendritic cells and polyinosinic-polycytidylic acid stabilized by lysine and carboxymethylcellulose in patients with recurrent malignant glioma. J Clin Oncol 29:330–336PubMedCentralPubMedCrossRef Okada H, Kalinski P, Ueda R et al (2011) Induction of CD8+ T-cell responses against novel glioma-associated antigen peptides and clinical activity by vaccinations with α-type 1 polarized dendritic cells and polyinosinic-polycytidylic acid stabilized by lysine and carboxymethylcellulose in patients with recurrent malignant glioma. J Clin Oncol 29:330–336PubMedCentralPubMedCrossRef
14.
go back to reference Wheeler CJ, Black KL, Liu G, Ying H, Yu JS, Zhang W, Lee PK (2003) Thymic CD8+ T cell production strongly influences tumor antigen recognition and age-dependent glioma mortality. J Immunol 171:4927–4933PubMedCrossRef Wheeler CJ, Black KL, Liu G, Ying H, Yu JS, Zhang W, Lee PK (2003) Thymic CD8+ T cell production strongly influences tumor antigen recognition and age-dependent glioma mortality. J Immunol 171:4927–4933PubMedCrossRef
15.
go back to reference Schon MP, Arya A, Murphy EA et al (1999) Mucosal T lymphocyte numbers are selectively reduced in integrin alpha E (CD103)-deficient mice. J Immunol 162:6641–6649PubMed Schon MP, Arya A, Murphy EA et al (1999) Mucosal T lymphocyte numbers are selectively reduced in integrin alpha E (CD103)-deficient mice. J Immunol 162:6641–6649PubMed
16.
17.
go back to reference Annunziato F, Cosmi L, Liotta F et al (2006) CXCR3 and αEβ7 integrin identify a subset of CD8+ mature thymocytes that share phenotypic and functional properties with CD8+ gut intraepithelial lymphocytes. Gut 55:961–968PubMedCentralPubMedCrossRef Annunziato F, Cosmi L, Liotta F et al (2006) CXCR3 and αEβ7 integrin identify a subset of CD8+ mature thymocytes that share phenotypic and functional properties with CD8+ gut intraepithelial lymphocytes. Gut 55:961–968PubMedCentralPubMedCrossRef
19.
go back to reference Li L, Kim S, Herndon J et al (2012) Cross-dressed CD8α+/CD103+ dendritic cells prime CD8+ T cells following vaccination. Proc Natl Acad Sci USA 109:12716–12721PubMedCentralPubMedCrossRef Li L, Kim S, Herndon J et al (2012) Cross-dressed CD8α+/CD103+ dendritic cells prime CD8+ T cells following vaccination. Proc Natl Acad Sci USA 109:12716–12721PubMedCentralPubMedCrossRef
20.
go back to reference Sung SS, Fu SM, Rose CE Jr, Gaskin F, Ju ST, Beaty SR (2006) A major lung CD103 (alphaE)-beta7 integrin-positive epithelial dendritic cell population expressing Langerin and tight junction proteins. J Immunol 176:2161–2172PubMedCrossRef Sung SS, Fu SM, Rose CE Jr, Gaskin F, Ju ST, Beaty SR (2006) A major lung CD103 (alphaE)-beta7 integrin-positive epithelial dendritic cell population expressing Langerin and tight junction proteins. J Immunol 176:2161–2172PubMedCrossRef
21.
go back to reference Allez M, Brimnes J, Dotan I, Mayer L (2002) Expansion of CD8+ T cells with regulatory function after interaction with intestinal epithelial cells. Gastroenterology 123:1516–1526PubMedCrossRef Allez M, Brimnes J, Dotan I, Mayer L (2002) Expansion of CD8+ T cells with regulatory function after interaction with intestinal epithelial cells. Gastroenterology 123:1516–1526PubMedCrossRef
22.
go back to reference Annacker O, Coombes JL, Malmstrom V, Uhlig HH, Bourne T, Johansson-Lindbom B, Agace WW, Parker CM, Powrie F (2005) Essential role for CD103 in the T cell-mediated regulation of experimental colitis. J Exp Med 202:1051–1061PubMedCentralPubMedCrossRef Annacker O, Coombes JL, Malmstrom V, Uhlig HH, Bourne T, Johansson-Lindbom B, Agace WW, Parker CM, Powrie F (2005) Essential role for CD103 in the T cell-mediated regulation of experimental colitis. J Exp Med 202:1051–1061PubMedCentralPubMedCrossRef
23.
go back to reference Liu Y, Lan Q, Lu L et al (2014) Phenotypic and functional characteristic of a newly identified CD8+ Foxp3-CD103+ regulatory T cells. J Mol Cell Biol 6:81–92PubMedCrossRef Liu Y, Lan Q, Lu L et al (2014) Phenotypic and functional characteristic of a newly identified CD8+ Foxp3-CD103+ regulatory T cells. J Mol Cell Biol 6:81–92PubMedCrossRef
24.
go back to reference Calzascia T, Masson F, Di Berardino-Besson W, Contassot E, Wilmotte R, Aurrand-Lions M, Rüegg C, Dietrich PY, Walker PR (2005) Homing phenotypes of tumor-specific CD8 T cells are predetermined at the tumor site by crosspresenting APCs. Immunity 22:175–184PubMedCrossRef Calzascia T, Masson F, Di Berardino-Besson W, Contassot E, Wilmotte R, Aurrand-Lions M, Rüegg C, Dietrich PY, Walker PR (2005) Homing phenotypes of tumor-specific CD8 T cells are predetermined at the tumor site by crosspresenting APCs. Immunity 22:175–184PubMedCrossRef
25.
go back to reference Masson F, Calzascia T, Di Berardino-Besson W, de Tribolet N, Dietrich PY, Walker PR (2007) Brain microenvironment promotes the final functional maturation of tumor-specific effector CD8+ T cells. J Immunol 179:845–853PubMedCrossRef Masson F, Calzascia T, Di Berardino-Besson W, de Tribolet N, Dietrich PY, Walker PR (2007) Brain microenvironment promotes the final functional maturation of tumor-specific effector CD8+ T cells. J Immunol 179:845–853PubMedCrossRef
26.
go back to reference Wakim LM, Woodward-Davis A, Bevan MJ (2010) Memory T cells persisting within the brain after local infection show functional adaptations to their tissue of residence. Proc Natl Acad Sci USA 107:17872–17879PubMedCentralPubMedCrossRef Wakim LM, Woodward-Davis A, Bevan MJ (2010) Memory T cells persisting within the brain after local infection show functional adaptations to their tissue of residence. Proc Natl Acad Sci USA 107:17872–17879PubMedCentralPubMedCrossRef
27.
go back to reference Casey KA, Fraser KA, Schenkel JM et al (2012) Antigen-independent differentiation and maintenance of effector-like resident memory T cells in tissues. J Immunol 188:4866–4875PubMedCentralPubMedCrossRef Casey KA, Fraser KA, Schenkel JM et al (2012) Antigen-independent differentiation and maintenance of effector-like resident memory T cells in tissues. J Immunol 188:4866–4875PubMedCentralPubMedCrossRef
28.
go back to reference Priatel JJ, Chui D, Hiraoka N, Simmons CJT, Richardson KB, Page DM, Fukuda M, Varki NM, Marth JD (2000) The ST3Gal-1 sialyltransferase controls CD8+ T lymphocyte homeostasis by modulating O-glycan biosynthesis. Immunity 12:273–283PubMedCrossRef Priatel JJ, Chui D, Hiraoka N, Simmons CJT, Richardson KB, Page DM, Fukuda M, Varki NM, Marth JD (2000) The ST3Gal-1 sialyltransferase controls CD8+ T lymphocyte homeostasis by modulating O-glycan biosynthesis. Immunity 12:273–283PubMedCrossRef
29.
go back to reference Moody AM, Chui D, Reche PA, Priatel JJ, Marth JD, Reinherz EL (2001) Developmentally regulated glycosylation of the CD8alphabeta coreceptor stalk modulates ligand binding. Cell 107:501–512PubMedCrossRef Moody AM, Chui D, Reche PA, Priatel JJ, Marth JD, Reinherz EL (2001) Developmentally regulated glycosylation of the CD8alphabeta coreceptor stalk modulates ligand binding. Cell 107:501–512PubMedCrossRef
30.
go back to reference Daniels MA, Devine L, Miller JD, Moser JM, Lukacher AE, Altman JD, Kavathas P, Hogquist KA, Jameson SC (2001) CD8 binding to MHC class I molecules is influenced by T cell maturation and glycosylation. Immunity 15:1051–1061PubMedCrossRef Daniels MA, Devine L, Miller JD, Moser JM, Lukacher AE, Altman JD, Kavathas P, Hogquist KA, Jameson SC (2001) CD8 binding to MHC class I molecules is influenced by T cell maturation and glycosylation. Immunity 15:1051–1061PubMedCrossRef
31.
go back to reference Brennan PJ, Saouaf SJ, Van Dyken S, Marth JD, Li B, Bhandoola A, Greene MI (2006) Sialylation regulates peripheral tolerance in CD4+ T cells. Int Immunol 18:627–635PubMedCrossRef Brennan PJ, Saouaf SJ, Van Dyken S, Marth JD, Li B, Bhandoola A, Greene MI (2006) Sialylation regulates peripheral tolerance in CD4+ T cells. Int Immunol 18:627–635PubMedCrossRef
32.
go back to reference Irvin DK, Jouanneau E, Duvall G et al (2010) T cells enhance stem-like properties and conditional malignancy in gliomas. PLoSONE 5:e10974CrossRef Irvin DK, Jouanneau E, Duvall G et al (2010) T cells enhance stem-like properties and conditional malignancy in gliomas. PLoSONE 5:e10974CrossRef
33.
go back to reference Phuphanich S, Wheeler CJ, Rudnick JD et al (2013) Phase I trial of a multi-epitope-pulsed dendritic cell vaccine for patients with newly diagnosed glioblastoma. Cancer Immunol Immunother 62:125–135PubMedCentralPubMedCrossRef Phuphanich S, Wheeler CJ, Rudnick JD et al (2013) Phase I trial of a multi-epitope-pulsed dendritic cell vaccine for patients with newly diagnosed glioblastoma. Cancer Immunol Immunother 62:125–135PubMedCentralPubMedCrossRef
34.
go back to reference Prins RM, Odesa SK, Liau LM (2003) Immunotherapeutic targeting of shared melanoma-associated antigens in a murine glioma model. Cancer Res 63:8487–8491PubMed Prins RM, Odesa SK, Liau LM (2003) Immunotherapeutic targeting of shared melanoma-associated antigens in a murine glioma model. Cancer Res 63:8487–8491PubMed
35.
go back to reference Prins RM, Incardona F, Lau R, Lee P, Claus S, Zhang W, Black KL, Wheeler CJ (2004) Characterization of defective CD4-CD8-T cells in murine tumors generated independent of antigen specificity. J Immunol 172:1602–1611PubMedCrossRef Prins RM, Incardona F, Lau R, Lee P, Claus S, Zhang W, Black KL, Wheeler CJ (2004) Characterization of defective CD4-CD8-T cells in murine tumors generated independent of antigen specificity. J Immunol 172:1602–1611PubMedCrossRef
36.
go back to reference Jouanneau E, Poujol D, Gulia S, Le Mercier I, Blay JY, Belin MF, Puisieux I (2006) Dendritic cells are essential for priming but inefficient for boosting antitumour immune response in an orthotopic murine glioma model. Cancer Immunol Immunother 55:254–267PubMedCrossRef Jouanneau E, Poujol D, Gulia S, Le Mercier I, Blay JY, Belin MF, Puisieux I (2006) Dendritic cells are essential for priming but inefficient for boosting antitumour immune response in an orthotopic murine glioma model. Cancer Immunol Immunother 55:254–267PubMedCrossRef
37.
go back to reference Shai R, Shi T, Kremen TJ, Horvath S, Liau LM, Cloughesy TF, Mischel PS, Nelson SF (2003) Gene expression profiling identifies molecular subtypes of gliomas. Oncogene 22:4918–4923PubMedCrossRef Shai R, Shi T, Kremen TJ, Horvath S, Liau LM, Cloughesy TF, Mischel PS, Nelson SF (2003) Gene expression profiling identifies molecular subtypes of gliomas. Oncogene 22:4918–4923PubMedCrossRef
38.
go back to reference Sempowski GD, Gooding ME, Liao HX, Le PT, Haynes BF (2002) T cell receptor excision circle assessment of thymopoiesis in aging mice. Mol Immunol 38:841–848PubMedCrossRef Sempowski GD, Gooding ME, Liao HX, Le PT, Haynes BF (2002) T cell receptor excision circle assessment of thymopoiesis in aging mice. Mol Immunol 38:841–848PubMedCrossRef
39.
go back to reference Pappu BP, Shrikant PA (2004) Alteration of cell surface sialylation regulates antigen-induced naive CD8+ T cell responses. J Immunol 173:275–284PubMedCrossRef Pappu BP, Shrikant PA (2004) Alteration of cell surface sialylation regulates antigen-induced naive CD8+ T cell responses. J Immunol 173:275–284PubMedCrossRef
40.
go back to reference Lee YC, Kojima N, Wada E, Kurosawa N, Nakaoka T, Hamamoto T, Tsuji S (1994) Cloning and expression of cDNA for a new type of Gal beta 1,3GalNAc alpha 2,3-sialyltransferase. J Biol Chem 269:10028–10033PubMed Lee YC, Kojima N, Wada E, Kurosawa N, Nakaoka T, Hamamoto T, Tsuji S (1994) Cloning and expression of cDNA for a new type of Gal beta 1,3GalNAc alpha 2,3-sialyltransferase. J Biol Chem 269:10028–10033PubMed
41.
go back to reference Wu W, Harley PH, Punt JA, Sharrow SO, Kearse KP (1996) Identification of CD8 as a peanut agglutinin (PNA) receptor molecule on immature thymocytes. J Exp Med 184:759–764PubMedCrossRef Wu W, Harley PH, Punt JA, Sharrow SO, Kearse KP (1996) Identification of CD8 as a peanut agglutinin (PNA) receptor molecule on immature thymocytes. J Exp Med 184:759–764PubMedCrossRef
42.
go back to reference Prins RM, Graf MR, Merchant RE, Black KL, Wheeler CJ (2003) Deficits in thymic function and output of recent thymic emigrant T cells during intracranial glioma progression. J Neurooncol 64:45–54PubMed Prins RM, Graf MR, Merchant RE, Black KL, Wheeler CJ (2003) Deficits in thymic function and output of recent thymic emigrant T cells during intracranial glioma progression. J Neurooncol 64:45–54PubMed
43.
go back to reference Wheeler CJ, Black KL (2011) Vaccines for glioblastoma and high-grade glioma. Expert Rev Vaccines 10:875–886PubMedCrossRef Wheeler CJ, Black KL (2011) Vaccines for glioblastoma and high-grade glioma. Expert Rev Vaccines 10:875–886PubMedCrossRef
Metadata
Title
Intrinsically de-sialylated CD103+ CD8 T cells mediate beneficial anti-glioma immune responses
Authors
Emmanuel Jouanneau
Keith L. Black
Lucia Veiga
Ryan Cordner
Shyam Goverdhana
Yuying Zhai
Xiao-xue Zhang
Akanksha Panwar
Armen Mardiros
HongQiang Wang
Ashley Gragg
Mandana Zandian
Dwain K. Irvin
Christopher J. Wheeler
Publication date
01-09-2014
Publisher
Springer Berlin Heidelberg
Published in
Cancer Immunology, Immunotherapy / Issue 9/2014
Print ISSN: 0340-7004
Electronic ISSN: 1432-0851
DOI
https://doi.org/10.1007/s00262-014-1559-2

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