HER2/neu Peptide-Based Vaccines, with GM-CSF as an ... · HER2/neu Peptide-Based Vaccines, with GM-CSF as an Adjuvant, in Patients with Advanced-Stage HER2/neu.. Expressing Cancers

HER2/neu Peptide-Based Vaccines, with GM-CSF as an Adjuvant, in Patients with Advanced-Stage HER2/neu.. Expressing Cancers

Kathy Schiffman and Nfary L. Disis

Rationale Despite advances in surgery, chemo­

merapy, and radiation, paciems wim solid mmors such as breast, ovarian, or lung cancer may relapse because of residual microscopic disease. The identification ofseveral tumor amigens, such as HER2! neu and p53, and an increased under­standing of the role rhey play in malig­nam cransformation, have led to clinical studies evaluaring antigen-specific' cancer V;lccines chat target biologically relevant proteins. l This approach holds meoretic promise for potential eradicatio n of residual subclinical disease through active . ..lmmuruzanon.

The HER2/neu prmem is a rumor anti­gen. It consiscs of a large cysteine-rich extraCellular domain (EeD) which prob­ably funccions in ligand binding, a shorr transmembrane domain, and a small cytoplasmic domain ,,:,iili tyrosine kinase a.crivity. In some nonna! adult tissue cells, me HER2/neu gene is present as a single capy.l Amplificacion of the gene or over­e..xpressiol1 by posnranscriptiol1al medl­al1isms leads W overexpression of the associated p[Qrein and, rhus, plays a role in malignanr transformarion by con­rriburing to the uncontrolled growm of cancer cells. HER2/ neu overexpression has been described in a variety of dif­ferenc tumor types, including breast,

ovarian, non-small-ce!llung, renal cd!, prost<ue, pancreas, colon, gastric, salivary, bladder, and oral squamous cell carcino­mas. HER2/neu overexpression, in gen­eral, is regarded as a poor prognostic factor. In addition, HER21 neu overex­pression appears w be a prediccive factor ror resistance m some chemomerapeucic agencs)-G

Studies from our laboratory and others have demonstrated that: some patients with HER2!nro-over=pressing cancers have existent antibody and T-cell re­sponses to the protein. 7 In particular, patients with HER2/neu-overexpressing non-small-cell lung cancers can have a derecrable antibody immunity to HER1/ neu.S HER1!ne-u-specific cytoroxic T lymphocytes (CTL) have been identified in patienrs with a variety of HER11 neu­overexpressing malignancies, including bteast, ovarian, and lung cancers. 9- 11

Additionally, helper T-cell proliferation specific for the HER2lneu protein and selected peptide epitopes has been de­tected in parienrs with HER2/neu-over­expressing breast cancers. 12

Once HER2!neu nad been defined as a human rumor ancigen, an immuniza­tion strategy ro augmenc immunity ill pa~iencs with a preexistent: immune response or co generate immunity in patients with no detectable HER2lmu

Division. of O~cojogy, Universiry ofW:lShlngmn., 5e:mJe, Washingm n

Submicred: Mar. [5, 2000, Revised, Jul. 15, 2000; Acc<:p<od: Jul. 20, 2000

Clinical Lung G1nC~ Vol. 2. No. l, 74-77, 2000

imm\,;niry needed co be defined. E;;,rly investigations had shown mac rats could not be immunized wi<:h ra~ neu pro­1:ein. 13 We quescioned whether thIS roler­ance to HER2/neu, a self-p rocein. could be circumvented by immunizacion with peptide-based vaccines. Immunization co foreign proteins normally generates immunity only to the subser of domi­nanr epitopes, whereas ocher, porencially immunogenic, subdominant epiropes are ignored. Indeed, a neu peptide-based vaccine incorporating subdominanr epi­topes from rat neu proved to be the most effective construcr in generating neu­

specific immunity in the rat. The addi· tion ofgranulocyte-macrophage colony­stimulatiilg facwr (GM-CSF) (Q the pepcide-based vaccines, as a vaccine adju­vant, resulted i11 the in£!ux of effective antigen-presenting celis (APCl and aug­menra~jon of che immune respomes genetated after imrnunUa.(ion_ i4

Our clinical erial srrategy is to creat:e or augment immunicy in patients whose tumors overexpress HER2/Ile<.t, using vac­cinaEion with pep tides derived from HER2/nL"u tbar have been predicted by computer modeling to be poten­cial subdominant pepcide epitopes in hu­mans. 12 The parienrs enrolled In this study receive one of rnree vaccine for­mularion5; each formulation comprises three pep tides, 15-18 amino acids in lengili, derived r£'om elmer cfl.e fCD or intracellular domain (ICD) of HER2/ neu. In addition, the third formulation consists of helper eplmpes mat encom­pass shorrer nine amino acid human

Addres' for correspondellce: M'lrY L. Dis;s, Box 356527, Oncology, University ofWashingron. leukocyre antigen (HL\)-Al bindingSeattle. WA 98195-6327 fax, ~OG-G85-31 ~s

peprides derived from rhe HER2/ neu

741 August 2000

procein sequence. Each vaccine formub­cion is admixed wim 125 flg ofGM-CSt:

,IS an adjuv:ln<.

Objectives The endpoints of the study J.re (I) to

Jdine the safeey of immunizing against:l

sdf-\Umor :lncigen and (2) co Jecermine whether immunity co HER2lm:u pwcein (111. be:: elicieed by immunizaeion \Vieh a

peptide::-based vaccine.

Toxicities The aneicipated toxicities of our vaccine

seraeegy include local injection Site re:lctions

mac would be expeaed \Vim immunizations

md cheorerica! systemic coxicicies rdaced

[0 development of immuniry [Q HfR21 l/I.'U, a self-protein. HER2/nne is expressed in high levels d~ring fecal growch and de. ,'-c::!opmenc and in low amounrs 011 a few

normal adult <issues, including breast,

merus. vagina. digestive tract epithelium.

bue and pancreanc ductS. kidney and ureter,

bronchi. and epidermis. The prorein has

noc be--..n detected in che circufacory. hema­

cologie. musculoskeleral, endocrine, or

ceneral nervous sYStems. Preclinical dara

from our lab looked at the hisropamology of tissues expressing basallevds of rat

JIm protein in the animals who developed immune responses after pep(ide-bas~d

\";lccinaoon. There were no signs of micro­

Kopic autoimmune damage.

All adverse events are scored by rhe

:-\acional Cancer lnsticute Common Toxic­icy Criteria. Pacienc evaluations include

assessment ofany local reactions ac the site

of me injecrion (p;lin, eendemess, erymema,

and induration) and assessment of any

svstemic reaction to immunization (such

~ malaise or fever).' Because induction of

J.llcoimmunieyby HER2lneu immuniza·

tion would potencially cause damage to

tissues expressing basal levels ofHER2lnrn,

such as skin. digestive tract epithelium,

liver. and lung, pacienrs have extensive serologic chemistries performed before each

immunizarion 10 assess organ fi.mcrion as

well as a complete physical exam. Finally,

HERlJ11m 15 overexpresse-d in a noncancer­

OilS sr:ue in the human fetus during the

third <rimester of pregnancy. It is possible

Lfa woman developed significant immunity

co HER2! I/I.'U [hat this immu nity may pre-

Tanle 1: Predided Response Roles

Observed -. .. .. .. . . • • Response ••

• I

. . •• . . Rate •

10% 2%-28% 2%-4%

20'1' 77f-40% 9"<-.\6%

30% 14%-51% 17$<---47%

22%-6[% 2jQ.;-0C

50% 30%-70% 34%-66%

GO'1 3991'-78% ~3<:t'·-5%

70% 49%-86% 54%-83%

60%-93s:f 6-tq ·91 q,80"<'

venc her from carrying a fetus to full eerm. For this reason female patientS enrolled

mllSr be finished with childbearing.

Treatment Plan Sixty patiems with breast. ovarian. and

non-smail-cell IWlg cancer will Se enrolled

in the srudy, 20 patients per vaccine formu­

!arion. While 20 patients per arm is a larger number than expecred for a wxicity study,

rhis is the minimum number ofparients

studied mar would allow us co extrapolate

che results co a larger pop ulatio n. If a re­

sponse rate (defined as eic..'J.er me generarion

of or the augmentation of an inunune re­sponse) is known for 20 patients, me ability ofa particular V<lccine formulaeion (Q elicit

these responses in a general population can

be prediCted. For example, from Table 1, if 20. pacien tS were entered onw a study

and [4 responses (70%) were observed, me ~rue response rare ar a 90% confidence in­

terval is 490/0-86%.15 Progressing to a. ph= n scudy of efficacy would require that we

could expeCt mat the majority of patients

vaccinated would generate che appropriate antigen-specific immune response.

Table 2: Ehgibility Requirements

Patiencs wili receive eidler che fCD or

the leO formulation. a1cema,ing sequen­

tially as they are enrolled. Those patients

who are HU..-A2 will r=ive che third fo,­

mulacion, which coomins HL\·A2 binding

epitopc:s. All treatment ,,,ill be conducted

:Ie the Umversiry of Washingran, Seattle,

Washingron. Eligibility "'ill be determined

by rdeprlOne communication with che patient and her/his private physician prior

to the first visit.

The subject's eligibilicy and me treatment

plan are outlined in Tables 2 and 3, respec­

tive!y. 'The components of rhe plan are

designed ro answer me follo"'mg questions.

Is There Any Baseline Organ Damage Which Would Preclude- Enrollment:'

A hisrory and physical, complere blood coum and diffi:renci:al, blood urea nitrogen,

se~ creatinine, alanine aminotransferase.

and tocal bilirubin are performed.

Does the Patient's Immu.ne System Function?

After informed consenr, delayed-type

hypersensitivity (DTH) to seven common

• Stage 1lI 0, IV di=

• Breo.> r, ovari~ n, 0r no O--<r:1 alI-cell lung Cance'

• HER21,..,. ovetexp=ion in primary mmo, or m""""rasis

• Complered srandMd of care m,a'ment for disease prior co enrollment

• No cytotoxic (hetapy or treacmenl dose of steroids for a minimum of 1 momh peiOt to enrollment

• No immufiomoduLJ.co<}' drug, Wfllie on study, :e. r"'Smzumab or other VaCCln~

• Age" IS yea", old

• Wh'te blood cell coune > 3500, pl-.1(ele< coum > 100,000. ",rum Creannll'" < !.5 mg'dL ur

c~kula,ed CreanOIO< clearance> GO cc.'mlO. b,l,rub,n < t.5 mgJdL

• Female P'''' ems m u" bt: posemenopamal

August 2000 I 75

Table 3: HER 2/neu Peptide Vaccine Treatment 5(hedule

Procedure

Vaccine Number

PhyslClI exam

Sj re ,n'peGion

V,t~l "";0,

Lab T,,~ts

cae Live r fllnetion

Pn:g rl.J.nc~- (esC

Renal funcroon, .kccro!;"tes

Immune S'udies

DTH '0 r"cdl an'igens

1<l.H I rnn~un Ll:;.l(lOn

OTH to HER21nm pepcides

Sk,n "'OF;" •An"gen-sp.,;iflc T,,,!!

and annbody assays

Pre

X

x

X

X

X

X

X

X

X j

I

X

X

X

x

X

X

X

KiH : kel'hole l,m~[ hemoc\"anin

recall antigens, reunus mxoid. diphtheria

roxoid. proreus, suepcoco=. cuberculjn.

candida alblCUls, and trichophyton (Mulci.

;:est CM!, Connaught Labs, Insritur,

!vlerieLL'l:, Lyon, France), IS placed. SubjectS

mLlSt have a DTH response of 2 mm o'r

greater co ;u least rwo recall amigens to

proceed on srudy. Ifconvenie~(, this test

can be placed by dIe printe ph.ysician to

determine digibiliry prior [Q coming to

tht: University of\Vashingwn_

Table 4: Patient Evaluation

Vaccine Schedule

3 4 6 POSt

X X X X X

X X X X

X X X X

x x x x X

X X X X X

X X X X X

X

X

X X X I X X

dda;-ed·eypt> hypersensicj",cy·:

Is There /111 Imlfllllll: Response to HER2lneu Peptides by DTH?

OTH {cst;ng co each peplidt: in the

vaccine ~ormubtlon. Glvl-CS F. ,md sterde

\VJter is performed pnor (0 J,dministr:lcion

ot' the £1m vaccina,lon. rnclufJ,{ion is read

at 48 hours. This is repe:l,ed 30 days after

cf:e l;J5t vaccine to :tssess ,he devdopmem

of In immune response. At rhar rime. skin

biopsies of DTH sites are obtained using

J 3-mm punch 10 be stained and ev:J.lua'ed

r'o r ,he presence of CD I a, H LA- 0 R, .1nd CD3- cells incorporaring both CD4­and COB- Iympho(,.ltes­

~re Thae Any ElLd-Organ Toxicities to Organs Expressing Basal Levels of HER2lneu?

Prior to each vacci ne, potenrial side

roxicities are reviewed. a brief physical is

performed, and complere blood coune and chemiscrics (as above) are evaluated and

moni(Ored for abnormalities (Q suggest

toXlciry.

Do Patients Gena-ate Measurable Immune Responses to HER2/neu Peptides and Pro(l:in Assessed by Lymphocyte and Antibody Assays?

Prior co rhe first vaccine, monthly,

and 30 days following [he last vaccine,

patierres donare 200 cc of blood ro obtain

peripheral blood mononuclear cells that

can be used for evalua,ing baseline and postvaccination immunity co rhe HER2! n...~ p<:ptides and protein. Parienes are eval­

uatc:d for immunity every 3 monrns follow­ing their last visit so long as they demon­

SIr<l.Ce lmmuniry.

2

X

X

X

X

X

X

X

Abbr"v!arions: CBC ~ complNe blood coum; DTH ~

Can the Parinzrs Be Immunized to a IVontumor Antigen?

Pacienrs rec.:ive a single immWlizarion

wirh a foreign amigen, keyhOle limper

hemocyanin (KLH). KLH will s~['.-e as a

posiciv.:: control neuunmuillzacion ro assess

the paciem's abiliry m be immunized and

,0 generare an immune ~esponse. An ,i ­

boay and T-c<>Il responses co KLH will

be compared wirh responses to HER2 pepride '-accines.

Antigen-Specific Immune Responses An,ibody immut"llty

T he! per Lmmun iry

Cyto'o:<ic T-<:eJl immurury

Delayed-,,.,,. hypel'$"nswvirl"

Method ofAnalysis

Quamira"ve EUSA (mglmL) measwcing response ro re<ombinan( ECD, (CO proteins, HER2hTtlJ peprjdes. KLH, and eemnus toxoid

IgG an d IgA respo nses

19G ismj'pe :espoose'

PcolifeeanM by modIfied llmiein,g djlll(ian analv", eval"",i,,!)"

res po lise '0 HER2/neu peP"".s. ECD and ICD proteins. cancrol

ant:lgenSi li '

ELlSPOT and chromIUm rele-ase ossays using JucoJogous cugecs

OTH responses m [he Lmmunmn,g pep,ides. >tenie wa,~r. ~nd

G~[ -CSF Pee- and pos' -VaCC' ne sene,

Abbeev,a,ions: DTH ~ rlelaycd .eype h;:peeSe'l$lClv"y; ECD ~ excmcellular dom~Ln:

ELISA ~ e'lz;:me·linked Lrr.mlHlosorbem a.I'''~: ELISPOT ~ ~n"yme·[,nked lmmunmpnc; GM,CSf : granuloc:-te-m..r.:rophag~ colonY"Clmulacing facme; ICD ~ I nr,....cdllllar domaIn: KlH : keynole Jimf'<" nemocynn:n

76 I Augusr 2000

Immunologic Evaluation There is no gold sranchrd for measuring

rhe developmenr of rumor antigen-specific

immune responses. 16 Therefore, immuno­

logic moniroring will include overlapping

merhods for directly and inferen [ially

measuring CD4 and CDB T cdls and anti­

bodies (Table 4). In vivo T-cell responses

will be assessed by subjects undergoing

OTH testing- to rheir immunizing pep­

rides. Prior co their fim vaccine, mon,hly,

and 30 days after their last vaccine, T· celt proliFeration a.ssays co their immuniz­

ing pep,ides, reranus toXOId, KLH, and rhe HER2fnt'U ECD and [CD prote:ns are

pCdiJrmcd on thcir peripheral blood mono­

nuckar cells. I , Ev:llu:uion of the gcnera­

[ion ofcywwxic T cdls speciFic for HER2/

"<'fI .i, ass~s5ed b(J[h by cnzym c" lin ked im­

munospor ~ay, which mC:J.Sures anogen­speci ric cywki nc re!<:;\.\e ,I ~ Jnd by rht: gen­

erarion or" CTL lines in vitro which cJ.n lyse HL.l,.-marched HER2/neu overexpres­

,ing: tumors,' 9.20 Antibody responses may

serve .1.\ a surrogat~ ror ,he developmem of:l T-c~lI response. parricuJarly !gG ,md 19A which require T-cell h.elp in Ig class :;wi[ching. Thus, quami[:lrivc an[ibody

subdJSS .lnd iso[ype analysis by ~nzyme­Ii rtk~d immunosorbenr assay is abo pcr­formed.~1

Acknowledgements This work is supponed For Mary L.

Disis by grams from the NariollJI Insti­{Utes of Healrh, &:lcional Cancer Institll(e

(K08 CA61334 and ROt CA75163), De­

partmem of Defense Breast Cancer Pro­

gram, and ilie Cancer Research Tre:l1:ment

Foundacioll.

References I. Dr~is ML. Cheever .\1A. O","O~~I\H. Pl"OtC'lI1:l ,13 rumor

,1nIlgcn:'i:. C;l.1'1' Oplfl Imm~n.o/l ~)C)(l; ~:6J.7 .6'i:. ~_ rr~SJ ~tF, CorcJon-C;Jrc" C. Sl.mwo 01- Expt~.sr()f1

"~-fht:' HER-1/lln~ Pforo·'JflCO~Cnl.'" 10 norm.L1 hum:.J,n ,tdlJlr JfLd fe~l tissul.'"S, O~~~(lgn1f:' 19L)O. );91 J-I.)(,2..

). P""r.m MD, P"ul«tl G. "l)mol1 OJ HER-~/~,u:\$.' p~ icn VC' ma rh r I) t rc5 pOn5C m brc;ts C';::J rt .... e-r t ne rJ py. Bn:.lSt Cdn,<r R<r T""", 19'H: 5~:6j· 77

•. :\lIr-:d DC, Cl"k G~l. Molio. R. <t .~. OV<f<,prmion uf HER~21 r1~1 .'\nd lCS fdac~onshLp 'l,.",Lh odler pmgr':If):,,:cK

f3 .....,urs dlan~ dLlr'tn~ ~hc p~IOI. of~n mu co inV::UJvc bre.l$c Cancel. Htm! fl.u/'/J; :9?.:!. 1_,:974-<)"1)

S, P;\L~ S. H<li:an R. Fisc,C'r E.~. cc ,J. r:JcnoJQglC ~ll1d;n~

from rhe- ~;ltlon:ll $llrgl<:.u ;\drUv,lnr B~~~ ,mJ Bowel r"\HCOCl prQ~Ooscll. slgn~~lc~n,c. of C'rbB·~ pCI)(Cln

o\"~r·<:~"pn:.s:(HJn !n pr1m.ti-- :nr::;J5c L..J.f1.'::U_ J CUll 011("01 1?"O:8:103·11~

6. ,Ill" HB. Tno' Ai). Bar. :::H.« 'J. ,'<rb3-, c'pre;.,ion ,1n.J rcs~nst: (0 ~lJiuqnc c::::-rJp .... In wom:n \\"lrh Ilod,,­p..,.~,nve. e~rl\' br~;lH CJr:..::~r..\' Engl;' .\{t(J· 19q~;

33<)-1,60.1266. DI31j .'-fl, C!l<t:lfcr .\Lo\. ~ER~::'III-!tl ptOt~LI"1:..l ~;lrg~~

for .l.r\tl~n -speci tic Immt.:.!':othcrJ.ptO of htlm.\f'l ~:mce('. Ad:' CJ.n~('T &J 1997; 71:}..d~371.

8. lG.rr q, Li,.;n~ ro n RV. \\ood D. ," oJ. S< rum m.,k«s ot the- HER2//fro oncog<;:"Jic protein m3.~' Serve JS an 0:1.!\ indlc:J,ror of m:1lign,L"lC'f in rton-smltl cd! lunS O"~". Elmer hdfir Gin "-,,,. I?9~

? Yoshino t. Go<d<~ebuu:< PS. P,opk' G!O. « .J. nER.;Ifh"It·deri""ed pl:? f Id~ oJ rc ~ n:.uotd an t19l: ns :J..Ino"'g ;,urnw L1on-small eel! lun~ .:.2,nc:::r mo OV';:lfl:1n oncer.

c."",,,, R" 1994, 54'33g~:.'}90 [0. r""pl" CE, Goed<gcbuur:< PS. Sm,rh R. " ,.1. Brcast

:lnd o"'~\tJn can,e:r~)pecdl:":: r:ytOlO:X.lc: T lymphocy[e$ fcc:agniz.-e ch.::: s:am~ HE~, lleu~decJ\'l:d p(prld.c::, Proc "'"t!. lui S<-< USA 1995: ~~,432""36.

1\ Fisk B. :lImns TL Wlurro" JT. CI JI. IdenlInu,ion of;U1

il nm unooom Ifun rPl,.'p ~ Id~ D t' HER· 1.1 Jl£'J pn:1fl.,\..o.1t'H:0!:,'t"nL,.'

rc:cfJ~n 1'f,r.:J b,~- tl .... :t't;l n ~u rn()r~"~pC'cifl, ~ \'CLl[()tl .... r ly'"phocycc I'"e•. {{'-rp ,II,.,/, 1')9';, :8r:~1lI'l·:117

1~ Om~ -"fL. Ch(.·~,\w M/\. HE.R-21n~'1l On1.:n~~nL... iJmf~lI':

iS~~Le_~ In V;U':GIH,,: d{.""'L:lopntc::n~. e,." Rtf.- fj1~mJlIl/ll1')9j:l;, IS:.F·~5.

lJ- BCrrL:ilrds R. Dt.';HCct: ". ,vkK.;,:-nw: S. ~r J.L E~"(l""~ (UI'J1or

;:mlnul'1mh('t.'\~,,·..tircc(c::[t ,1~p,n§r ,111 f)nco~tnC'~':lcodd

proJ'lo;t u.sinS"' "-,l(;C:nl.il .... 1n.lS VCGQ(_ fJroc .\:.':i_ lout St.'1 US., 1987, ".:68 >4-63;8

14. D"i. ,'vH., Bcrnlw<l H, Sh,o," F~l. cr.LI. Cr,nulocytc . rn<l<:roph"g~ CO!I,J"r~~(irnLJl:mng t~cror: an o:;:'t~r:\"t~ auiu· '.~am for pl"Qttin ~mJ ptptH,k-fnsed "'JCCLr:~ B:~wd 17)G, 3~:20Z·110

15. ,\khra CR. C,i" KC Ch",,, to' ,hc ""rI~' "op?,ng of pilot studi", J C!", On,,! 1984: 2:676-68:

~6. D:s;, M. MeN«1 D. SchilT""" K. <r.LI. Pep",l<·b's<d Cum(]~ VJCCInt::s- (ul7'mt Op1J'lllJ!1. in Onn.JIOgrc 5~~(rJ/"ll!,

rmd ......ftrn.bobc f!lI'l'H~(Mlol/lll Onl!' 1999~ !_"':"j-~59

, Dim iYlL. G"b"c;n Ki-i, Sle,ch ~R ... JJ. G''-<''lion u~ Immun It'· r.l,) rho::: HER·21 n(u Q'nCO-:::;~:lL":- i:li(JCCll~ In

~;1t1c:ms WIth br::~l.S[ ,\nd OV'H::;tn ..:.mc~r-wln~.l ::'l~pr:d~­b"sd vac«n•. 0111 em'tr R", 1999, 5: I ~89·l :?7

1S ~c:"I~lbc:n~gl:n C. ~o::::- KH. _vf ~yer S. ~I jl. _-\ )eI1SIO ....e

ELISI'OT ""~ tOr de':eClon of CD3- T I~.",phoey,,> 'pec,r,~ lor HL\d= [.binding pep,,<k cpirof"" demed l<-om inHucn... pro<cins i0 d1< blood of~<althv -!ono» ;md ;nd.ln.om:l p3f1e=ntt, Clirt. C(ln4~ Rn t99-; 3~~~l~~~6

19 Knu~n K. 5chLtfu,m K Dim l\1, Gc:nCJ.iDOfL (It'J.1lngen~

spec:frc CU8~ T [vmphocy~~ foJ[Qw,n~ imml.lr'lLUdQr, w,~h herp~r epuopes ofHER·2In(tl (HER;), _1/11!:'fm:Jn .1J"iOr.atllut fir C;Il(U R:~~rcb t9')9, VOl. 40_

':0. Mu"on K.C:u,Ovp, Di,,, M. r",lanon ofHER-Cin'" (HER2) sp<:<:ine T <ell don'" from, brcm =.::r p>"cn, iUl]owmg Lmmuniz3fton WLch a HER:! pep rid.: ~".I:cdn~

Amm",n ,ufQ<io.tio"jor Cdr>r<rfln€4l"f, 1999 lot 4D. 11. W>rd Rl. Hawk'M NJ, Coornbcr D. c' .I..\nClbody

unmLlOi!j' '" the HER-V""" on<X>g<nie ?ro",in", 0'a<n<s 'vitn eololecCll Clt1e<r. H"m bnm'InQ{ 1999: (,4):510·51 S

August 2000 I 77 I