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Acute myeloid leukemia

Clinical and functional characterization of telomerase variants in patients with pediatric acute myeloid leukemia/myelodysplastic syndrome

Leukemia volume 35, pages 269–273 (2021)Cite this article

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Human telomeres are composed of tandem TTAGGG repeats at chromosome ends. Telomerase is composed of TERT, a specialized reverse transcriptase that is the catalytic subunit, and hTR, an integral RNA subunit that provides the template for the addition of repeats onto chromosome termini, replenishing those lost during semi-conservative DNA replication. Germline mutations in telomerase and related genes are associated with very short age-adjusted telomeres and a spectrum of telomere biology disorders (TBDs) that includes dyskeratosis congenita (DC) [1]. A diagnosis of DC confers high risk for bone marrow failure (BMF), myelodysplastic syndrome (MDS), and cancer [1, 2]. Hematopoietic cells are sensitive to reduction in telomerase, so that a pathogenic variant in TERT or TERC, encoding hTR, produces progressive leukocyte telomere shortening over successive generations [3]. An unexpectedly high incidence of deleterious TERT variants is observed in adults with MDS and hematologic malignancies and lacking other DC manifestations [4].

Prolonged myelosuppression and other treatment-related toxicities are common events in pediatric acute myeloid leukemia (AML) [5], but host factor risk determinants of therapy-related toxicities are not well understood. We determined the frequency of rare or previously-undescribed TERT variants in children (age ≤ 21 years) diagnosed with de novo, non-Down syndrome-associated AML or MDS. Cases were compared with non-cancer controls and a similar racial and ethnic distribution. Rare variants were defined as those with a minor allele frequency (MAF) < 1% in the Genome Aggregation Database (gnomAD), or with MAF 1–1.5% and prior association with TBDs. Variants not present in gnomAD were labeled as ‘previously-undescribed.’ The exons and intron/exon boundaries of TERT were sequenced by the Sanger method in DNA obtained from diagnostic bone marrow and confirmed in remission marrow or nonmalignant hematopoietic tissue. Lymphocyte telomere length (LTL) was determined by flow cytometry fluorescence in situ hybridization (flow-FISH) from banked diagnostic sample. Human embryonic kidney (HEK) 293T cells were co-transfected with TERC and TERT expression plasmids containing either wild type (WT) or mutant TERT. The immunopurified telomerase enzyme complex was assessed for specific activity and processivity by the direct primer extension assay. A masked investigator reviewed medical records and tabulated presence of six pre-determined clinical criteria associated with a DC phenotype: (1) 1st degree family history of cancer, liver, or pulmonary disease, (2) persistent liver or pulmonary disease of unknown etiology and preceding stem cell transplant (SCT), (3) any treatment delay > 60 days due to cytopenia(s), (4) prolonged cytopenia(s) (e.g. absolute neutrophil count < 500/μl and/or platelet count < 75 × 103/μl) persisting ≥60 days after treatment completion, (5) second cancer, and (6) evidence for nail dysplasia, skin hyperpigmentation, or oral leukoplakia preceding SCT. See Supplementary Materials and Methods and Supplementary Figs. 1–3 for methodological details.

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Fig. 1: Telomerase activity and processivity determined from the direct primer extension assay for all TERT mutants, compared with WT and K570N as controls.

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Acknowledgements

This work was supported by a St. Baldrick’s Foundation Scholar Award to MMG, a National Cancer Institute K23 Award (K23CA158148) to MMG, a National Heart, Lung and Blood Institute Award (R01HL131744) to AAB, a National Institute of General Medical Sciences T32 Training Award (T32GM088129) to BMG, a Cure Cancer Australia Foundation/Cancer Australia project grant (1048376) to CGT, a Cancer Institute NSW Career Development and Support Fellowship (11/CDF/3-05) to TMB, and a Cancer Council NSW project grant (RG 12-02) to TMB. The authors would like to thank John Belmont, MD, PhD for contributing control samples to this study, and Scott Cohen, PhD, for helpful discussions. The authors acknowledge support of this work from the Texas Children’s Cancer and Hematology Centers Research Flow Cytometry Core.

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Authors and Affiliations

  1. Cell Biology Research Unit, Children’s Medical Research Institute, University of Sydney, Sydney, NSW, Australia

    Christopher G. Tomlinson & Tracy M. Bryan

  2. Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA

    Ghadir Sasa, Bailey Martin-Giacalone, Sharon E. Plon, Alison A. Bertuch & Maria M. Gramatges

  3. Terry Fox Laboratory, British Columbia Cancer Agency, Vancouver, BC, Canada

    Geraldine Aubert

  4. Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA

    Sharon E. Plon, Alison A. Bertuch & Maria M. Gramatges

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  1. Christopher G. Tomlinson
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Correspondence to Maria M. Gramatges.

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SEP is a member of the Scientific Advisory Board of Baylor Genetics Laboratory. GA is an employee of Repeat Diagnostics.

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Tomlinson, C.G., Sasa, G., Aubert, G. et al. Clinical and functional characterization of telomerase variants in patients with pediatric acute myeloid leukemia/myelodysplastic syndrome. Leukemia 35, 269–273 (2021). https://doi.org/10.1038/s41375-020-0835-8

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