Telomere length shortening is associated with treatment-free remission in chronic myeloid leukemia patients
- Giovanni Caocci1Email authorView ORCID ID profile,
- Marianna Greco1,
- Giuseppe Delogu2,
- Christian Secchi2, 3,
- Bruno Martino4,
- Claudia Labate4,
- Elisabetta Abruzzese5,
- Malgorzata Monika Trawinska5,
- Sara Galimberti6,
- Federica Orru1,
- Claudio Fozza7,
- Carlo Gambacorti Passerini8,
- Francesco Galimi2, 3 and
- Giorgio La Nasa1
© The Author(s). 2016
Received: 8 June 2016
Accepted: 25 July 2016
Published: 29 July 2016
We studied telomere length in 32 CML patients who discontinued imatinib after achieving complete molecular remission and 32 age-sex-matched controls. The relative telomere length (RTL) was determined by q-PCR as the telomere to single copy gene (36B4) ratio normalized to a reference sample (K-562 DNA). Age-corrected RTL (acRTL) was also obtained. The 36-month probability of treatment-free remission (TFR) was 59.4 %. TFR patients showed shorter acRTL compared to relapsed (mean ± SD = 0.01 ± 0.14 vs 0.20 ± 0.21; p = 0.01). TFR was significantly higher in CML patients with acRTL ≤0.09 (78.9 vs 30.8 %, p = 0.002). CML stem cells harboring longer telomeres possibly maintain a proliferative potential after treatment discontinuation.
Telomeres are specialized nucleoprotein structures composed of long arrays of TTAGGG repeats localized at the ends of human chromosomes able to maintain genome stability and integrity and to protect the cell from progressive DNA shortening during repeated division . Telomere biology has been more extensively studied in chronic myeloid leukemia (CML) than in any other blood cancer. Shorter telomeres have been associated with CML, disease progression, poor prognosis, higher Hasford score, and acquisition of cytogenetic aberrations [2–4]. As yet, no studies have considered the possible association between telomere length and treatment-free remission (TFR) after discontinuation of therapy with tyrosine kinase inhibitors (TKIs).
Thirty-two chronic-phase CML patients discontinued TKI treatment after achieving complete molecular remission (CMR) for at least 18 months. All patients received imatinib therapy for more than 24 months. Two patients underwent second-line treatment with nilotinib because of molecular relapse. The median follow-up after discontinuation was 30 months (range 18–60). A complete molecular response was defined as undetectable breakpoint cluster region-Abelson (BCR/ABL1) by real-time quantitative polymerase chain reaction (qRT-PCR) with a sensitivity of the assay corresponding to molecular response (MR)4 and MR4.5. Peripheral blood samples from 32 age- and sex-matched healthy individuals were used for control purposes. The relative telomere length (RTL) was determined by q-PCR according to the technique described by Cawthon in 2002  (Additional file 1). Age-corrected RTL (acRTL) represented the difference in telomere length between patients and age- and sex-matched controls.
Characteristics of 32 CML patients according to treatment-free remission (TFR) or molecular relapse after imatinib discontinuation
Patients in TFR no. 19 (59 %)
Relapsed patients no. 13 (41 %)
Age at diagnosis (mean, range)
Leukocytes at diagnosis ×103/uL (mean, range)
Platelets at diagnosis ×103/uL (mean, range)
Months to CMR (median, range)
Months of TKIs (median, range)
Months of TKIs >60 (no., %)
Male gender (no., %)
Sokal risk (no., %)
First-line TKI treatment (no., %)
Previous IFN treatment (no., %)
Imatinib first-line TKI treatment (no., %)
Nilotinib second-line TKI treatment (no., %)
Age-corrected relative telomere length (mean ± SD)
0.01 ± 0.14
0.20 ± 0.21
Previous studies suggest a dual-step model for telomere length changes in CML. In the earlier phases, increased turnover of Philadelphia positive (Ph+) progenitors would result in telomere shortening, leading to genetic instability. Later, CML cells would escape senescence and apoptosis through upregulation of telomerase and restored telomere length. This would promote the occurrence of genetically unstable CML subclones with a selective growth advantage . Discontinuation of TKIs is the next hurdle to be overcome in the management of CML patients. Several factors have been identified as potentially capable of predicting durable TFR and hopefully definitive recovery [7, 8]. A significant correlation between younger age and molecular relapse was reported . In our study, CML patients had a slightly shorter telomere length than healthy controls and we found a statistically significant correlation between aging and telomere shortening. However, the most interesting finding was that TFR patients showed significantly shorter acRTL compared to molecular relapses. A possible explanation is that quiescent CML stem cells harboring longer telomeres somehow manage to escape senescence mechanisms and maintain a proliferative potential even after discontinuation of imatinib treatment, but this hypothesis should be supported by CML stem cell telomere assessment in patients with molecular response. Some limitations need to be noted in our study. First, the cohort of patients was relatively small and a longitudinal telomere assessment from diagnosis is lacking. Furthermore, we did not determine sorted myeloid compartment telomere length, but previous reports showed that no significant differences in CML telomere lengths are observed when comparing peripheral mononuclear blood cells, fractionated peripheral neutrophils, and non-fractionated bone marrow mononuclear cells . The present study is the first to suggest that patients with longer telomeres would seem to be more susceptible to relapse after TKI treatment.
CML, chronic myeloid leukemia; TFR, treatment-free remission; CMR, complete molecular remission; MR, molecular response; qRT-PCR, real-time quantitative polymerase chain reaction; BCR/ABL1, breakpoint cluster region-Abelson; TKIs, tyrosine kinase inhibitors; RTL, relative telomere length; acRTL, age-corrected relative telomere length; WBC, white blood cell; PLT, platelets
We are deeply grateful to the patients who participated in this study. We also wish to thank Anna Maria Koopmans for her professional writing assistance.
The authors did not receive any financial support.
Availability of data and materials
DNA samples are available at CTMO-Ospedale Binaghi, Università di Cagliari.
GC, MG, FO, and GLN participated in the conception and design of the study. GC, MG, GD, CS, BM, CL, EA, MMT, SG, FO, CF, CGP, FG, and GLN contributed to the collection and assembly of the data. GC, MG, and GD carried out the statistical analysis. GC, MG, FO, and GLN contributed to the manuscript writing. All authors approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
Approval for the study was obtained from the competent Ethics Committee of Rome, Reggio Calabria and Cagliari; enrolled patients were informed of the potential risks and benefits of stopping TKI treatment.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Blackburn EH. Structure and function of telomeres. Nature. 1991;350:569–73.View ArticlePubMedGoogle Scholar
- Lobetti-Bodoni C, Ferrero D, Genuardi E, et al. Telomere loss in Philadelphia-negative hematopoiesis after successful treatment of chronic myeloid leukemia: evidence for premature aging of the myeloid compartment. Mech Ageing Dev. 2012;133:479–88.View ArticlePubMedGoogle Scholar
- Boultwood J, Fidler C, Shepherd P, et al. Telomere length shortening is associated with disease evolution in chronic myelogenous leukemia. Am J Hematol. 1999;61:5–9.View ArticlePubMedGoogle Scholar
- Drummond M, Lennard A, Brummendorf T, Holyoake T. Telomere shortening correlates with prognostic score at diagnosis and proceeds rapidly during progression of chronic myeloid leukemia. Leuk Lymphoma. 2004;45:1775–81.View ArticlePubMedGoogle Scholar
- Cawthon RM. Telomere measurement by quantitative PCR. Nucleic Acids Res. 2002;30:e47.View ArticlePubMedPubMed CentralGoogle Scholar
- Brummendorf TH, Holyoake TL, Rufer N, et al. Prognostic implications of differences in telomere length between normal and malignant cells from patients with chronic myeloid leukemia measured by flow cytometry. Blood. 2000;95:1883–90.PubMedGoogle Scholar
- Caocci G, Martino B, Greco M, et al. Killer immunoglobulin-like receptors can predict TKI treatment-free remission in chronic myeloid leukemia patients. Exp Hematol. 2015;43:1015–8.View ArticlePubMedGoogle Scholar
- Rousselot P, Charbonnier A, Cony-Makhoul P, et al. Loss of major molecular response as a trigger for restarting tyrosine kinase inhibitor therapy in patients with chronic-phase chronic myelogenous leukemia who have stopped imatinib after durable undetectable disease. J Clin Oncol. 2014;32:424–30.View ArticlePubMedGoogle Scholar
- Mori S, Vagge E, le Coutre P, et al. Age and dPCR can predict relapse in CML patients who discontinued imatinib: the ISAV study. Am J Hematol. 2015;90:910–4.View ArticlePubMedGoogle Scholar
- Iwama H, Ohyashiki K, Ohyashiki JH, et al. The relationship between telomere length and therapy-associated cytogenetic responses in patients with chronic myeloid leukemia. Cancer. 1997;79:1552–60.View ArticlePubMedGoogle Scholar