Understanding TERT Promoter Mutations: A Common Path to Immortality

Telomeres are composed of “TTAGGG” repeats at the end of chromosomes, and telomere length plays a critical role in multiple human diseases including cancer (1, 2). Telomere length is regulated by telomerase, the large multicomponent reverse transcriptase that recognizes, binds, and elongates the telomere ends using its intrinsic RNA template (3, 4). The TERT gene encodes the catalytic subunit of telomerase, and its transcriptional regulation is usually the limiting step in telomerase activity (5–8). Telomerase activity is silenced in the majority of normal tissues, causing telomeres to shorten with each successive round of cell division (9, 10). Eventually, a critical telomere length is reached (9, 11–13), and cells enter replicative senescence (14–16). In contrast, cells that require high rates of self-renewal such as cells in the ovary (10), intestinal epithelium (17), and hematopoietic stem cells (18) have telomerase activity and can maintain telomere length over many cell divisions. The expression of telomerase is considered a hallmark of tumorigenesis, as over 90% of human cancers express the enzyme (10, 19, 20). The cancers found to be telomerase negative use an alternative mechanism of telomere lengthening termed ALT (21–23). Furthermore, germline variation in genes involved in telomere regulation such as RTEL1, POT1, TERC, TERT, and genes of the CST complex underlies increased risk of glioma (24–27), melanoma (28), and cancers of the lung (29, 30), bladder (28), and pancreas (31).

In 2013, two hotspot point mutations were found in the TERT promoter in 71% of melanomas (32, 33). The mutations were located 124 and 146 bp upstream of the translation start site and referred to as C228T and C250T, respectively, based on their hg19 genomic coordinates. The mutations are typically heterozygous, occur in a mutually exclusive fashion, and both create an identical 11 bp sequence “CCCGGAAGGGG.” The mutated sequence has an increased similarity to an ETS binding motif, leading to the hypothesis that the mutations generate a de novo binding site for an activating ETS family transcription factor (TF). Soon after their initial discovery, the TERT promoter mutations were found to be the most common point mutations in several tumor types including 83% of glioblastoma (34), 71% of melanoma (32, 33), 66% of bladder cancer (35), and 47% of hepatocellular carcinoma (HCC; refs.34, 36). To date, the hotspot mutations have been identified in over 50 distinct cancer types (Fig. 1). Both mutations activate TERT promoter activity and TERT gene transcription (32, 33). In bladder cancer, Borah and Xi and colleagues have also demonstrated that the promoter mutations are associated with increased telomerase activity and stable telomere length (37). Less commonly, TERT can be activated by other genetic mechanisms including rare point mutations at other promoter positions (37), rearrangements (38, 39), duplication (40), or amplification (41, 42). TERT promoter mutations were not detected in other common cancer types, such as breast and prostate cancer (Fig. 1).

The high frequency of TERT promoter mutations in just two nucleotide positions strongly implicates them as driver events, arising upon tumor initiation or potentially later in tumor evolution (43). However, recent studies suggest TERT promoter mutations are among the earliest genetic events in bladder cancer (35), HCC (44), thyroid carcinoma (45), cutaneous melanoma (46–48), basal cell and squamous cell carcinoma (49), and oligodendroglioma (50). TERT promoter mutation may be the second genetic event following the activation of an oncogenic signaling pathway, such as MAPK signaling in melanoma (46) or Wnt signaling in HCC (44). It is unclear whether reactivation of telomerase through TERT promoter mutation is required only for early stages of tumorigenesis or is also necessary for sustained neoplastic growth (37).

Stem cells have been proposed as the cell of origin in multiple types of cancer. Because these cells express TERT, tumors originating from stem cells may not require TERT promoter mutations to activate telomerase and maintain telomere function. Interestingly, TERT promoter mutations occur most frequently in cancers with low rates of self-renewal, such as cancers of the brain, liver, and melanocytes (34). In human embryonic stem cells genetically engineered to contain the hotspot mutations, there was little effect on TERT expression, but these cells failed to silence TERT upon differentiation (51). These observations raise the possibility that cells with low rates of self-renewal and lack of TERT expression acquire a TERT promoter mutation to avoid replicative senescence during early carcinogenesis. In contrast, transformation of TERT-expressing stem cells such as hematopoetic stem cells may not require promoter mutation to maintain TERT expression through tumorigenesis. As an alternative to mutation, TERT promoter activation may occur through an epigenetic switch (52). Stern and colleagues have additionally suggested that TERT promoter mutations can convert the silent TERT promoter into an active chromatin state (53).

Germline variation near or within the TERT gene is associated with telomere length in peripheral blood leukocytes and risk of TERT promoter mutant (25, 54) and nonmutant (55–57) cancer. Notably, the TERT promoter polymorphism rs2853669 modulates the prognostic value of TERT promoter mutations across a variety of tumor types. The rs2853669 common allele is thought to create a binding site for the ETS/TCF factor ETS2 99bp and 121bp upstream of the C250T and C228T hotspot mutations, respectively (58). In the presence of a somatic TERT promoter mutation in the tumor, patients with the rs2853669 common allele showed decreased overall survival and increased tumor recurrence rate in bladder cancer (58, 59) and decreased mean survival in glioma (60). In addition, gliomas bearing the common allele of rs2853669 and a hotspot promoter mutation have significantly increased TERT expression compared with tumors with the rs2853669 minor allele, suggesting a possible molecular link between the hotspot mutation sites and the rs2853669 site in the TERT promoter (61). However, other studies reported the minor allele to associate with decreased overall survival in TERT-mutant glioma (62) or have no prognostic effect with either allele (63). Thus, determining the precise prognostic value of rs2853669 may require larger sample sizes and cohorts with more extensive treatment information.

The prognostic power of TERT promoter mutations highlights their potential use as clinical biomarkers. In addition to bladder cancer and glioma, the presence of TERT promoter mutations is associated with decreased overall survival in medulloblastoma (64), thyroid cancer (65–67), urogenital cancer (58, 67), melanoma (69, 70), and laryngeal tumors (71). Furthermore, TERT promoter mutations may serve as biomarkers to distinguish subtypes of urologic malignancies (35, 72–74). They also predict malignant transformation of premalignant nodules in HCC (75) and meningiomas (76), and associate with the anatomic origin of squamous cell carcinomas (77). A new and powerful molecular classification of glioma subtypes is based on three common genetic alterations in the tumors, including TERT promoter mutations (78–80), that predicts overall survival with higher accuracy than traditional classification based on histology. The molecular classification will be useful in clinical trials to enable improved interpretation of patient response to therapy (80, 81).

On the basis of the identical 11bp DNA sequence motif created by the TERT promoter mutations, the mechanism of promoter activation was hypothesized to involve recruitment of an ETS family TF. Indeed, site-directed mutagenesis of the hotspot positions in a promoter–reporter plasmid revealed the generated ETS motif was necessary for promoter activation (40). There are 27 ETS factors, however, and most bind a very similar DNA sequence in vitro, suggesting extensive redundancy (82). It was therefore surprising that GABPA but no other ETS factors were identified to be the TF responsible for mutant TERT activation (40). GABPA is the only ETS factor of those expressed in GBM to selectively regulate the mutant TERT promoter without affecting wild-type promoter activity. Single-molecule binding assays, chromatin immunoprecipitation and sequencing (ChIP-seq), and ChIP-qPCR analysis revealed that GABPA is exclusively recruited to the mutant allele in vitro and in vivo. GABPA binding to the mutant TERT promoter was conserved across cell lines from multiple cancer types including GBM, melanoma, HCC, and neuroblastoma. This finding was later corroborated in bladder cancer (53). Although the other ETS factors are active as a monomer GABPA is unique in that it can only function as a heterodimer or heterotetramer with GABPB (83–85). Analysis of the sequence content of GABPA binding sites at the TERT promoter and genomewide from GABPA ChIP-seq data, suggested that the promoter mutations create the second in a pair of binding motifs that are optimally spaced to recruit the heterotetramer complex (Fig. 2). This work begins to explain how the mutant TERT promoter is activated, though factors binding to the sequences upstream and downstream of the mutation sites may cooperate (Fig. 3). This study also provided supporting evidence as to why GABPA is a key, mutation-selective activating factor across multiple cancer types. It also raised a new, testable hypothesis as to why the mutations occur in the same two nucleotides in nearly all TERT-mutant tumors.

Li and colleagues have suggested that the C228T and C250T mutations may be subject to differential regulatory mechanisms in glioma (86). Utilizing a cell culture system of noncanonical NF-κB activation, p52 is recruited to the C250T mutation but not to C228T. Furthermore, p52 cooperated with ETS1/2 to induce TERT expression specifically in the context of C250T. That C228T and C250T are not functionally identical is independently supported by the fact that the two mutations do not occur at equal frequency within a given tumor type. For example, in one study of glioma, although 48% of patients were found to harbor the C228T mutation, only 22% contained the C250T mutation (50; Fig. 4). Whether these biases in mutation prevalence reflect differences in upstream regulatory factors or significant differential effects on downstream TERT expression remains to be determined.

The mechanism of mutant TERT promoter activation has just begun to be revealed. It will be critical to elucidate the similarities and differences of all the proteins bound to the mutant promoter compared with the active wild-type TERT promoter. For example, MYC (87), SP1 (88), USF1/2 (89), ID2 (90), and ETS2 (91) have all been reported to regulate TERT promoter activity. Analysis of ENCODE ChIP-seq in HepG2 and SK-N-SH cells shows binding of the MAX TF downstream of GABPA in the TERT promoter. However, this is also observed in the MCF7 breast cancer cell line that is wild type at the TERT promoter, implying that MAX could be involved in regulation from the mutant and wild-type TERT promoter (Fig. 3).

It remains unclear how GABPA is regulated by upstream signaling pathways within the context of TERT promoter mutant cancer cells. GABPA function is primarily regulated by its transport to the nucleus. Both the MAPK and Hippo signaling pathways modulate GABPA activity through posttranslational modification and nuclear localization in different cell contexts (92, 93). EGFR amplification and BRAF^V600E mutation, both MAPK-activating events, significantly cooccur with TERT promoter mutations in GBM and melanoma, respectively (32, 34).

An increased mechanistic understanding of both germline variation and somatic mutation at the TERT promoter could help inform newer strategies to therapeutically target telomerase. Several attempts have been made to block telomerase activity in cancer patients, but thus far none are standard of care. Past strategies have included the use of small molecules, immunotherapy, gene therapy, and G-quadruplex stabilizers (94). One promising approach is the antisense oligonucleotide therapy GRN163L (Imetelstat) from Geron. By hybridizing and inhibiting the RNA template of telomerase, GRN163L reduced tumor growth in preclinical models of breast cancer (95, 96), GBM (97, 98), and pancreatic (99) and liver cancer (100). The preclinical success has not translated to clinical benefit in cancer patients, as trials in breast, lung, and pediatric CNS cancers were discontinued (101–103). In each trial, frequent grade III/IV hematopoietic toxicities were observed, potentially resulting from telomerase inhibition in healthy hematopoietic stem cells. As a result, trials with GRN163L have been restricted to myeloproliferative diseases. Promising results have been reported in myelofibrosis patients treated with GRN163L (104). Determining whether TERT promoter mutations can act as a biomarker to predict patient response to existing telomerase inhibitor trials, or foster the creation of new telomerase inhibitors will be an exciting area of research in the future.

RJAB is co-founder of Telo Therapeutics Inc. J.F. Costello has ownership interest (including patents) in Telo Therapeutics and is a consultant/advisory board member for Telo Therapeutics. No potential conflicts of interest were disclosed.

The support for this work was provided from a generous gift from the Dabbiere family (to R.J.A. Bell, A. Mancini, J.F. Costello), the Hana Jabsheh Research Initiative (to R.J.A. Bell, A. Mancini, J.F. Costello), and NIH grants NCI P50CA097257 (to R.J.A. Bell, A. Mancini, J.F. Costello), P01CA118816-06 (to R.J.A. Bell, A. Mancini, J.F. Costello), R01HG003008 (to H.T. Rube), and R01CA163336 (to J.S. Song). Additional support was provided from the Sontag Foundation Distinguished Scientist Award (to J.S. Song), Fundação para a Ciência e Tecnologia SFRH/BD/88220/2012 (to A. Xavier-Magalhães), IF/00601/2012 (to B.M. Costa), Programa Operacional Regional do Norte (ON.2—O Novo Norte; to B.M. Costa), Quadro de Referência Estratégico Nacional (to B.M. Costa), and Fundo Europeu de Desenvolvimento Regional (to B.M. Costa).