Journal of Neuro-Oncology

, Volume 142, Issue 3, pp 435–444 | Cite as

Telomere elongation via alternative lengthening of telomeres (ALT) and telomerase activation in primary metastatic medulloblastoma of childhood

  • Simone Minasi
  • Caterina Baldi
  • Torsten Pietsch
  • Vittoria Donofrio
  • Bianca Pollo
  • Manila Antonelli
  • Maura Massimino
  • Felice Giangaspero
  • Francesca Romana ButtarelliEmail author
Laboratory Investigation



Elongation of telomeres is necessary for tumor cell immortalization and senescence escape; neoplastic cells use to alternative pathways to elongate telomeres: telomerase reactivation or a telomerase-independent mechanism termed alternative lengthening of telomeres (ALT). Telomerase and ALT pathway has been explored in adult and pediatric gliomas and medulloblastomas (MDBs); however, these mechanisms were not previously investigated in MDBs metastatic at the onset. Therefore, we analyzed the activation of telomerase and ALT pathway in a homogenous cohort of 43 pediatric metastatic medulloblastomas, to investigate whether telomere elongation could play a role in the biology of metastatic MDB.


We evaluated telomeres length via telomere-specific fluorescence in situ hybridization (Telo-FISH); we assessed nuclear expression of ATRX by immunohistochemistry (IHC). H3F3A and TERT promoter mutations were analyzed by pyrosequencing, while UTSS methylation status was analyzed via methylation-specific-PCR (MS-PCR).


H3F3A mutations were absent in all MDBs, 30% of samples showed ATRX nuclear loss, 18.2% of cases were characterized by TERT promoter mutations, while 60.9% harboured TERT promoter hyper-methylation in the UTSS region. Elongation of telomeres was found in 42.8% of cases. Metastatic MDBs control telomere elongation via telomerase activation (10.7%), induced by TERT promoter mutations in association with UTSS hyper-methylation, and ALT mechanism (32.1%), triggered by ATRX inactivation. Among non-metastatic MDBs, only 5.9% (1/17) showed ATRX nuclear loss with activation of ALT.


Our metastatic cases frequently activate ALT pathway, suggesting that it is a common process for senescence escape in primary metastatic medulloblastomas. Furthermore, the activation of mechanisms for telomere elongation is not restricted to certain molecular subgroups in this high-risk group of MDBs.


Alternative lengthening of telomeres Telomerase TERT mutations ATRX H3F3A Metastatic medulloblastomas 



Simone Minasi was supported by “Associazione Fabrizio Procaccini Onlus” (Grant No. 121). The study was also supported by “Associazione con Lorenzo per mano” (Grant No. 212).

Compliance with ethical standards

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Ethical approval

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Supplementary material

11060_2019_3127_MOESM1_ESM.doc (1.9 mb)
Supplementary material 1 (DOC 1954 KB)
11060_2019_3127_MOESM2_ESM.doc (41 kb)
Supplementary material 2 (DOC 41 KB)
11060_2019_3127_MOESM3_ESM.xls (28 kb)
Supplementary material 3 (XLS 28 KB)
11060_2019_3127_MOESM4_ESM.xls (22 kb)
Supplementary material 4 (XLS 22 KB)


  1. 1.
    Oganasian L, Karlseder J (2009) Telomeric armor: the layers of end protection. J Cell Sci 122:4013–4025. CrossRefGoogle Scholar
  2. 2.
    Rubtsova MP, Vasilkova DP, Malyavko AN, Naraikina YV, Zvereva MI, Dontsova OA (2012) Telomere lengthening and other functions of telomerase. Acta Nat 4(2):44–61Google Scholar
  3. 3.
    Remke M, Ramaswamy V, Peackock J, Shih DJH, Koelsche C, Northcott PA, Hill N, Cavalli FMG, Kool M, Wang X, Mack SC, Barszczyk M, Morissi AS, Wu X, Agnihotri S, Luu B et al (2013) TERT promoter mutations are highly recurrent in SHH subgroup medulloblastoma. Acta Neuropathol 126:917–929. CrossRefGoogle Scholar
  4. 4.
    Ceccarelli M, Barthel FP, Malta TM, Sabedot TS, Salama SR, Murray BA, Morozova O, Newton Y, Radenbaugh A, Pagnotta SM, Anjum S, Wang J, Manyam G, Zoppoli P, Ling S, Rao AA et al (2016) Molecular profiling reveals biologically discrete subsets and pathways of progression in diffuse glioma. Cell 164:550–563. CrossRefGoogle Scholar
  5. 5.
    Cesare AJ, Reddel RR (2010) Alternative lengthening of telomeres: models, mechanisms and implications. Nat Rev Genet 11:319–330. CrossRefGoogle Scholar
  6. 6.
    Koelsche C, Sahm F, Capper D, Reuss D, Sturm D, Jones DTW, Kool M, Northcott PA, Wiestler B, Bohmer K, Meyer J, Marwin C, Hartmann C, Mittelbronn M, Platten M, Brokinkel B et al (2013) Distribution of TERT promoter mutations in pediatric and adult tumors of the nervous system. Acta Neuropathol 126:907–914. doiCrossRefGoogle Scholar
  7. 7.
    Mangerel J, Price A, Castelo-Branco P, Brzezinski J, Buczkowicz P, Rakopoulos P, Merino D, Baskin B, Wasserman J, Mistry M, Barszczyk M, Picard D, Mack S, Remke M, Starkman H et al (2014) Alternative lengthening of telomeres is enriched in, and impacts survival of TP53 mutant pediatric malignant brain tumors. Acta Neuropathol 128:853–862. CrossRefGoogle Scholar
  8. 8.
    Bechter OE, Zou Y, Shay JW, Wright WE (2003) Homologous recombination in human telomerase-positive and ALT cells occurs with the same frequency. EMBO Rep 4:1138–1143. CrossRefGoogle Scholar
  9. 9.
    Gessi M, Van De Nes J, Griewank K, Barresi V, Buckland ME, Kirfel J, Caltabiano R, Hammes J, Lauriola L, Pietsch T, Waha A (2014) Absence of TERT promoter mutations in primary melanocytic tumors of the central nervous system. Neuropathol Appl Neurobiol 40(6):794–797. CrossRefGoogle Scholar
  10. 10.
    Horn S, Figl A, Rachakonda PS, Fischer C, Sucker A, Gast A, Kadel S, Moll I, Nagore E, Hemminki K, Schadendorf D, Kumar R (2013) TERT promoter mutations in familial and sporadic melanoma. Science 339:959–961. CrossRefGoogle Scholar
  11. 11.
    Kim J-H, Huse JT, Huang Y, Lyden D, Greenfield JP (2013) Molecular diagnostics in paediatric glial tumours. Lancet Oncol 14:19. doiCrossRefGoogle Scholar
  12. 12.
    Dorris K, Sobo M, Onar-Thomas A, Panditharatna E, Stevenson CB, Gardner SL, DeWire MD, Pierson CR, Olshefski R, Rempel SA, Goldman S, Miles L. Fouladi M, Drissi R (2014) Prognostic significance of telomere maintenance mechanisms in pediatric high-grade gliomas. J Neurooncol 117(1):67–76. CrossRefGoogle Scholar
  13. 13.
    Huang DS, Wang Z, He XJ, Diplas BH, Yang R, Killela PJ, Liang J, Meng Q, Ye ZY, Wang W, Jiang XT, Hu L, He XL, Zhao ZS, Xu WJ, Wang HJ, Ma YY, Xia YJ, Li L, Zhang RX, Jin T et al (2015) Recurrent TERT promoter mutations identified in a large-scale study of multiple tumor types are associated with increased TERT expression and telomerase activation. Eur J Cancer 51(8):969–976. CrossRefGoogle Scholar
  14. 14.
    Castelo-Branco P, Sanaa C, Mack S, Gallagher D, Zhang C, Lipman T, Zhukova N, Walker EJ, Martin D, Merino D, Wasserman JD, Elizabeth C, Alon N, Zhang L, Hovestadt V, Kool M et al (2013) Methylation of the TERT promoter and risk stratification of childhood brain tumours: an integrative genomic and molecular study. Lancet Oncol 14:534–542. CrossRefGoogle Scholar
  15. 15.
    Noushmehr H, Weisenberger DJ, Diefes K, Phillips HS, Pujara K, Bergman BP, Pan F, Pelloskj CE, Sulman EP, Bhat KP, Verhaan RG, Hoadley KA, Hayes DN, Perou CM, Schmidt HK et al (2010) Identification of a CpG island methylator phenotype that defines a distinct subgroup of glioma. Cancer Cell 17(5):510–522. CrossRefGoogle Scholar
  16. 16.
    Killela PJ, Reitman ZJ, Jiao Y, Bettegowda C, Agrawal N, Diaz LA Jr, Friedman AH, Friedman H, Gallia GL, Giovanella BC, Grollman AP, He TC, He Y, Hruban RH, Jallo GI, Mandahl N, Meeker AK et al (2013) TERT promoter mutations occur frequently in gliomas and a subset of tumors derived from cells with low rates of self-renewal. Proc Natl Acad Sci USA 110:6021–6026. CrossRefGoogle Scholar
  17. 17.
    Nonoguchi N, Ohta T, Oh JE, Kim YH, Kleihues P, Ohgaki H (2013) TERT promoter mutations in primary and secondary glioblastomas. Acta Neuropathol 126:931–937. CrossRefGoogle Scholar
  18. 18.
    Reifenberger G, Weber RG, Riehmer V, Kaulich K, Willscher E, Wirth H, Gietzelt J, Hentschel B, Westphal M, Simon M, Schackert G, Schramm J, Matschke J, Sabel MC, Gramatzki D et al (2014) Molecular characterization of long-term survivors of glioblastoma using genome- and transcriptome-wide profiling. Int J Cancer 135(8):1822–1831. CrossRefGoogle Scholar
  19. 19.
    Episkopou H, Draskovic I, Van Beneden A, Tilman G, Mattiussi M, Gobin M, Arnoult N, Londono-Vallejo A, Decottignies A (2014) Alternative lengthening of telomeres is characterized by reduced compaction of telomeric chromatin. Nucleic Acids Res 42:4391–4405. CrossRefGoogle Scholar
  20. 20.
    Nabetani A, Ishikawa F (2011) Alternative lengthening of telomeres pathway: recombination-mediated telomere maintenance mechanism in human cells. J Biochem 149:5–14. CrossRefGoogle Scholar
  21. 21.
    Ebrahimi A, Skardelly M, Bonzheim I, Ott I, Mühleisen H, Eckert F, Tabatabai G, Schittenhelm J (2016) ATRX immunostaining predicts IDH and H3F3A status in gliomas. Acta Neuropathol Commun 4:60. CrossRefGoogle Scholar
  22. 22.
    Heaphy CM, De Wilde RF, Jiao Y, Klein AP, Edil BH, Shi C, Bettegowda C, Rodriguez FJ, Eberhart CG, Hebbar S, Offerhaus GJ, McLendon R, Rasheed BA, He Y, Yan H, Bigner DD et al (2011) Altered telomeres in tumors with ATRX and DAXX mutations. Science 333(6041):425. CrossRefGoogle Scholar
  23. 23.
    Heaphy CM, Subhawong AP, Hong SM, Goggins MG, Montgomery EA, Gabrielson E, Netto GJ, Epstein JI, Lotan TL, Westra WH, Shih Ie M, Iacobuzio-Donahue CA, Maitra A, Li QK et al (2011) Prevalence of the alternative lengthening of telomeres telomere maintenance mechanism in human cancer subtypes. Am J Pathol 179:1608–1615. CrossRefGoogle Scholar
  24. 24.
    Lovejoy CA, Li W, Reisenweber S, Thongthip S, Bruno J, de Lange T, De S, Petrini JHJ, Sung PA, Jasin M, Rosenbluh J, Zwang Y, Weir BA, Hatton C, Invanova E et al (2012) Loss of ATRX, genome instability, and an altered DNA damage response are Hallmarks of the alternative lengthening of telomeres pathway. PLoS Genet 8(7):e1002772. CrossRefGoogle Scholar
  25. 25.
    Gerrit H, Gielen GH, Gessi M, Hammes J, Kramm CM, Waha A, Pietsch T (2013) H3F3A K27M mutation in pediatric CNS tumors: a marker for diffuse high-grade astrocytomas. Am J Clin Pathol 139:345–349. CrossRefGoogle Scholar
  26. 26.
    Schwartzentruber J, Korshunov A, Liu XY, Jones DT, Pfaff E, Jacob K, Sturm D, Fontebasso AM, Quang DA, Tonjes M, Hovestadt V, Albercht S, Kool M, Nantel A, Konermann C et al (2012) Driver mutations in histone H3.3 and chromatin remodelling genes in paediatric glioblastoma. Nature 482:226–231. CrossRefGoogle Scholar
  27. 27.
    Cavalli FMG, Remke M, Rampasek L, Peacock J, Shih DJH, Luu B, Garzia L, Torchia J, Nor C, Morrissy AS et al (2017) Intertumoral heterogeneity within medulloblastoma subgroups. Cancer Cell 31:737–754.e6. CrossRefGoogle Scholar
  28. 28.
    Northcott PA, Korshunov A, Witt H, Hielscher T, Eberhart CG, Mack S, Taylor MD (2011) Medulloblastoma comprises four distinct molecular variants. J Clin Oncol 29(11):1408–1414. CrossRefGoogle Scholar
  29. 29.
    Ramaswamy V, Remke M, Bouffet E, Bailey S, Clifford SC, Doz F, Kool M, Dufour C, Vassal G, Milde T, Witt O, · Von Hoff K, Pietsch T, Northcott PA, Gajjar A, Robinson GW et al (2016) Risk stratification of childhood medulloblastoma in the molecular era: the current consensus. Acta Neuropathol 131:821–831. CrossRefGoogle Scholar
  30. 30.
    Taylor MD, Northcott PA, Korshunov A, Remke M, Cho YJ, Clifford SC, Eberhart CG, Parsons DW, Rutkowski S, Gajjar A, Ellison DW, Lichter P, Gilbertson RJ, Pomeroy SL, Kool M, Pfister SM (2012) Molecular subgroups of medulloblastoma: the current consensus. Acta Neuropathol 123(4):465–472. CrossRefGoogle Scholar
  31. 31.
    Van Bueren AO, Kortmann RD, Von Hoff K, Friedrich C, Mynarek M, Muller K, Goschzik T, Mühlen A, Gerber N, Warmuth-Metz M, Soerensen N, Deinlein F, Benesch M, Zwiener I et al (2016) Treatment of children and adolescents with metastatic medulloblastoma and prognostic relevance of clinical and biologic parameters. J Clin Oncol 34(34):4151–4160. CrossRefGoogle Scholar
  32. 32.
    Louis DN, Ohgaki H, Wiestler OD, Cavenee WK (eds) (2016) WHO classification of tumours of the central nervous system, 4th edn. IARC, LyonGoogle Scholar
  33. 33.
    Kool M, Koster J, Bunt J, Hasselt NE, Lakeman A, van Sluis P, Troost D, Schouten-van Meeteren N, Caron HB, Cloos J, Mrsic A, Ylstra B, Grajkowska W, Hartmann W, Pietsch T, Ellison D, Clifford SC, Versteeg R (2008) Integrated genomics identifies five medulloblastoma subtypes with distinct genetic profiles, pathway signatures and clinicopathological features. PLoS ONE 3(8):e3088. CrossRefGoogle Scholar
  34. 34.
    Schwalbe EC et al (2017) Novel molecular subgroups for clinical classification and outcome prediction in childhood medulloblastoma: a cohort study. Lancet Oncol 18:958–971. CrossRefGoogle Scholar
  35. 35.
    Morrissy AS, Cavalli FMG, Remke M, Ramaswamy V et al (2017) Spatial heterogeneity in medulloblastoma. Nat Genet 49(5):780–788. CrossRefGoogle Scholar
  36. 36.
    Wu X, Northcott PA, Dubuc A, Dupuy AJ, Shih DJ, Witt H et al (2012) Clonal selection drives genetic divergence of metastatic medulloblastoma. Nature 482:529–533. CrossRefGoogle Scholar
  37. 37.
    Lannering B, Rutkowski S, Doz F, Pizer B, Gustafsson G, Navajas A et al (2012) Hyperfractionated versus conventional radiotherapy followed by chemotherapy in standard-risk medulloblastoma: results from the randomized multicenter HITSIOP PNET 4 trial. J Clin Oncol 30:3187–3193. CrossRefGoogle Scholar
  38. 38.
    Shih DJ, Northcott PA, Remke M, Korshunov A, Ramaswamy V, Kool M et al (2014) Cytogenetic prognostication within medulloblastoma subgroups. J Clin Oncol 32:886–896. CrossRefGoogle Scholar
  39. 39.
    De Braganca KC, Packer RJ (2013) Treatment options for medulloblastoma and CNS primitive neuroectodermal tumor (PNET). Curr Treat Options Neurol 15:593–606. CrossRefGoogle Scholar
  40. 40.
    Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Burger PC, Jouvet A, Scheithauber BW, Kleihues P (2007) The 2007 WHO classification of tumours of the central nervous system. Acta Neuropathol 2007 114(2):97–109. CrossRefGoogle Scholar
  41. 41.
    Gandola L, Massimino M, Cefalo G, Solero C, Spreafico F, Pecori E, Riva D, Collini P, Pignoli E, Giangaspero F, Luksch R, Berretta S, Poggi G, Biassoni V, Ferrari A, Pollo B, Favre C, Sardi I, Terenziani M, Fossati-Bellani F (2009) Hyperfractionated accelerated radiotherapy in the milan strategy for metastatic medulloblastoma. J Clin Oncol 27(4):566–571. CrossRefGoogle Scholar
  42. 42.
    Poon SS, Lansdorp PM (2001) Quantitative fluorescence in situ hybridization (Q-FISH). Curr Protoc Cell Biol Chapter 18:Unit18 14Google Scholar
  43. 43.
    Sturm D, Witt H, Hovestadt V, Khuong-Quang DA, Jones DT, Konermann C, Pfaff E, Tonjes M, Sill M, Bender S, Kool M, Zapatka M, Becker N, Zucknick M, Hielscher T, Liu XY et al (2012) Hotspot mutations in H3F3A and IDH1 define distinct epigenetic and biological subgroups of glioblastoma. Cancer Cell 22:425–437. CrossRefGoogle Scholar
  44. 44.
    Cifuentes-Rojas C, Shippen DE (2012) Telomerase regulation. Mutat Res 730:20–27. CrossRefGoogle Scholar
  45. 45.
    Montanaro L, Calienni M, Ceccarelli C, Santini D, Taffurelli M, Pileri S, Trere D, Derenzini M (2008) Relationship between dyskerin expression and telomerase activity in human breast cancer. Cell Oncol 30:483–490. Google Scholar
  46. 46.
    Nandakumar J, Cech TR (2013) Finding the end: recruitment of telomerase to telomeres. Nat Rev Mol Cell Biol 14:69–82. CrossRefGoogle Scholar
  47. 47.
    Rodriguez FJ, Brosnan-Cashman JA, Allen SJ et al (2019) Alternative lengthening of telomeres, ATRX loss and H3-K27M mutations in histologically defined pilocytic astrocytoma with anaplasia. Brain Pathol 29(1):126–140. CrossRefGoogle Scholar
  48. 48.
    Lee J, Solomon DA, Tihan T (2017) The role of histone modifications and telomere alterations in the pathogenesis of diffuse gliomas in adults and children. J Neurooncol 132(1):1–11. CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Radiological, Oncological and Anatomo-Pathological SciencesSapienza University of RomeRomeItaly
  2. 2.Department of Human NeurosciencesSapienza University of RomeRomeItaly
  3. 3.Pediatric UnitFondazione IRCCS Istituto Nazionale dei TumoriMilanoItaly
  4. 4.Department of Molecular MedicineSapienza University of RomeRomeItaly
  5. 5.IRCCS NeuromedPozzilliItaly
  6. 6.Pathology UnitOspedale Santobono-PausiliponNaplesItaly
  7. 7.Neuropathology UnitIRCCS Istituto Neurologico Carlo BestaMilanoItaly
  8. 8.Institute of Neuropathology, DGNN Brain Tumor Reference CenterUniversity of Bonn Medical CenterBonnGermany

Personalised recommendations