Telomere length is an independent predictor of survival, treatment requirement and Richter's syndrome transformation in chronic lymphocytic leukemia

Telomere length (TL) has been associated with outcome in chronic lymphocytic leukemia (CLL). The aim of this extensive analysis carried out on 401 CLL patients was to assess TL conclusively as a prognostic biomarker. Our study included two cohorts used as learning (191 patients) and blinded validation series (210 patients). A TL cutoff of 5000bp was chosen by receiver operating characteristic (ROC) analysis and Youden's index in the learning series. In this series, TL<5000bp was independently associated to a worse outcome for both overall survival (OS; 105.5 vs 281 months, P < 0.001) and treatment-free survival (TFS; 24.6 vs 73 months, P < 0.001). In the blinded validation series, TL<5000bp was confirmed as an independent outcome predictor for OS (79.8 vs not reached, P < 0.001) and TFS (15.2 vs 130.8 months, P < 0.001). Moreover, TL<5000bp independently predicted the risk of Richter's syndrome (5-year risk: 18.9 vs 6.4%, P = 0.016). Within CLL subsets defined by biological predictors, TL consistently identified patient subgroups harboring unfavorable prognosis. These results demonstrate that TL is a powerful independent predictor of multiple outcomes in CLL, and contributes to refine the prognostic assessment of this disease when utilized in combination with other prognostic markers. We thus believe that this prognostic biomarker has the potential for a more widespread use in CLL.