Associations between TERT Promoter Mutations and Survival in Superficial Spreading and Nodular Melanomas in a Large Prospective Patient Cohort

Survival outcomes in melanoma and their association with mutations in the telomerase reverse transcriptase gene TERT promoter remain uncertain. In addition, few studies have examined whether these associations are affected by a nearby common germline polymorphism or vary on the basis of melanoma histopathological subtype. We analyzed 408 primary tumors from a prospective melanoma cohort for somatic TERT^-124[C>T] and TERT^-146[C>T] mutations, the germline polymorphism rs2853669, and BRAF^V600 and NRAS^Q61 mutations. We tested the associations between these variants and clinicopathologic factors and survival outcomes. TERT^-124[C>T] was associated with thicker tumors, ulceration, mitoses (>0/mm²), nodular histotype, and CNS involvement. In a multivariable model controlling for the American Joint Committee on Cancer stage, TERT^-124[C>T] was an independent predictor of shorter recurrence-free survival (hazard ratio = 2.58, P = 0.001) and overall survival (hazard ratio = 2.47, P = 0.029). Patients with the germline variant and TERT^-124[C>T]-mutant melanomas had significantly shorter recurrence-free survival than those lacking either or both sequence variants (P < 0.04). The impact of the germline variant appeared to be more pronounced in superficial spreading than in nodular melanoma. No associations were found between survival and TERT^-146[C>T], BRAF, or NRAS mutations. These findings strongly suggest that TERT^-124[C>T] mutation is a biomarker of aggressive primary melanomas, an effect that may be modulated by rs2853669.