TelomereShorteningIsAssociatedwithGeneticAnticipation in ...epididymis or broad ligment (4–6). The...

Prevention and Epidemiology

Telomere Shortening Is Associatedwith Genetic Anticipationin Chinese Von Hippel–Lindau Disease Families

Xiang-hui Ning1,3,4, Ning Zhang5, Teng Li1,3,4, Peng-jie Wu1,3,4, Xi Wang1,3,4, Xue-ying Li2,Shuang-he Peng1,3,4, Jiang-yi Wang1,3,4, Jin-chao Chen1,3,4, and Kan Gong1,3,4

AbstractVon Hippel–Lindau (VHL) disease is a rare autosomal dominant cancer syndrome. A phenomenon known

as genetic anticipation has been documented in some hereditary cancer syndromes, where it was proved torelate to telomere shortening. Because studies of this phenomenon in VHL disease have been relativelyscarce, we investigated anticipation in 18 Chinese VHL disease families. We recruited 34 parent–childpatient pairs (57 patients) from 18 families with VHL disease. Onset age was defined as the age when anysymptom or sign of VHL disease first appeared. Anticipation of onset age was analyzed by paired t test andthe other two special tests (HV and RY2). Relative telomere length of peripheral leukocytes was measuredin 29 patients and 325 healthy controls. Onset age was younger in child than in parent in 31 of the 34parent–child pairs. Patients in the first generation had older onset age with longer age-adjusted relativetelomere length, and those in the next generation had younger onset age with shorter age-adjusted relativetelomere length (P < 0.001) in the 10 parent–child pairs from eight families with VHL disease. In addition,relative telomere length was shorter in the 29 patients with VHL disease than in the normal controls(P ¼ 0.003). The anticipation may relate to the shortening of telomere length in patients with VHL insuccessive generations. These findings indicate that anticipation is present in families with VHL disease andmay be helpful for genetic counseling for families with VHL disease families and for further understandingthe pathogenesis of VHL disease. Cancer Res; 74(14); 3802–9. �2014 AACR.

IntroductionVon Hippel–Lindau (VHL) disease (MIM 193300) is an

autosomal dominant hereditary cancer syndrome causedby germline mutations in VHL gene (1, 2). The incidence ofthis disease is roughly one of 36,000 living births, and itspenetrance is estimated to be more than 90% by 65 years ofage (3). Clinically it is characterized by a wide spectrumof tumors, including central nervous system (CNS) heman-gioblastoma, clear cell renal cell carcinoma (RCC), retinalangioma, pancreatic cyst and tumor, pheochromocytoma,endolymphatic sac tumor, and papillary cystadenoma inepididymis or broad ligment (4–6). The risk of a patientswith VHL disease developing CNS hemangioblastoma,retinal angioma, and/or clear cell RCC is up to 70% to80% (3). The variable phenotype of VHL disease may relate

to the various mutation types and other gene modifiereffects (7–9).

VHL gene is located in chromosome 3p25-26 (2). It dis-plays tumor suppressor effect through the gene productVHL protein to degrade the hypoxia-inducible factor andinhibit the expression of hypoxia response genes such asVEGF, erythropoietin, platelet-derived growth factor, andcarbonic anhydrase (10). Recently, the VHL gene producthas been proved to participate in DNA damage repairresponse (11, 12).

Anticipation is a phenomenon that the successive genera-tions progressively manifest earlier onset age and moreserious presentations for an inherited disease. To date, antic-ipation has been found in two types of hereditary diseases,neurologic diseases such as fragile X syndrome, X-linkedspinal and bulbar muscular atrophy, myotonic dystrophy andHuntington disease, and hereditary cancer syndromes such asdyskeratosis congenita, hereditary breast cancer, Li–Frau-meni syndrome, and hereditary nonpolyposis colorectal can-cer syndrome (Lynch syndrome). Two molecular changesmay be involved in the anticipation, expanding of trinucle-otide repeats found in the anticipation in neurologic diseases,and shortening of telomere detected in the anticipation ofhereditary cancer syndromes (13–21). The gradual decreaseof telomere length with aging is attributed to the decrease oftelomerase function or mutations accumulated in the DNArepair system besides aging (22).

Authors' Affiliations: Departments of 1Urology and 2Medical Statistics,Peking University First Hospital; 3Institute of Urology, Peking University;4National Urological Cancer Center; 5Department of Urology, BeijingChaoyang Hospital, Capital University of Medicine Science, Beijing, P.R.China

Corresponding Author:KanGong, Institute of Urology, Peking University,National Urological Cancer Center, Department of Urology, Peking Uni-versity FirstHospital, No. 8, XishikuStreet, XichengDistrict, Beijing 100034,P.R. China. Phone: 86-10-66551032; Fax: 86-10-66551032; E-mail:[email protected]

doi: 10.1158/0008-5472.CAN-14-0024

�2014 American Association for Cancer Research.

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Because the study about the anticipation in VHL diseasewas scarce, we used the clinical data and DNA samples of thefamilies with VHL disease recruited in our research group toevaluate the anticipation and its relevance to telomerelength.

Patients and MethodsPatients and samplesThis project was approved by theMedical Ethics Committee

of Peking University First Hospital (Beijing, China) andinformed consent was obtained from the patients. During theperiod from 2009 to 2012, 39 families with VHL disease werediagnosed with hereditary VHL disease at the Department ofUrology, Peking University First Hospital based on the clinicalcriteria and mutation detection in VHL as previous described(23). In these families, 19 families had two or more than twopatients in two or more than two generations, including onefamily with obscure onset age. Therefore, a total of 57 patientswith VHL disease from 18 families were enrolled in this study.In the 18 families, 23 patients were diagnosed in the firstgeneration and 34 patients in the second or third generationto form 34 parent–child patient pairs (one pair in 8 families,two pairs in 6 families, three pairs in 2 families, and four pairsin 2 families; Table 1). In the 18 families, DNA sample wasavailable for assay in 29 patients, so that the relationshipbetween anticipation and relative telomere length could beevaluated in 10 of the 34 parent–child pairs. Relative telomerelength was also measured in 325 healthy individuals (15–90years of age, mean age 48.7 years) from those for health check-up as controls.

Relative telomere length assessmentGenomic DNA was isolated from peripheral blood by

using a blood DNA extraction kit (Tiangene). We followedthe method described by Cawthon to quantify relativetelomere length by measuring copy number ratio of telomererepeats (T) to the single copy gene 36B4 (S) using qRT-PCR(24). The 10-mL PCR mixture contained 2X SYBR mastermix (Takara) 5 mL, genomic DNA 30 ng, 300 nmol/L telomereprimer Tel1 (50-GGTTTTTGAGGGTGAGGGTGAGGGTGAG-GGTGAGGGT) and 900 nmol/L Tel2 (50-TCCCGACTATCCC-TATCCCTATCCCTATCCCTATCCCTA), or 200 nmol/L sin-gle copy gene primer 36B4u (50-CAGCAAGTGGGAAGGTG-TAATCC), and 500 nmol/L 36B4d (50-CCCATTCTATCAT-CAACGGGTACAA; ref. 19). qRT-PCR was run in an ABI 7500PCR instrument using the profile of 95�C for 30 seconds and40 cycles of 95�C for 15 seconds, 54�C for 2 minutes, and72�C for 15 seconds. A standard curve from a control DNAsample (male, 45 years old) by serial 1/4 dilutions from 50 ngto 0.19 ng was constructed to evaluate the amplificationefficiency (E), and this sample was measured in every batchof PCRs as the inter-run calibration. Threshold cycle (Ct)values were automatically determined by the 7500 softwarev2.0.5. The measurements of telomere length and single copygene 36B4 were triplicate in one batch for each sample, andthe mean of the three Ct values (Cm) was used for thecalculation. PCR efficiency and the calibration of copy

numbers were also enrolled in the telomere length calcula-tion (19, 25). The formula to calculate the copy number ratioof telomere repeats (T) to single copy gene 36B4 (S) is asfollows, and T/S represents the value of relative telomerelength.

T=S ¼ ðETel;sampleÞ�CmðTEL;sampleÞ

ðE36B4;sampleÞ�Cmð36B4;sampleÞ

� ðETel;calibratorÞ�CmðTEL;calibratorÞ

ðE36B4;calibratorÞ�Cmð36B4;calibratorÞ

The relationship between age and relative telomere length in325 normal controls can be expressed by the linear regressionequation of Y ¼ 1.4503-0.0117�X (see Fig. 2). Normal relativetelomere length at the DNA sample-obtained age can then bepredicted by this equation. The difference between predictednormal relative telomere length at the DNA-obtained age andthe relative telomere length actually measured was the age-adjusted relative telomere length (19), which was used for thecomparison among patients with VHL in generations.

Telomere lengthmeasurement by Southern blot analysisThe oligonucleotide (TTAGGG)4 was tailed with DIG-dUTP

as the probe by using terminal transferase. Twomicrograms ofgenomic DNA were digested with HinfI/RsaI and separated in0.8% agarose gel. The DNA fragments in the gel were thentransferred onto a Hybond-N membrane by Southern blotting.After UV cross-link and prehybridization, the membrane washybridized in a solution containing 2 pmol/mL probe, 50%formamide, 2� SSC, 0.1% lauroyl sarcosine, 0.02% SDS, and 1%milk powder at 42�C for 6 hours, washed at room temperaturein 2� SSC, 0.1% SDS for two times, and in 0.1� SSC, 0.1% SDS,15 minutes for two times. Hybridized probe on the membranewas recognized by alkaline phosphatase conjugated anti-DIGantibody and chemiluminescent method. The luminescentimage was developed on a phosphoimager. The telomerelength was calculated by a telomeric software (version 1.2;ref. 26).

Statistical analysisPaired t test was used to examine the difference of onset age

between generations. HV (parametric conditional maximumlikelihood approach of Huang and Vieland) and RY2 (specialnonparametric method of Rabinowitz and Yang) tests wereused to lower the truncation bias when paired t test is con-ducted (27). t test was used to evaluate the difference of relativetelomere length between patients with VHL disease andhealthy controls, and paired t test to analyze the differencesof age-adjusted relative telomere length in parent–child pairs.Statistical analyses were performed using R software. P < 0.05was considered to be statistically significant.

ResultsOnset age was earlier in patients in the next generationthan in those in the first generation in the 18 familieswith VHL disease

In the 34 child–parent pairs in the 18 families with VHLdisease (Table 1), onset age was younger in child than in parentin 31 pairs and was older in child than in parent in three pairs.We compared the onset age between children and parents

Genetic Anticipation in VHL Disease

www.aacrjournals.org Cancer Res; 74(14) July 15, 2014 3803




Tab

le1.

Gen

otyp

ean

dphe

notypein

18families

with

VHLdisea

se

Germlin

emutation

Sym

ptomsdiagno

sedag

eGermlin

emutation

Sym

ptomsdiagno

sedag

e

Family

(pair)

Patients

Exo

nNuc

leotidean

dprotein

chan

ge

CNS

RA

RCC

PCT

Phe

oELS

TEC

Ons

etag

ebFa

mily

(pair)

Patients

Exo

nNuc

leotidean

dprotein

chan

ge

CNS

RA

RCC

PCT

Phe

oELS

TEC

Ons

etag

eb

1(1)

Father

2,3

Deletion

50—

——

——

—50

9(2)

Mothe

raNoDNAsa

mpleav

ailable

33—

——

——

—33

(Proban

d1,

M)

2,3

Deletion

3731

——

——

1616

(Proban

d9,

M)

1c.26

9A>T

p.Asn

90Ile

28—

3838

——

—28

2(1)

(Proban

d2,

M)

1Deletion

2841

4142

42—

—28

Aun

taNoDNAsa

mpleav

ailable

32—

——

——

—32

Dau

ghter

1Deletion

16—

——

——

—16

Cou

sina

NoDNAsa

mpleav

ailable

30—

——

——

—30

3(1)

(Proban

d3,

M)

1c.28

0G>T

p.G

lu94

Stop

54—

5353

——

—53

10(1)

(Proban

d10

,M)

3c.53

3T>G

p.Leu

178A

rg39

5757

57—

——

39Son

1c.28

0G>T

p.G

lu94

Stop

——

2929

——

2323

Son

3c.53

3T>G

p.Leu

178A

rg—

—30

——

——

304(2)

Mothe

r1

c.26

9A>T

p.Asn

90Ile

——

63—

——

—63

11(1)

Mothe

r1

c.26

3G>A

p.Trp88

Stop

36—

——

——

—36

Brother

aNoDNAsa

mple

available

19—

——

——

—19

(Proban

d11

,M)

1c.26

3G>A

p.Trp88

Stop

——

3438

——

—34

(Proban

d4,

M)

1c.26

9A>T

p.Asn

90Ile

2232

——

——

—22

12(1)

Mothe

raNoDNAsa

mpleav

ailable

30—

——

——

—30

5(3)

Father

3c.49

9C>T

p.Arg16

7Trp

——

54—

——

—54

(Proban

d12

,M)

1c.28

0G>T

p.G

lu94

Stop

31—

——

——

—31

(Proban

d5,

F)3

c.49

9C>T

p.Arg16

7Trp

37—

3737

39—

3737

13(2)

Mothe

raNoDNAsa

mpleav

ailable

43—

——

——

—43

Sister1

3c.49

9C>T

p.Arg16

7Trp

38—

—36

——

—36

Sister

3Deletion

30—

3030

——

—30

Sister2

3c.49

9C>T

p.Arg16

7Trp

—34

——

——

—34

(Proban

d13

,M)

3Deletion

2324

2323

——

—23

6(2)

Mothe

raNoDNAsa

mple

available

45—

——

——

—45

14(3)

Mothe

raNoDNAsa

mpleav

ailable

50—

—62

——

—50

(Proban

d6,

F)Not

assa

yed

——

4242

——

—42

Sistera

NoDNAsa

mpleav

ailable

40—

49—

——

—40

Dau

ghter

Not

assa

yed

—8

——

——

—8

(Proban

d14

,M)

1c.29

2T>A

p.Tyr99

Asn

40—

4141

40—

—40

7(4)

(Proban

d7,

M)

2c.34

9T>G

p.Trp11

7Gly

3644

4440

——

—36

Brother

aNoDNAsa

mpleav

ailable

2720

——

——

—20

Son

2c.34

9T>G

p.Trp11

7Gly

13—

——

——

—13

15(1)

Father

aNoDNAsa

mpleav

ailable

42—

——

——

—42

Brother

1aNoDNAsa

mple

available

47—

51—

——

—47

(Proban

d15

,M)

3c.48

1C>T

p.Arg16

1Stop

29—

2936

—33

2929

Nep

hew

12

c.34

9T>G

p.Trp11

7Gly

——

——

——

3737

16(2)

(Proban

d16

,M)

3c.50

0G>A

p.Arg16

7Gln

29—

46—

46—

—29

Sister1a

NoDNAsa

mple

available

——

—46

——

—46

Dau

ghter

NoDNAsa

mpleav

ailable

2414

——

——

—14

Niece

2c.34

9T>G

p.Trp11

7Gly

—13

——

——

—13

Sistera

NoDNAsa

mpleav

ailable

50—

——

——

—50

Brother

2aNoDNAsa

mple

available

—43

44—

——

—43

Nep

hewa

NoDNAsa

mpleav

ailable

15—

26—

——

—15

Nep

hew

22

c.34

9T>G

p.Trp11

7Gly

1211

——

——

—11

17(1)

Mothe

raNoDNAsa

mpleav

ailable

——

4343

——

—43

8(4)

Grand

father

aNoDNAsa

mple

available

40—

60—

——

—40

(Proban

d17

,M)

1Deletion

—21

——

——

2121

Mothe

r1

Deletion

4335

——

——

—35

18(2)

Mothe

raNoDNAsa

mpleav

ailable

—29

——

——

—29

(Proban

d8,

M)

1Deletion

2317

—19

——

1917

(Proban

d18

,F)

1c.28

8ins

AFram

eshift

2920

29—

——

4020

Aun

t1a

NoDNAsa

mple

available

41—

——

——

—41

Brother

1c.28

8ins

AFram

eshift

—34

4343

——

—34

Aun

t2

NoDNAsa

mple

available

19—

——

——

—19

Abbreviations

:CNS,h

eman

giob

lastom

asof

CNS;R

A,retinal

angiom

as;P

CT,

multip

lepan

crea

ticcy

stsor

tumors;

Phe

o,phe

ochrom

ocytom

a;ELS

T,en

dolym

pha

ticsa

ctumor;E

C,e

pididym

al/ova

rincy

stad

enom

a.aDea

thbeforediagn

osis.

bTh

eon

setag

ereferred

totheag

ewhe

nan

ysy

mptomsor

sign

sof

VHLdisea

sebeg

an.

Ning et al.

Cancer Res; 74(14) July 15, 2014 Cancer Research3804




(Table 2), which indicated that the mean onset age was 16.8years earlier (paired t test, P < 0.001), 9.7 years earlier (HV test,P ¼ 0.01), and 19 years earlier (RY2 test, P ¼ 0.04) in children.The distribution of onset age in the 34 parent–child pairs alsoshowed the same tendency of onset age in children and parents(Fig. 1). Therefore, significant difference in onset age waspresent between children and parents in the 34 VHL diseaseparent–child pairs.

Relative telomere length was shorter in patients in thenext generation than in those in the first generation inthe 10 parent–child patient pairsTo assess the difference of relative telomere length

between patients with VHL and healthy controls, we mea-sured relative telomere length of blood leukocytes in the 29patients with VHL disease and compared with 325 normalcontrols (Fig. 2). Relative telomere length was shorter in the29 patients with VHL disease than in the normal controls(P ¼ 0.003), and 23 of the 29 patients with VHL diseaseshowed the relative telomere lengths shorter than the aver-age value of normal controls.In the 10 parent–child pairs from eight families with VHL

disease, patients in the first generation had older onset age

with longer relative telomere length, and those in the nextgeneration had younger onset age with shorter relativetelomere length (Fig. 3). The difference of age-adjustedtelomere length in the 10 parent–child patient pairs (Table3) also indicated that the telomere length was significantlyshorter in children than in their respective parents (P <0.001). The relative telomere lengths assayed by PCR arecompatible with the telomere lengths measured by Southernblot analysis (Fig. 4).

DiscussionAnticipation and its molecular mechanism have been

proved in many hereditary diseases. In this study, we providethe evidence of earlier onset age and shorter telomere length inthe successive generations in families with VHL disease,

Table 2. Difference in onset age between parents and children with VHL disease

Paired t test HV test RY2 test

nOnset age (y)mean (range) MOAD (y)a P MOAD (y) P MOAD (y) P

Parents 23 42.9 (28–63) 16.8 <0.001 9.8 0.01 19 0.04Children 34 26.1 (8–42)Total 57 32.3 (8–63)

aMOAD, mean onset age difference between parents and children.

Figure 1. Onset age in the parent–child pairs. Kaplan–Meier curveindicates the difference of onset age in 34 parent–child pairs (log-ranktest, P < 0.001).

Figure 2. Relationship between age and relative telomere length inpatients with VHL disease and normal controls. In normal controls (n ¼325), the relative telomere length is negatively correlated with age, withthe linear regression equation of Y ¼ 1.4503-0.0117�X, R2 ¼ 0.162 (thecontinuous line). In patients with VHL disease (n ¼ 29), the averagerelative telomere length (the dotted line) is slightly lower than that innormal controls.






indicating that anticipation exists in families with VHL diseaseand that it may be attributed to the shortening of telomerelength in successive generations.

Anticipation has been a controversial issue probably dueto the bias in clinical data evaluation and the undeterminedmechanism behind anticipation (28). The identification of

Figure 3. Relationship between onset age and age-adjusted relative telomere length in the 10 parent–child pairs. Arrow, proband; filled square and circle,affected; slant line onsquare or circle, died; questionmark, suspectedVHLdiseasepatient.Onset ageandage-adjusted relative telomere length of theparent–child pairs are shown in bar charts under pedigrees.

Table 3. Age-adjusted relative telomere length and onset age of the 10 parent–child pairs

Parent Child

Parent–childpair

FamilyNo. Tumor

Onsetage

TELagea

TEL (ageadjusted)b Tumor

Onsetage

TELagea

TEL (ageadjusted)b TELchild � TELparent

1 1 CNS 50 69 �0.372 CNS, RA 16 38 �0.688 �0.3162 2 CNS, RA, RCC 28 42 0.074 CNS 16 15 �0.152 �0.2263 3 CftNS 53 53 �0.262 RCC 23 25 �0.791 �0.5294 4 RCC 63 63 0.637 CNS, RA 22 32 �0.042 �0.6795 5 RCC 54 64 �0.007 CNS, RCC 37 37 �0.386 �0.3796 5 RCC 54 64 �0.007 CNS 36 36 �0.354 �0.3477 5 RCC 54 64 �0.007 RA 34 34 �0.273 �0.2668 6 RCC 42 42 0.008 RA 8 17 �0.121 �0.1299 7 CNS, RA, RCC 36 45 �0.069 CNS 13 17 �0.283 �0.21410 8 CNS, RA 35 46 �0.328 CNS, RA 17 26 �0.437 �0.108

Abbreviations: CNS, hemangioblastoma of the CNS; RA, retinal angioma; TEL, telomere length.aTEL age, the age when DNA sample was obtained.bTEL (age adjusted), age-adjusted relative telomere length.

Ning et al.





anticipation in an inheritable disease has to rely on thejudicious use of statistics methods. Paired t test was com-monly used for anticipation analysis, but this method mayintroduce a truncation bias, leading to the increase of type Ierror (29). Statisticians have been trying to design bettermethods to make anticipation test more accurate (30–32).Currently, there are two recommended methods, HV andRY2 tests, for anticipation analysis as they display a balancebetween reducing truncation bias and increasing examina-tion efficiency (27). In this study, we used paired t test as wellas HV and RY2 tests to treat our data and obtained identicalresults with statistical significance from the three methods(Table 2). Though the truncation bias can be adjusted by HVand RY2 tests, other factors such as the insidious onset ofsymptoms and the presence of more sensitive diagnosistechnology may also affect the recognition of anticipationin hereditary diseases. Despite the fact that the lowerincidence of VHL disease limited us to recruit a large cohortof VHL families, anticipation was found in 31 of the 34

parent–child pairs in our 18 families with VHL diseasefamilies.

To define the molecular basis for anticipation in patientswith VHL disease, we measured relative telomere length in10 parent–child pairs (totally 18 patients) from eight familieswith VHL disease and correlated these values with onset agein these patients. To appropriately compare relative telo-mere length with onset age, the relative telomere length wasadjusted by the age when DNA sample was obtained (19, 25).Our results clearly showed that the age-adjusted telomerelength was significantly shorter in child than in his or herparent in all of the 10 parent–child pairs in the eight familieswith VHL disease (Table 3 and Fig. 3), suggesting the closerelationship between shortening of telomere length andanticipation in families with VHL disease. Therefore, theanticipation in VHL disease may correlate to the progressiveshortening of telomere in successive generations. However,why telomere shortens in the offspring of patients with VHLdisease is yet unknown.

Figure 4. Telomere length measurement by Southern blot analysis for four pairs of parent–child patients. Telomere length was measured by Southern blotanalysis for four pairs of parent–child patients (Family 2, I:1 and II:3; Family 4, I:1 and II:3; Family 6, II:1 and III:1; Family 7, II:6 and III:7; see Fig. 3) and fournormal controls. TEL age (years), the age when genomic DNA was obtained; TEL length (bp), mean telomere length by Southern blot analysis; qPCR data,relative telomere length by quantitative PCR method. The measurements were separated in two blots.






Decrease of telomere has been considered to be the cause ofgenetic anticipation in three cancer syndromes, includingdyskeratosis congenital, hereditary breast cancer syndrome,and Li–Fraumeni syndrome. Dyskeratosis congenita is causedby dominant mutations in TERC encoding RNA component oftelomerase (33). Most hereditary breast cancer syndromepatients carry mutations in BRCA1 or BRCA2, which areinvolved in repair of dsDNA breaks, and BRCA2 has beendescribed to affect telomere replication (34–36). Li–Fraumenisyndrome is associated with the mutations in TP53 tumorsuppressor gene responsible for initiating DNA repairmechan-isms (37). We found that the relative telomere length wasshorter than normal controls in 23 of 29 patients with VHLdisease (Fig. 2). Besides, relative telomere length was alsoshorter in patients with VHL disease than in their respectivefamily members who carried normal VHL gene with normalphenotype (data not shown). Together with the recently find-ing of VHL gene participates in the repair response to DNAdamage, we can suppose that the mutation of VHL gene canpartly influence the telomere length although the exact mech-anism has not been studied fully.

The screening guideline for VHL disease proposes that theoffspring of patients with VHL should have ophthalmoscopyand other screening methods examined beginning from infan-cy (4–6). In the 34 child–parent pairs of our 18 families withVHL disease, the onset age in children was about 10 yearsearlier than their respective parents, which suggests the timewhen enhanced screening methods such as CT scanning forVHL tumors should be performed in family members carryingVHL mutations.

We first investigated the anticipation in VHL diseasethrough rigid statistical analyses of clinical data and search

for its possible mechanism. These findings indicate that antic-ipation was present in families with VHL disease and may behelpful for genetic counseling for families with VHL diseaseand for further understanding the pathogenesis of VHLdisease.

Disclosure of Potential Conflicts of InterestNo potential conflicts of interest were disclosed.

Authors' ContributionsConception and design: X.-H. Ning, K. GongDevelopment of methodology: X.-H. Ning, N. Zhang, X.-Y. Li, K. GongAcquisition of data (provided animals, acquired and managed pati-ents, provided facilities, etc.): X.-H. Ning, N. Zhang, T. Li, P.-J. Wu, X. Wang,S.-H. Peng, J.-Y. Wang, J.-C. Chen, K. GongAnalysis and interpretation of data (e.g., statistical analysis, biostatistics,computational analysis): X.-H. Ning, N. Zhang, T. Li, P.-J. Wu, X.-Y. Li, K. GongWriting, review, and/or revision of the manuscript: X.-H. Ning, N. Zhang,T. Li, P.-J. Wu, X. Wang, S.-H. Peng, J.-Y. Wang, J.-C. Chen, K. GongAdministrative, technical, or material support (i.e., reporting or orga-nizing data, constructing databases): K. GongStudy supervision: K. Gong

AcknowledgmentsThe authors thank Hong Zhang, Renal Division, Peking University First

Hospital, and Dingfang Bu, Medical Experiment Center, Peking University FirstHospital, for their technical assistance.

Grant SupportThis work was supported by the grants from the Program for New Century

Excellent Talents in Universities (grant NCET-10-0190) and the National NaturalScience Foundation of China (grants 30872560 and 81172418).

The costs of publication of this article were defrayed in part by the payment ofpage charges. This article must therefore be hereby marked advertisement inaccordance with 18 U.S.C. Section 1734 solely to indicate this fact.

Received January 8, 2014; revised April 4, 2014; accepted April 27, 2014;published OnlineFirst July 1, 2014.

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2014;74:3802-3809. Published OnlineFirst July 1, 2014.Cancer Res Xiang-hui Ning, Ning Zhang, Teng Li, et al.

Lindau Disease Families−Chinese Von Hippel Telomere Shortening Is Associated with Genetic Anticipation in

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