Early Onset Colorectal Cancer: An Emerging Cancer Risk in Patients with Diamond Blackfan Anemia

Jeffrey M Lipton, Christine L S Molmenti, Pooja Desai, Alexander Lipton, Steven R Ellis, Adrianna Vlachos, Jeffrey M Lipton, Christine L S Molmenti, Pooja Desai, Alexander Lipton, Steven R Ellis, Adrianna Vlachos

Abstract

Diamond Blackfan anemia (DBA) is a rare inherited bone marrow failure syndrome, the founding member of a class of disorders known as ribosomopathies. Most cases result from loss of function mutations or deletions in 1 of 23 genes encoding either a small or large subunit-associated ribosomal protein (RP), resulting in RP haploinsufficiency. DBA is characterized by red cell hypoplasia or aplasia, poor linear growth and congenital anomalies. Small case series and case reports demonstrate DBA to be a cancer predisposition syndrome. Recent analyses from the Diamond Blackfan Anemia Registry of North America (DBAR) have quantified the cancer risk in DBA. These studies reveal the most prevalent solid tumor, presenting in young adults and in children and adolescents, to be colorectal cancer (CRC) and osteogenic sarcoma, respectively. Of concern is that these cancers are typically detected at an advanced stage in patients who, because of their constitutional bone marrow failure, may not tolerate full-dose chemotherapy. Thus, the inability to provide optimal therapy contributes to poor outcomes. CRC screening in individuals over the age of 50 years, and now 45 years, has led to early detection and significant improvements in outcomes for non-DBA patients with CRC. These screening and surveillance strategies have been adapted to detect familial early onset CRC. With the recognition of DBA as a moderately penetrant cancer risk syndrome a rational screening and surveillance strategy will be implemented. The downstream molecular events, resulting from RP haploinsufficiency and leading to cancer, are the subject of significant scientific inquiry.

Keywords: Diamond Blackfan Anemia; cancer predisposition; cancer screening and surveillance; colorectal cancer.

Conflict of interest statement

The authors declare no competing interests, financial or otherwise.

Figures

Figure 1
Figure 1
(A). Bone marrow aspirate demonstrating red cell aplasia, characterized by a selective absence of red cell precursors, in patients with DBA. (B) Typical radial ray anomalies: triphalangeal thumb and congenital absence of a thumb in a single patient. Image is post-pollicization surgery to construct thumb from the index digit. (C) Increased hazard rate for solid tumors beginning at age 20 years and increasing to 2% per year at age 45 years and continually increasing thereafter (purple). The hazard rate for acute myeloid leukemia (AML) starts to increase at age 45 years (green). The rate of deaths from other causes increased to over 1.5% per year at age 30 years (black) and the rate of hematopoietic stem cell transplant (HSCT) is highest under age 10 years with more patients undergoing transplantation at younger ages (red) [13].

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