Colonic carcinoma in two adult cystic fibrosis patients

Cancer in Cystic Fibrosis: A Narrative Review of Prevalence, Risk Factors, Screening, and Treatment Challenges: Adult Cystic Fibrosis Series

Cystic fibrosis (CF) is a progressive monogenetic disorder that causes persistent pulmonary disease, but also affects other organ systems, including the digestive tract. Recent advances in treatment and care of patients with CF, including the use of new and highly effective CF transmembrane conductance regulator modulators, have led to a dramatic increase in survival. Young patients with CF now can expect to live to or beyond middle age, when cancer is more frequent. Patients with CF now are known to face an increased risk of digestive tract cancer, particularly cancer of the colon. The risk, which could be triggered by associated CF-related conditions or other genetic mechanisms, is even greater in patients who received a transplant. Also some evidence suggests that adenomatous polyps develop more frequently in patients with CF and at an earlier age than in patients without CF. To reduce the excess risk of intestinal cancer in patients with CF, the Cystic Fibrosis Foundation has developed colonoscopy-based guidelines. For nontransplanted patients, colonoscopy should begin at 40 years of age, with rescreening at 5-year intervals; the screening interval should be shortened to 3 years if adenomatous polyps are discovered. For transplanted patients, screening should start at 30 years of age, or within 2 years of the transplant operation. Before colonoscopy, it is essential for patients with CF to undergo a special, more intensive bowel preparation than normally used for those without CF. Whether the new drugs that have dramatically improved morbidity and mortality for patients with CF will alter the risk of cancer is unknown and needs to be assessed in future studies.

Role of ion channels in gastrointestinal cancer

In their seminal papers Hanahan and Weinberg described oncogenic processes a normal cell undergoes to be transformed into a cancer cell. The functions of ion channels in the gastrointestinal (GI) tract influence a variety of cellular processes, many of which overlap with these hallmarks of cancer. In this review we focus on the roles of the calcium (Ca2+), sodium (Na+), potassium (K+), chloride (Cl-) and zinc (Zn2+) transporters in GI cancer, with a special emphasis on the roles of the KCNQ1 K+ channel and CFTR Cl- channel in colorectal cancer (CRC). Ca2+ is a ubiquitous second messenger, serving as a signaling molecule for a variety of cellular processes such as control of the cell cycle, apoptosis, and migration. Various members of the TRP superfamily, including TRPM8, TRPM7, TRPM6 and TRPM2, have been implicated in GI cancers, especially through overexpression in pancreatic adenocarcinomas and down-regulation in colon cancer. Voltage-gated sodium channels (VGSCs) are classically associated with the initiation and conduction of action potentials in electrically excitable cells such as neurons and muscle cells. The VGSC NaV1.5 is abundantly expressed in human colorectal CRC cell lines as well as being highly expressed in primary CRC samples. Studies have demonstrated that conductance through NaV1.5 contributes significantly to CRC cell invasiveness and cancer progression. Zn2+ transporters of the ZIP/SLC39A and ZnT/SLC30A families are dysregulated in all major GI organ cancers, in particular, ZIP4 up-regulation in pancreatic cancer (PC). More than 70 K+ channel genes, clustered in four families, are found expressed in the GI tract, where they regulate a range of cellular processes, including gastrin secretion in the stomach and anion secretion and fluid balance in the intestinal tract. Several distinct types of K+ channels are found dysregulated in the GI tract. Notable are hERG1 upregulation in PC, gastric cancer (GC) and CRC, leading to enhanced cancer angiogenesis and invasion, and KCNQ1 down-regulation in CRC, where KCNQ1 expression is associated with enhanced disease-free survival in stage II, III, and IV disease. Cl- channels are critical for a range of cellular and tissue processes in the GI tract, especially fluid balance in the colon. Most notable is CFTR, whose deficiency leads to mucus blockage, microbial dysbiosis and inflammation in the intestinal tract. CFTR is a tumor suppressor in several GI cancers. Cystic fibrosis patients are at a significant risk for CRC and low levels of CFTR expression are associated with poor overall disease-free survival in sporadic CRC. Two other classes of chloride channels that are dysregulated in GI cancers are the chloride intracellular channels (CLIC1, 3 & 4) and the chloride channel accessory proteins (CLCA1,2,4). CLIC1 & 4 are upregulated in PC, GC, gallbladder cancer, and CRC, while the CLCA proteins have been reported to be down-regulated in CRC. In summary, it is clear, from the diverse influences of ion channels, that their aberrant expression and/or activity can contribute to malignant transformation and tumor progression. Further, because ion channels are often localized to the plasma membrane and subject to multiple layers of regulation, they represent promising clinical targets for therapeutic intervention including the repurposing of current drugs.

Increased risk of colorectal neoplasia in adult patients with cystic fibrosis: a matched case-control study

OBJECTIVE

As the lifespan of patients with cystic fibrosis (CF) increases, concerns regarding the occurrence of bowel cancer have arisen. However, previous cohort studies have yielded contradictory results as to the risk of colorectal cancer (CRC) in the CF population. The aim of this study was to determine whether CF is associated with an increased risk of colorectal neoplasia.

METHODS

We performed a matched case-control study at a statewide CF center. Cases were adult CF patients undergoing colonoscopy in a 5-year period from 2007 to 2012. Controls were matched in a 2:1 ratio for age, gender, and colonoscopy indication.

RESULTS

A total of 50 patients with CF who underwent colonoscopy were identified. Among CF patients, there were 5 (10%) cases with CRC, 1 (2%) with ileal adenocarcinoma, 13 (26%) with adenomas, and 16(32%) with advanced adenomas. In contrast, there was 1 (1%) case with CRC, 11 (11%) with adenomas, and 6 (6%) with advanced adenomas identified among controls. Compared to controls, CF was associated with a 10-fold increased risk of CRC (odds ratio [OR] = 10.0, 95% confidence interval [CI]: 1.2-85.6; p = 0.03), threefold increased risk of adenomas (OR = 3.34, 95%CI: 1.23-9.08; p = 0.018], and sevenfold increased risk of advanced adenomas (OR = 6.95, 95% CI: 2.30-21.01; p = 0.001). Moreover, the quality of bowel preparation was significantly worse in CF patients with a fourfold (p = 0.01) increased likelihood of a poor preparation.

CONCLUSIONS

Our data suggest that CF patients are at significantly increased risk of CRC compared to age, sex, and colonoscopy-indication matched controls. Consideration should be given to the introduction of a CRC surveillance program in the CF population.

Colon cancer in lung transplant recipients with CF: increased risk and results of screening

OBJECTIVE

To determine the incidence of colon cancer in lung transplant recipients with cystic fibrosis (CF) and review screening colonoscopic findings in other recipients with CF.

METHODS

A retrospective chart review was performed for all patients with CF transplanted at the University of Wisconsin Hospital and Clinics (January 1994 through December 2010).

RESULTS

Four of 70 transplant recipients with CF developed fatal colon carcinoma following transplantation, and the cancer was advanced in all 4 recipients (age 31, 44, 44, 64) at the time of diagnosis. In contrast, only one of 287 recipients transplanted for non-CF indications developed colon cancer. Of all recipients with CF who did not develop colon cancer, 20 recipients underwent screening colonoscopy at 1 to 12 years following transplantation. Seven (35%) of the screened transplant recipients (ages 36, 38, 40, 41, 43, 49, 51) had colonic polyps in locations ranging from cecum to sigmoid colon and up to 3 cm in diameter.

CONCLUSIONS

In contrast to non-CF recipients, patients with CF displayed a significant incidence of colon cancer (4 of 70 recipients; 5.7%) with onset ranging from 246 days to 9.3 years post-transplant, which may be due to a combination of their underlying genetic disorder plus intense, sustained immunosuppression following lung transplantation. Colonoscopic screening may identify patients with pre-malignant colonic lesions and prevent progression to colonic malignancy.

Management dilemma; a woman with cystic fibrosis and severe lung disease presenting with colonic carcinoma: a case report

Introduction

There are increasing reports of bowel cancer in cystic fibrosis, suggesting a possible causal link. Individuals with cystic fibrosis who have advanced lung disease present a high operative risk, limiting curative treatment options in early bowel malignancy.

Case presentation

We describe a 41-year-old Caucasian woman with cystic fibrosis and severe lung disease who had been considered for lung transplantation, who presented with rectal bleeding and was found to have a Stage I adenocarcinoma of the sigmoid colon. After considerable discussion as to the operative risks, she underwent a laparoscopic resection and remains relatively well 1 year postoperatively with no recurrence.

Conclusion

We discuss the complexity of the management decisions for cystic fibrosis patients with severe lung disease and early stage colonic malignancy, particularly in the context of potential need for lung transplantation. The case demonstrates that cystic fibrosis patients with very severe lung function impairment may undergo laparoscopic abdominal surgical interventions without compromising postoperative airway clearance.

Congenital syndromes involving the lungs: pathogenetic models based on chinese medicine theories

BACKGROUND

Striking similarity seems to exist between the Jing-Luo and Zang-Fu theories of Chinese Medicine (CM) and clinical features of many so-called multiple congenital anomaly/mental retardation syndromes (MCA/MRs), as both may involve multiple organs and/or body systems.

MATERIALS, METHODS, AND RESULTS

Comparison of MCA/MRs involving the lungs and paths of 5 Jing-Mai traversing the organ has suggested that development of lung and radial ray (embryonic structure that gives rise to radial-side structures of the upper limb, in particular thumb and radius) are closely connected. The Lung Jing-Mai and those traversing the Kidneys may well explain combined malformations involving the lungs, radial ray, and the body's developmental midline. Furthermore, Zang-Fu theories such as "The Lungs rule the skin and body hair," and "The Lungs as a Zang pair with the Large Intestine" also seem to be in keeping with syndromes simultaneously affecting the lungs, colon, and skin. It may be deducible that the Jing-Mai, as described by CM, probably exists, and that the Jing-Mai and Zang-Fu theories have correctly summarized the connections between particular parts of the human body during embryonic development.

CONCLUSIONS

The CM theories therefore may provide important insights into the pathogenesis of relevant diseases as well as clues for development of new treatment for lung-related diseases.

Colonic adenocarcinoma in a 13-year-old with cystic fibrosis

The increase in longevity among patients with cystic fibrosis has brought to light comorbidities associated with the disease that are less acutely fatal than its pulmonary manifestations. Modern retrospective analysis has demonstrated an increased risk of gastrointestinal malignancy in patients with cystic fibrosis, with a marked elevation in malignancy rates among patients in their 20s and 30s. Here we report a case of colonic adenocarcinoma presenting as pneumaturia in a 13-year-old patient with cystic fibrosis.

Review of the abdominal manifestations of cystic fibrosis in the adult patient

Cystic fibrosis is a common inherited fatal disease. As the life expectancy of affected individuals continues to increase with advances in disease management, this disease is no longer limited to the pediatric population. Currently, 40% of patients with cystic fibrosis are adults. In addition, patients may not present until adulthood and frequently have extrapulmonary symptoms. Abdominal manifestations are common and affect multiple organ systems. Hepatobiliary manifestations include fatty infiltration of the liver, gallbladder abnormalities, bile duct abnormalities, focal biliary fibrosis, and multinodular cirrhosis. Manifestations in the pancreas include acute pancreatitis, fatty replacement, calcifications, cysts, duct abnormalities, and carcinoma. Gastrointestinal manifestations include gastroesophageal reflux, peptic ulceration of the gastric and duodenal mucosa, distal intestinal obstruction syndrome, intussusception, appendicitis, fibrosing colonopathy, pneumatosis intestinalis, rectal mucosal prolapse, malignancies, and pseudomembranous colitis. Renal manifestations include nephrolithiasis, as well as secondary renal complications such as interstitial nephritis due to antibiotic therapy and amyloidosis. Awareness of these manifestations is important to successfully guide management of cystic fibrosis in adult patients.

Cystic fibrosis: an overview

Cystic fibrosis (CF) is one of the most common inherited disorders of white populations. The isolation and cloning of the gene in CF that encodes the production of a transport protein that acts as an apical membrane chloride channel, termed cystic fibrosis transmembrane conductance regulator (CFTR), have improved our understanding of the disorder's pathophysiology and has aided diagnosis, but has also revealed the disease's complexity. Gene replacement therapy is still far from being used in patients with CF, mostly because of difficulties in targeting the appropriate cells. Life expectancy of patients with this disorder has greatly improved over past decades because of better symptomatic treatment strategies. This article summarizes advances in understanding and treatment of CF.

Abdominal manifestations of cystic fibrosis in adults: a review

Gastrointestinal manifestations of disease are present in most adults with cystic fibrosis. Radiologists are familiar with the classical imaging characteristics of end-stage pulmonary disease and the radiological findings of meconium ileus in neonates. As most patients now live into adulthood, recognition of the imaging appearances of abdominal disease is important to enable prompt diagnosis and treatment. Accordingly, this article presents typical imaging appearances of the adult gastrointestinal manifestations of cystic fibrosis.

Cancer risk in nontransplanted and transplanted cystic fibrosis patients: a 10-year study

BACKGROUND

Cancer in patients with cystic fibrosis (CF), the most common genetic disorder in Caucasians, has been a rare event. However, more patients now reach adulthood, and more patients undergo organ transplantation-factors associated with an increased cancer risk. Our aim was to assess the risk of cancer in nontransplanted and transplanted CF patients.

METHODS

We followed 28 858 patients whose data were reported to the Cystic Fibrosis Foundation patient registry from 1990 through 1999 and compared the number of cancers observed in transplanted and nontransplanted patients to the number expected from population-based cancer incidence data. All statistical tests were two-sided.

RESULTS

In 202 999 person-years of observation of nontransplanted CF patients, 75 cancers were observed, but 69.7 were expected (standardized incidence ratio [SIR] = 1.1, 95% confidence interval [CI] = 0.8 to 1.4). Twenty-three digestive tract tumors were observed, but 4.5 were expected (SIR = 5.1, 95% CI = 3.2 to 7.6). More cancers than expected were observed of the small bowel, colon, and biliary tract but not of the stomach or rectum. We found that the deficit of non-digestive tract tumors was not statistically significant (52 observed versus 65.2 expected; SIR = 0.80, 95% CI = 0.6 to 1.0; P =.055). In 2725 person-years of observation of 1063 transplanted patients, 13 cancers were observed, but 2.05 were expected (SIR = 6.3, 95% CI = 3.4 to 10.8), and more digestive tract tumors (four observed versus 0.19 expected; SIR = 21.2, 95% CI = 5.8 to 54.2) and lymphomas (seven observed versus 0.16 expected; SIR = 44.0, 95% CI = 17.7 to 90.7) were observed than expected.

CONCLUSIONS

We observed an increased risk of digestive tract cancers among adult CF patients, particularly of the small bowel, colon, and biliary tract. This increased risk appeared to be more pronounced in patients who had had an organ transplantation.