Document 0qDvbJq4wOaqqk1jG8NnQXnZJ

ARCHIVES O JF EDITORIAL BOARD PAUL S. RHOADS, Chief Editor, Chicago AUTHOR BLOOMFIELD, San Francisco RUSSELL M. WILDER, Rochester, Mica. REGINALD FITZ, Boston GEORGE E. BURCH, New Orleans RICHARD J. PLUNKETT, M.D., Chicago, Managing Editor ( Volume 88 1951 PUBLISHERS AMERICAN MEDICAL ASSOCIATION CHICAGO 10, ILL, Case Reports ASBESTOSIS ASSOCIATED WITH BRONCHOGENIC CARCINOMA ROGER STOLL, M.D. RICHARD 3ASS, M.D.' AMO Aimo A ANGRIST, M.O. r.- JAMAICA, H. HOLL3 and Angr.s: *1 2in 19-2 reported two cases of bronchogenic carcinoma in association with pulmonary asbestosis. The nrst case of carcinoma of the lung in association with pulmonary asbestosis was reported in 1933 by Lynch and Smith.* In that year Gloyne reported two cases and in 1936 another.3 Ggber: and Geiger4 5re6p7or8te9d one case in 1936. Xordmann * presented two cases in 1938. One year later Lynch and Smith * added another. Of these, six were of scuam.ouscell carcinoma, one of squamous-cell carcinoma with glandular features, two of oat-ceil carcinoma, one of glandular carcinoma, and another of squamous-ceil non keratinizing carcinoma. The age of the patients ranged from 35 to 71 years, and the duration of exposure, from 19 months to 2S years. All but two had metastases. Freedom from exposure before death varied from four months to 15 years. We have found four additional cases not mentioned in the report by Koileb and Angrist.1 Two cases reported by Kcelsgh* in 1940 were in an oral communication, and no details are known. Two more cases were reported by Linzbach and Wedler * in 1941, one of which was of a squamous-ceil carcinoma in a man 61 years old, exposed for at. least three years to asbestos; ot the other, no details were known. v In 1941 also Desmeuies * added two more cases to the literature, one of a man 57 years old in whom alveolar-ceil carcinoma was found and who had been exposed From the Departments of Pathology and Medicine (Dr. James R_ Reuiing, Director), Queens General Hospital. I. Hoilefa, H- and An grist. A.: Bronchiogenic Carcinoma in Association with Pulmonary Asbestosis: Report of 2 Cases, Am. J. Path. 18:123-135. 1942. 2. Lynch, K, M,, and Smith, W. A.: Pulmonary Asbestosis: III. Carcinoma of Lung in Asbesto-Silicosis, Am. J. Cancer 24:56-64, 1935. 3. Gtoyne, $. R.: Two Cases of Squamous Carcinoma ot the Lung Occurring in Asbestosis. Tubercle 17:5-10, 1935; Case of Oat Ceil Carcinoma of Lung Occurring in Asbestosis, ibid. 18:100-101, 1936, 4. Egbert, D- S,, ana Geiger, A. J.: Pulmonary Asbestosis and Carcinoma: Report of a Case with Necropsy Findings. Am. Rev. Tubere. 34:143-150, 1936. 5. Xordmann, M.: Der Berufskrebs der Asbestarbeiter. Ztschr. Krebstorsch. 47:338-102. 1938. 6. Lynch, K. M-, at.d Smith, W. A.: Pulmonary Asbestosis: V. A Report oi 3ronchiai Carcinoma and Epithelial Metaplasia. Am. J. Cancer 36:567-573, 1939. 7. Koelsch: Lungenkrebs und Berut, abstracted in Zentralbl. Gewerbehyg. 27:32-33, 1940. 8. Linxbach, A_ J, and Wedler. H. W.: Beitrag turn Berufskrebs der Asbestarbeiter, Arch. path. Anat. 307:387-, 1941. 9. Desmeuies. R.; Rousseau. L-: Giroux. . M., and Sirois, A.: Amiantose et cancers pulmonaires, Laval med. 6:97-108, 1941. `.o asbestos :'or 25 years. The ocher was of a man of 50 with squamous-cei! carmr.ctr.a ho had been exposed for 22 years. Boch had metastases co :he pleura. Since 1941. a number ot similar cases has been reported. In 19**2 Hcrr.burger : reported'three cases in men 45, 43. and 49 years ot age. In two, so.uamous-ceil ::.:::r.crra was found ; in che other, an anaplastic carcinoma. One had been exposed to asbestos for five years, another for 20 years. The duration of exposure :r. the third was not known. All three had metastases. In Hamburger's laboratory from 1913 to 193S, in *,137 autopsies, osbestosis was diagnosed in eight cases. Puimcnarv carcinoma was found in tour of these. N Wedler11101i2n 194-3 collected 92 postmortem reports of cases of asbestoses from different parts ot the world and found an incidence of 16% with associated pulmonary carcinoma. In. 1947 Merewether 1S reviewed the accumulated data over a period of 22 years (1924 to 1946) in the "Annual Report of Chief Inspector of Factories in England." la 235 cases asbesrosis was found, and in 31 ot these pulmonary card- noma was also present, an incidence of 13.2%. The incidence of pulmonary cardr.oma in the general adult population was 1.0%. Lynch and Cannon in 194S,13 reported that among 40 cases of asbestosis over a period of IS years in their postmortem series a total of 3 cases of carcinoma of the lung was encountered, an incidence of 7.5%. Each of these three cases showed medium to advanced grades of asbestosis. Wvers in 1949 14 reported on a series of 115 cases of asbestosis. Pulmonary carcinoma was present in 17, an incidence of 14.8%. Squamous carcinoma was present in nine cases, oat-cell carcinoma in five, and coiumnar-ceil carcinoma in one. REPORT OF CASE D. L., a white man 40 years old, was-admitted to Queens General Hospital complaining ot cough, fever, and weakness of two weeks' duration. For four to five months prior to admission he felt weak and slightly anorectic, with a weight loss of about 10 '.br (4.5 kg.). Two weeks prior to admission his weakness became more marked, and he began having a dry persistent cough which was nonbloody. He visited his local physician at that time and -was found to be febrile. A roentgenogram was taken, and he was told he had virai pneumonia. He was treated with penicillin, sulfonamides, chloramphenicol (chioromycetin*),. and aureemydn without a fall in temperature, and with persistence of the cough. His local physician then advised hospitalisation. There was no history ot previous illness. From 1925 to 1940 he had. worked as a plumber but did not use asbestos in his work. In 1940 he obtained a job with the Works Progress Administration as a pipe coverer in which he worked with asbestos exclusively for one and a bait years. For the next four and a half years he continued to work as-a pipe coverer in a shipyard, where he again used asbestos only. During this time he was told to wear a mask while working but neglected to do so and complained that the smell always made him sick. 10. Hotnburger, F.: Co-Incidence of Primary Carcinoma of Langs and Pulmonary Asbesto sis; Analysis of Literature and Report ox 3 Cases, Am. J. Path. 19:797-807, 1943. 11. Wedler, H- W.: Asbestose und Lungenkrebs, Deutsche med. Wchnschr. 69:375, 1943; abstracted. Bull. Hyg. 19:363, 1944. 12. Merewether, E. R. A.: Annual Report of the Chiei Inspector ot Factories, London. His Majesty's Stationery Office, 1947. 13. Lynch, K M,, and Cannon, W\ M.; Asbestosis; VI. Analysis oi 40 Mecropsied Cases. Du. Chest 14:874-580, 1948. 14. Wyers, H.: Asbestosis, Post-Grad. M. J 23:631-638. 1949. i - rcritoir.n ; CX!K''C<i :rc the .;^ry 'tktir.nr.rv :rotn -..''-KXHCfi :j.1 of 22 .clones in :.'.ry arc;* 'tthnoiury DM5 UV(.T c:::omn of cs ;howc<l 'ninicninrv ooinn w.ts nn in one. .nplaminc :s ;>rirr to i-i.S kg.). -v.ng 3 dry e :nd was rrnni.i. He inrevruycta s:can then his work, covcrer in .t four ami vd asbestn* j to do so y Ashes to- j. :i". 1?-U: :s, London, 'led Cases. S.A STOLL Ho Jco f."-3ros chccbs:c . r: physical examination revealed a weil-developcd. .veil-nourished. rr.ocerateiy :i! white man lying in bed and coughing. Examination of his chest disclosed a slightly diminished percussion note with depressed breath sounds and occasional expiratory wheezes at the base of the right 'ung. There were no unusual findings in the hear, abdomen, extremities, or venous system. Laboratory Data.--The temperature was 102.4; the pulse rate, IW per minute, and the biced pressure, [20/76. The urine was norma!. The hemoglobin concentration was 15.5 gm. per ICO cc. and the white blood ceil count 10.000 per cubic millimeter, of winch "5% were polymorphonuclear ceils. The Wassermann reaction was negative, and blood chemical values were within die normal range. examination of the bone marrow revealed clumps of malignant ceils. An electrocardiogram was normal. ' A chest roentgenogram taken shortly after admission showed generalized, large discrete' oval shadows of increased density throughout both lung herds Indicative of pulmonary metastases. A bone survey revealed multiple osteolytic lesions in the cranial vault in the frontal and parietal regions. The long bores and pelvis showed no lesions. The appearance on retrograde urography and on a gastrointestinal series was normal. Proctoscopy revealed no abnormal hr,dings. ' Throughout the patient's hospital stay the temperature continued to range from 101 to 104 P. On the ninth hospital day he complained of numbness of the right arm, with definite weakness of the right peripheral facial nerve. There were no definite motor changes in the extremities. A spinal tap performed at this time revealed crystal-clear fluid under no increased pressure. The ceil count was 0; sugar measured 72 mg., proteins, 23 mg., and chlorides, 115 mg., per 100 cc. On the 23th hospital day the patient displayed 3abinski's sign with hyperrehexia on the right side. On the 31st hospital day a course of treatment with nitrogen mustard (methyl-bir or tru(2-chloroethyl]amine hydrochloride) was stoned and given tor three days without improvement, rlts condition svent gradually downhill, and he died on the ;4th hospital day. The final clinical diagnosis was metastatic carcinoma to lung and bone, primary site unknown. - Postmortem Observations.--There were no adhesions or fluid in either pleural soace. The pleural surface of the lung was studded with nodules varying to 2 cm. in diameter. These were yellow, slightly raised, and roughly rounded in outline. The cut surface of the lur.g showed these nodules to be scattered throughout both lungs and varying to 4 cm. in diameter. The right lower bronchus opened into a cavity about 2 cm. in diameter which was filled with necrotic material. The right upper bronchial site of rumor tissue was not discovered. Interstitial fibrosis was present throughout the lung, with areas of chronic pneumonitis. In addition, there was an area in the upper part of the middle lobe of the right lung which was dark red and noncrepitant, measuring about 2 cm. in diameter. This resembled infarct in the gross, but on microscopic section it was seen to be atetectasis and pneumonitis. At the upper pole of the right kidney, a nodule measuring 2 cm. in diameter was noted. This `was raised, rounded, firm, and yeilow. A similar nodule was observed in the lower pole of the left kidney. Several swollen nodules were seen scattered through the remainder of both kidneys. In each frontal lobe of the brain was seen an ovai-shaped area, 2 an. in diameter, containing small hemorrhages, which was slightly paler than the surrounding tissue These areas were surrounded by a small area of softening. In the liver occasional small, white, discrete nodules were noted. The largest of these measured 0.5 an. in diameter. The other organs appeared normal. Microscopic Study.--The neoplasm was composed of looseiy arranged cells, irregular in shape, varying in sue, and staining quite markedly. Many mitoses were seen. There was no regular arrangement of these ceils into any pattern. These cells were mingled in an unusual manner with plasma cells, lymphocytes, and fibroblasts, and many giant muirinuclear cells were noted. Large areas of necrosis were seen throughout the lung. Typiol club-shaped brown asbestos bodies were seen throughout the lung in the tumor and outside the tumor areas. Metastases observed in the kidneys, brain, and liver showed a similar histological appearance, including extensive areas of necrosis. 1 I i:-; a. a. AACA.r/is of ;a~22:-al ;.;22'c:a2 0''c:t:icai txaniir.ation y:c:ccd SO "ng. oi silicon dioxide per ICO gm. si tissue. The :*.oai diagnoses vere {\) anaplastic carcinoma ot the lung -s-.th possibility oi muit;- certtrtc origin, metastases to <;d.ney, brain, and liver, ar.d (2) pulmonary asoestos;s. COMMENT Tice diagnosis ot pulmonary asbestosis is 'cased primarily on a history ot a long exposure to asbestos dust. The most consistent complaint is dyspnea. Other symp toms are a chronic cough, weight loss, fatigue, and occasionally chest pain. Exami nation ot sputum may disclose asbestos bodies. A .roentgenogram may reveal little or show a haziness only. In regard to the mechanism ot the malignant change in asbestosis, it is question able whether the silicate in asbestos itself is directly carcinogenic or whether the silicate causes bronchiectasis with metaplasia due to irritation ot the bronchial epithelium, thus leading to carcinoma. The former mechanism seems significant, since this high an incidence of carcinoma does not occur in other forms of silicosis, though they do tend to produce an equivalent degree of bronchitis and bronchiectasis. A- '- --7f?fw-c--.' .-w, $? conclusions A case of bronchogenic carcinoma in association with pulmonary asbestosis is presented. The importance of this association of carcinoma in cases of asbestosis is indicated from the review of the literature presented. This association emphasizes the hazards of industrial exposure, the compensa bility of the cancerous process as well as the asbestosis, and the need of carefui preventive .measures. ^ `