Document 2qXKy1M14Jq8zwVXMRXkYda6a

FILE NAME: Asbestos Cement Pipe and Sheet (ACPS) DATE: 1965 Feb DOC#: ACPS010 DOCUMENT DESCRIPTION: Published Journal Article - Mesothelioma * 9 f '< i ; I t !! I V s. 4 $ f Diffuse Mesothelioma o f the Pleura and Asbestos P. C ELMES,* MJ>,, MJLCJ. W . T . E M cCAUGHEY.t tu>. ; O. L. W A D E * MJ>,, Bnt. mti. T . IXri, 1,1 - ) Diffuse mesothelioma of the pleura it an unoommon tumour which, after prolonged contrast tsy, hat now become (enerally accepted at an entity (Campbell, 1950; Godwin 1957 ; McCaughey, 1951; Wagner, Munday, and Harington, 1902). Evidence hat recently been accumulating that inhalation of aibmtaa may be an important factor in the aetiology of thit tumour, and groups of catet associated with exposure toatbettoa have been reported from South Africa (Wagner, SIcqs, and Marchand, I960), Germany (Knig, I960), the United Kingdom (McCaughey, Wade, and Bm ct, 1962; Hourihaae, 1964 i Owns, 1964), and the United States (Selikoff, Churg, and Hammond, 1964). Crocidolhc, the blue aubcttot mined in 'South Africa, appears to be particularly carcinogenic io this respect (Wagner tt al* I960). There it alto evidence that similar tumours arising in the peritoneum are alto related to asbestot exposure (Kcal, 1960; E m idm ip and Smither, 1964 ; Hourihane, 1964). In a previous report (McCaughey f t af,, 1962) we described the finding of asbestot bodies in the lungs of 12 out of 13 patients who bad died of diffuse pleural mesothelioma in Belfast. Details of the working life wem available for only nine of these patients, but in four of them there amt a dear history of exposure to asbestos. This paper describes three further -''VZ 'r * Deptnmtat at Tlanpcudcs and fhaimaratny, 6 t Qn u r t UarettUty at Belj'tu. ` . '" ' t Department at Fatbolocy, tfaa thnm*a Uafvcnfty af BcJfale investigation carried out in Belfast: (1) a study of the industnsl occupation of 42 patients with mesothelioma of the pleura and of 42 control patients without mesothelioma ; (2) an investigitioa of (be prevalence of asbestos bodies in the lungs of patients srith and without mesothelioma of the pleura or carcinoma of the lung ; and (3) an tnvestigatua of the relation between the prescoo: of asbeatoe bodies in the lungs at death and a history (if exposure to asbestos. 1. Iadastrial Occupation ' P atitnlt with M aothdiom a c f (h t Platam. Occupational histories were obtained from the patients themselves or, if the patients had died, from friends and neighbour*. Tnrfnrfmy those previously reported, 45 cues of mesothelioma of the pleura had been diagnosed in Belfast by the time this study sane completed. Only 42 were included in the analysis because three of the early patients had died more than 15 yean previously and no details were available. . Control Patitnts. Occupational histories were obtained from matched eootxols selected from the teooeds of the department of pathology. If diagnosis of mesothelioma of the pleura in the propositus had been made by biopsy the paired control was selected as that patient of the tame sex and within 1 year of age whose name appeared closest to the iisme of the T X < \ \ \ *>i i i -a ry 1965 M e so th e lio m a o f P le u ra -- E lm e s e t a l. 351 propositus in the " biopsy report book " in which t doily record of report! on biopsy spocimcru a kept. If diagnosis of me*o- theliomi of the plctin in the proposmu hid been nude a necropsy the piired control patient was (elected front the " necropsy report book " in the tame way. The occupational histories of the paired control patients were obtained in the same wav as for the patients with mesotliehomi of the pleura and for 41 of the control patients. Information could not be obtained for one of the control patients initially selected, as he had lived in an area of extensive slum dearance and no relatives or neighbours could be traced. The next nearest suitable patient in the record book was chosen in his place. The Taking o f Histories.--Occupational histories were obtained by one of-us from a few of the patients with meso thelioma and from a few of the control patients in hospital. Otherwise the industrial histories were obtained by one of two social workers with a special knowledge of the industrial processes in which asbestos may be a hazard. Their inquiries were greatly helped by the stability and social cohesion of the population of Belfast. Even when death had occurred many years ago dose relatives were often still Urine at the same address, or neighbours knew how they might be found, or remembered the patient well enough to give tome information about his occupation. Although the knowledge that informants gave of the type of work undertaken by patients was often limited, this defect applied equally to patients who had died of mesothelioma and to control patients. Assessment o f Exposure to Asbestos.--The asbestos usad in the insulating and building industry in Belfast has varied in composition and contained croddolitc as well as chryaotile and amosite; because of this no attempt was made to identify the material to which each individual was exposed. Exposure was aaaensed from the industrial history and graded arbitrarily aa foUows: Heavy exposure; A definite history of working with asbestos fuil-time lor at least one year. Light exposure: A history of working with asbestos full-time for leu than one year or of working over a period of many yean at fob such as boiler repairer, plumber, or fitter in the ih'py"M * Intermittent exposure to asbestos. Alo expoiurs: No history of exposure to'sibttiat. " Results.--The age, occupational history, and assessment of exposure to asbestos of the 42 patients with mesothelioma of the pleura and of the matched controls are tummarued in Table I. At the time of diagnoait the mesothelioma patients the duration of exposure varied from 3 to 56 yean (mean 35.5 15.3 yean). The interval between first exposure and the diagnosis of mesothelioma varied from 22 to 73 yean (mean 43.4 f 13 yean). Eighteen of die exposed cases were still working when they became disabled by their mesothelioma. In the remainder the interval between the last known exposure and the diagnosis of the disrasr varied from 2 to 49 yean (mean 23.1 15.6 yean). 1 Prevalence of Asbestos Bodies ia Methodst--A search for aabeatoa bodies baa been made by histological examination of all available tectiona (usually between two and six) of lung tissue from each patient studied. The result of the search was called positive if asbestos bodies were identified. T o be identified asbestos bodies had to be of classical form that is, yellowish blown or golden yellow in colour, elongated, and usually segmented. Shapes corresponding to those illustrated in Figurea 1 ,9,10, I t , 21,24,25,27,32, 33, and 40 in the paper by Gloyne (1932) were most often teen.- Patients seitkout Mesothelioma o f the Pleura or Carcinoma o f the Bronchus*--To determine the frequency with which asbestos fibres could be identified in the lungs of male patient dying in Bedsit on whom necropsy was performed, lung sections were esamined from 100 patients aged SO- ' and from 100 patients aged 60-69 yean. The patients were chosen randomly from the " necropiy record books " except that there with mesothelioma of the pleura or carcinoma of the bronchus were excluded. Asbestos bodies were found in 14 of the 100 patients aged 50-59 yean and in 27 of the 100 patimts aged 60-69 years (Table II). The difference between these two groups ia significant. Tama II.--Asbenm 1,4its ht lames T atti No. A tm an Mm fT > y< sm m * 90-9* too 1 14 lime* \ D y i M a l 04-00 too IT *7 m m w all o w fio w a m m ch ia . . . 100 00 40 D M m a f U M * t ........................... 90 1 M auted caauotot 0 u Fata* w u km m m ^ m M au M laan U , u m H 4 a T am s t --Espo o so Asbestos aswws Tari Hmmr Usa No* MtibtcghUaodnamt.w. l pm..a t t 11 a C o itio n huT) m i lirtl i ii r w i i r o n ihi dtflman IIII in i--infcifrrTM md coctroto h yn^iflrw ( l ) W P - l. 0-001). varied In age from 31 to I I years (mean 59 10.9 yean standard deviation). There were only two women. lo 32 of the 42 patients with mesothelioma there was a history of exposure to asbestos. In eight the exposure was assessed as heavy and in 24 as light. In the 42 paired control patients there was a histnrr of exposure m nine, and in only two of these w u it classified as heavy. Tlus difference is highlv significant (dilfermces are regarded as significant when F<0.U3). Most of the individuals with heavy exposure had worked lor tome yean as pipe-covrren or had often been exposed so asbestos dust in confined s,wcn when repairing W'llcrs and steam pipes. Most of those classified under light exposure had worked in the ahipysrds as rlcctncisns, plunder, or (omen, being mfermittmtlv exposed to asbestos dust when working close to pipecovrrrn in confined spaces. Shipyard workers were not classified u exposed to ashrstm unit- a drhntrr exposure was described. In the eases where exposure to ashntus was admitted Patim ts with Cmcinoma of the Bronchus*--Sections of lung tissue from 100 men who died with carcinoma of the bronchus were examined and asbestos bodies were identified us section from 20 of them. For the 50 patients who bad died moat recently paired control patients without carcinomi of the hmg were chosen. These controls were men of the same age whose names were closest to those of the propositi in the " necropsy record hook" Among these 50 p srm ti with carcinoma of the kvotxhui there were nme in whose lungs axbestos bodies were identified ; in the 50 matched controls there were 13 in w hen lungs asbestos bodies were identified. The difference is not significant (Table II). Patients vnth Mesotheiiosesa of the Piesera.--Necropsy material was available Irotn only 24 of the patients who died with mesoiheiaana of the pleura. The lung tissue of .matched control patterns was also examined. The lungs o( 21 of tlie 24 panents with mesotlirtinrna of the pleura contained ashestea bndrs. In (our caws Hit m uons shotted numerous todies, in the rest etnlv small numlwn were found. Atlto.lt bodies were kleni.lted m lung a n t tons from onlv 6 of the 24 matched control patients who <lut not hare mesothelioma of the pleura. T hu difference n highly tigniKvint ifabie II) / t A t a & u jg jit 352 6 F e b ru a ry 1965 M e so th e lio m a o f P le u ra -- E in u s e t a l. X A ibntoi Bodies and Ia d s s o U History srith mesothelioma of the pleura were found whereas previously never more than five patients had been disarm ed in a single I To dirow light both on the meaning of the presence of sheaos bodies in lung tissues and on the accuracy of industrial histories taken after death from relatives, friends, or neighbours, 20 patients were chosen who had died in recent yean, who had not had either carcinoma of the lung or mesothelioma of the pleura but in whose lung tissues at necropsy asbestos bodies had been identified. Matched control patients who had neither carcinoma nor mesothelioma and in whose lung tissues no asbestos bodies had been found were also selected, the controls being selected as that patient of the same age and sex whose name was nearest to that of the propositus in the " necropsy record book." The selection of the 40 patients was done by the pathologist fW. T . E. McC). The occupational history of each of these 40 patients in s obtained by one of the social workers who visited and questioned relatives and friends. The exposure to asbestos was afssnrt from the industrial history as heavy, light, or none by the other two authors (P. C. E. and O. L. W.) before the year. The investigation hat shown that a history of exposure to asbestos during working life was found in about three-quarters of patients in whom a firm diagnosis of mesothelioma of the leura was made compared with such a history in only ooe- t uarter of those srithout mesothelioma. A study of the occupational histories suggests 'that the interval between first exposure to asbestos and the disoowxy of the tumour is often long and may exceed 40 yean, and the exposure may be light and in some inttanort very transient. A similar obaervstioo was made by Wagner <t of. (1940). The long latent period meant that the present inridmttr of this divusr may have been determined by industrial practice IS to 50 yean a g o ; it also meant that preventive measures undertaken now will not affect the incidence far many years. Ibtetiwseiennte6re0stainngd t(h9atyaebaonutoaldqiunarBteerlfoafstmshenoudldyinhgavreecaebnetsltyo/a' y . pathologist revealed which were the patients in whom asbestos bodies in their lungs. These older men started their working bodies had bees identified and which were the controls. life between 1905 and 1915. But asbestos bodies were found R n vlti.--The result ate summarized in Table III. A history of heavy or light exposure to asbestos eras elicited for 14 of the 20 patients whose lungs conti med asbestos bodes, only in 14% of the younger men (dying between the ages of 50 and 59 years) who had started work between 1915 and 1925. The shipbuilding industry in Belfast was particularly active between 1906 and 1925 and over 1,000 tons of boilq - insulation T aau 1II.-44M II M i n m I w n "4 Erpsars_____ composition (containing asbestos) res used a year compared with a more usual level of 600 tons a year. By the time ship building recovered from the slump and tried to meet the needs of the 1939-45 star, the angers of handling asbestos were known and precautions were taken. The difference in frequency of finding asbestoa fibres in the lungs of men in die two age-groups presumably reflects these changri in industrial conditions. . but only two of these patients had had heavy exposure to asbestos. A history of exposure to asbestos was obtained from five of the 20 matched control patients in whose lungs no asbestos bodies were seen: only one of these had had heavy exposure. The differences in history of exposure to asbestos between the two groups are significant. In about a third of the patients who have had sufficient exposure to asbestos to have asbestos bodies identified in their lungs it hat not been possible to obtain a history of exposure from relatives, friends, or oeighbouis. In a search for asbestos bodies m lung tissue, confined to the examination of two to six sections, asbestos bodies may not be found although the patient has been exposed to asbestos during his working life. ' Diacaaaioa Exposure to high concentrations of asbestos dust has long been known to cause asbesttma with fibroin rtf the lung and pleura, and there is in this condition an increased incidence of carcinoma of the lung (Mcrewethrf, 1949} Doll, 1955). Although working cvnditions hare been improved and the prevalence ol ashesmsta with acvrrc hhrrms of the lung has been reduced. Williams and lIuRh-Jonei (I960' fiats: slumn that manv workers in an asbestos factory mav liare dnturhed lung function even though no pulmonary hbntats has b * n detected hv clsrst faduigrepitv. The shipyards are situated in a circumscribed area on the lough aide. There is one small factory in which asbestos is used in the middle of a compact residential area. Plotting oo a map the homes of patients with mesothelioma of the pleura does not show any geographic*! yuumilnjTWTiKgeit'contain*' nation of a residential ares by asbestos duar either from the factory or from the ahipyaidi. Until recently most asbestos used outside the shipyards res in the form of corrugated roofmr. T his res imported from England, and til l bibxiiy cut and handled in tbc open under Iconditions of good ventilation. The use of asbestos in many industries, and especially in the building trade, isnow increasing (771# r u n , 1964!, and this gives roe to anxiety that there trill be an increased incidence of mesothelioma of the pleura. It it often difficult to obtain details of past employment from a patient, and this it especially difficult if the information sought concerns work dune 20 or 40 years ago. Prom relatives or neighbour such information it bound to be lets accurate, and thu mav account (or the absence of a history of exposure to asbestos in tome of the patients in whose lungs asbestos bodies were found, and possibly alto tn tome of the patimts with mesothelioma of the pleura. There sre also uw iiv" whu-h ssfw 'im b v lirt f t r nm found in tie lune of m rn h o Im t h j.rT v t'Y and Prolong-'! CM*' T in ii-br:.. Vm.i Vouhl tend u IcrJ in llm ^nvrslu:aiiim~To CMiuniion of tie part played by exposure to aibrMut etiology of mesothelioma ol the pleura. The prewatt investigation confirms that mesothelioma of the ti.-ura is another luirard for rhose exposed to asbestos. > Summary th-ugh m rso tn eiu im i is a ra re tu m o u r it Iws hern possible to A history of occupau.<<ul rxrsw ure to ad<estna was obtained i I m He':.itt 45 i w u m w ith niesoiliriiniiia of the pleura in 32 out o( 42 p t i i r n n kith fn rv t.v l < n u of the pkrurt n irm cJ Intiolori* . v hv b m p s'- o r at n c tr 'P 'v . T h e true RcMukf. in 42 i n t J r v l cin u n il p r^ -n r ol the mitk ag r and r* P " \ r.Irn.T m a t 'veil br huffier, bespuM the eliopw l d u isn v i ' is trx it hmtrv o! cx'" uic wi ol*tt-nru in oniv cunr. .1; a i d w o li'Hit I'l.'P V o r rv. ,t . " lltr u n p i i re. lit >, tp- . : f., I'- trivm p* ti i n f ' Z u ry - in Auv* *t tan! trre f.'unvJ at ncvnvve in tJte lur:: of 14 : a -- e 1m l I ................ ir . t r e T P t n l l it t l . c C o m t e * 1. 1 2"* . of m m M vo reesrlv ot d u t o o ou.er th in i *. *. .. -* j l :*. ;, : v t * . C * " 5 - " * " *- .; -- s - h . E p J M S ; . . ] . ' y t'e fc ru a ry 1 9 6 5 M e so th e lio m a o f P le u ra -- E lm e r e t d . 353 carcinoma of the bronchia and mesothelioma a t the pleura. Asbestos bodact were found in the lungs of about 20% of patient! dying with cucinama of the lung. They wot found in mate d a n S0% of men dying of anothelioma of the pleura. I A history of an indtattiai occupation with ropoane to asbestos was obtained from td a tim , neighboun, o r friendt of about three-quarttn of patients m whom asbestos bodies wccc found in the lungs at necropsy. Such a histoty was obtained for o n e-q u an cr of patiems in sham asbestos bodice w oe not found in the lungs at necropsy. It is concluded that there is evidence that rumsiire to asbestos, even though it may hare been transient and many yean previous, a an important factor in the aetiology of mesothelioma if the pieun. This conclusion gives cause for anxiety because the increasing commercial use of asbestos. V t wish to thank Mrs. Yvonne Dudgeon end Mrs. Marion Simpson who worked untiringly with patience and tact so obtain occupational histories from pabents or their relatives, Iliads, or neighboun. We are grateful to the records officers of Belfast hospitals for their help in searching out old notes and so nutty colleagues who have helped by referring patients to its. We wish to thank Dr. Metre, of lbs Department of Social Medicate, for etedsdoal advice. We are irdefend for greats aa the Strwert M ar Fund administered by the Faculty of Medicine of Quern's Untar* aity, d>c Bntish Empire Cancer Campaign, the Northern Ireland Hospitals Authority, the Royal Vietaria Hospital Endowment Fua4 sod the Medical Research Council. Campbell, W. N . (IMO). Amar. J. PW h. M , 473. D oll. R. (1953). Bril. f. M u m . M e A /ll il. _ Bnuckaap, J. A . and S ald ati, W. J. (1964). IW d, 21, 28. d o m a , S. X. (19)2) la n a ri, I . D M . Godwin. M. C (1937). Caesar, I t . 291 Hourihenc, D. O B. <1964). I W s , 29, 261 . Real, E. R (I960), smisi, 1 D U . KOois, ) (1940). trek. Gswsrbrpath. CwwrrW kyf- l i , I H McCauchcy, W. T . E . (1951). 9. rmk. B s a , 74. 317. Wade. O. U , ta d E lm , 7 . C. (1*62) Sr*, mad. 9 , 2. 1997. M m w rthn. E. R . A. (194) Annasi A ryan af the C M f Im paciar af Panamas fa r ska yssr 947. ILM .S.Q , LandaOL Owen. W. C . (1964). BrU. su d . J , 1 714. lalik.sff. I. | . Chore. J ., aad Hammond, fi- C (1964). f. Amar. a n i. A n. ISS. 22. The Timii (leaden), S March 1964, p. 17, eaL 7. . Wasncr, J. C , Monday, D. E , and Harhssna, ). S. (I960. 7. t a l Ban. 64. 73. ----- Skgm, C. A . md Maickand, T. (I960), grit. J. M am . Mad, 17, Winimas X. and Hagh-Jowss, T. (I960). Tim m , U , 1*9. / \