Document 3QLjdj2BJMG4nQz15XB4kBGa6

136 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 Q. The doctor that was caring for you 2 for your heart was also taking care of you for 3 some depres s ion? 4 A . Mildly, yes. f, Q . Sometimes I just don1 t hear you 6 clearly. 7 A . He was, yes. . 8 Q . And whatever medicine he put you 9 on, you are no longer on, is that co rrect, other 1 0 than the heart? 1 1 A . Not on today, no. 1 2 q . And when did you stop taking 5 3 whatever medicine it was for the depression? 5 4 A . Some time last year. 1 5 q . Some time last.year. Had you had 1 6 heart problems prior to being hospitalized? 1 7 A. Well, I was only in the hospital 1 8 for ten hours. 1 9 Q. Ten hours, yes, sir. 20 A. They thought they had it under 2 1 control. It's been going on since about 1970. 2 2 Defibri11 ation, as I recall. 2 3 Q. Which hospital did you go to for 2 4 ten hours. Doctor? 2 5 A. A hospital in Poole. A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 37 DR. .JOHN CHRISTOPHER WAGNER - DTRECT BY MR. BRIOKMAN 1 Q. Poole, how do you spell that? 2 A. P O 0 L E. 3 Q. What's the name of the hospital? 4 A. The Poole General Hospital, and I 5 was under a physician called Dr. Andrew McCloud 6 w h o I h ad seen a couple of times about the heart 7 business. They wanted me to see a physician when ft I first got down there, having left Cardiff, and I 9 saw him then. We had one of these fibrillations in occur after that.' 1 1 Q After? 1 2 A . About two months a f t e r I had seen 1 3 him. No , that 's not right. More than two. I saw 1 4 him in August. August last year, and this 1 5 occurred in April, this year, so . . . 1 6 Q No . I apo1ogi ze . Apparently in 1 7 August o f last year, you had the heart problem? lft A. No. I was referred down to see him 19 because I had had a previous heart problem, and I 20 had come down from Cardiff, Pernarth down to his "21 area. He was recommended as a physician to see 22 me. At that stage I was perfectly fit, and then 23 recently in April, I had another attack. ,2 4 Q. Lastmonth? 26 MR. GARRARD: No, April of '89. A. WILLIAM ROBERTS, JR., & ASSOCIATES 138 1)R. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. RRICKMAN 1 BY MR. BRICKMAN: o<_ Q That's what I'm asking. ,,-Aprll of 3 '89? 4 A . No, this April. S Q. April of '90, last month? 6 A . I'm sorry, March. 7 Q March of this year, 1990? 8 A . Yes. Quite recent. 9 Q Was that when you were hospitalized 1 0 for ten hours in March? 1 1 A . Yes. Either March or April. It 1 2 wa s April. 1 3 Q. Within the last month or two? 1 4 A . Last month or two. 16 16 hours? Q You were ho spitalized for ten 1 7 A . Yeah . 1 8 Q In the year 1989? 1 9 A . In the yea r 1 990. 20 0 . Okay . But j n the yea r -- Jet me 2 1 finish my q u estion. I n the year 1 OHO -- let's 2 2 hack another year . 2 3 A . Yeah . 24 Q -- were you >d at all? 2 6 A . Not at all. A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 4 5 6 7 8 10 il 12 13 14 15 3 <S 17 18 19 20 -- 21 22 23 24 2 f> 1 39 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN Q And you were not under any doctor's nare in 1989 for any heart problem? A . Yes . T was under the . 1 oca 1 chap there. n . Not Dr. McCloud? A . Not Dr. McCloud. I was seelng him after that. Q- When you had the problem with the depression, was that based on the 1990 hospitalization or some problem in 1989? A . '89, just after I saw you. Q 1989. Were you having your heart prob1em then , too? A . I had it a while , yes . Q . Were you hospitalized then for that? A . No. It came on by itself. Q So the only time you have been hospitali zed for yoxir heart has been in the year 3 990? A . 1990. Q- And in 1989, you were under the care of a doctor for your heart and depression; that Yeah, mild depression. Yeah A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 4 5 fi 7 8 9 10 13 12 13 14 15 16 17 1ft 39 20 ~21 22 23 24 25 140 T)R. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN Q. Mild depression; is that what you sa id? - A. Ye s. Q. And you have not been on any medication for the mild depression in the year 3990? A. No. Q. Are you in any way restricted as to what you can do because of your heart? A. No. Q. Are you restricted in any way or are you under any doctor's instructions with regard to your mild depression you had in '89? A. No. Q. Doctor, do you make clinical diagnoses of diseases such as asbestosis, or do you only do so pathologically? A. Only pathologically. One reads the clinical notes, but mine has always been the pathological. Q. Can you tell me how you diagnose a mesothelioma pathologically? A. First of all, the ideal way of doing it is having a microscopic examination and a postmortem seeing the whole body and making sure A. WILLIAM ROBERTS, JR., & ASSOCIATES 141 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 no other tumor exists in the other parts. 2 Q. Okay, wait a minute. Is-that the 3 first thing you do or is that the most important 4 thing? 5 A. This is the ideal way of doing it, 6 wo uId he to see the whole situation, make sure 7 there were no other tumors and then carry out a 8 histological examination of the tissue making 3 sure -- making sure that this was the -- we were 10 taking sections from the whole tumor. 11 Q. Taking sections from the whole 12 tumor? 13 A. Taking sections from various parts 14 of the tumor. And one would examine these 15 sections to see the histological features of the 16 mesothelioma. 17 Q. And which features are those, 18 Doctor? 19 A. The mesothelioma is a mixture of 20 the type of material which can go two ways. It '21 can go into the sort of epithelial tissue forming 2 2 glands o r ma sses of cells. It can also go into 23 sarcoma s or fibrous or spind1e cell type of 24 tumor. And in the ideal case, one should find 2 5 both of the epithelial type and the spind1e cell A. WILLIAM ROBERTS, JR. & ASSOCIATES 142 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 type. 2 Q. When you say ideal, does, that mean 3 that's the easiest to identify? . 4 A. That's the easiest to identify. 5 You have various patterns of both the epithelial 6 type . 7 8 Q. And the sarcomatous? A. Sarcomatous type, which would 9 indicate that you're probably dealing with a 1 0 mesothelioma. 1 1 Q. Anything else you do or look for? 1 2 A. in doubt, a confirmation, if you 1 3 have got the tissue fresh, you can look for the 1 4 hyaluronic acid. 1 6 Q. Tf the tissue is fresh, do you want 1 6 to look for that? 1 7 A. If it's fresh, then you have to put i e the tissue in a special mixture containing acetic 1 9 acid and alcohol. 20 Q. Acetic? 2 1 A. Ace tic. 2 2 Q. How do you spell acetic? 2 3 A . ACETIC. 24 Q. Acetic acid? 2 5 A. Formalin acetic acid and alcohol. A. WILLIAJ4 ROBERTS, JR., & ASSOCIATES 3 2 3 4 5 fi 7 fi 9 3 <> 33 32 33 34 15 3b 37 38 39 20 ~2 3 22 23 24 25 1 43 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN And this keeps the secretion in the tissue. You can then stain for hyaluronic acid, which is snluable. You can do various stains which you stain for the presence of hyaluronic acid, and then you use an enzyme hya3uronidase, which should remove the stains from the tissue if hyaluronic acid is present. Q If hyaluronic acid is present, what does that indicate? A . Indicates it is probably a mesotheli oma Q Probably is? A . If you use a specific hyaluronic -- sorry, it indicates you are dealing with a mesothelioma under these circumstances. Q If it turns up positive? A . Posifive. O . It's a meso? A . Meso. Then the other test is the one we also use which is the periodic acid shift, PAS, periodic acld-Schiff. If that stains positively, it's -- identifies the mucin as coming from the epithelial tissue, and what you are dealing with is probably an adenocarcinoma, not a mesothelioma. A. WILLIAM ROBERTS, JR. & ASSOCIATES 144 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 Q. If the PAS is positive, it's an 2 adeno? . 3 A. It's an adeno. 4 Q. Any other things you do? 6 A. Then one of the more recent ones i: 6 the careinoembryonic antigen. 7 Q . Spell t ha t ? 8 A. CAR-- it's CEA. 9 Q. CEA, okay. Now I know what you're 1 0 talking about. CEA. 3 3 A. If CEA is positive or strongly 1 2 positive, one realizes one is dealing with a tumor 3 3 which is probably epithelial in origin. 14 Q. Does that mean it's a meso or not a 1 5 mesn? 1 6 A. CEA positive is not a meso. Weak 3 7 positive, a few oases of meso have been reported. 3 8 Q. Weakly positive may be a meso; 19 strongly positive, not a meso? 20 MR. GARRARD: Said moderately or 2 1 strongly positive. 22 BY MR. BRICKMAN: . 2 3 Q. Okay, moderately or strongly. Any 24 other things? 2 5 A. Some people do the keratin test. A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 4 5 6 7 8 9 10 31 12 33 34 15 16 17 38 39 20 -2 1 22 23 24 25 145 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN Q. Do you do the keratin test? A. I have done It once or twice. I saw it done in these cases. . Q. Do you rely on the keratin tests? . A. Not nearly as much as on the other two . Q. And tell me what results should show up for that to determine whether it js a meso or no t ? A. Strongly positive keratin would indicate towards a carcinoma. Q. And not a mesothelioma? A. And not a mesothelioma. Q. Anything else. Doctor? A. Mainly most of the things really -- most of the cases you would do on the histology itself. And you do these tests to confirm it. Q. When you say the histology, you mean just looking at it? A. Looking at it, you get most of the answers except when you've got these large secreted areas, and then you have to decide whether it is a mesothelioma or adenocarcinoma. n. Just so I know, the most important to you is looking at it? A. WILLIAM ROBERTS, JR., & ASSOCIATES 3 2 a -4 5 6 7 8 0 30 11 12 13 34 i r> 16 17 18 19 20 ^2 3 22 23 24 2b 146 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN A. Yes. Q. And then ynn do the stains to help confirm or deny or add information? . A. Yeah. I think the reason is so far there is no specific stain -- we all try to find a specific stain for mesothelioma. At the present moment, there is no specific stain but a series of nega fives. Q. With regard to the stains you have mentioned, let's talk about the hyaluronic acid. If that is positive, that would militate in favor of a mesothelioma? A . Yes. Q, Is that a 100 percent sure test? A. No. Because it can occur in certain ovarian tumors. percent. Q. In wha t ? In a male it's 100 A . In men. Q. Males it's 100 percent. So if we have a male and the hyaluronic acid is positive, it's a meso? A it's a meso Q. It Let me -- . on process Yes , A. WILLIAM ROBERTS, JR., & ASSOCIATES 3 47 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 3 A. You've got to show -- you've got 2 your areas of specialties or glands; and in the 3 gland-like structures, you have to have hyaluronic -4 ft acid there. Q. If it's In the right place, it's a 6 nesri? 7 A. Yes. 8 Q. The PAS, periodic acid-Schiff, you 9 told me that if that is positive, it's not likely 1 0 an adeno? ] 1 A . Yes . 1 2 Q . What percentage do we get false 1 3 positives on? 1 4 A . Very, very low. 1 6 Q . What percentage, Doctor? 1 6 A . I have only seen one. 17 Q You have seen one fals e positive? 1 ft A . I was never convinced that -- it 3 9 was a borderline case; let me put it that way. 2 0 Other than that , the PAS is a pretty reliable --2 3 stain. '2 2 Q You have seen apparently one 2 3 borderline case that may not have been correct? 2 4 A . Yes . 2 5 Q . Have you seen reports of others A. WILLIAM ROBERTS, JR . , & ASSOCIATES 14 8 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 3 where the PAS test showed false positives? O A. No, roost people are happy- about the 3 PAS . - 4 Q. Have you seen reports or false 5 positives In the PAS test? 6 A . No . 7 Q. So as far as you are concerned, if 8 the PAS test turns up positive, there is virtually 9 no question in your mind, it's an adenocarcinoma? 1 0 A . No . 1 3 Q. No, or was what I said correct? 3 2 A. In my mind, it's an adenocarcinoma. 3 3 Q. So why do you do anything more than 3 4 the PAS test if that's an absolute indicator 1 5 whether it's a meso or adeno? 3 6 A. Well, I think the other tests, like 1 7 the CEA, give you an extra -3 8 Q. But you don't need it If it's 300 3 9 percent certain, do you? 20 A. I think one does it because it's an 2 3 extra confirmatory test. 2 2 Q. I don't understand why you need 2 3 extra confirmation if it's 100 percent correct. 2 4 MR. GARRARD: Wait a minute. I 2 5 think you either are confusing him, or you are A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 '4 5 fi 7 8 9 ,10 11 33 14 15 18 17 18 19 20 21 22 23 24 20 149 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN confused. Because what he has said, if it is positive, that shows it's an adenocarcinoma. He has not said that if it is negative that means that it is a mesothelioma. BY MR. BRICKMAN: Q. If it's negative, what does that indicate. Doctor? A. Negative -- well, itcanbea malignancy, and some adenocarcinomas you get that are negative, particularly in a rapidly growing tumor. ij. So an arteno can be negative or positive? A Yeah. Q But a mesothelioma has never shown positive on a PAS test? A , Not in my experience. n . How about in the literature? A , I think there -- no, I'm not sure about that. T don't think so. n . So any time you do a PAS test, and it turns up po sitive, you are 100 percent certain it's an adeno? A . Yeah. But then the confirmatory test is the CEA . A. WILLIAM ROBERTS, JR. & ASSOCIATES 1 50 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 3 Q. Why would you do the CEA if you 2 were 100 percent sure that the PAS showed up 3 posit1ve? - 4 A. Belt and braces situation. 5 Q. I don't know anybody that wears 6 both. 7 fi A. Pardon? Q. 1 don't know people that wear both, 9 Doctor. 1 0 A. This is the sort of additional 3 1 tests. These are the two that are being suggested 1 2 at the moment. 1 .9 Q. What I want you to explain to me is ] 4 why would you suggest doing an extra test if you 1 fi don't need it? It leads me to believe that the 1 6 PAS test is not 100 percent certain. 3 7 A. I think there are some people who 1 R are not 100 percent certain of the PAS test. 3 9 Q. How about the CEA test, are there 2 0 people who say that is not 100 percent certain? 2 3 A. There are people who say in certain oC. o(. mesotheliomas, as far as I know, you can get a 2 3 slight positivity. 2 4 Q , You can? A. Yes, but the majority of the people A. WILLIAM ROBERTS, JR., & ASSOCIATES 3 51 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 say that the PAS is a much mote reliable test. o Q. What percentage of CEA testing 3 shows up false positives? . 4 A. Well, the series we have done, I 5 think one in 200. 6 Q. All right, the series that others 7 have done? 8 A. Some of the other ones have got 9 higher. 30 Q 3 3 high as 25 Have some of them gone, in fact, as 1 2 A. I think so, yes. Going into this, 3 3 and they say this is a slight. You get a slight 3 4 positivity, the cell gets more and more intense. 1 5 It's not the intensity. - 1 6 Q. And how do you determine whether 1 7 something is moderate or slightly positive with 1 8 the CEA test? 3 0 A. The intensity of the staining. 20 Q. Be more specific. Does it turn a 2 1 deeper blue, darker blue, deeper red, darker red? 22 A. A deeper orange-brown. 2 3 Q. Deeper orange-brown. 2 4 A. Yeah. 2 5 Q. So to distinguish between a slight A. WILLIAM ROBERTS, JR., & ASSOCIATES 3 52 L>K . -JOHN CHRISTOPHER WAGNER - DIRECT BY MR. RRTCKMAN 1 and moderate is a matter of how you determine the 2 color? ? 3 A . Yeah. ' 4 Q. And the keratin test you said you 5 don't rely on; is that correct? 8 A. Not how it's done. 7 Q. But that's got a high degree of 8 margin of error, however? 9 A. It depends upon t. he fixation of the 1 0 tissue. I'm not very up on the keratin. 5 1 Q. In any of the three cases, did you 1 2 re]y on the keratin test at all? 3 3 A. Well, when it is strongly positive, 3 4 ye; 35 n , If" it's strongly positive, you rely 3 fi on it? 3 7 A . Yeah. 3 8 Q. Is that 300 percent correct? 1 9 A. No, I don't think so. 20 Q. What margin of error is there for 2 3 the keratin test? 2 2 A. Well, I think it depends on when I 2 3 have reported it, but T am not very happy about 2 4 it. 2 6 Q. When you say you are not very happy A. WILLIAM ROBERTS, JR., & ASSOCIATES 3 53 DR. .7 0 H N CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN ' 3 about it, you are not very happy in these o particular cases or just in general? - 3 A. In genera 1 . ~4 Q. Because it shows a larger margin of 5 error? 5 A. Because there are so many keratins 7 involved. I think the cytokeratin is strongly 8 positive, is in favor of adeno, of carcinoma. 9 Q. The cytokeratin test. 1 0 What is the margin of error for the 1 1 percentage of false positives with cytokeratin? '3 2 A. I'm not certain. 3 3 Q. You don't know one way or the 3 4 other? 3 5 A . No . 3 6 Q. There is some margin of error 1 7 apparently with it? 1 8 A. That's what I believe, yes. 3 9 Q. Doctor, could you te.l.l me how you 20 diagnose ashestosis pathologically? "2 1 A. Well, looking at it 2 2 microscopically, the fibrosis of the lungs. 2 3 usually starting at the base of the lower lobe and 24 working upwards. Histologically one has 2 8 interstitial fibrosis, starting from the smaller * A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 '4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 154 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN bronchioles or respiratory bronchioles, and spreading out around the lung and in the fibrous tissue, one should find asbestos bodies or fibers. Q . Do you require a certain number of asbestos bodies or fibers to be found before you would attribute fibrosis to or call it asbestosis, ra t he r ? A. Well, they certainly should be - the minimal asbestosis, one sees one or two. After serious asbestosis, one seer, large numbers o f them. Q. One or two what? A. Asbestos bodies. This is looking under the light microscope and the equivalent of that js 100,000 on the electron microscope. O . 100,000? A. Fibers or bodies. Looking at the ordinary microscope, one would expect to find -- minimal is about two or three asbestos bodies in the interstitial tissue to take it as a reaction. o . Is what you told me, when you see one asbestos body, you typically find 100,000 asbestos fibers? Is that what you just said? A. Yes. That's if you break down the lung to look in detail. A. WILLIAM ROBERTS, JR., & ASSOCIATES ( ' ( * 1 2 3 ~4 5 6 7 8 9 10 11 12 13 14 18 16 17 18 19 20 "2 1 22 23 24 25 * 155 PR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN Q. That's an average breakdown, that for every asbestos body you can expect to see 100,000 asbestos fibers? A. Yes. Q. Is that correct? A. Yes. This is in a case where you do it, you would expect to see 100,000 in the electron-microscopic field. Breaking it down to a gram per dry weight of lung tissue. Q. Say it for me one more time, Doctor. If you see an asbestos body, what do you expect to see under the electron microscope? A. Same area. If you took a gram of tissue, you would find at least 100,000 fibers. Q. Did you discuss these three cases with anyone other than Dr. Gibbs and Mr. Garrard? A . No. ' Q. You have not talked to Dr. Poo ley or anybody like that? A . No . Q. And you yourself came to the opinion as to how each one of these stains showed vi p, whether it was positive, strongly positive or negative? A. Yes. A. WILLIAM ROBERTS, JR., & ASSOCIATES 156 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 3 Q. Those are your opinions and not 2 that of a technician or Dr. Gibbs? * 3 No. I agreed fairly well with Dr. ' 4 Gibbs. 5 Q. But what I'm getting at is those 6 are yoxjr own personal opinions and not those of 7 anyone else? 8 A . No . 9 Q What I'm saying is 3 0 A . The ones I did, yes. 3 3 n. And you looked at, for instance, on 1 2 Mr. Harris. You looked at the mucicarmine stain? 3 3 A. Yes. 3 4 Q. And the PAS stain? 3 5 A. Yep. 3 6 MR. GARRARD: Get your Harris 3 7 report out. 3 8 THE WITNESS: Mucicarmine, yes. 3 9 BY MR. BRICKMAN: 20 Q. You looked at the mucicarmine stain 2 3 ynurself? 2 2 A. Yes. 2 3 Q. And when you wrote on the report, 24 that was your own opinion and not some 2 5 technician's opinion? A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 o 3 -4 5 8 7 8 9 10 31 12 33 34 i5 36 37 38 39 20 --2 1 22 23 24 25 157 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN A . No, that was my own. o . And the CEA you looked at yourself? A . Yes. Q yourse1f? And the cytokeratin you looked at A . Yes . 0 . Do you know where these slides are that were nut by Dr. Gibbs that were stained? A . Yes. They are in Pernarth. 0 . And were any other tests run or any other staining s done that are not written down here? A . No. Just the ordinary hemotoxin assay who is the same one that does the routine on the tissue. Q That was done also? A. This was done routinely. It's the routine stain we use. Q What did that show in these oases? A . That showed the histological picture. Call out from the hemotoxin staining. Q Is that indicative of anything in particu1 a r or just to look at it histologically? A . Just to look at it histologically. Q No other stains were done to your A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 -4 5 6 7 8 9 10 11 1O 13 14 ] f> 16 17 18 19 20 .2 1 22 23 24 25 1 58 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN knowledge? A. That I was concerned with, no. Q, Could I see your handwritten -- your reports you have in front of you, Doctor, please, sir? A. The notes on the cases? Q. Yes. A. Which one, sir? Q. All of them. The typed reports that have some handwritten language at the hot tom, ' A. All I have that for is to remind me of human chorionic gonadotropin. Q. What is human chorionic gonadotropin? ' A. It's a materia] which is ext ranted from the placenta which is used for staining for primitive tumors, germ cell tumors, and teratoma mass. Dr. Gihhs had done it, hut I hadn't done it, because it was a test I discovered later when he really explained it to me. Because it occurs in the notes, what actual notes, and in the hospital. The evidence, we get germ cell teratoma as wel]. Q. Did you yourself run a human A. WILLIAM ROBERTS, JR., & ASSOCIATES 159 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 3 chorionic gonadotropin? 2 A . No . ^ 3 Q. Did Dr. Gibbs? - 4 A. I think it was done for Dr. Gibbs 5 by Dr. Jasani, .3 A S A N I. 6 Q. You didn't look at that? 7 A. I didn't realize its significance. fl Q. And what is its significance with Q regard to whether this tumor is a mesothelioma in 1 0 Mr. Warrick's case? 11 A. It doesn't stain positively for 1 2 mesothelioma, only for germ cells. 1 3 Q. Is that a 100 percent positive 1 4 test? 3 5 A. So I have been informed. 3 6 Q. Who informed you of that? 3 7 A. Dr. Gibbs after reading the 3 6 literature on the subject. 3 9 Could I see the other reports like 2 0 this? 2 1 Discussing the carinoembryonie 22 anti gen? 2 3 Q . Yes. 2 4 (Whereupon, a recess transpired.) 2 5 BY MR. BRICKMAN: A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 60 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 Q. Dr. Wagner, let's talk specifically 2 about the caseof Billy Harris. With regard to 3 Mr. Harris, do you believe that he has 4 mesothelioma? 5 A. No. 6 Q. Did you see in the medical records 7 where he was diagnosed as having mesothelioma? 8 A . He was diagnosed as adenocarcinoma. 9 Q . Doctor, you didn't see in the 1 0 medical recordsi where he was diagnosed as having 1 3 mesothelioma? 3 2 MR . GARRARD: You're talking about 3 3 medical records o r the autopsy report? 1 4 MR . BRICKMAN: Aren't those medical 3 5 records ? They are all medical records in my 3 6 hook . 3 7 MR . GARRARD: Not when the 1 8 Plaintiffs' lawyer generates it at the funeral 3 9 home , 20 THE WITNESS: Maybe I misread it. 2 1 but T thought he was diagnosed as mesothelioma 2 2 only at the end 23 BY MR . BRICKMAN 24 Q - Say that again, Doctor? 2 5 A . Mesothelioma at the end. A. WILLIAM ROBERTS, JR., & ASSOCIATES 10 1 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 3 Q. He was diagnosed as mesothelioma? 2 A. Cause of death was given-.?-- by Dr. 3 Le Ber, mesothelioma, and he evaluated it on the -4 fart that the earlier PAS was positive. There was 5 no evidence of mucin production. 6 Q. Let's talk a second. 7 MR. GARRARD: Did you finish your e answer? 9 THE WITNESS: Yes. 1 0 BY MR. BRICKMAN: 3 1 Q. You said the certificate of death 3 2 says carcinoma of the lung. My death certificate 3 3 doesn't say that. Did yours say cancer of the 3 4 lung, your death certificate? 1 5 A. Yeah. 3 fi Q. It did? Okay. . 37 MR. GARRARD: 1 think it says 1 8 cardiopulmonary arrest. 1 9 BY MR. BRICKMAN: 20 Q. Mr. Garrard has shown you the death ~2 1 certificate. Is that the same one you saw? 2 2 A. Yes, it must be the same one . I 23 thought I saw that the death certificate said 2 4 carcinoma of the lung. 25 * MR. GARRARD: I think that's A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 -4 5 6 7 8 0 ]0 11 12 13 14 i r. 16 17 18 19 20 U. 1 22 23 24 162 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN another one of the cases. BY MR. BRICKMAN: Q. It doesn't say carcinoma of the lung on that death certificate, does it? A. No. I apologize. Q. So in the autopsy report, it diagnosed mesothelioma; is that correct? A. Yes. Q. Now, where did this guy go about making his mistake in the autopsy report? A. Well, the main thing, he said -- he said the PAS was positive, hut no evidence of mucin production. The PAS that was done for us showed very marked positivity and also secretion. Q. Have you looked at the slides he did, the stains -- the slides he did with the stainings on them? A. No, I'm afraid not. These are going back before I was involved. Q. Well, let me ask you this. What would account for the difference in the evidence of mucin production in your opinion? A. It's hard to say, but -- certainly the sections that I saw showed one lump of tissue, one block of tissue, with marked mucin secretion A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 .4 P. 6 7 ft q 10 11 1? 13 14 35 16 37 16 19 20 21 22 23 24 25 163 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN on the PAS. Q. If this Hoc tor in Texas was correct that there was no evidence of mucin production, would that then indicate to you it was a mesothelioma, if he is right? A. If he was right, except we have now got the CEA in strong support of what we have got. Mucin showed a local positivity and the cytokeratins were strongly positive. Q. So, in your opinion, this gentleman had an adenocarcinoma? A. Adenocarcinoma, yes. Q. All right. Nov/, you only studied the material in which tumor was present; is that correct? I'm reading your report, second sentence. A. Yeah, with a certain amount of lung on there. Q. You did not study the lung tissue where tumor was not present? MR. GARRARD: Said there was a certain amount of lung on there. BY MR. BRICKMAN: Q. I misheard him. A. It showed extensive evidence of the A. WILLIAM ROBERTS, JR. & ASSOCIATES 1 2 3 ~4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 28 164 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN permeation of lymphatics with carcinoma. Q. Do you see the second sentence in your report: I only studied the material where tumor was present? A. Yes. Q. There was lung tissue that was not tumor that you examined? A. There was lung tissue infiltrated by tumor which I studied. Q. Did you have any lung tissue that was not infiltrated by tumor that you studied? A. As far as T know, no. It was infiltrated. Q. So you wouldn't be in a position of determining whether this person had asbestosis, would you, based on the materia] you looked at? A. There was no evidence of what I had seen that he had asbestosis. Q. You wouldn't expect to see asbestosis in the tissue? A. No, this is lung tissue attached to the tissue. Q. So just so I'm straight, you did see some lung tissue that did not have tumor in i t? * A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 65 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 3 A. 2 lymphatics. I saw lung tissue with i;o- 3 Q And that didn't have asbestosis, 4 your opinion? 5 A . No. No. 6 Q Did you see in the autopsy whe r e 7 the doctor found asbestosis, or he found - - 8 A , He found brown granules. 9 Q . He found ferruginous materi a 1 s 3 0 consisting of bedded bodies consistent with 31 fragmented asbestos bodies. Did you see that? 32 A. No, that I didn't see. isawa 33 certain amount of iron in the tissues. 3 4 Q Did you find interstitial fibrosis? 3 5 A . Interstitial fibrosis I found was 3 6 i nvo1ved with the lymphatics being infiltrated 1 7 with tumor. 3 8 Q And the tumor was- on which side, as 1 9 far as you know? 20 A . The tumor was the right side. 2 1 Q Right side. Did you look at any of 2 2 the left 1 ung? 2 3 A . No. I don't think I did, no . 24 0 . And if he found in the left lung 25 areas o f interstitial fibres is, what would account A. WILLIAM ROBERTS, JR., & ASSOCIATES DR. JOHN CHRISTOPHER WAGNER DIRECT BY MR. BRICKMAN for that, in your opinion? A. Well, by the presence of^the tumor going through the lungs I saw, once again, this would probably be the continuation of the lymphatic impermeation. Q To the other side? A . Yes. It usually does both sides. Q So you're saying there was interstitial fibrosis on the left-hand side, if there was, caused by the tumor? A . Yeah . 0 . How do you differentiate the interstitial fibrosis caused from asbestosis from that c a u.s e d by a tumor. Doctor? A . Well, closely around the vessel, the 1 ympha tics which are infiltrated. Q No. between the two? No. How do you differentiate A . Well, one is much more apparently lymphatic than theother. o . One is much more what? A . Around the lymphatics. o . How do you know the fibrosis on the left-hand side was around the lymphatics if you didn't look at it? A. WILLIAM ROBERTS, JR., & ASSOCIATES 167 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 A . I thought I had, actually. 2 Actually, I haven't. - 3 Q So you don't know what that 4 interstitial fibrosis on the left-hand side was. 5 do you, on the left lung? 6 A . No . 7 Q Let me ask you, sir, to assume that ft this gentleman had asbestos is. Would you then 9 attribute the cancer, as you believe it to be, at 1 0 least in part to his asbestos exposure then? 1 1 A . If there was definitely evidence of 3 2 ashestosis? 1 3 Q Yes, sir. 1 4 A . Well, all I can say, if there was is evidence, I should have seen something. I saw 16 absolutely nothing of this. 1 7 q . I am asking you the question , sir: 1 ft If there was asbestos!s -- . 1 9 A . If there was asbestosis, yes . We 20 have got no proof that there was asbestosis 2 1 Q , You didn't look at the left lung. 22 did you? 2 3 A . According to this, I thought I had 2 4 looked at more sections. As I stated, I had only 26 looked at the one section. A. WILLIAM ROBERTS, JR., & ASSOCIATES DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN Q. Yes, sir. I am asking you to assume, sir, that this pathologist who looked at the left lung said there was fibrosis, Interstitial fibre:sis. Would you agree with me, sir -- A . Oh , yes, except -- MR . GARRARD: Except what? THE WITNESS: I thought -- what I say, I saw one lung. I have only got proof that I saw the one section. I thought I saw more. BY MR. BRICKMAN: Q. Yes, sir, I understand that. You also thought the death certificate said he died of carcinoma. MR . GARRARD: I object to that and move to strike it. Inappropriate comment. MR . BRICKMAN: Why is it inappropriate? MR . GARRARD: That's just a catty remark MR . BRICKMAN: He obviously made a mistake if he didn' t look at the lung, and he thought he did MR . GARRARD: He is saying it's not on his report. A. WILLIAM ROBERTS, JR., & ASSOCIATES 169 PR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 BY MR. BRICKMAN: - 2 Q. Doctor, do you have any evidence to a indicate that you looked at the leftside of the - 4 lung 7 5 A. There is no evidence here. 6 MR. GARRARD: But he says he 7 thought he did. 8 BY MR. BRTCKMAN: 9 0. Did you. Doctor? 1 0 A. I was wondering where I got this ] 1 thing from. As the report stands now, you are 12 1 3 Q. I am asking you to assume that the 1 4 gentleman had asbestosis. If he had asbestosis, 1 6 would you agree with me that asbestos exposure 1 R played a role in his, what you think, is an 1 7 adenocarcinoma? 1 8 A. If it was severe asbestos. 1 9 Q. Severe asbestos or severe 20 asbestosis? 2 1 A. Asbestosis. 2 Q. What do you mean by severe 2 3 asbestos is? 24 A. More than just localized focal 2 5 fibrosis. A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 i5 16 17 18 19 20 -2 1 22 23 24 25 170 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN Q. So now you not only have to have asbestosis, but you have to have severe aasbestosis for you to attribute a lung cancer to asbestos exposure? A. I would suspect it to be different from asbestosis. His situation doesn't bring this out . Q. Whose situation? A. The previous pathologist. 0 . Well, he writes in here, both lungs demonstrated and the pres lungs. A . Yeah . Q Assuming he is correct -- A . Assuming he is correct, it would be . o . -- would you agree with me that ashes tos p 1 a' 1 a role? A . It could have, yes.I Q adenocarcinoi A. adenocarcinoi respiratory ] I think the peripheral -- he had had the -- he had A. WILLIAM ROBERTS, JR., & ASSOCIATES 171 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 Q. What does that have to do with the 3 MR. GARRARD: Let him finish his 4 a nswer. ft THE WTTNF.SS: One would assume that ft the lung cancer was an association with his heavy 7 cigarette smoking. 8 BY MR. BRICKMAN: 9 0 * What 1s his cigarette smoking 1 0 history as you be 1ieve it to be? 1 1 A Heavy cigar ette smoker up until 1 2 '79, Two pa ck s a day. 1 3 Q Until 1979? 1 4 A Yeah . 1 6 Q And where did you get that 1 6 information from? 1 7 A That occurred in the records. I've 1 8 got it down a & 7-24-79. 1 9 Q * 7-24-79 is when you have he quit? 20 A He was smoking two packs a day and 21 later notes said he stopped smoking, hasn't smoked 22 since his retirement, which was in '79. 23 Q. Now, Doctor, would you call this 24 cancer a pleural cancer? 25 A. No. Originated in the periphery of A. WILLIAM ROBERTS, JR. & ASSOCIATES 1 2 3 -4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 172 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN the lung. Q. So when some of these other doctors refer to it as a pleural cancer, that would he incorrect? A, Well, that would be a cancer presenting on the pleura. That would he correct. It wouldn't be a cancer arising from the pleura. Q , r looking at Hr. Binkowitz1 report where he says it's a pleural carcinoma. He was the surgeon. A. Yes, sir, he wa s talking about peripheral carcinoma presenting in the pleura, in my opinion. n. Wouldn't you normally say carcinoma if it was a peripheral carcinoma? A . Yes, I don't think they are talking about pleural carr. i noma . Q . I'm sorry, I didn't hear that. A . When he was talking about pleural cancer, I think he was meaning the peripheral cancer. 0 . It had to be the peripheral cancer? A . That's what he was suggesting. Q All he says in my s urgical report is pleural carcinoma. Preoperative diagnosis A. WILLIAM ROBERTS, JR., fk ASSOCIATES 173 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 pleural carcinoma; postoperative, pleural 2 carcinoma? - 3 A. A carcinoma involving the pleura. -4 Q. Let me ask you this; What are the 5 typical clinical features of a malignant fi mesothelioma? 7 A. A tumor completely surrounding the ft lungs. 3 Q. Are there any certain signs we 10 would look for that we typically wouldn't have 11 with a peripheral carcinoma? 12 A. No, the features are very similar. 1 3 The mesothelioma probably going more into the 1 4 chest wa11. 1 ft Q Are pleural effusions more likely 1 6 with one than the other? 1 7 A . No . 1 ft Q . So both adenocarcinomas and 1 9 mesotheliomas are likely to cause pleural 20 effusions? 2 1 A . Yes. 22 O . Do you know Oscar Auerbach? 2 3 A . Yes, by name. 24 MR. GARRARD; Is he going to be 2 5 used as a witness in this case? * A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 o 3 -4 5 6 7 8 9 10 11 12 13 14 13 16 17 18 19 20 -21 22 23 24 25 174 PR. -JOHN CHRISTOPHER WAGNER - DIRECT BY MR, BRICKMAN MR . BRICKMAN: Migh t. MR . GARRARD: I hope so BY MR. BRICKMAN: Q. He says that peripheral carcinomas aren't caused by cigarette smoking. Do you hold to that opinion? He has written an article -- A, Yes, I know. It could or could not be . Q. Could or could not be. Yes, sir, that's possible. But are you of the opinion that peripheral carcinomas can be caused by cigarette smoking? He is of 1 he opinion that they cannot be. I want to know what your opinion is. A. I think that they can, but it is an unlikely tumor. But in peripheral carcinoma, it's possible that cigarette smoking played some part. n. It-'s possible. You wouldn't say to a reasonable degree of medical certainty then? A. No. Q. Now, with regard to the staining that you did or that you had done, do you recall the precise day that you looked at the staining on the Harris case? Do you have it in your notes anywhere, sir? A. No, I don't have it in my notes. ' A. WILLIAM ROBERTS, JR., & ASSOCIATES 175 L>R . JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 3 Q. Dontor, I am asking you to assume 2 this hypothetical. If this man did have a 3 mesothelioma, would you have attributed his 4 mesothelioma to his asbestos exposure? 5 A. His asbestos exposure is -- the fi fact that he got exposed to asbestos fairly late 7 in the story -- he claimed in '69 he had his first p. exposure to asbestos. 9 Q. So that would fit within your 1 0 latency period, wouldn't it? 1 1 A. Well, only just, yes. 1 2 Q. So the latency was sufficient? 1 3 A. Just sufficient, yes. 1 4 Q. Just sufficient. Well, it's a 1 5 couple of years over your timetable, but -- 1 6 MR. GARRARD: Object to your 1 7 characte r i zsition, Mr. Brickman. He said a typical 1 P latency wa s much longer than that, that some 3 9 accepted 1 5 years; but I don11 t know that he said 20 that is his necessary time frame -- just a moment. 2 3 please. 2 2 MR. BRICKMAN: Is that an objection 2 3 to the form of the question? It sounds more like 24 your -- 26 * MR. GARRARD: T started to add an A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 o 3 -4 5 6 7 8 9 10 11 12 13 14 1s 16 17 18 19 20 -2 1 22 23 24 25 176 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN objection. MR. BRICKMAN: It's gone^way beyond that. MR. GARRARD: I wouldn't think so. I overrule you on that. MR. BRICKMAN: We took it up to a three court judge panel, and they definitely said you were wrong on your ruling. MR. GARRARD: They were English judges, so they don't know. Some said 15 and some said longer than that. I object to your characterization as fits your parameter. MR. BRICKMAN: He also said he would go down to 14. BY MR. BRICKMAN: Q. Doctor, the latency period was sufficient in thip time? A. I wouldn't be very happy with it. but it has been reported. n. I'm sure this man wasn't happy, either. But it is sufficient; is that correct? A. Right on the borderline of being sufficient, yes. Q. If this man had a mesothelioma, would you agree with me. Doctor, that the most A. WILLIAM ROBERTS, JR., & ASSOCIATES 177 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 likely cause of the mesothelioma was his asbestos O exposure? 3 A. We don't know the extent of his 4 asbestos exposure. We don't know what sort of 5 fiber he was exposed to. 6 Q. Well, what else would you have 7 attributed it to in this circumstance if it's a 8 meso? 9 A. It's a hypothetical I don't want to 1 0 get caught up in, because I don't think it is a 1 1 meso . 3 2 Q. I'm asking you to assume it is a 3 3 meso. The jury may find it is a meso, and they 3 4 will want to know what caused that meso. If it is 3 ft a meso, will you agree with me that his most 3 fi likely cause is ashestos exposure? 1 7 A. If it was a meso. But it is not a 3 8 meso . 3 9 Q. I understand your opinion. But if 20 it is a meso, would you agree with me that the 2 3 most likely cause is the asbestos exposure? 2 2 A. Once again, to what type of 2 3 asbestos was he exposed? 24 Q. He was exposed to Mr. Garrard's 2 S asbestos which had Amosite in it? T.1 T T r> a n nn DR. JOHN CHRISTOPHER WAGNER DIRECT BY MR. BRICKMAN MR. GARRARD: I object to that, because there is absolutely no evidence-that he was exposed to asbestos manufactured by anybody 1 represent. MR. BRICKMAN: Why are you in the case? MR. GARRARD: Because the judge won't grant summary judgments, that's why, which are filed. He won't even rule on them. BY MR. BRICKMAN: Q. Assuming he was exposed to Mr. product which had Amosite, would you agree with me that the most likely cause - A. You need a tremendous amount of Amosite to cause mesotheliomas. Q. Maybe he had a tremendous amount. You don't know, either? A. He denies it himself. He said four or five times a month he supervised -- Q. So in your opinion -- MR. GARRARD: Ret him finish. THE WITNESS: He said he supervised the men replacing the asbestos insulation. BY MR. BRICKMAN: Q. So if it was a meso, you would be A. WILLIAM ROBERTS, JR., & ASSOCIATES 179 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 of the opinion that it was not caused by his 2 asbestos exposure? 3 A . I think it would be an open 4 question. Could not be caused by his asbestos 5 exposure. ft Q. It could not be caused by his 7 ashestos exposure? 8 A. Yeah. I think until we know what 9 his ashestos exposure was. 3 0 Q. Well, based on the records that you 1 3 have in front of you and that you reviewed, would 1 2 you say that the most likely cause of his 1 3 mesothelioma was asbestos? 1 4 MR. GARRARD: Excuse me. The 3 ft doctor has not said it is a mesothelioma. He has 1 6 said it is not a mesothelioma. 3 7 THE WITNESS: We are getting 3 8 involved with a very hypothetical situation. 3 9 BY MR. BRICKMAN: 20 Q Yes, sir, I under stand that 2 3 am asking you to assume that, that it is a 2 2 mesothelioma. What is the most likely c a u 2 3 it, sir, under the facts as you know them? 24 A . If it wa s -- 2 5 Q Yes, sir. ft IaI T T T TAM DnDTD'T'C TO f. a o o r\ r> t k nr e 1 2 3 '4 5 fi 7 8 9 10 11 12 13 14 1s 16 18 19 20 21 22 23 24 180 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN A. -- It's possible that he had sufficient exposure to produce i.t. Once again, we are in a hypothetical situation. The part -- I would expect to see something in the lung tissues that I saw which would indicate this. Q. Yes, sir, hut you only looked at one side of the lung, correct? MR. GARRARD: Excuse me. We don't know that, Mr. Brickman. When you say you only looked at one side, he said he thought he looked at both sides, but he doesn't have it written down. I object to you trying to make that into something more positive than what he said by your statement. BY MR. BRICKMAN: Q. Doctor, do you normally write down you look at when you do these reports? A. Yes. Q. Did you write down that you looked at the left lung? A . No . Q. Ordinarily, if you had looked at the left lung, would you have written it down? A. What T have got here is the lung, so I think I would have. A. WILLIAM ROBERTS, JR. & ASSOCIATES 3 2 3 4 5 8 7 8 9 30 31 32 13 54 '1 5 36 17 38 39 20 23 22 23 24 25 Cl 3 81 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN Q. Ycni would have written it down? A. Well, I said the lungs. Should have been -- If I had, it would have said the lung showed evidence. Q. Doctor, I'm lost. I don't know what you ' re talking about. A. As far as I can see from this report, I just say the lung showed evidence. . Q. The lung. That was in the singular? A. Yes. Q. And you also said up top, the only material you studied was the one in which tumor was present, and that was only on the right side, correct? And you normally write down, if you look at something, you normally write it down? A. Yes. I should have written down the lungs. Q. From looking at your report, does it appear that you only looked at the right lung? A. It does, yes. Q. Is there anything else. Doctor, other than what's in your report that makes you think this is an adenocarcinoma and not a lesothelioma? ft WTTTT6M P O R P P T S TP JT, RCCflDThTPC 18 2 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 A. No. All the evidence I got is in n the repo r t. 3 Q. All the evidence you base it on is ,,4 in your report. That's what I'm getting at, okay? 5 A. We've gnl the cellular structure 6 which shows the cells look much more like the 7 adenocarcinoma than the mesothelioma. 8 Q. In what way, Doctor? 9 A. You have these -- the glands are 1 0 lined by about -- mesothelioma, the glands are 1 1 lined by sort of cuhoidal cells. These are lined 1 2 by these big, tall columnar cells. 1 3 It doesn't occur to me he has -- : 4 which occurs in carcinoma. And the fact that the 1 s cell's nucleus changed, nuclear stating very 1 6 strongly, and the changes in the cytoplasm. 1 7 Q. What would we expect the cytoplasm 1 8 to look like In a mesothelioma as opposed to an 1 9 adenocarcinoma? 20 A. Cytoplasm is very clear in a _2 1 mesothelioma . --2 2 Q. Clear in a mesothelioma? 2 3 A. Yes. 2 4 Q. What does the word vacuolated mean? 25 # A. Vacuoles are holes. A. WILLIAM ROBERTS, JR., & ASSOCIATES 183 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 Q. What does vacuolated cytoplasm 2 mea n ? : 3 A . D i-d I use the word vacuolation? 4 Q Sir? 5 A . Did I use the word vacuolation? 6 Q I don't know i f you do or no t. I'm 7 looking at one of the medical records which refers 8 to it as vacuolated cytoplasm. You used a 9 different word, dark cytoplasm. 10 A. Vacuolated would suggest that there 11 were holes, vacuoles in the cytoplasm. Variance 12 in staining, I presume. 13 Q. Does that have any bearing on 14 whether it's more likely an adenocarcinoma versus 15 a mesothelioma? 16 MR. GARRARD: 1 think if you want 17 to see where he is referring to, Doctor, that's 18 what he is referring to in here. 19 MR. BRICKMAN: What are you looking 20 at, Henry? I'm not looking at what you're looking 23 ar . ' 22 MR. GARRARD: What are you looking 2 3 at? 24 MR. BRICKMAN: Mine has a different 25 number than yours. A. WILLIAM ROBERTS, JR., & ASSOCIATES 185 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 being an adeno or a meso? o A . This would favor it being an adeno. 3 Q A vacuo1 ated? 4 A . Yes. 5 Q Okay. And would the size of the 6 cells have any significance here? 7 A . The meso cells are usually not as 8 large and not as tall. 9 Q. And are the meso cells normally the 1 0 same shape, different: shapes? 1 1 A . Frequently the same shape. 1 2 Q Mesos? 1 3 A . Yes . 1 4 O . How about adenos? 1 5 A . Adenos tend to vary in size and the 1 6 shape o f the cel Is. 1 7 Q Okay . 1 8 A . Or have more variation than the 1 9 meso . 20 Q The nucleoli, would we expect them 2 1 to appear one way with mesos and differently with 22 an adeno? 2 3 A . They are usually very clear with 2 4 the me SOS &o *f.;* Q- What is cyto glandular A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 .3 ... 4 5 6 7 8 9 30 33 12 13 34 15 36 37 38 39 20 ^21 22 23 24 25 3 86 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN di A . This is where they look as though they are forming glands. Q or adeno? Is that typical of a mesothelioma A . It occurs in both, really. Q Both. In your opinion, what was the cause of Mr. Harris' death? A . Adenocarcinoma of the lung was the cause. Q. Did you note any emphysema or emphysematous changes in the material you looked at ? A . I didn't mention it. Q Well, did you note any or did you recall seeing any? A . No, I recall seeing what I had described. 0 . So did you not see any emphysematous changes, apparently? A . No . Q. Okay. Just for the record. Doctor, would you tell me the exposure history as you believe it to be for Mr. Harris? A . As far as I know, he was -- when he A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 fi 7 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 was working for ARCO Products as a safety o inspector, four or five times a -month he ,3 supervised men in asbestos installation. .. 4 Q . Anything else? 5 A. That's the only one that was 6 mentioned, since we have no evidence of any other 7 jobs that exposed him. 8 Q. With the mucicarmine stain, what 9 does it mean to be focal positive as to be just 1 0 positive? 3 1 A. Positive in localized areas rather 1 2 than generally. 1 3 Q. What does that indicate, that it is 3 4 positive''in focal areas as opposed to a 3 8 generalized area? 1 8 A. It suggests mucin is present. It 3 7 is not as clear as the PAS. ' 18 Q. If" it was positive all over and not 3 9 just focally, that would militate more in favor of 20 an adenocarcinoma? ^2 3 --- o- o 23 A. I think so. Yes. Q, Doctor, let me back up just a minute. Have you been deposed at all in the last 2 4 year, had a deposition like this? 25 t* A . No . A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 88 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 Q. Have you testified in court in the o last yea r? _ 3 A . No . 4 Q. Now , doctor, how long did this 6 gent 1eman 1ive from the time of inii ial diagnosis 6 to the date of death? 7 A . He 1ived from August until October 8 Q- Okay 9 A . All these people had a very short 1 0 survival period 1 1 Q Does that militate in favor of it 12 being a meso versus an adeno? 13 A. Neither way. If the adeno was 14 pretty much into the pleural cavity, they both is would have a very short period of survival. 16 Q. As a general rule, would you agree 17 with me that mesotheliomas typically take a 18 shorter period of time before onset of death than 19 adenos, as a general rule? 20 A. As a general rule, I don't know. 21 If the adeno actually -- I presume you are 22 continuing on the pleural surface. I think they 23 are very much the same. Most cases from initial 24 diagnosis, you would expect the adeno to be more 26 rapid. A. WILLIAM ROBERTS, JR., & ASSOCIATES 189 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 Q. Let's go to your number one step in 2 determining whether something is an adeno or meso 3 and that is looking for a primary site other than 4 the pleura. 5 Wasthatdoneinthisca.se? 6 A. As far as what one gathers from the 7 record, the only place he found the tumor was in 8 the lung. Q. In the lung or in the pleura? 1 0 A . Pleura. 11 Q Was there anything to indicate that 1 2 there was a primary site other than the pleura? 1 3 A . There were some nodules in the 1 4 lung , but I don't know whether these played a part 1 5 in it or not . There was no other mention of any 3 6 other organ having that. 1 7 Q And you have no evidence of the 1 R pa t ho 3 ogy that you looked at other than to show a 1 9 site at the p1eura, do you? 2 0 A . No . 2 1 Q And in the autopsy, the doctor 4o. o appeared to look at the other parts of the body. 2 3 did he not? 2 4 A . Appeared, yes. 25 Q Have any pictures been made of any A. WILLIAM ROBERTS, JR., & ASSOCIATES 190 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 of the slide materials, to your knowledge. Doctor? 2 A. Notasyet,no. _ ~ 3 Q. Do you know whetherplans are being 4 made? 5 A. Plans are being made. 6 Q. They are? 7 A. Yes. 8 Q. Who is going to do that, sir? 9 A. Well, Dr. Gibbs and his team. 1 0 Q. Doctor, do you look at chest 11 x-rays? 1 2 A . Yes.. 1 3 Q. Did you look at any chest x-rays in 1 4 this case? 1 5 A. No, just saw the reports. 1 fi Q. Did the chest x-ray reports that 1 7 you looked at in any way assist you in making a 1 8 determination as to whether this person had a 1 9 mesothelioma versus an adenocarcinoma? 20 A. No. There was no. indication it 2 1 wasn ' t. 2 2 Q. Did you already answer that, 2 3 Doctor? There was nothing in the record? 24 A. To separate the two. There was 2 5 some suggestion of a previous disease, and the A. WILLIAM ROBERTS, JR., & ASSOCIATES 191 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 nodules in the right lung. The lung had been 2 there so long, it didn't look like it pLayed a - 3 part in the tumor. - 4 Q. Now, going back to the stains. 5 Doctor, that you did, there was no staining with 6 hyaluronic acid? 7 A. No. The tissue -- in all these 8 cases, the tissue had been fixed, blocked in wax. 9 If there had been any hyaluronic acid, it wouldn't 1 0 have been washed out. Only if we received the 1 1 tissue directly immediately from the necropsy, you 1 2 can put it in a special fixative to keep the 1 3 hyaluronic acid in the tissue. 1 4 Q. Now, Doctor, in looking at stains, 1 A is there much in the way of interobserver 1 6 variability, meaning you might say something is 1 7 positively stained or strongly positive, and 1 8 somebody else equally as competent might say it's 1 9 weakly stained? 20 A. I don't think there is that much. 2 1 But there maybe -- I think strongly and positively 2 2 weak are pretty close. I don't think you would 2 3 have any difficulty there. 24 Q. Now, with regard to the CEA 2 6 staining, is it easy to tell the difference A. WILLIAM ROBERTS, JR. a ASSOCIATES DR. JOHN CHRISTOPHER WAGNER DIRECT BY MR. BRICKMAN between something that is strongly positive and moderately positive? Is that an easy d i-s tlnction to make? A. I think you can make it, yes. Q. Is there something where there might be interobserver variability where you can make a variation? A. I think very weakly positive or negative, I think there would be people who would be happy to say whether it is very weakly positive or minus or very positive. ' Q. Doctor, with regard to animal experiments, is there any way to look at the latency in animal experiments on things like rats and somehow convert it over to human beings? MR. GARRARD: Latency? MR. BRICKMAN: Yes. THE WITNESS: It's -- people have attempted it. It's extremely difficult. You can -- there has got to be a long latency in animals which suggests there may be long latencies in humans. BY MR. BRICKMAN: Q, How about if there is a.short latency in animals; would that probably indicate A. WILLIAM ROBERTS, JR., 6 ASSOCIATES 1 O 3 ~4 5 6 7 ft 9 :o il 32 13 14 15 36 17 1 ft 19 20 21 22 23 24 25 193 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN that there is a short latency in humans? A. One substance we see a short latency in animals is the Erionite, and we fortunately haven't seen any in humans. Q. With asbestos, if animal studies showed a short period of time, would that mean that it could cause mesothelioma in a short period of time with humans? Does that mean it could happen ? A. 1 don't think there is a correlation here. Most asbestos fibers take the same amount of time to cause tumors in animals. Certainly in my experience, if you inject the stuff, between 700 and a thousand days. Q. Have you ever seen animal experiments where it has taken a day to get a mesothelioma? A. A day's exposure? Q. Yes, it's a day's exposure if the latency exposure is a day. A. No. No. Q. Where the latency was as short as one day? A. No, I have never seen that. T don't believe that would occur. A. WILLIAM ROBERTS, JR., & ASSOCIATES 194 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 Q. How about If the exposure was only 2 one day's exposure in an animal? Would that have 3 any diagnose -- strike that. . 4 MR. GARRARD: Wait a minute. He 5 struck it. Don't answer it. Saves me an 6 objection. 7 BY MR. BRICKMAN: 8 Q. Doctor, with regard to the 9 distinction between pleural mesotheliomas and 10 peritoneal mesotheliomas, do you have any opinions 11 one way or another as to Amosite's ability or 12 likelihood to cause a peritoneal, mesothelioma? 1 3 A . I don't think it has been reported 1 4 that they have caused it. 1 ft Q Do you accept those opinions? 1 S A . If they were Amosite exposures, 1 7 yes. 1 8 Q If they were what? 1 9 A . If they were Amosite exposures, 20 yes . 2 1 Q . And peritoneal mesothelioma you 2 2 would look a t the same way you would a pleural 2 3 mesothe1ioma, same features, same staining? 24 A . Same, yes. 2 ft Q . And the location would be the A. WILLIAM ROBERTS, JR., (k ASSOCIATES 1 95 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 difference between a peritoneal and a pleural? 2 A . Yes . ; 3 Q. And you would hold the same opinion . 4 with regard to all these matters we have 3 discussed? 8 . MR. GARRARD: Hold on. I object as 7 to all these other matters we have discussed. We 8 have discussed matters from 9:00 AM until 1:00 PM 9 and Prom 1.00 PM to whatever time you have got 1 0 hack here to 20 m-i nutes to 4:00. 1 1 And to ask him do you hold the same "i 2 opinion with regard to all these matters, I would 1 3 object to as too broad and ask you to rephrase 1 4 that in some other fashion. 1 8 RY MR. BRICKMAN: 1 6 Q. The issue on the staining would be 1 7 the same with regard to a peritoneal mesothelioma 1 8 as they would for a pleural? 1 9 A. They would stay negative on these 2 0 stains. 2 1 Q. And the histological features would 2 2 he the same for a peritoneal meso as a pleural? 2 3 A. Yes. 2 4 Q. Now, there was apparently some sort 2 5 of bloody -- was it a bloody effusion that this A. WILLIAM ROBERTS, JR., & ASSOCIATES 3 96 DR, JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 Mr. Harris had? o A. Yes. 3 Q. Would you agree with me that that - 4 is not d i agnos t. but; indicative of it being a ft mesothelioma? 6 A. No. Could be an adenocarcinoma. ' 7 Q. But is that typical for an 8 adenocarcinoma or is that more typical with regard 9 to an adeno? 1 0 A. I think the presence of a bloody 1 1 effusion is a suggestion either way. 1 2 Q. So it doesn't make a difference, 1 3 then. Now, in this case, did the tumor encase the 1 4 lung, or how did it appear, or how was it 1 s described as appearing in thin individual? 1 6 A. It was described more prominent on 1 7 the mediastinum. 1 8 Q. Is that typical of an a 9 adenocarcinoma or a mesothelioma, that appearance 20 you have just described to me? 2 1 A. It could occur in either. 22 Q. Could occur in either. It's not 2 3 more typical for a mesothelioma to encase the 2 4 lung? Isn't that a typical description for 2 ft mesothelioma? A. WILLIAM ROBERTS, JR. & ASSOCIATES 1 2 3 4 8 fi 7 8 9 10 11 12 1 .3 14 1S 18 17 18 19 20 ^2 1 22 23 24 2h 197 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN A. Yes, but the peripheral adenocarcinoma can do so as well, but not as common. Q. Now, was there any metastasis from the pleural area in this case, to your knowledge? A. Well, I saw one lymph gland that showed a tumor. Q. Does that indicate to you there was some degree of m e*t astasis? A . Yes , which would be more common in the adenocarcinoma than mesothelioma. o . The fact that there was metastasis A . Yes Q Did you find any inflammatory cell in this material you looked at? A . I have no record. Q If, in fact, your records are accurate and there was no inflammatory component to this malignancy,, would that militate in favor of a mesothelioma? A . No , it wouldn't militate either way . Q . It wou1d not? A . No , inflammatory changes have nothing to do with the tumor itself. He had this A. WILLIAM ROBERTS, JR.,.& ASSOCIATES 3 o 3 ~4 S 6 7 8 9 30 . 31 12 13 14 1 fi 1 fi 17 38 19 20 ~2 3 22 23 24 . 25 *- 3 98 PR, JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN background of chronic obstructive lung disease. Q. Now, Doctor, what is basement membrane? A. Basement membrane is the -- when the ceil comes in contact with the connective tissue. It's the membrane between the cell and the connective tissue or on the next cell. Q. Have you ever seen it reported. Doctor, that in many mesotheliomas, that the cells form a basement membrane? A. Well, I think any cell would form a basement membrane. Q. And that basement membrane would stain positive with PAS? A. If it attached. If it did stain, it would stain very weakly. Q. It would stain weakly, but it would stain positive for PAS; is that correct? A. I'm not sure. The only thing that really stains positive for PAS other than the mucin is diastagen. One stains with a diastasis, the diastagen, DIASTAGEN. Q. Now, with regard to the CEA stain. I thin lc I got my numbers wrong actually before, Doctor. I said that some studies have shown that A. WILLIAM ROBERTS, JR., & ASSOCIATES 199 DR. JOHN CHRISTOPHER WAGNER - DIRECT RY MR. BRICKMAN 1 up to 25 percent of mesotheliomas test positive. o But actually, one study has shown that at 1 most 50 ' 3 percent of those studied were positive for CEA. ' 4 Do you recall that? 5 A. It was a small study, yes. 6 Q. Small. They looked at 20 7 mesotheliomas, and nine of them stained positive R for CEA? 9 A . Will cli one is that? 1 0 Q I'm referring to a Churg article 1 1 that cited a Corson article. Cor son i s the one 1 2 you're familiar with, aren't you? 1 3 A. I thought it was with Churg. 1 4 Q. He referred to the fact that in 3 6 mesotheliomas, in 20 cases, nine stained positive 1 6 for CEA mesothelioma? 3 7 A. Churg goes on to say, if it was 1 8 strongly positive, he feels much more in favor of 3 9 the adenocarcinoma. 20 Q. Would you agree with his statement 2 1 that this is still an area of great controversy, 2 2 this immu nohistochemistry? 2 3 A. On that. But his later articles, I 24 thought he said pretty clearly that it was - 2 6 strongly positive, he would be more in favor of A. WILLIAM ROBERTS, JR. & ASSOCIATES 200 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 mesotheli oma . 2 Q. But he still says it's an area of 3 great controversy? ' 4 A. Is that a recent -5 Q. Yes, sir. Do you agree with that? 6 MR. GARRARD: What's the date on 7 that, Mr. Briekman? 8 MR. BRICKMAN: I don't have the 9 date on it, Mr. Garrard, hut it is recent, I can 1 0 tell you. 1 1 MR. GARRARD: I'm sure it has a 1 2 date on the article, Mr. Briekman. 1 3 MR . BRICKMAN: I don't s ee it. 1 4 MR . GARRARD: I f I could look at 1 fi i t , I could probably find it for you . 1 would 3 6 happy to. I don't want to mislead the doctor this 1 7 is a 1990 article when we both know it's not. 1 8 THE WITNESS: My recollection was 1 9 that Churg said if it was strongly positive, he 20 would be in favor of the adenocarcinoma. 2 1 BY MR. BRICKMAN: ' 2 2 Q. That's not my question, though. He 2 3 has also commented that there is great controversy 2 4 fthnut the use of immunohistochemical staininge. 2 3 MR-. GARRARD: Doctor, I am going to A. WILLIAM ROBERTS, JR., & ASSOCIATES 201 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 instruct you not to answer that question unless o*- Mr. Brickman gives you the date of that - artirle 3 which he is purporting to read. 4 BY MR. BRICKMAN: 5 Q. Do agree there is a controversy or 6 not? 7 A. Yes, there is a controversy, 8 depending on how strong the stain was, yes. 9 Q . N o'w, the histological appearance of 1 0 this tumor, in your opinion, favored an 1 1 adenocarcinoma; is that correct? 1 2 A. That's correct. 1 3 Q. Did it resemble more an epithelial 1 4 mesothelioma as opposed to a sarcomatous 1 S mesothelioma if you had to make that 3 6 differentiation? 3 7 A. Yes, if it was an adenocarcinoma. 3 8 It certainly was more in favor of a -- be closer 3 9 to an epithelial mesothelioma. 20 Q. There was no element in your "2 1 opinion of any sort of a sarcomatous feature to 22 it? ,2 3 24 A. Not in this particular case. Q. Okay. And the epithelial pattern 2 5 is the one that is most easily confused with a * V A. WILLIAM ROBERTS, JR.,. & ASSOCIATES 202 c DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 metastatic carcinoma? oc. A. Yes. This is the one we hope the 3 ~4 histochemistry is differentiating. Q. Now, have you also seen it h reported, Doctor -- and this is why I asked you 6 about the information -- that CEA will often stain 7 positive where it's done in areas of inflammation? 8 A. Yes, that's right. 9 Q. Now, in this case, you were unsure 1 0 whether there was inflammation or not? 1 1 A. No. The CEA was done; there was no 1 2 inf 1amma tion. 1 3 Q. How do you know that? 1 4 A. There were no -- the sighting 1 5 around the cells and the area of the acini, I 1 6 could see no inflammatory cells in that particular 1 7 section. I said the area where it was staining, 1 8 it was staining very clearly on the borders of the i u cells, particularly those in the subliminal area. 20 and there didn't appear to be any infection in 2 1 that area. 2 2 Q. Where would we expect inflammation 23 in mesothelioma cells? 24 A. One wouldn't. The inflammation is 2 5 probably bordered by secondary infection or A. WILLIAM ROBERTS. JR.. A ASSOCIATES 3 o 3 -4 5 6 7 8 q 10 ll 32 13 34 36 36 37 38 39 20 -2 3 22 23 24 25 203 PR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN something of that nature. Q Which would be on the border, wouJdn' t it? A . No. The inflammatory cells were covering as a mass, yes. . Q A. As a what? The inflammatory cells would cover - - the mesothelioma cells, unless they were necroti c would be unaffected by the inflammatory cells. Two different processes. Q Would you be able to distinguish inflammatory cells from the mesothelioma cells easily without any problem? A . Yes . Q And in this case, you actually 1ookert at some lung tissue, not just some pleural tissue; is that correct? A . There was tumor tissue. Q . Prom the lung? A . This was from the tumor. Q Do you distinguish between the lung and the pieura? A . It was the actual one that came from the tumor which was mostly external to the 1 vi n g in this situation. A. WILLIAM ROBERTS, JR., & ASSOCIATES 204 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 Q. That's what I'm asking you. So, o you weren't -- 3 A. Yes. " 4 Q. The tumor you saw was tumor from 5 the pleura and not from the lung? 6 A. As far as I know, the CEA was done 7 on the tumor which was at that site outside the 8 lung . 9 Q. It was outside the lung. 1 0 MR. GARRARD: Wait a minute, so you 1 1 don't get your record confused here. He is 1 2 talking ahout where the CEA staining was done in 3 3 response to your question, not whether or not he 1 4 looked at lung tissue at all. 1 5 THE WITNESS: Yes. 16 BY MR. BRICKMAN: 1 7 Q. The tumor material that was stained 1 8 came from where? 19 A. It came from the tumor tissue 20 which, as far as I know, was the tumor tissue on 2 1 the surface or outside of the actual lung tissue. 22 Q. And was tumor tissue apparently on 23 the pleura? 24 A. Well, you've got two pleural 2 S layers, haven't you? It was on the -- as far as I A. WILLIAM ROBERTS, JR., & ASSOCIATES 205 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 know, it was on the lung external -- external to o the lung. Most of the tumor was outside the lung. 3 Q. Was there any tumor on the lung _4 itself, on the actual lung tissue? 5 A. On the actual border, it was hard 6 to distinguish which was what. It seemed to me 7 the tumor was in the lung and going outwards. 8 Q. It had invaded the lung? 9 A. It was started off at the surface 1 0 of the lung and moved out. 1 1 Q. What is entrapped alveolar 1 ? epithelium? What is that, Doctor? 1 3 A. That's when the alveolar epithelium 1 4 gets entrapped in fibrous tissue, and you no 1 6 longer get the -- as far as you know, you no 1 6 longer get the normal purposes of the alveolar 1 7 because the tissue is compressed into the fibrous 1 8 tissue. 1 9 Q. Did you notice any of that in this 20 case? 1 A. Not in the sections I saw, no. 2 2 Q. Now, as I understand correctly. 23 Doctor, the mesothelioma starts out on the pleura 2 4 and eventually invades the lung itself .in some 2 5 fashion? * * A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 -4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 ^21 22 23 24 25 206 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN A. It can, yes. Q. Did it do that in this case? MR. GARRARD: Wait a minute. Hold it. Object to the form of your question, because you are suggesting that he is saying a mesothelioma existed in this case. BY MR. BRICKMAN: Q. Did the cancer invade the lung in this case? A. I was under the impression that the cancer was coming from the surface of the lung more than invading. Q. Is that the same 'thing? Does that to you mean it invaded the lung, or it means it did not invade the lung when you say it was on the surface? Did not? A. It started peripherally in the lung. Q. But did it invade the lung tissue itself, or did it just stay on the surface? MR. GARRARD: He answered you that it started in the periphery of the lung. In the periphery of the lung. BY MR. BRICKMAN: Q. So does that mean to you that it ' A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 ,,4 5 6 7 8 9 10 i3 12 13 14 15 36 37 3b 39 20 23 22 23 24 25 2 07 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN was already in the lung, so to speak, and not just onthesurfaceofit? A. Very slightly. . Q. Slightly what? A. I mean, all I saw were the sections showing the tumor which I presumed was the adenocarcinoma coming from the lung into the pleura. Q. So the answer to the question was it was in the lung and not just on the surface of i t? A. It had invaded, yes. Q. Had invaded. A. I'm not quite certain which way it went. As I said, a possibility it was arising somewhere else other than the lung. It was being invaded. Q. But it was inside the lung somehow in your opinion? A. Yes. Q. Doctor, was there anything else of significance in Mr. Harris' case that helped you with your diagnosis? A. NO, there wasn't. I was going to say, the evidence of the tumor being inside the A. WILLIAM ROBERTS, JR., & ASSOCIATES 2 08 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 3 lung was extensive lymphangitis carcinomatosis, 2 what I saw Involving the lung. 3 0. Okay. That's all the questions I ` 4 have on Mr. Harris. f> MR. BRICKMAN: The only thing I 8 would like to add is the doctor's -- are we going 7 to do this all in one deposition, or are we going 8 to have separate covers? Do you care? 9 MR. GARRARD: T just assume do 3 0 one. 1 3 MR. BRTCKMAN: We have identified 1 2 for the record and marked as exhihits these three 1 3 iterns . 34 MR. GARRARD: We haven't marked as a 5 exhibits 1 6 MR. BRICKMAN: I have marked them 1 7 as exhibits. 1 8 MR. BRICKMAN: Doctor, I need to 1 9 mark all of your papers if I could. We will 20 substitute copies. 2 1 THE WITNESS: Which ones? 22 MR. BRICKMAN: All of your papers. 2 3 Hand me all of your papers, and I will identify 24 them In some fashion and then we will make copies. 2 5 THE WITNESS: I tried to keep the A. WILLIAM ROBERTS, JR., & ASSOCIATES 209 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 information. 2 MR. BRICKMAN: I'll give-jthem right 3 bark to you. Just hand them all to me, and I will -- 4 identify them in some fashion would be the S simplest. 6 BY MR. BRICKMAN: 7 Q. Doctor, T think you have a couple 6 of other pages nf handwritten notes? 9 A. Just the human chorionic . 1 0 gonadotropin. It comes in the next case. i i Q. I understand. Let me mark them 1 2 before I go home without marking everything and -- 1 3 A . A brief thing about bronchoscopy 3 4 Q Doctor, do you have some other 3 5 handwritten notes? 3 6 A. Just the train timetable. 3 7 Q. Oh, we need to have those train 3 8 times. Doctor. Tliat would be real important for 3 9 this. We have gone through these. 20 (Whereupon, an off-the-record 2 3 conference transpired.) 2 2 MR. GARRARD: I am just saying, I 23 am not agreeing to mark them at this point. 2 4 THE WITNESS: Can I have my notes 2 5 hack? A. WILLIAM ROBERTS, JR., & ASSOCIATES 22 0 OR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 MR. BRICKMAN: I have got to o identify them for the record. r 3 THE WITNESS: Those are exactly the ' 4 same . 5 MR. GARRARD: You are going to get 6 them hack 7 MR. BRICKMAN: We are going to make 8 copies for the record. Plaintiffs' Exhibit 4 will 0 be the doctor's medical report on Billy Harris 1 0 with some handwritten notes at the bottom of the 2 1 page. That will be 4. 1 2 Plaintiffs' 5 would be the doctor's 1 3 one-page of handwritten notes written on both 2 4 front and hack, and Billy Harris Exhibit 6 will be 1 5 the report of Dr. Wagner on -- typed report on 2 6 Horace McBryde. That will be 6. 2 7 7 would be the two pages of 1 8 handwritten notes on Horace McBryde, one of which 2 9 is on front and back. One is just the front. 20 8 would be the typed medical report 2 1 on Alvin Warrick. 2 2 THE WITNESS: Just the same as the 2 3 other reports you have got. 2 4 MR. BRICKMAN: Yes, sir, I have got 2 6 to put them in the record, though. A. WILLIAM ROBERTS, JR. & ASSOCIATES 23 1 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 9 would be his handwritten notes 2 front and back on Alvin Warrick. y 3 10 would be a sheet of notes, looks * 4 like a cite to a particular article and the 5 spelling of two different types of stains of some 6 sort . 7 BY MR. BRICKMAN: 8 Q, Doctor, what is the significance of 9 this article that you refer to at the bottom of 1 0 this last page which I have just wir.iSlt 1 1 10? 32 . THE WITNESS: Th i! reft: 3 3 to a paper written by Goodwood -- Greenwood and 1 4 coauthors in 1971 in the medical journal -- I'm 1 S sorry; the Journal of Industrial Medicine. And it 1 fi just points out the fact that in the germ cells 1 7 which you're coming to in the later case, you can 1 8 have a very small small primary in the tests that 3 9 is quite often missed and can be as little as 1 2 0 millimeter in diameter. 2 3 MR. GARRARD: Which case do you 2 2 want to do next, Mr. Brickman? 2 3 MR. BRICKMAN: Doesn't matter to 24 me. We can take the Warrick report next. 2 S (Whereupon, Plaintiff's Exhibits 4 A. WILLIAM ROBERTS, JR., & ASSOCIATES 212 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 through 10 were marked for identification.) 2 (Whereupon, an off-the-record 3 conference transpired.) ~4 6 BY MR. BRICKMAN: Q. Doctor, you have issued a report in 6 the case of Alvin Warrick; is that correct? 7 A. Yeah. H q. And in this case, you appeared to 9 have looked at the tumor tissue and the lung 11 A. Yeah . 12 Q. Now, in this case, do you believe 13 he has a diagnosis of mesothelioma? 14 A. No. I think this is a very unusual 15 germ cell tumor. 16 Q. Priorto your having made this 17 diagnosis of a germ cell tumor, you apparently had 38 a different diagnosis? 19 A. No -- oh, the thing was -- ye-s . 20 Sorry. Comes from the same thing. This was a --21 tumor to be incriminative of an embryonal in -22 nature. This comes down to the same as a germ 23 cell tumor. Very incriminative tumor. 24 Q. Was this the case that Dr. Gibhs 26 talked to you about where he showed you a certain o A. WILLIAM ROBERTS, JR. & ASSOCIATES 2 13 OR. .lOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 report or certain article on germ cell tumors? 2 A. No. He showed me the -- s' 3 Q. Orastain? '4 A. The stain. He showed me the stain, 5 the human chorionic gonadotropin. It also occurs 6 in the notes. They found it increased in the 7 serum. 8 Q. What is a teratoma? 9 A. Teratoma is a primitive tumor hut 1 0 slightly advanced on what I was calling it, in 1 1 which you pick up three different types of tissue 1 ?. which arc not normally expected in that area. 1 3 Q. Where does a teratoma arise? 1 4 A. Both usually arise in the testes or 1 5 the ovaries or occasionally in the midline, and 1 6 they do arise in the anterior sternum of the 1 7 chest. 1 8 () . Did you do staining of this tissue? .1 9 A. I didn't, no. 20 Q. Did Dr. Gibbs, to your knowledge. "2 1 do stain!ng? 2 2 A. He got the stain for the chorionic 2 3 gonadotropin, yes. 2 4 Q. Why didn't you do stains in this 2 5 case? f' A. WILLIAM ROBERTS, JR. & ASSOCIATES 1 2 3 "4 5 6 7 8 9 10 11 12 13 14 15 ,16 17 18 19 20 ~21 22 23 24 25 214 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN A. I recognized -- I claimed this was a very primitive 'cell tumor or embryonic tumor; and until it was pointed out to me, I hadn't gotten knowledge of this particular stain. Q. You hadn't gotten what? A. Didn't know of this particular stain . Q. Why didn't you do the other type stains on it. Doctor, or did you? A. No. Q. Why didn't you? A. Because I was sure -- there was no need to vise the stains we used to differentiate between adenocarcinoma and mesothelioma. Q. Dr. Gibbs apparently did some staining on this, didn't he? Do you know why he did the staining? A. no. no. Q. You didn't even bother to look at his staining, did you? A. I haven't recorded on thiscase. Q. What? A. I have no record of date on this. Q. The fact that the CEA was negative, does that have any significance to you in this A. WILLIAM ROBERTS, JR.. & ASSOCIATES 235 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 case? 2 A. I don't know how the CEA -tjoes in .3 these " 4 Q. But if it was a mesothelioma, we 5 would expect the CEA to be negative, wouldn't we? 6 A. It could be, yes. And some 7 adenocarcinomas are negative. 8 Q. And what did this tumor appear like 9 to you? How would you describe it? 1 0 A. It was a tumor -- sort of regular 11 large foamy cells. A large hemorrhage and 1 2 necrosis possibly due to treatment and the large 1 3 tome cells and these large giant cells without 3 4 circles which are very primitive. They have no 1 5 boundaries, no margins, no cell membrane. 3 8 Q. And do you have an opinion. Doctor, 1 7 as to where this tumor arose? 3 8 A. Could have arisen from the anterior 3 9 chest wall. Unlikely -- they did examine his 20 testes several times, but sometimes the primate in 2 1 this thing could be so small, you could be a 2 2 millimeter in diameter, yet you would have large 2 3 tumors within the lung, within the thoracic 24 cavity. 2 5 Q. Say that again. Doctor. I missed A. WILLIAM ROBERTS, JR. & ASSOCIATES 2 16 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN It. A. I was quoting the Greenwood article which did say that in cases, he had seen a case in which the tumor actually of the testis was one millimeter in diameter, and yet the sectile was occupying the whole of the chest, one side of the chest, whole one side of the thoracic cavity. Q. Who is a Jasani, B. Jasani? A. He is the authority on doing the 1 0 more detailed immunohistochemistry in Cardiff. 1 1 Q. Is he the one who did the stainings 1 2 in these cases? 1 3 A. I believe just in the one case. 1 4 Q. He did it in one case, the Warrick 1 ft case? 1 6 A. The Warrick case, yes. 17 Q, He is a doctor? 1 8 A. Yes. 1 9 Q. And you didn't look at his 20 stainings, though? 2 1 A. No. Not at that stage, no. 22 Q. Not at any stage, have you? 2 3 A. Well, no. Yes, I have. I looked 24 at it later on. 25 Q. You did? A. WILLIAM ROBERTS. JR., & ASSOCIATES 1 2 3 ~4 5 6 7 8 9 10 11 12 13 14 18 16 17 18 19 20 --2 1 22 23 24 25 2 17 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN A. It stains the giant cells very neatly. '-f Q. You looked at his. staining, but you didn't put it in your report; is that correct? A. Well, I sent the report off when I came back and had him show me how this thing worked in. I was thinking that we had sufficient on the histology Just to make the comment. Q. Did you see in the autopsy where the pathologists found asbestosis? A. I couldn't see any asbestosis. Q. Did you see any asbestos bodies? A . No . Q. Is a teratoma a carcinoma of the lungs? A. No. Teratoma is a primitive tumor of -- Q . Are you -- MR'. GARRARD: Wait a minute. Let him finish. Did you finish? THE WITNESS: It's a primitive tumor of embryonic origin. It's slightly more developed than a germ cell tumor, which is what I always called It. Q. Are you and Dr. Gibbs the only two * A. WILLIAM ROBERTS, JR., & ASSOCIATES 2 18 DR. JOHN C HR T STOP HER WAGNER - DIRECT BY MR. BRICKMAN people to say this was a teratoma? A. In the records, I don't know who else had seen it. T didn't say it was a teratoma. Q. What? A. He used the word teratoma. I thought it was an earlier more primitive. Q. Oh, you don't believe it was a tera toma? A. It could be a teratoma at the stage I examined it. I thought it was a germ cell tumor which is more primitive than a teratoma. Teratoma, the tissue has organized itself in three layers of tissue, whereas in the germ cells, it's even before this happens. n. What causes germ cell tumors? A. These are sort of vestigial clumps of cells left over from the maturation of the fetus, maturation from the earliest part of conception. Q. So this man had this cancer from the very beginning of his life? A. No. They develop usually in the - between 30 and 40 in men. It's there as a group of cells. I'm sure a lot of them they don't develop. If they do develop, this is the usual A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 '4 5 6 7 8 9 10 11 12 13 14 15 16 17 28 19 20 ~2 1 22 23 24 26 2 19 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN age. And also the question, gynecomastia, which Is clearly with It. y Q. What is that, sir? A . That's round developing breast as seen in a woman. ' Q And that's a result of -- A . This is a result of the sec re tion of the human chorionic gonadotropin. Q cell tumor? And that indicates it is a germ A . Yes . Q Does that indicate it's more of a germ cell tumor than a teratoma? A . It would cover both. Q - Would it have anything to do with any other type of tumor? A . No. The answer is no. It'S a primltive -- it's primitive to the development of the lung and the organs of the body. Q. Now, did you note where this g en 11ema n had some prior drug problem? A . Yeah . Q In your opinion, did his drug problem in the past have anything to do with his tumor? A. WILLIAM ROBERTS, JR., & ASSOCIATES 220 I1R. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 A. Nothing at all. Actually, in the 2 notes, they mention that they think of a germ cell 3 tumor there as well. ~4 Q. What notes are you referring to, 5 Doctor? 6 A. The notes on -- of Alvin Warrick. 7 Q. One doctor's notes, you mean? 8 A. Yes. 9 Q. Does this type of tumor where there 1 0 is a teratoma or a germ cell tumor typically cause 1 1 pleural effusions? 1 2 A. If it occurs in the p.leural cavity. 1 3 yes . 1 4 Q. The tumor that you saw came from 1 5 what part of the body, sir? 3 6 A. It was certainly coming from the -- 1 7 in the thoracic cavity, probably from the anterior i e mediastinum because it described the tumor as 1 9 being nodules In the anterior. 20 Q. Did you do any iron stains to look '2 1 for asbestos bodies? 2 2 A. I saw a few fragments of tissue, 23 iron granules. They weren't asbestos bodies. 24 Q. But did you do any iron staining to 2 5 see if they were asbestos bodies? * 0 A. WILLIAM ROBERTS, JR., & ASSOCIATES 221 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 A. No. They didn't have the 2 appearance of the asbestos. They were purely 3 granules without any fiber in between them. There 4 was no fiber there. ft Q. Did you see where the pathologist 6 found scattered ferruginous material? 7 A. Yes. That just means scattered - 8 scattered iron products in the tissue. That 9 doesn't mean asbestos bodies at all. 1 0 Q. Now, did you have an exposure 1 1 history to asbestos for this individual? 1 2 A. It was suggested that his father 1 3 had worked for Chevron for a while. 38 years. 1 4 But in the report, it doesn't say where Chevron 1 5 was or what it is. 1 6 Q. Do you believe he was exposed to 1 7 asbestos? 1 8 A. It doesn't sound very likely to me. 1 9 Q. So, it's not likely that he had an 20 exposure to asbestos, in your opinion, based upon 2 1 the records you reviewed? 22 A. Yes. 2 3 Q. Is there any treatment for a germ 2 4 cell carcinoma? 25 A. They tried chemotherapy in this A. WILLIAM ROBERTS, JR., & ASSOCIATES 222 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 case. It didn't seem to respond. 2 Q. Is that the typical treatment for a 3 germ cell carcinoma as opposed to an 4 adenocarcinoma? 5 A. Either try chemotherapy or 6 radiation. 7 Q. The treatment for a germ cell 8 cancer is no different than that for any other 9 type of cancer? 10 A. T don't think so. They do respond 33 in some cases. There didn't seem to be any 32 response there. The tumor just went on growing. 13 Q. Is this typically a fatal or most 34 likely a fatal disease in people who have it? 35 A. Usually is a fatal disease. 1 fi Q ,, Usually is? 1 7 A .. Yes . '1 8 Q., And is there a timetable between 1 9 the time o f first discovery of the tumor and 20 death? A . It is very rare . I have no 22 evidence o f 11 . 2 3 Q. You have what? 2 4 A . No evidence of it, the timetable 2 5 Q- The timetable. Is this type of A WTT.T. TAM ROBERTS. JR.. & ASSOCIATES CM 223 DR. JOHN CHRISTOPHER WAGNER - DIRECT RY MR. RRTCKMAN 5 tumor easily confused with a squamous cell 2 carcinoma or an adenocarcinoma? ;3 A. It contains bits of keratinized ~4 tissue which could he compared to the squamous 5 cell carcinoma, and possibly by itself the 6 structure of these abnormal primitive cells could 7 possibly be mistaken for adenocarcinoma. 8 Q. For what type of tumor? 9 A. Adenocarcinoma. 1 0 Q And in this individual , he.was 1 1 first diagnosed as having a squamous carcinoma, 1 2 and then later the doctors said it wa s an 1 3 adenocarcinoma, and then on autopsy, the doc tor 14 said it was a mesothelioma? 15 A . M e-s othelioma . 16 MR. GARRARD: It was also diagnosed 17 as a germ cell tumor in the records. 18 MR. BRICKMAN: Is that an 19 objection? 20 MR. GARRARD: A statement. You 21 seemed to be listing - 22 MR. BRICKMAN: I didn't know you 23 were under oath to tell the truth. 24 THE WITNESS: I did mention this. 28 MR. GARRARD: You did. I didn't A. WILLIAM ROBERTS, JR., & ASSOCIATES 224 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 want Mr. Brickman to leave that out of his list of 2 mentions in this case. ^ 3 (Whereupon, an off-the-record 4 conference transpired.) 5 BY MR. BRICKMAN.- 6 Q. Doctor, the germ cell cancer is not 7 caused by smoking then, I assume? R A . No . 9 Q So it's your opinion that smoking 1 0 played no role in this man's cancer? 1 1 A . No . 1 2 n . And a germ cell cancer, arc those 1 3 large celIs? 1 4 A . They can be large cells. 1 5 Q Were they in this case? 1 6 A . Yes, there were these large 1 7 syncytial giant cel Is. 1 8 Q What does that mean, syncytial? 1 9 A . It means that there is no sort of 20 boundary to the cells, no cell membranes. 2 1 Q What is the significance of there 2 2 being a minimal alveolar reaction? What does that 23 indicate to you , Doctor? 24 A . The reaction was in the alveolar, 25 not in the general lung tissue, not in the A. WILLIAM ROBERTS, JR., & ASSOCIATES 225 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 3 interstitial tissues. 2 Q. Now, if this was a germ cell 3 carcinoma, is that the type of -- and it was in - 4 you said the hilar region of the lungs? 5 A. In the anterior chest wall. 6 Q. Is that something that one could 7 typically easily find at autopsy and identify as 8 su ch? 9 A. No. At this stage, it was a 1 0 massive tumor. And one would have found the whole 1 1 tumor occupying the one side, the right side of 3 2 the chest, as it was in this case. It was 3 3. presenting more anteriorly than ... 3 4 Q. So it's not anything specific in 1 fi finding it grossly that you could identify it as a 3 6 germ cell carcinoma? 3 7 A . No. No . 11 was just a huge tumor 1 8 mass by the time they found it. 3 9 Q This wa s not, in your opinion, a 20 pie u r a 1 tumor of any s or t then; is that correct? 2 3 A . Tha t ' s correct . 2 2 0 And he died as a result of this 2 3 tumor? 7 4 A . Yes . 2 8 Q. Did you have sufficient tissue. A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 .< 4 5 6 7 8 9 ln l1 12 ]3 14 15 16 37 18 19 20 --2 1 -2 2 23 24 26 226 DR. JOHN CHRIST O.P HER WAGNER - DIRECT BY MR. BRICKMAN Doctor, in this case for your opinion? I mean, you don't have any problem with the amount of tissu e you had? There was a sufficient amount? A . Yes n . Have you talked to Dr. J a s a n i about this case? A . No . o Is there anything else of any significanc e in the Warrick case that is not con tained i n your medical report. Doctor? MR . GARRARD: And that you have not ta1ked about? MR . BRICKMAN: I'm trying to think what else we talked about. THE WITNESS: This is my opinion. BY MR . BRICKMAN: q . You did not rely on the stains in this case; is that correct? ' A . No . Q In fact, you did not even sec f stains in this case; is that correct? MR . GARRARD: Wait a minute. He did not rely on the CEA stain, but he has told you he did rely on the results from the HCG. THE WITNESS: Subsequent to my * A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 .3 4 5 6 7 8 9 I0 13 12 13 34 38 36 37 38 39 20 3 -2 2 23 24 25 227 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN coming down. This was afterwards. BY MR. BRICKMAN: r Q You relied on the HCG for what. Doctor? A . For the evidence of this being a germ cell tumor or teratoma. Q Is there a difference between the germ cell and teratoma? A . Teratoma is slightly more developed . Teratoma is a germ cell tvsmor. The primitive cell tumor is more primitive than the teratoma, Q Based on that staining you did or Dr. Gihbs did , do you now have an opinion it is a germ cell tumor rather than a teratoma? A . c o;u Id be either. o . So that stain didn't help you either? A . Could be positive for both. Q How would that stain be for an adenocarcinoma? A . Negative, as far as I know. Q How would it be for a mesothelioma? A . Negative. Q- And that stain is called a what A. WILLIAM ROBERTS, JR. & ASSOCIATES 1 2 3 4 5 6 7 8 9 30 11 12 ,3 3 34 16 36 37 18 19 20 -2 1 ^2 2 23 24 26 228 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN again? Tell it to me again. A. It's called human chorionic gonadotropin. . Q, That's an HCG stain? A. HCG stain. Q. And do you know what the margin of error is or the percentage of cases that show up false positives? A . No . Q. And you do not believe that this was a tumor that metastasized from the testicular primary, do you? A. It could, but -- it could, but there is no evidence there of histological examination of this. Possibly it could, but I don't think this is. Q. But that's now where you think it came from, from the testes? A. Probably from the anterior mediastinum. But they had examined fairly well, although not microscopically. Q. That's all I have on Mr. -Warrick. Thank you, Doctor. Let's go to the next one. (Whereupon, a recess transpired.) BY MR. BRICKMAN: A. WILLIAM ROBERTS, JR., & ASSOCIATES 229 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 Q. Doctor, did you at the request of 2 Mr. Garrard besides looking at the Harris and .3 Warrick tissue also look at the case of Horace . 4 5 6 McBryde? A. Q. Yes. Now, you apparently looked at some 7 stains of Mr. McBryde; is that correct? 8 A. That's correct. 9 Q. Was there an autopsy done on 10 Mr. McBryde? 31 A. I could find no evidence of it. 1? Q. Okay. And would you agree with me 13 that his treating physicians seemed to indicate 14 that he had a mesothelioma? 15 A . Y e s . 16 Q. Did you see the death certificate 17 of Mr. McBryde? Ifi A. Yes. 39 Q. And what did that indicate that he 20 .21 had? A. On second thought, I didn't see the 22 death certificate. I knew that he died on 233-14-1980. 24 Q. But did you not see the death 25 certificate? A. WILLIAM ROBERTS, JR., & ASSOCIATES 230 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 MR . GARRARD: Do you have a copy 2 it, Mr. Brickman? V-. 3 MR . BRICKMAN : Yes , Ido. 4 MR . GARRARD: Could I see it? 5 MR . BRICKMAN : You mean you don' 6 have it? 7 MR . GARRARD: No , I don't. 8 MR . BRICKMAN : I ' 3 1 think about 9 it. Do you have to know right now whether I'm 1 0 going to give it to you or not, or can we wait 3 1 until the end? 12 MR. GARRARD: It was the order of 1 3 the judge which you have obviously violated to 1 4 provide us with all of the records in the case 3 5 three weeks ago. 3 6 MR. BRICKMAN: Your staff obviously 3 7 must have messed up. 1 8 MR. GARRARD: You are obviously in 1 9 contempt of court. 20 MR. BRICKMAN: You mean you're not 2 1 going to turn over your doctor's reports to us? 2 2 MR. GARRARD: Already turned them 2 3 over to you. 2 4 MR. BRICKMAN: Not with this one. 2 5 What is that? A. WILLIAM ROBERTS, JR., & ASSOCIATES -3 -4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 .9 1 22 23 24 25 23 1 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN MR. GARRARD: Support notes. MR. BRICKMAN: You mean you don't have to turn those over to me? (Tendered) BY MR. BRICKMAN: Q. Doctor, let me show you the death certificate in case you haven't seen it? A. Mesothelioma. Q. Mesothelioma is listed as the cause of death? A. Yes. Q. Now, the staining that you did was apparently from a biopsy of subcutaneous nodule. What is that? A. There is a nodule growing up from the tumor. Q. Is that a good place to look at the tissue to determine what it is? A. Yes. Q. That's not a problem, the fact that you looked at it from a subcutaneous nodule as opposed to the tumor itself? A. It was done on the pleural biopsy. Q. No, if you read your report, you appear to say that you could not do histochemistry and immunohistochemistry on the pleural biopsy. A. WILLIAM ROBERTS, JR., & ASSOCIATES 23 2 DR. JOHN CHRISTOPHER WAG N F R - DIRECT BY MR. BRICKMAN 1 Do you see that? - 2 A. Yeah. Yes, I see that. =We)l, this G would he the best hit of tissue available. 4 Q.Well, I understand that. But what 5 are the problems of doing it from the tissue that fi you looked at that you wouldn't have had if you 7 had been able to do it from the pleural biopsy? 8 A. I don't think -- except we were 9 dealing with the more recent growth of this tumor. 1 0 Q So it wouldn't make any difference 11 at all, wo uld it? 3 2 A . I don't think so, no. 1 3 Q. 1 4 diastase? Now, in this case, the PAS 3 5 A . Diastase. 3 fi o . Stained negative. That indicates 3 7 more 1ike1y a mesothelioma, doesn't it? 3 8 A . It can happen in a rapidly growing 19 20 -- 21 adenocarcinoma Q That, however, militates more in favor of it being a mesothelioma than an "22 23 24 25 adenocarcinoma , doesn'tit? A . It's a neutral finding. Because we know rapidly growing adenocarcinomas quite frequently don 't have evidence of mucin secretion. A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 4 5 6 7 8 9 10 31 12 33 14 15 i6 37 38 39 20 ~ 2 3 '&> o(. 23 24 25 233 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN Q. Mesotheliomas however stain negative for PAS with diastase, correct? A. Yes. Q. And in this case, it was a negative stain? A. Yes. Q. The CEA stain in this case you reported was not strongly positive, but was moderately positive; is that correct? A. Yes, that's correct. Q. And were you able to look at this tumor from a histological point of view? A. Yes. Histological point of view. There was little tissue, and the tumor really showed features which could be of an adenocarcinoma. Q. Did it also show any features that it was a mesothelioma? A. Well, in my views, it came out more likely to be an adenocarcinoma. Q. All right, sir. A. But obviously we were differentiating on the CEA and the other stains. There wasn't a great deal of tissue to come to diagnosis on. A. WILLIAM ROBERTS, JR., & ASSOCIATES 234 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN ( 3 Q. Did you find that there were 2 atyplca] cells present? 3 A. Yes, there were. 4 Q. And -- 5 A. Undifferentiated tumor which would fi he atypical cells. 7 Q. Is that consistent with a R mesothe1ioma? 9 A. Slightly more to fit in with the 1 0 adenocarcinoma. 3 3 Q. The mesotheliomas show up typically 3 2 as cuhoidal cells? 3 3 A. Usually. Usually smaller cells. 3 4 You can get larger cell varieties of them. 3 6 Q. Did you see any cuhoidal cells in 3 6 the material you looked at? 3 7 A. Not that I recall, no. 1 8 Q. You do not report on what you saw 1 9 on the pathology labeled S 87-2779. 20 A. In two of the specimens, four small _-.2 3 -- to, oL. biopsies in two of them, there was evidence of fragments of undifferentiated tumor. 23 <1 24 Q. And what was in the other two? A. These were, as far as I know, just 25 fragments of connective tissue. % A. WILLIAM ROBERTS, JR., & ASSOCIATEKS 235 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 Q. And what did that tumor look like? 2 Did those cells have any particular appearance? 3 A. According to my notes, no. They , 4 looked like a tumor. 5 Q. Did they appear to have cuboidal 6 cells? 7 A. The cells were of variation in 8 shape and size. Some small, some large. 9 Q. I'm sorry, some smal1 , some large? 10 A. Yeah. 1 1 Q. Why do you say that? 1 2 A. As I said, the tumor was composed 1 3 of cells varying in shapes and size. 1 4 Q. No, you are looking at a different 15 one than I am. 1 fi A. No. Once again, differentiation of 1 7 the cells. All sizes and shapes. i e Q. I'm looking at the pathology marked 1 9 S 87-2779? 20 A. There was a picture of sheets of 2 1 malignant cells. No clear indication which they 2 2 were. 2 3 Q. You just recollect that, or are you 2 4 reading that in your report? 2 5 A. Minute fragments of A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 4 5 6 7 8 9 10 3X 32 13 14 15 .1 6 17 18 19 20 JZ 1 22 23 24 25 236 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN undifferentiated tumor. Q . T h'a t's what that means? A. Yes. Q. All different sizes andshapes? A. Just a massive tumor whir, h was hard to -- Q. I'm just curious. You put that, undifferentiated tximor describing the pathology S 87-2779, and you're telling me that means the tumor was composed of cells varying in shapes and sizes? A . With a lot of activity. Q Why when you were describing S 87-4107 did you use the phrase the tumor was composed of cells varying in shapes and size as opposed to undifferentiated tumor? Is there a difference? A . Not rea11y. rea 1 ly? Q Is there a difference or not A . Forming definite bacilli in the subcutaneous nodule . QS 87-2779? A. Did you see any cuboidal cells in There may have been, but I didn't A. WILLIAM ROBERTS, JR., & ASSOCIATES 2 37 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 particularly notice that there was a sheet of 2 malignant cells. _ 3 Q. You saw cuboidal cells; is that 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 *2 1 '2 2 23 24 25 MR. GARRARD: Wait a minute. He said there may have been. THE WITNESS: I didn't notice them. Some of the cells in their size differed in shapes and sizes, and some of them may have been cuboidal. BY MR. BRICKMAN: Q Do you recollect that some of them may have been cuboidal, or are you just talking off the top of your head? A . Cell o of different shapc3 and sizes. o . You recollect that? A. Q cuboidal? Yeah And they may have appeared A . They may have. The majority, there is no evidence the majority showed any particular pa 11 e rn. Q For mesotheliomas, do they all have to be cuboidal for it to be typical mesothelioma? A. WILLIAM ROBERTS, JR., & ASSOCIATES 2 3ft UR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 3 A. No, they can vary. 2 Q. And that's apparently what you saw, 3 that they varied with some o f them bef i ng cuboidal, " 4 correct? 5 A. Some o f them be i ng larger and some 6 h e i n g smaller. 7 Q Is that typical for a mesothelioma? B A . 11 could fit in for a mesothelioma, 9 but it would be more particular for an 1 0 adenocarcinoma . 1 1 Q. Even the cuboidal cells? 3 2 A. A few of the cuboidal cells vary in 3 3 size. 34 .3 5 Q. Doesn't cuboidal refer to shape? A. Yes. Can be shape or can be 3 6 e1onga t ed. 3 7 Q. Do adenocarcinomas often appear as 3 8 cuboidal cells? 3 9 A. Occasionally. Occasionally they do 20 have cuboidal cells in them. 21 Q. But more likely if it is a 2 2 cuboidal, it's a meso rather than an adeno, 2 3 speaking in general terms? 2 4 A. Massive. Sort of massi v e tumor 2 5 cells of different shapes and sizes. Some of them A. WILLIAM ROBERTS, JR. & ASSOCIATES DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN may be small and some of tliem were large. Q. Doctor, let me ask my question. Maybe we are not understanding each other. A. You're saying was this typical of a mesothelioma, I understand. Q. The fact that there were cuboidal cells, is that more typical of mesothelioma than it is of adenocarcinoma? A. If the predominant cell was cuboidal, yes. Q. Now, when you say the specimen had been crushed for the pleural biopsy, are you r e f e r rin g to the tissue in the glass? A. Where the tissue had been removed. It wasn't a clear biopsy. 0 . Oh, I see. So nobody would have been able to look at that pleural biopsy and make a determination from it? THE COURT REPORTER: Your answer? THE WITNESS: My answer is I don't think so. They may have been, but it would have been very difficult to make a diagnosis from it. BY MR. BRICKMAN: Q. Did you see where it was done in the records and that they didn't say it was A. WILLIAM ROBERTS, JR., & ASSOCIATES 240 OR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 crushed in any way? 2 A. This can happen quite of ten taking ; 3 a hiopsy. . - 4 Q. But did you see where the hospital 5 where this man was being treated had this tissue, 6 this pleural biopsy, and looked at it and didn't 7 say it was crushed? 8 A. I saw that, yes. 9 Q. So apparently it wasn't crushed at 3 0 the time they had it? 1 1 A. Well, I felt it was difficult to 1 2 make out details of it. 1 3 Q. Well, did you read the report of 1 4 the doctor that did get a chance to look at it? 15 A. Yes. 1 6 Q. If that doctor is correct, and 3 7 there were sheets and clusters of large polyhedral 3 8 cells, is that consistent with a mesothelioma? 1 9 A. Large polyhedral cells would he 2 0 more consistent with a carcinoma. It could be 2 1 either way. 22 Q. Could be either way. And the fact 2 3 that it came in sheets, would that have any 2 4 significance? 25 A. No. Undifferentiated. Once again. A. WILLIAM ROBERTS, JR., & ASSOCIATES 24 3 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 this could go either way, hut I think slightly in o favor of the adeno. 3 Q. Even the fact that it came in 4 sheets? 5 A. You can get sheets there. But the 6 fact that they are large polygonal cells. 7 Q. Polyhedral? 8 A. Was it polygonal or polyhedral. 9 Q. Polyhedral. Does that make a 1 0 difference to you, sir? 1 1 A . No . 1 2 Q. What's the difference between 3 3 polygonal and polyhedral? 14 . A. Well, I always thought polyhedral 3 5 was in three dimensions and polygonal was in two. 3 6 I may be wrong on this. 3 7 Q. Did you attempt to look at the 1 8 tissue in S 8 7 - 2 6.2 1 ? 3 9 A. Yes, I attempted to look, but I 20 couldn't see any clear differentiating site on the 2 1 tube. And I referred to the fact that it had been o C o*- crushed . 2 3 Q. Doctor, what do you believe to be 24 this gentleman's exposure history to asbestos? 2 6 A. I didn't find any -- he had been in A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 -3 4 5 6 7 e 9 10 11 12 13 14 5 .0 16 17 18 19 20 ""2 1 22 23 24 25 24 2 PR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN the Air Force and at NASA. There seems to be no clear suggestion of an exposure. Cl , ...... you. do not have any evidence of exposure? A. No . Q Did that in any way affect your opinion? A. No. No, I reviewed his; occupation in detail. I received that after the d i agnosis. Gibbs? Q Did you discuss this case with Dr. A . Yes, we discussed this case. Q . And did y'all both agree that it was an adenocarcinoma? A . Yes. Q. Do you have an opinion as to where the primary site of this tumor was? A . No. There was no clear indication where the site was. A massive tumor in the pleural cavity Q What's that? A . Except it was in the -- there was a tumor in the pleural cavity. It also -- the destruction of the tenth rib, more in favor of an adenocarcinoma A. WILLIAM ROBERTS, JR., & ASSOCIATES 243 OR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 Q. Doctor, let me go back a minute. 2 Doctor, if the cells are large and polygonal, 3 aren't those the ones that are typical for -4 5 epithelial mesotheliomas? A. Not necessarily. Because there are 6 forms of mesotheliomas which this can happen, but 7 the typical one is the smaller cuboidal cells, as e we mentioned earlier. 9 Q. Doctor, what did you believe to be 3 0 the latency in this case? 1 1 A. Let's see. July, '87 to -- July 3 2 1 R 7 to March '88. 1 3 MR. GARRARD: You mean the period 3 4 of time between diagnosis and death? 1 ft THE WITNESS: Diagnosis and death. 1 6 Was that the question? 3 7 BY MR. BRICKMAN: 3 8 Q. No, latency. What was the latency 3 9 in this case? , 20 A. Could you rephrase the question? 2 3 Q. What do you believe to be the 2 2 latency period in this case? 2 3 MR. GARRARD: He is talking time 2 4 from initial exposure to asbestos to diagnosis. 2 ft THE WITNESS: I have no evidence of A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 -3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 --2 1 -22 23 24 25 244 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN exposure to asbestos is my problem. BY MR. BRICKMAN: > Q . 0 k-a y. Doctor, would you agree with me that virtually every doctor that was examining him at the end of his life within the last year or so of his life believed he had a mesothelioma? A. Yes, I would. Q. And those doctors apparently had the benefit that you did not have, of being able t o examine the pleural biopsy; is that correct? A . Yes. They came to a conclusion on it . Q Sir? A . They came to a conclusion on it. Q. They had the benefit of being able to look at some material that you apparently could not look at? A . I didn't have all of it. Q Whatever reason, you weren't able to 1 ook at the pleural biopsy that they were able t o 1 ook at ; is that correct? MR. GARRARD: He looked at it. He couldn't make a determination. THE WITNESS: It wasn't suitable to come to a differential diagnosis or diagnoses. A. WILLIAM ROBERTS, JR., & ASSOCIATES 245 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN , 1 BY MR. BRICKMAN: 2 Q. Is there anything else o ther than . 3 what's in your report. Doctor, as to why you r. 4 believe this to be an adenocarcinoma as opposed to 5 a mesothelioma? 6 A . No . 7 MR. GARRARD: You mean inclusive of ft the things you have talked about here? 9 MR. BRICKMAN: I don't know what 3 0 else he has talked about. 1 1 MR. GARRARD: It's on the record 1 2 what he has talked about here. Your question, 3 3 Mr. Brickman? 1 4 MR. BRICKMAN: I'm asking him if 1 5 there is anything else in his report that he 3 6 relied on. 3 7 MR. GARRARD: I am going to object 3 8 to the question because the doctor has told you a 1 9 number of other things as he has testified here 2 0 that provide some of the bases for his diagnosis. 2 1 And unless you incorporate that into it, I object 2 2 to the question. 23 BY MR. BRICKMAN: 2 4 Q. Anything else, Doctor? 2 6 A. I was talking about the destruction A. WILLIAM ROBERTS, JR., & ASSOCIATES PR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN of the tenth rib. Q. Anything else? " MR. GARRARD: That's anything in addition to what you have talked about in your report. MR. BRICKMAN: That is not my question. You can have whatever question you want later but that is not my question. . MR. GARRARD: I don't think it's a proper question to have asked the doctor questions all along about this case in toto and then say, is there anything in addition to your report that supports your opinion when he has given you other things. 1 think that's an improper question. MR. BRICKMAN: That's why we are allowed to make objections, Mr. Garrard. MR. GARRARD: We are not allowed to create an incorrect record, Mr. Brickman. BY MR. BRICKMAN: Q. Go ahead, Doctor. MR. GARRARD: Don't go ahead. I am telling you not to answer that question unless Mr. Brickman wants to incorporate the report as well as other things you testified about. MR. BRICKMAN: Are you instructing A. WILLIAM ROBERTS, JR., & ASSOCIATES DR. JOHN CHRISTOPHER WAGNER DIRECT BY MR. BRICKMAN him not to answer? MR. GARRARD: Yes. ~ MR. BRICKMAN: We will obviously move to have the doctor stricken as a witness. MR. GARRARD: You can move whatever you want to. That's not a proper question. BY MR. BRICKMAN: Q. Doctor, do you intend not to answer that question? Do you intend to follow Mr. Garrard's advice and not answer the question? MR. GARRARD: Yes. THE WITNESS: Yes BY MR. BRICKMAN: Q. Is Mr. Garrard your attorney? MR. GARRARD: No. THE WITNESS: No. MR. GARRARD: Mr. Garrard does have an obligation to protect the record, however, as an officer of the court. MR. BRICKMAN: You can do that by objecting to the question, and the question and answer gets struck if you are correct. It doesn't get struck if you are wrong. But I don't believe you have any right to tell the witness not to answer a question like that. A. WILLIAM ROBERTS, JR., & ASSOCIATES DR. JOHN CHRISTOPHER WAGNER BY MR. BRICKMAN: DIRECT BY MR. BRICKMAN Q. Doctor, how many doctors ^diagnosed mesothelioma in this case? MR. GARRARD: TH-E WITNESS: If you know, Doctor. I don't know. The majority certainly did. BY MR. BRICKMAN: Q. Did any of them diagnose adenocarcinoma that you saw? A. No. Did they? Q. So the only two doctors that diagnosed adenocarcinoma in this case are you and you believe Dr. Gibbs? MR. GARRARD: I object to that because that is not correct. MR. BRICKMAN: I'm asking him. You want to testify, or you want the doctor to? MR. GARRARD: Just a moment, and I will show him where that is not a statement . MR. BRICKMAN: Apparently the doctor has not looked at the medical records carefully enough. MR. GARRARD: He has looked at the records. There are a lot of medical records. A. WILLIAM ROBERTS, JR., fit ASSOCIATES 249 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 3 This is not a memory test. We don't need to be 2 rude,Mr.Briekman. i 3 MR. BRICKMAN: Who is being rude? . ~ 4 I am trying to get the doctor's opinions, not 5 yours. 6 BY MR. BRICKMAN: 7 Q. Mr. Garrard is showing you a something? 9 MR. GARRARD: Mr. Garrard is 3 0 showing you a pathological report that is in the 1 1 record. 3 2 BY MR. BRICKMAN: 1 3 Q. Doctor when you give your opinions. 3 4 do you do it with Mr. Garrard giving you the 1 5 material and showing you what to find? 1 6 A. No. This was either an 3 7 adenocarcinoma or a mesothelioma. 3 8 MR. GARRARD: According to. 3 9 THE WITNESS: Dr. Curt Weiss, 20 WEISS. , "2 3 BY MR. BRICKMAN: '"2 2 Q. And what's the date on that report 23 that Mr. Garrard has shown you? 2 4 A . 7- 3 6-87. 25 t MR. GARRARD: It's from Saint A. WILLIAM ROBERTS, JR. & ASSOCIATES 250 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 John's Hospital, Mr. Brickman. I'll be happy to 2 show it to you. :: - 3 MR. BRICKMAN: No, that's okay, Mr. - 4 Ga r ra rd . 5 MR. GARRARD: I just didn't want 6 you to miss that one. 7 BY MR. BRICKMAN: ft Q. He said it could be either an adeno 9 or a mesothelioma. Doctor? 3 0 A. Yeah. This has been the problem 3 3 throughout this case. We felt it was the finding 3 2 of the CEA which I couldn't ignore, which is a 3 3 crucial factor. 3 4 Q. But the CEA didn't stain strongly 1 5 positive, did it? 1 6 A. It was a moderate stain. 1 7 Moderately positive. 1 ft Q . If it had been weakly positive 3 9 instead of moderately positive, would you then 20 have diagnosed this as being a mesothelioma? ^ 1 A. One was considering this all the 2 2 way through. 2 3 Q. Considering what? 24 A. Whether it was a mesothelioma. 2 5 Q. But if the CEA was only - A. WILLIAM ROBERTS, JR., & ASSOCIATES 251 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 A. I think the CEA was the factor o which moved -- put him towards the adenocarcinoma. 3 Q. If the CEA had only stained weakly 4 positive Instead of moderately positive, would you 5 then have been of the opinion that it was a 6 mesothelioma and not an adenocarcinoma? 7 A. If it had been negatively staining, 8 yes . 9 Q . How about if it had been weakly 1 0 stained? 1 1 A. It would be very hard to make an 1 2 opinion. 1 3 Q. You wouldn't have been able to say 1 4 one way or the other? 1 5 A . No . 1 6 Q. That is correct, you mean? 1 7 A. We found it very difficult. The 3 6 thing that's obviously going between the 1 9 mesothelioma and the adenocarcinoma, this was the 20 one factor which seemed to influence the others, 2 1 the other diagnoses. 22 Q. Do you in any way rely upon the 2 3 document that Mr. Garrard showed you by Dr. Weiss 2 4 to support your opinion that it is an 2 5 adenocarcinoma? A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 "3 "r 4 5 6 7 8 9 10 11 32 13 14 1 ft 16 37 38 39 20 21 22 23 24 25 252 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN A. I think everyone was obviously trying to decide on this, on either an adeno or mesothelioma, according to the tissue they had. Q. Would you agree with me that everybody in their final analysis came down to the opinion of mesothelioma except for you and Dr. Gihbs? A. Yes . Q. Yes? MR. GARRARD: That ' s not what that record says he just looked at MR. BRICKMAN. I'm asking him whether he thinks that's the case or not. MR. GARRARD: Let's don't miss ta t e the record. THE WITNESS: One chap trying to make up his mind, too. I think the decision as far as I was concerned was on the cytochemistry. BY MR . BRICKMAN: Q. Yes, sir. But what I'm asking you Doctor , is every other doctor in the record that looked at the material in deciding whether it was an adeno or mesothelioma came down with the opinion It was a mesothelioma , correct? MR. GARRARD: 1 object to the form A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 '4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 253 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRTOKMAN of the question because you have just been shown a pathology report where a doctor said either/or. And to say now, with that In the record, that every other doctor has said this is just not a correct statement of the record. That's just not correct, Michael. You don't do things like that. You're too good a lawyer to do things like that. BY MR. BRICKMAN: Q. Is what I said correct. Doctor, or is what Mr. Garrard said correct? A. I think you've got the one chap who hasn't made up his mind entire1y. Q. Did you rely upon that report at all? A. I saw the report after I made my statement . Q. Do you think that doctor's report supports you in some way. Doctor? A. I think he shows the dilemma I was in about this case. Q. The fact that the tumor was crushed in the pleural biopsy, I can understand how that would affect the histological examination, but how does that affect the use of stainings. Doctor, immunohistochemica1 stainings? A. WILLIAM ROBERTS, JR., & ASSOCIATES 2 54 PR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 3 A. I really don't know. It 2 shouldn't. The small amounts of tissue--- 3 Q. But it shouldn't affect the ability ` 4 to do immunohistochemieal stainings? 5 A. The tissue -- it would be hard to fi see where the actual -- if you're working on the 7 fact that the CEA gives the staining around the 8 edge of the cells, around the margins, it would 9 affect that. I don't think it would affect the 10 PAS. 11 (Whereupon, an off-the-record 12 conference transpired. ) . 13 BY MR. BRICKMAN: 14 Q. Did I ask you, Doctor, what the 15 timetable was between the period of onset of 16 discovery of disease and death in this case? 17 MR. GARRARD: He told you. You 18 didn't ask him. 19 BY MR. BRICKMAN: 20 Q. Would you tell me again? 21 A. On my notes, he was in the Air 22 Force and there was no -- 23 MR. GARRARD: He is asking you time 24 between diagnosis and when he died. 25 THE WITNESS: Yes. A. WILLIAM ROBERTS, JR., & ASSOCIATES 265 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 MR. GARRARD: You told him that 2 once before, but he didn't hear you. So tell him 3 once again. . 4 THE WITNESS: Between July *87 and 5 March '88. 6 BY MR. BRICKMAN: ` 7 Q. Is that a typical time period for a 8 mesothelioma? 9 A. They can be -- that's, what, l 1 0 March? Five months which would be a short time. 1 3 Q. But typically mesotheliomas have a 1 2 shorter period of time between discovery and death 1 3 than adenocarcinomas? 1 4 A. Yes. The whole thing is a very 1 5 short time for a tumor. 1 6 Q. Assuming, Doctor -- all these cases 1 7 are blurring together, and I apologize. You said 1 8 you did not have any exposure history on 19 Mr. McBryde? 2 0 A. Yes. 2 1 (Whereupon, an off-the-record 2 2 c o n f e r e n.c e transpired.) 23 BY MR. BRICKMAN: 2 4 Q. Doctor, the materials you have 2 5 gotten in these three cases and the other six A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 4 5 6 7 8 9 10 11 32 13 14 15 16 17 18 39 20 ^2 3 ' 22 23 24 26 256 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN cases, when did you first begin work on these cases? - A. It was last month. Q. Last month? About 30 days ago, approximately? A. About 30 days ago. Q. And in that time frame, you gave me a number earlier of having spent over 24 hours. but was that over 24 hours on the three cases or on all nine cases? A. All nine cases. Q. All nine cases. So on the average, you only spend about three hours per case, give or take something? MR . GARRARD: I ' m not trying to put words In his mouth , but that wouldn't be correct. because he didn't have full medical records in all the other oases to review. MR . BRICKMAN : But on the average. he would spend about three hours per case. MR . GARRARD: The average would be -- MR . BRICKMAN : He might have spent all 20 on this one MR . GARRARD: But the average A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 ~4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 ~2 1 22 23 24 25 257 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN wouldn't be an accurate statement with regard -- MR. BRICKMAN: It would be an average statement. It may not give an accurate time on what he spent on these cases. MR. GARRARD: That's what we are after. We don't want misleading averages. BY MR . BRICKMAN: Q . Go ahead, Doctor. A . I'm trying to think when I went up t o see the first one. MR. GARRARD: About a month ago. RY MR . BRICKMAN: Q . But you still think you only spent, you said in excess of 24 hours, but you don 't know how much in excess? You spent less than 50 hours on these cases, haven't you, on these nine cases? MR. GARRARD: Before today? BY MR . BRICKMAN: Q . Before today. A . It must be somewhere in the region o f more than 50 hours, traveling up and d own. Q . Do you think it's as much as 100 hours for the nine cases? A . No . Q . Somewhere around 50? * A. WILLIAM ROBERTS, JR., & ASSOCIATES 258 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN 1 A. 50, 60. 2 Q. 50, 60 hours, not including today? 3 A . No . ' 4 (Whereupon, an off-the-record 5 conference transpired.) 6 BY MR. BRICKMAN: 7 Q. Doctor, do you plan on coming to 8 wonderful Beaumont, Texas, next month? 0 A. T would rather not be. 1 0 Q. Do you have it presently calendered 1 1 in? 1 2 A . No . 1 3 Q. If. Mr. Garrard asks you to come to 1 4 Beaumont, Texas, will you show up next month? 1 5 A. If Mr. Garrard aeke me. 1 6 Q. If he asks you, will you show up 3 7 next month? 1 8 A. Yes. 1 9 (Whereupon, an off-the-record 20 conference transpired.) 2 1 BY MR. BRICKMAN: 22 Q. Are you scheduled to be anywhere in 23 the month of June other than perhaps Beaumont? 2 4 A. Not June. 25 Q. So June you have free? A. WILLIAM ROBERTS, JR., & ASSOCIATES 1 2 3 *' 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 -2 1 22 23 24 25 259 DR. JOHN CHRISTOPHER WAGNER - DIRECT BY MR. BRICKMAN A. June I'm going to Washington and see my daughters in San Francisco. Q. Well, when you're over in the States, then, you can be testifying in Beaumont. I just want to know. Mr. Garrard played a mean trick on me last time. He had me depose a Dr. Murray and made me come all the way to Beaumont, Texas and never put Dr. Murray up. Mean trick Henry played. The only comfort I have is that it cost Henry a lot of money to bring the guy over. That's all I have. Doctor. Thank you very much for your time. I appreciate it. It was nice seeing you again, sir. And tell your wife I'm sorry you had to stay in here so long. (Whereupon, the deposition was concluded at 5:40 PM.) .A. WILLIAM ROBERTS, JR., & ASSOCIATES 260 1 SIGNATURE OF DEPONENT 2 3 I, the undersigned, J. Christopher 4 Wagner, do hereby certify that I have read the 5 foregoing deposition and find it to be a true and 6 accurate transcription of my testimony, with the 7 following corrections, if any: 8 9 PAGF. LINE CHANGE REASON 10 11 12 ]3 14 15 16 17 18 19 20 21 22 23 J. Christoper Wagner Date 24 25 A. WILLIAM ROBERTS, JR., & ASSOCIATES t ^ - r 4 261 1 CERTIFICATE 2 -3 -4 5 6 7 8 9 10 11 12 33 14 15 16 17 18 19 20 - 21 22 23 24 25 I, A. William Roberts, Jr., Registered Professional Reporter and Notary Public for the State of South Carolina at Large, do hereby certify: That the foregoing deposition was taken before me on the date and at the time and location stated on page 1 of this transcript; that the witness was duly sworn to testify to the truth. the whole truth, and nothing but the truth; that the testimony of the witness and all objections made at the time of the examination were recorded stenographically by me and were thereafter transcribed by computer-aided transcription; that the foregoing deposition as typed is a true. accurate, and complete record of the testimony of the witness and of all objections made at the time of the examination. I further certify that I am neither related to nor counsel for any party to the cause pending or interested in the events thereof. A. WILLIAM ROBERTS, JR., & ASSOCIATES f ^ i * 262 , 2 ,3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 -2 1 - 22 23 24 25 Witness my hand, I have hereunto affixed my official seal this 5th day of June, 1990 at Charleston, Charleston County, South Carolina. A. William Roberts, Jr. Registered Professional Reporter, CP, CM My Commission expires May 20, 1991 A. WILLIAM ROBERTS, JR., & ASSSSOOCCIIAATTEESS L/ (P Name. MED I CD-LEGAL. `CASE,. TEXAS SERIES. f *n U.S.A.Hospita1/Path No. OZl-ly-fo Llcindouqb No. Slides Received, Jl? 7^ / a' 7 <7 -jP^Tiy'^T ^ 5 -`/> ^ Blocks Rece i ved . la.t-* ^ /Vlt-W.y 'L^ /i_ Js, ^,7 3i/il.t / rzW /f7' Recu ts , H<a/tI. P:{ - h i Lc?wO C-uP-^ r^-e-v.i / ?/? c< }'P<t' tykh ^ Histo/ 1 mmunocy tochei/istry . Lv( r'i-J^ ^ e^1'^ ^ ^ ` J , / zr^' -yrf_ <;_,y /,,..ri.t <--( dA l. I / .,,<;/m t^ fc.*, , v i--v-^y it's;-,, /4~ Cm<L i'ft- Mineral Analysis^ 7 /^/t^c-,7 t^>lP C<>Pl ' *- 1 7/ci '^~P,l/cyl *' J ' ^<^-Jt.L^ \,- (VlPl Other blocks or slides sent elsewhere. (i~k fc. hd' jytA^ ' I lb J t'L^i^vs 'J Cc^-c-^- iS<:(l pu*~-( ^Jf<l '- o&sU' s; ( ' T f'<i> :j Cy^A ^ 7^ /)--' ) 7 7`1 i foft> Exhibit IP' Date _>/}<)/1,> A.W.R Assoc. " I1\ <u i - fibrosis asbestos bodies other features Tumour type , LLANDOUGH NO. r*r) 1 1 ,T j lr-^ UL^i ft J~! r>-^yit-' Diagnosis: Is there an asbestos related disease? Other tissues 1 * Name . Slides Received. 4 U.S.A.Hospita1/Path No. cy"7' / Vi'J, Llandough No. <:/- $y ~ /ns Blocks Received. I 4C>-csic CY- fry-^/sT/i Hi5to/ Immunocy tochBdiistry . Hinera 1 An a 1 y c `S . 01 her block >*. oi* si 1 ries sen t e ! sewnere . t AODRESS Lung - fihrns ls asbestos bodies other features Tumour type P 1 <?u r a Hi storhpin t stry Immu n o his t rac hemis t r y D i agnost s: t i AM DOUGH Nf). Is there an nop<;tn related disease7 Other tissues (>7 yv Name . MEDICO-LEGAL CASE. TEXAS SERIES. rn\ / y U.S.A.Hospita1/Path No. Llandough No. e't,3>|5,`) ^I 7 Slides Received. $.7. 9^- *- /w Blocks Received. , 87- >ii xs' 7- ^ "7/1 Histo/Immunocy tochemistry. Mineral Analysis. Other blocks or slides sent elsewhere. 1 NHrifc ADDRESS Lung - fibrosi! asbestos bodies other featu res LHD.MU y / - ||'i o LLANDQUGH NO. Tumour type P1eura l ir"' j,K-n ,A~L y ^ ,.|'Krvn J"ivW H------ f>--^ '>X<->A_4 ^>rft >- rX Histochemistry f'ls-r - t+t Immunohis tochemis try Diagnosis: C /> ' *" jji-t--, _^w'c /^U^, . CK - <r *" f)cL> Is there an asbestos rel ated disease' Other tissues St4- _ v' y v' '> l d I rY 4 l .0' Uv>- . ---------C, Name. TEXAS SERIES. t^ U.S.A.Hospital/Path No. 4 Llandough No. cm- 8i S fe-7 - * oa. Slides Received. i (*U~` Ob%7- fro/ &"7 - <>2 *-i , ci * i-3 Blocks Received. ' .Hn-iox. Hls to/Immunocytochemistry . Mineral Analysis. Other blocks or slides sent elsewhere. NAME ADDRESS 0- a Lurig -- f ibroci: asbestos bodies other features LAB.NO LLANDOUGH NQ. Tumour type P1eura bl'1* c Histochemistry ^ Immunohistochemistry Diagnosis: r'/ Ur~ J < X.'V^' --p Is there an asbestos related disease? Other tissues INFORMATION REQUIRED Name B\\ly \\<xrns (by <i4jy 3^n4Wi-f Address Mc>4 lAb S-f.^ t^ediertancf, ~T/\ Date of Birth ^bj\\J\Q Occupation (boQicb ^ &Ce4f i nSfCjcAtC To what materials exposed including non-asbestos materials. f'B-f-S-peci Cic, Date of first exposure MM Duration of exposure y/S. Intensity of exposure U n KVlduJiA Date of last exposure lAias. Ki/plcu/a I Date of present illness and clinical diagnose* )j CXl/fOpSy^ -mo^aW4--fo be ar\ Alive or d__e_a__d ,,(d__a__te_ of -d-e---a---t-h--j-U---D---c---c--.--'---&--.-S---'--u^%~ ^, 1 `^xb^QC, XL_CCi 1.6.fVW-_T before cIq^+Il Any other non-asbestos related conditions C-OpX> S)f)C. 19 ' Kidl'Ctf -fon&' Smoking history >3 fAcX} <CS . J al0 ci\eu)<Z^l "^ODaCOS If dead - cause of death according to the - CdndbopulOlOnarv/ firfesf deatli certificate '} Radiological findings Fibrosis Plaques __________________ xmour -pi&ural e(rhjSiO>im> Lung function tests (One representative result) /W - \}c - 39^o fNJC-^,Vo 1 * .POSTMOK i iLil HiAAiriJLiXAi iOiN XVJirum S.M. Le BER, M.D. Pathologist 5840 Monroe Street Groves. Texas 77619 NAME: HARRIS, Billy AGE: 67 SEX: M. RACE: Caucasia DATE AND TIME OF DEATH: 10-26-87 - 0455 AUTOPSY NO. MEA-87-119 PLACE OF DEATH: Residence - 1404 12th Street, RederLand, Texas DATE AND TIME OF AUTOPSY: 10-26-87 - 1300 PLACE OF AUTOPSY: Nederland Memorial Funeral Home, Nederland, Texas AUTHORIZATION FOR AUTOPSY: Betty Harris (Wife) PROSECTOR: S.M. Le Ber, M.D. ANATOMIC DIAGNOSIS IMMEDIATE CAUSE OF DEATH: PLEURAL MESOTHELIOMA - RIGHT LUNG MANNER OF DEATH: NATURAL CAUSES MECHANISM OF DEATH: RJIMONARY INSUFFICIENCY ADDITIONAL DIAGNOSES: SECONDARY MESOTHELIOMA IN REGIONAL LYMPH NODES PULMONARY EMPHYSEMA OF RIGHT & LEFT LUNGS INTERSTITIAL FIBROSIS OF RIGHT & LEFT LUNGS ASBESTOSIS ADHESIVE PERICARDIUM SML:ms 0000! Page 2 MEA-87-119 HARRIS, Billy , PRELIMINARY NOTE: The following has been excerpted from notes from the Texas Lung Institute at which Mr Harris was examined on 9-15-87. He apparently worked for Arco, In the Safety Department from 1969 - 1979- During that period he was apparently exposed to asbestos. In late August or early September, 1987 Mr Harris was diagnosed at having a malignancy in his right lung. A needle biopsy was diagnosed as adenocarcinoma. Since that time he apparently had received a number of radiation therapy treatments to the right side of his chest. He died at his son's home in Nederland on 10-26-87. Permission for autopsy was granted by Mrs Harris, wife of the deceased. Postmortem examination was done at Nederland Memorial Funeral Home in Nederland on IO-26-87 at 1300. EXTERNAL EXAMINATION: The deceased was an adult Caucasian male 67 inches in length, and weighing an estimated 170 pounds. He was moderately well developed and well nourished. He had gray-white hair'and blue eyes. There were ink mark lines In the form of a rectangle over the right anterior chest such as are placed as aiming point for radiotherapy. No other significant external findings were noted. INTERNAL EXAMINATION: The body was opened through a high-Y incision, the incision being exteneded to the superior border of the symphysis pubis. The skin flaps were reflected and the sternum was removed in the usual manner. There was no free fluid in the peritoneal cavity, and the organs were in their normal position. The right pleural space was entirely obliterated by dense fibrous tissue which required mostly sharp dissection to free it. Between this thickened tissue and the underlying lung tissue there were pockets containing coffee-colored fluid together with necrotic lung tissue. The left lung was enlarged and there was a slight shift of the mediastinum to the right. There were no adhesions on the left side of the chest. The organs were removed en-bloc from the larynx to the anus for definitive dissection, CARDIOVASCULAR SYSTEM: The heart was covered by an adhesive pericardium requiring sharp dissection for its removal. The heart was normal in size and shape. The coronary arteries were patent, large, and demonstrated no significant atherosclerosis. The myocardium showed no evidence of recent or previous myocardial infarcts. The aorta showed moderate degrees of atheroma, present mainly in the abdominal portion. LUNGS: The tracheobronchial tree contained small amounts of mucus, clear in appearance. Dissection of the bronchial tree revealed no gross evidence of primary neoplasm. The right lung was markedly contracted and was moderately atelectatic. The pleura was densely attached and thickened to an average thickness of one-half to one centimeter. It engulfed the entire lung, and was more dense in the medial aspect. It- was yellowish-white in appearance, and portions in the area of the posterior mediastinum, the appearance was that of solid, yellowish-white tumor. The cut surface of the right lung showed atelectasis, hyperemia and edema. The cut surfaces of the left lung were moderately hyperemic and markedly edematous. No gross evidence of tumor was seen in the left lung. LIVER: The liver was normal in size and shape. It was moderately hyperemic. The gallbladder contained normal bile. No stones were present. No lesions were present. PANCREAS: The pancreas was normal In size and shape, and demonstrated a normal, creamy-tan lobular architecture. 0000.2 SPIEEN: The spleen was nomax xn sue. consistency. c --------. . ADRENALS: Both adrenal glands were essentially normal. There was alight postmortem autolysis. KIDNEYS: Both kidneys were normal in size and shape. The capsules stripped with ease to reveal smooth cortex. The cut surfaces demonstrated normal cortico-medullary markings. There was a slight Increase in peripelvic fat. The ureters were noma;. The urinary bladder was normal. The prostate was not palpably enlarged. GASTROINTESTINAL SYSTEM: The esophagus was normal and was empty. The stomach contained approximately a cup Of gray, soupy fluid. The mucosa was intact. The small and large intestines were normal, and contained normal fecal material. The appendix was present. CENTRAL NERVOUS SYSTEM: No examination of the cranial contents was conducted. T ill'll! >1*9 COOO^-' / Page 4 MEA-87-119 HARRIS, Billy MICROSCOPIC: TUMOR: Sections demonstrate many pleomorphic malignant cells with large vesicular ,nuclei and prominent nucleoli, irregularly combined with dense fibrous tissue ''-which was taken from the pleura of the right lung. The tumor cells are arranged In columns, cords and nests of pleomorphic cells which show no evidence of aorganold pattern. The tumor cells are locally infiltrating adjacent lung tissue, and are present In adjacent mediastinal lymph nodes. Special stains show the tumor to be PAS positive, but show no evidence of mucin production. The gross and microscopic findings show that the tumor is a Malignant Mesothelioma. LUNGS: Both right and left lungs demonstrate patchy areas of interstitial fibrosis with focal emphysema and fairly diffuse pulmonary edema. There is no evidence of pneumonia or tumor in the left lung. Iron stains demonstrate the presence of grouped ferruginous material consisting of beaded bodies consistent with fragmenting asbestos bodies. LIVER: Sections demonstrate acute hyperemia. PANCREAS: Sections are histologically normal. SPLEEN; Sections show no histologic abnormalities. SUMMARY: The deceased was a 67-year-old man who had apparently been exposed to asbestos inhalation in the past. He developed a malignant mesothelioma Involving the entire pleura of the right lung. Both lungs demostrated emphysema and inter stitial fibrosis, and the presence of asbestos material. The tumor had apparently been treated by external radiation to the chest, and there was moderate necrosis of peripheral tissue of the right lung and areas of loculated fluid. The Immediate cause of death was Pleural Mesothelioma of Right Lung. The manner of death la deemed to be natural causes. The mechanslm of death was due to pulmonary insufficiency and terminal pulmonary edema. KXXXXXXX-XXXKXX XXX* UK X X K X XXX ooon-i * WEST CARDIFF AREA LABORATORY HISTOLOGY 6193 f*TIDtr lUKHUal i>Kcl Util'll h/AG&tS COACMAMti IM run ('St.T) ACC ID U*1T Mi. none *nfm in ruu. HOSPITAL AMO MlAMD lUTVJtf DM <3=iS. CONICAL HISTORY -- 87 -- frf /? C. mvjicun u umcg> AATC AMO TtttC CBLUTTCO REPORT -- Doctor'j Signature e ^ ^"HAFR r S. CBILLY STEPHEN -r-V-ii'iH .: 0 ; b T 8 .T1' o 5 - n - 7 9 p y.i i a r:L:. V*r?^7" '* * 0 R , GI R a R D fv . ' O T59^-0*3O-5A1V6?A -> A ',v.;-;:*:' v-Vi--3 2 8. ::r.]\ " y CASE NOy'inj~ SURGEON . V PATIENT NAME 'rffarjnuA7," PERTINENT CUNICAL INFORMATION: 1 J^f PRE-OPERATIVE DIAGNOSIS:"'" Y^) jSMISM. iS%.. .DATE ':''% - ^ ^jrr-r^:. - - .^: Stk.1 206*4 Rev. 8/11/82 The University of Tevas Health Canter at Tyler, Department of Pathology. P,0. Bo* 2003, Tyler, Texas 75710 P -j A 5 9 - 0 3 ~ $ 1 6 ? ?; -i y.r,.br;i3 2 8 E -i**a5nj *T#2;3BdX ^'2 2 0 ' BZ A VALLA "AMJLELINA "557 59 80 V-i ^08-04-87 ^ OCOJ^^t' ACI rsfe*.? : -. -..-_. vj*~;\; \ DEPARTMENT OF PATHOLOGY "-' ' A:i';..*.,-attSal*-T*' r-iivirii,.CSsivs i-i-' O'.- ' -i ~ -: PATIENT NAME rn^"''>;-"'''' " I'-T ';: * - -u.-. - -V '- AGE_ --- - .;- . PERTINENT CUNICAL INFORMATION: _S^J/?/. 4^ff~U.Jrt- . - ^*-rf A.is<-U: PRE-OPERATIVE DIAGNOSIS:. ACCESSION NO..-stSb^; 8 r7-%DZl ;;j*s NICROSCOP | C EX An I NATION; .-*?&The -.pleuraljib iopsy'Tfi's/comprised a f .,'s k e 1 e t al^mus*cle^fascicles _ ;5 f ibroconnective 'tissue_and Ja tag "of 'pleura. ^Jjemorrhage^is -also 'present ." ""'-I t :lri_Wi th'i'n^h~areasV [hemorrhage -'tha t apprbximatelyVS /small Telus tens ' %%Qf >;mal i gnantfeel 1 s can^be /identified .siA .Vinglevciustergof-rma'l ignant,^^ - cells is present within the pleura. -i-The malignant_cells 'themselves have : large, * pleomorphic i ''eccentric 'nuclei and abundant ("`occasional ly L-j^^r.'ry^ a-vt* COMMENT: /EA ;'ma 1 ignant_jmesothe 1 ioma canlnot be excludejiifrom^thijp 3|3*K5efr2 /'^differential..diagnosis [if thereare no other intraparench ymslp u 1 mo nary _ . ruvsn'.T: .,5^(1.'. F.*; Fagan'* M.D. */?.- i3b-izS^r Date ' -'' Asst."Chairman>' Dept.".'of Pathology MFF/jh S|J 2D*4 Rev. 8/li/82 The University of Texas Health Center at Tyler, Department of Pathology, P.O. Box 2003, Tyler, Texes 75710- - 02 Name. Kl'^V/>r V *"C u. SA-Hospita1/Path No C*. 4*csC**j Llandough No. SI ides Received. IX &Ucv-* Blocks Received. $1- ^on y h S f7 - }??<? <287 CS7 c7 ' VH < if v3 y 2~ // kl*v(u Utol i-S Zl-Tnyi x V- tl - 3^'/ */ i^r- /f?y. y/ H is to/Immunocytochemistry. gy-r<-i *1 S ts~ - /<? 1 ) S *7 -2ta/ 11 / S *7 -39JJ < y Mineral Analysis. fj,r ?.mVK_ rr-c-^'-'TO. Other blocks or slides sent elsewhere. 1 ~--(d^diT\ Exhibit IT. 3- I Date SLU/^i. I A.W.R. <?i Assoc. 1 ADDRESS ^Ic, LLANDOUGH NO. Lung - fibrosis asbestos bodies other features Tumour type ^"7-2777 Q *) h.~k^A <>> t --tv Pleura Histochemistry $7-4io7 P.h,-*? Immunohistochemistry vi' ^`"7 c tK rrr 1 f-r Diagnosis: ^ u-^J'To /'U.-- K:0 S ^ >'*7" S' .tv--* /itl m T T+- l&'tX T jr0-"--'i i) -U_L _ t6- V7 Is there an asbestos related disease? ,s 7 - I - ^ - ----- J \ w r"*-'7 Other tissues ^ - L, i Cl (Ih. fv. cU-H_ .-Iv'' " --U~ `l /),yTui-t<-L ll-Vr-t- 7 7 C`-iLy t '| tr ^ j ^ U.^KJ-v~L 7 " >` /tv-Jr / / /j-t- - *--.7' ) i > >-<- .v. 4.- J^T-tv. J Ki.uk.. ^ 'V~L 'n - ' 6x-u />u-'-L~ <ric-'5t'i " f tl it--l " 3' u-'^v i )(Cv" -V ^. <*.i- >u>i -- o<^y -^ ^ ao t i^..-n.- ` tU t>-> itliologr No. C-bfl-5ol itlMt: MCBRIDE, HORACE Ium: itfcnlwftc Magnosls: Hospital ho. 1 b5154- 15t. Room No. 419 Date 3-',,-ot> Age 59 Sex H inctor h. RODELKS ............... rTOU^F PERITONEAL RUID: ATYPICAL CELLS DEMONSTRATED CONSISTENT KITH MALIGNANT ------------------------------------------------------MESOTHELIOMA4SNOMED T-EX93Q Jlr9050/Uj.................. ................. ytologic sneers and cell block preparations denonstrate clusters and Individual atypical cell ied1un to large size having eosinophilic cytoplasm. There Is nuclear enlargement with regularity of nuclear newbrane and clumping of chromatin material including occasional ironinent nucleoli. The atypical callularlty Is consistent with nalignant nesothelloea. I0:ch 34T: 3-ll-8e Ivet Diaz, M.D. Pathologist Pathology No. S-B3-561 11406 10 ST. JOHN HOSPITAL OF NASSAU NAY SURGICAL PATHOLOGY CONSULTATION ethology No. C-87-1B48 NtlMt: MCBRYOE, HORACE ItWI PLEURAL FLUID atholoflc Diagnosis: Hospital Ho. 155154-123 Rooa No. 41D Date U-17-B7 Age 56 Sex M Doctor P.OOGERS PREOPERATIVL DIAGNOSIS: MESOTHELIOMA. LEURAL FLUID: NEGATIVE FOR MALIGNANT CaLS (SNOMED T-2Y600 M-00120). lD:ur ICJPSCOPIC: ie specimen receivec for cytologic evaluation is one cc. Amber clear fluid. Cylcspin operations demonstrate scanty cellular material. There is a saw11 population of large cells ' ivlng abundant vacuolated cytoplasm and large lobulated nuclei undergoing degeneration. Thes. irge cells are most likely phagocytic histiocytes. There Is no evidence of 1r<flaanatory or loplastlc cellular component. :br I: 11/16/b/ Iver Diaz, M.D. Patnologist n*n* 9 SURGICAL PATHOLOGY CONSULTATION y. C-87-lin ARYDE, HORACE jtc Magnesia: Hospital No.155164-065 Rocs No.416 A0 68 Sax M Oate 9/24/(5? Doctor R.r.oLSL>\5 JRAL-PLUIC-CYTOLOGY: NO NALIGNANT-CELLS IDENTIFIED (SNOWED T-iYuCL, W-UU1201 KW:jdc ascopic: ini col aou staineu cytocentrifuge preparations of pleural fluid sf.ov. a aouerate amouii ular material. Tnis consists mostly of blood eleaets. Also setii are scw. macrour. cells present are poorly preserved. No malignant cells can be identified on the >arations. Jdc : S-25-87 /-'/ \ , Kurt'Neiss, H. D. Pathologist iw r Hology No. C-e7-1527 06 8 c-b7-iO^ /fcRYDC,HCKAi-c / rK, Diagnosis: Hospital Ho.iu;>i->i-uu'/ too* Wo.-t-o A^e U. Sex l- Date //-!., j/ Doctor : . iv;.u j[Ji,L FUHu CYlui.k/CY; iii^r.LY Se'Si*.. iOLs rOi- < 1A1_I/!<t -UCL- ,_Y-c;< , >.c RQSCOPIL: dnl CC I dw* Still ^ ,,i -i. .1 i t> |ii ^ flfcli.. fcj! U ! 4 ! 1 jt ---- * -- *- - - t V i ! I" ' - - il '- I . I present, numerous clusters ot atypical cells characterizeu jj a jr. .lucita.' cytupls io, by an irregular cnromattr. structure ana by presence oi multiple r.uclcoll or cnroi laeiisitior.s. Many ot these are somewhat degenerated, iua`.ir.j class'ft cat: on cifficult Is are nicely suspicious tor raul celts ar.u suj^eats *ii-. prest/tcc 01 ci Liter On tnocarclncwr.a or a s,esi)tntl ioma. / / >> Hurt 'r.r'-St . L. :joc ' T: iLholo^y no. o.cntoi 7 / / ST. JOHN HOSPITAL Of kASSAU BAY SURGICAL PATHOLOGY CONSUlTATIOW *. S-67-41Q7 yit; MCilRYDE, HORACE lswo: ftoliyfc tlagwls: > Hospital No. 155164-123 Room No. 419 Date 11/2//c7 Age 58 (DOD) Sax H Doctor NATilAi.S'jN/iibuscRi, MOOOUM REPORT CUTANEOUS NODULE ROM CHEST NALL: METASTATIC MESOTHELIOMA (SNOMEO T-Y2130 M-9050/6) ;EIGK ROOT FROM RIGHT SHOULDERS -REMOVAL OF POP.T-CAIHETER------------------- ----- ID:ch ,, )SS: :cnneii A is labeled biopsy from chest Mil for frozen section. It is comprises of ar. ellipse skin. 2.5 x 1.5 x 0.3 ca. Also received In the same container is a poorly circuizscrioea lid nodule, 1 an. In diaaeter. Its cut surface Is firm, pale gray anu solio. Representative .tlons are taken for frozen section. 1ZEN SECTION DIAGNOSIS: METASTATIC MESOTHELIOMA. ; skin surface is light brown and saooth. On cut section. It is grayish-white and -e*arkable. The specimen Is submitted in toto in cassettes A through 0. DK:sb * ;cimen b is labeled port A catheter, removed from right shoulder. The specimen consists of a tal oevlce atcacnea to a catheter. Tne catlieter is in plastic, measuring 31 cm. in it,igt!i ana 5 cm. in diameter. The catheter is soft, transparent, but having a white line all along the igth of the catheter. The line measures 0.2 cm. In width. There are ten; small holes located one end of the catheter on 6.5 cm. length. These holes are seen at 0.5 cm. apart ano appeal one line. The tip of the catheter measures 0.4 cm. in diameter. Two portions of Oacron-iiM. Lerial wrapped around the catheter are seen in two locations, one at 15 qm. from the tip ano i seconu is at 25 cm. from the tip. The other end of the catheter is attached to a metal vice. The metal device is In conic form. The top measures 2 cm. in oiameter, snowing a nm metal, measuring 0.4 cm. in tnicxness and plastic material in the center which (measures 1.2 . In aianeter. The base of the cone is a square metal plate, measuring 2.4 x 2.4 cm. There 3 four aii.cl! roles at sacli angle of the plate from where sofus sutures are see-'. Thi catheter attached to the device through a metal projection which measures 1 cir.. in length anu o.e cr. 6iur. Inert is no d'ioog clot seen in tnc catheter luuen. (Gross uescriptiyn or-'ivj. :sb IROSCOPIC: `, Tranent sections conf'fnn the aoove frozen section diagnosis. The tumor Is ctApostn of ;1! flneo tubular structures enueddeu in fiorotic stroma. The tumor cells are polygonal ano nave larged pleoaorpnic nuclei Having prominent nucleoli. Few mitoses are noted. Tne suwCucuntsus auie extends into the dermis ot overlying skin. :cn T: ,12/1/6/ thology No. 6 s-a/-^i07 l*er Dia7, Pathologist 6 7 m No. $-87-3551 it: MCMTOC. HORACE m: PHAGAL BIOPSY /elofhi tlagnosls: Hospital Mo. 155154-iZj Rook No. 415 Age 68 Sex H Date li-13-c> Hector MCKIKhEY 0PHA6EAL BIOPSY:. ACUTE ULCERAtlVE ESOPHAGITIS {SHCfcEO Jr.62000 K-4^03u).... ID:br ICTOSCOP1C: Icroscopy reveals acute Infl amatory-fibrinous exudate atelxed with necrotic tissue debris and generating squaaous cells. The esophageal aucosa Is obviously ulcerateo ano a viaole mucosal issue it hot Identified. Cellular norphology of herpes infection is not noted. Silver stain .lows no evidence of fungus organises. . Iver Uiaz, K.O. Pathologist IDiiar AT: 7 Pathology No.S-67-395i 11406 5r f' / ST. JOHN HOSPITAL OF NASSAU SAY SURGICAL PATHOLOGY CONSULTATION l*r . S-67-277* fati MCYDE, HORACE Hospital Ml. 155154-OS7 1mm No. 4cL Afi 50 iw H ate 7/o/b7 BKtor YOUMHS/POhe /l!m57!f?RAL CHEST HALL: CONS1STWT HITH MESOTHELIOMA, (SEE CtfHEMT) IY2LU-S053) / lIOfSY # B1APHMGM: MO filAfiNQSTIC ALTERATIONS (Y240-0001) - -MOPST-flf -AHTLRIOR CHESf-HALL-F-COMS I STENT -M lTH-ICSOTIIELIOMA J YZ2U.-9Q531. L5EE_CttWthTl : BIOPSY OF APICAL PLEURA: NO 0IA6H0STIC ALTERATIONS (Y220-0001J ' ' KW:jdc * QHCMT; Tlx histological features are sinllar to the previous pleural uicpsy which represents Mt likely a nesathellOM. MOSS: .pecinen A is labeled lateral cnest h11 ana consists of s*all wiiitlsn flaky tissue, lucsurir,, n greatest dlaension 3 m. The entire tissue is submitted in cassette labeled A. Ipeclnen b Is labeled dlephragn and consists of saall whitish flaky tissue, assuring In jreatast alaenslon about 2-3 ma. The entire tissue is suoaitted in cassette labeled b. Specimen C is labeled anterior chest wall and consists of whitish tissue, Maturing in greatest laension 2-3 >. The entire tissue is submitted In cassette labeled C. Specimen D is labeled apical pleura and consists of a pinkish-white fragment of tissue, neasurlng In greatest distension 3-4 no. The entire tissue is submitted in cassette labeled D. CR:sb MICROSCOPIC: . ` AC: Sections of Diopsies fron lateral chest wall and frou anterior chest Jail shows similar -ilstologlcal features. The oiopsy shows maoerous proliferating atypical cells with a atypical cnroeatin structure ano irregular nuclear shape as well as numerous nicotic figures. Sue of these appear like cudoIouI cells. The features of these biopsies are similar to the previous pleural biopsy. i` ,&D: Sections of biopsy of ciapnragc and sections of biopsy of apical pleura are examined at multiple levels an- sho. fibrous tissue with hemorrhage and mesothelial cells, kj uefiniU ceilul&r atypia c-n at cemcnstratee or. tnese biopsies. IO.:jdc bitl: 7-3G-S7 ' Kurt keiss, P. b 'fa'thwlc.gist I'-' Pathology No. S-ts7-L7?S 4 Mespltal Mo. 155154-057 Hoorn Mo. 445 Dot* 7/il/a7 Aft 5b Sul h Doctor POta f pVtWUi'HOrjT: COMSISTEMTG WITH MALIMI(T HESOTKLIA (&-90S3) JA:cn fragments, aeasunn;, in aggregate 1 x 0.5 x 0.5 cm. The specimen is suuaittea in tctJ ir. a single cassette. ' BM:sb WCM0SC0P1C: ' Sections reveal pleural tissue with attaches skeletal muscle fibers. The pleura snows fiurosi ! and Infiltrating within the fibrotic pleura are sheets ana clusters of large polyhedral cells i with hyperchromatic pleomorphic nuclei. The cytoplasai Is aoundant. These show no evidence of ` gland formation. These are arranged as solid sheets of cells. Mo significant papillary formation is noted. No evidence of psamraa bodies are noted. The morphologic features are consistent with malignant mesothelioma. COPMEMT: i The slides were sent to M.D. Anderson for their opinion ano tney concurred witn the uignosis i malignant nesothelioua. ' JA:cn D4T: Pathology Mo. S*o7-2uti M mo^ctuq* 2 IIIIIIIIKH.M * * ww * . wi i i w tvww^v Wn SURGICAL PATHOLOGY CONSULTATION . ^JCOCir MO. v-c NT: rtCr'^YDf ^*c t Gallbladder. fMOlXKMC MAONOtlfc - HOiPfTAL NO. J.-.:.- . NOON NO. AOC^r-^ to RACE . OATt OOCTOR : ALV CALCULUS CHOLECYSTITIS (57-3100). OS'l-SS: toe specimen 1$ labeled gallbladder consisting of ar. unopened gallbladder neasuri'.., * S x 2.< cm. On opening at the cystic duct the duct wall is found to be quite thic.- measuring up to S m. in thickness and there is a stone very low in the neck o` tv galIbladder which is obstructing the duct. On opening this stone is dark green ir color and measuring 1.1 * 1 * .9 cm. It is a mixture of yellow and green crystalline toateri,-1. On opening the gallbladder contains several smaller stones and mixture of cloudy lisv. brown bile mixed with yellow material. The entire mixture has a consistency of ex-ref.rl.; thick and tenacious mucoid naterial. Nixed within this are several smsll dark or f`> nes. The serosa of the gillbladder is unrtnarlsable bet the wall is appreciate/ ".cl : (Measuring up to 3 ins. in thickness and 'there is dark brc*n material within c* ' : v gailoladder rtsc-vl ing stones measuring up to 4-5 m. in greatest dimension. T ,, ,c of te gallbladder exhibits focal hemorrhage. Representative sections are suin' - : < one cassette. MY:cm ' ? *preset>tative sections obtained frjr talliUrvr demonstrate irrejuifr tv.c . ...oil sfa.-im. .aoral ir!e,w ' i xca*ri.; jsseciated '.it!: i of1 arenatory celinlfr ' r. . ar.d r.ultiple Ki tsnshs--... i-o** sinuses, T vrosi shows foci of ulcc-rjtirv i-i: r'o - v v . ' ? PATHOLOGY NO. m+enmy (**. v2) - ----------- v LABORATORY COPY 1 TEXAS SERIES. i* **"*'"' Name. 1/4 (M~ /fai/i * yjjjj- -- U.S.A.Hospital/Path No. -4 Llandough No. K ' Slides Received. 21 Zt-ic<A~ Blocks Received. &-?(!) *WhOj; U- %(& <* *'*'. Ar G+) it' % Q iJ, At, %l-1 (g) 2-cv<zt//r(t <%-% (?) A****, 4*. (**) C*er>~--u~c % l 8W W*S- ? * Histo/Immunocytochemistry. % Mineral Analysis. Other blocks or slides sent elsewhere. ^ puJU- VCJ ILu.^ Sb. fr^lKM />t OxE 4 (x odj-Jt*'* /iOj C^V>E ryx^t-*~ !(([(> (fir^ l^cJ Lsc*~^- /<?$(? qj\ A )C\^ ~ nu\ 1#f 7^"- M)vg- Exhibit JCr_ Date A.W.R. P Assoc. NAME / ADDRESS tfw.n. i LLANDOUGH NO. Lung - fibrosis asbestos bodies 0 other features Jjb' Tumour type P1eura ^ ' ~? 'Z't*' K .itJx fy^- . .rt. t-r*-r C .T" ' '.UU, - Histochemistry " "> ^u-i~ l~ hb - r? r I mmunohistochemistry t6-+ry o< r r r Diagnosis: .v-*^ .4-^--K* liCir c/.j'-l* -t r t- -- -i-t- fot. 4--fc"yT~ Is there an asbestos related disease? u Other tissues 1 rosiMum UtM S.M. Le BER, M.D. Palhologist 5840 Monroe Street Groves, Texas 77619 avaja. wav * NAME: KAHRICK, Alvin AGE: 40 SEX: M. RACE: Black DATE AND TIME OF DEATH: 1-12-88 - 0300 AUTOPSY NO. MEA-88-8 PLACE OF DEATH: Ben T&ub Hospital, Houston, Texas DATE AND TIME OF AUTOPSY: 1-14-88 - 0950 PLACE OF AUTOPSY: Moody-Harris Funeral Home, Port Arthur, Texas AUTHORIZATION FOR AUTOPSY: Greta Warrick (Wife) PROSECTOR: s.M. Le Ber, M.D. ANATOMIC DIAGNOSIS IMMEDIATE CAUSE OF DEATH: MALIGNANT MESOTHELICMA - RIGHT LUNG MANNER OF DEATH: NATURAL CAUSES MECHANISM OF DEATH: CARDIORESPIRATORY INSUFFICIENCY ADDITIONAL DIAGNOSES: ACUTE RJIMONARY EDIMA ASBESTOSIS SML:ms Page 3 MEA-80-8 WARRICK, Alvin ' ' ADRENALS: Both adrenal glands were normal in size, shape and color. No secondary neoplasm was present. _ GENITOURINARY SYSHM: Both kidneys were normal in size, shape and texture. The capsules stripped with ease to reveal slight retention of the fetal lobular pattern. The cut surfaces showed uniform hyperemia. The archtectural markings were normal. There was no increase' in peripelvlc fat. The ureters were normal. The urinary bladder was normal and contained less than 10 cc.'s of normal appearing urine. The prostate was not palpably enlarged. Both testes were present and normal. GASTROINTESTINAL SYSTEM: The esophagus was normal. The stomach contained a omnii amount of fluid and gastric mucus. The mucosa was normal. The small and large Intestines were normal, and contained normal fecal matter. The appendix was normal. CENTRAL NERVOUS SYSTEM; No specific permission was given for examination of the cranial contents; accordingly no examination was done. X X X X XXX X X X X X X X X X X XX X II X mm MICROSCOPIC: LUNGS: Sections through the lungs demonstrate acute pulmonary edema, increased numbers of alveolar histiocytes, and patchy Interstitial fibrosis. The tumor of the right chest is seen to invade the right lung, and is composed of a haphazard arrangement of cells with no organoid structure. Special stains were used to differentiate these tumor cells from epithelial cells, and identify them as mesothellal in origin. The tumor is identified as a malignant mesothelioma. Iron stains also identify the presence of scattered furruginous material, found chiefly in areas of interstitial fibrosis. SUMMARY: This is the case of a bO-year-old man who died as a direct result of a malignant mesothelioma arising in the right chest. . xxxxxxxxxxxxxxxxxxxxxxxxxxx 3 v JSPITAL WARD A Llandoigh PATHOLOGIST Dr. A.R. Gibbs HOSPITAL UNIT Nu. ggAgiULULI NU. jm'iuma.1 iuuimisini ivu. Llandough 6261 i/89 A 2829/89 NATURE OF SPECIMEN : Clinical Diagnosis : Ling tunour Conventional histology : ? metastatic teratoma Reference Clinicial/Patholcgist : : Dr. A.R. Gibbs Hospital : Specimen details : LlandOMgh Markers required : Cate received : Please ring the boxes below Processing Details : Number of specimens/blocks : ^wo blocks 12 uss on each Pre-staining. Processing : Results : Key -i-m- Strong, Positive; ++ Positive; + Weakly Positive x not done; R = Reactive cells only. FTesh Frozen Fixed Spare Sections + Equivocal; - negative; OKT 6 RFT 6 RFT 1 WBC Leu 3a ' RFB *1 Y 25a i HLA-DR ' 1 (LN 3) LEU Ml MB 2 MT 1 Ki-1 UCHL 1 L 26 M400 KP 1 IgC ' IgM j IgA ' i GH PRO LH sec Piece FSH Chain /\ j K ] TSH j ACTH SOMAT ^ antitrypsin) LYZ ^ AT^ - FVIII RAC Fibrin-j logen 1 C3 1 INS GLUC C-Peptide : PP GAST _s _ | HPL BGP ^HCG } ^AFpy BOM VIP CAL I 1 i MYOG 1 v.foca L +++ -ve MYOS DES VIMENTIN GFAP NEURO FIL S100 I CGRP CEA THYR GCFP- HMF 15 G11 NSE Epi- Cyto derma 1 keratin PaPH kerat in (CAM 5.2 ) MT j 5HT PSA Chr A FX111 A SAP SAA THP LAMINIA PLAP | j i i i Ii Ft FULL REPORT SEE OVERLEAF. The tissue in block 88.8 (2) shows a few multi-nucleate cells positive for HCG. BothoC -.-antitrypsin and ^-feto protein markers are either negative or show non-specific staining only. The overall findings are consistent with a tunour of teratoma or germ cell origin. B JASANI 21.12.89 MEDICAL REPORT ON BILLY HARRIS My report, is based on the examination of the autopsy report of Dr. Le Ber and pathological materials received from Mr. Henry Garrard ITI. I only studied the material in which tumour was present. f.riV -4Bd appeared to Le a blood clot, containing occasional cells and groups of cells which were suspicious of malignancy. CY 07-1 hid was a cytological specimen containing groups of large i.T I 1 s which appeared malignant. M? - lid, H7 - 1 1S 7E. This, material was from the autopsy. The* tumour consisted of masses of vesicular cells many of which appeared to have formed glandular structures. These glands were lined by columnar cells. In foci the cells had small hypo rc h roma tic nuclei and dark cytoplasm. The histological features of this tumour were consistent, with those of an adent icarc. i noma. This was confirmed by special stains and i mmun< di i stoohemi stry . Huei carmine - focal positive PAH Diastase strongly positive i'EA - strongly positive fytokeratin - strongly positive exhibit. Date AWR RAf 1 lymph gland showed a metastatic tumour The long showed evidence of extensive lymphangitis careinomatosa. Ho evidence of asbestosis or asbestos bodies seen. Coalmen t, In my h< ,;t medical opinion I consider the tumour to be an adeno carcinoma. This is strongly supported by the results ot tin h 1st.oohemi stry and ,i mmunohi stoohemi stry. fat\.f) o T^'0 ^ lh' R UuHftlY CfbAl'fi* fO/vfiA~T'0 M Ewhibil f&i Dale _ AWR Assoc QjiLj /4xtor 6 % ** jt\Ift ~ 7-11 yc b * cJ~-- le)U j$l be; hr {siiA*~r,, l ir*M- c*-piXc~Sl yty^~. t* (i, |C Aw-c-^ l---'p >^CVO-'*-< pfbJ^jU. *\ r^\J- y^XkjM. oA~ Ik-, L--7^7v^- , lAvU. ^ 7 y &-----^jto-v-^4 1--; ^--1~^a to | f n , /Wlj^otJU^-P /Lsia-cP" *C~-- pA-l^kr*- P*A'I ^ b>-^- cb^cjci^ ---j II hjn ^jo-t-c^7 ^ Pi 0\*A**~s-tL^ _ S -A- Atci7'pL'<''0 ^~'vjj-. . t<^r 0Lstx-4^c^A.0dbzA p SC.t-<-~*x~4 K-ccl^ /^> v/'?/?/ O^JUa^JJaP, ^X-^~ c*-zsc~XL- |,^1--t Cjbts^lKA-c- lf^>ACSisttZX Pa---J {?j-c-y<_*- cJLe*^ Jis&ifv~ (Zvi-Ccrf*-- J\*----- J ?/zV 7f i ^ ^c U ( r^&l't S3j ci^,--ML --cP-^-t-A i{y I A- ^ (^Myle . Ac* <iAj-^-rkA--^i~ Ci^es^O-e- ^L^-cX*- ^~- /' A**J ( t'<^ J x^-Z- ^ Zc^~-1 Cj-A* * ~'~Z'C^-e f it-J - >P{3 ixtcs~ J^. . l^K-e/yi a-----1/ S'C'y^t 'yi^-J^ c*s-*j IxCj--c y^itwA *-- xit-j ^/s.7 ..- &- i. .. u. ^:jkkr1').-. J- / /o /i-/A . L^jJkjS tju 'tk: i^tKX^\jtJ yA^v-tj b-^'py |JLrt-^J "T^vv- cam-4^; Py J-A&-^~^l.j( c/i i^LcJL~^> d'./H-t.vM'vi- /il-- d"l--(_ ^ Tel. 0305 833902 J. CHRISTOPHER WAGNER. MD. FBCPxth, MFQM " Foxstones " 69 Coombe Valley Road Preston, Weymouth Dorset DT3 6NL May 16, 1990 MEDICAL REPORT ON HORACE McBRYDE My report is based on the examination of pathological materials submitted by Henry Garrard. I was only referred material which .was relevant to the diagnosis of the tumour. * Pathology S87 - 2779. This consisted of four small biopsies from chest wall, diaphragm and anterior chest wall and apical pleura. In two of the specimens there was evidence of minute fragments of undifferentiated tumour. S87-4107. This biopsy of the subcutaneous nodule shows the presence of a small fragment of fibro-fatty tissue in which there was a small focus of tumour on one edge. The tumour was composed of cells varying in shape and size, some of which were forming definite acini. :Z'c7 - ! . Th: a was a pleural biopsy which consisted of lar*?e cells surrounded by fibrous tissue and muscle. The specimen had been crushed and it was not possible to comment on the histology. Therefore histochemistry and immunohistochemistry were undertaken on tissue from specimen S87-4107 with the following results. PAS Diastase - negative Cytokeratin - strongly positive Qiijumeut AWH h In my best medical opinion this tumour is an adeno-carcinoma. C aac ufo C.MK Jr offi c f) *J<.\nV ^ 4-2- txnid Date <1 W<h6 (-[ cr^u. Mc y? ~ 2./$!'*, f - j11 i/&7 i )h |^j J<ui. Stf yL - /iu^ f<j fa<JA cL*U**j- _ Lrjjdfc~~~sf- r 6-0 DlA^^iA^-^A ci>~3jj ^-^^04----- ttCrCr-tL C\Jr i^-y '%J~ i--r^K. j^vft-^--- 7jiil'b7 X)hsIsxy%-^^te^\ tv1- /\x^l ij lb I 51 frvb1' [Ji-oi \yr***^ob~ 'SfauJj ^___,7 cJjxJsC^, CxJh U^e ^<--r^c.--c-t_ ^ ' --~'t sj p*'l<j fx. w*--- Ri^o4Le^f f:;KT7 Mhi ^ *S StycA^/T^c*--. ^t^rrU\XK. J--~ C&cf^i-VK^ B^j(v , , . \y^jry(2i-j>-^~ L^/^Le PtUaMi ijtf /^> </b*--e^^-v~i cA (Usl- "/ ^/< ftktM* '"Ji-YJjV.J 3/ /'Y/r ?) , I, /pky, 'W^l I ' ffllff V tX^J ] I 4ti-, C e&- *-cv <-^-4 5^1,.^A i*-^-cl^b_ x*ty*~ ^ f' %M)&7 O j l,-<0,-^---- A-f t) K'n-cX^ '^(^~eJS'J ^r oJL\< A li^viA/* [/'^ti'f^^t-ii'l'/\M'b (A^-OC'-~d fYt}~^--^ I Tel. 0305 833902 J. CHRISTOPHER WAGNER. MD. FRCPaih. MFOM " Foxstones " 59 Coombe Valley Road Preston. Weymouth Dorset DT3 6NL MEDICAL REPORT ON ALVIN WARRICK My report is based on the examination of the autopsy report of Dr. Le Ber dated 1.14.88 and pathological material sent to me by Mr. Henry Garrard III of which I only examined the tumour tissue and lungs. Slides 88-8 1 & 2 Sprt.ions taken at autopsy from the lung and pleura show the presence of sheets of large foamy cells and large syncitial giant cells. These cells are surrounding vesicular spaces in which there is considerable evidence of haemorrhage and necrosis. The remaining lungs showed evidence of minimal alveolar reaction, but no signs of asbestosis or asbestos bodies have been observed in the sections examined. In my best medical opinion I consider this tumour to be primitive and embryonal in nature. There is no evidence for the diagnosis of mesothelioma. UNIVERSITY HOSPITAL OF WALES PATHOLOGY DEPARTMENT TMMUNOCYTOCHEMISTRY REQUEST / REPORT NAFE (Surname First - Block Letters) j PATIENT'S HOE ADDRESS DATE OF BIRTH SEX WARRICK HOSPITAL WARD Llandough PATHOLOGIST Dr. A.R. Gibbs HOSPITAL UNIT NO. ggA'^JOLOGY NO. ITMJNCXTTOCHEKLSTRY NO. Llandough 626 3/89 A 2829/89 NATURE OP SPECIMEN : Qlrucal Diagnosis ; Ling tunoar Conventional histology : ? metastatic teratoma Reference Cltnicial/Patholcglat : ' Dr. A.R. Gibbs Hospital : Specimen details : Llandough barkers required : Please ring the boxes below Date received : Processing Details : Nmtier of specunens/blocks : Two blocks 12 uss on each Pre staining Processing : Results : Key +-h- Strcr^ Positive; ++ Positive; * Weakly Positive; x not done; R = Reactive cells only. Fresh Fhozen Fixed fc>are Sections Equivocal; - negative; OKT 6 RFT e RFT 1 WBC Leu 3a RFB It Y 25a HLA-DR (LN 3) LEU Ml MB 2 MT 1 Ki-1 UCHL 1 L 26 MHOO KP 1 | IgC IgM j IgA j GH ; pro LH Sec Chain Piece FSH TSH /\ | K ; antitrypsin LYZ )at3 - FVin RAC fFociebnrin-'1 C3 ! ACTH SOMAT INS GLUC C-Peptide . PP CAST '"N ! / )1 HPL BGP ^ HCG 1 (^AFP ; BOM VIP CAL I MYOG v.foca, L -ve MYOS DES VIMENTIN GFAP NEURO swo FIL CCRP CEA THYR GCFP- HMF 15 Gil NSE Epl- Cyto derma L keratin PaPH kerat tn (CAM 5-i ) MT i ! 5HT * PSA Chr A FX111 A * SAP SAA THP LAMINIH PUP _ FOR RIM RPOOPT err OVFRICftR i I xmt>u JH_4 Date A IV ft & 1 Pr (i/'vv lYfrOS-iCX ---- --------------------------------- /Jj^J^ vH 0c-x/~*-^ C^C-A^--L C--X. ^~y-- ^& j>'w--i- "^= U t4fe--/kU,.~4 A --*--A. ' . ,)m*. -Av--" h(_--prjP'*'} oLyppo^ IU L^<K pptj l^C /u*A-\ j<^ `^Arus.Jr ^ u^,\-Jq / X -- fi**j <--->X Cf~p^-Yl y*-jY tskjy)^ . /x> ^ S^cy/t~7 . ^ oy cc-XJsp <.--^ r-^<^lY~ I s >K jJL--.-A t-cyVi ? <*-c,i^- . ^Ly ^ h-y/lY i^pyya^ L^-Y*. ? 'Tv^CttX UJ tX^T (f--t-c.rT^^j Q --L ---'""'--A OU/1--t/^w^ ^~arzL C-j '-'-t-` Lc pLas(*<~~*. lf-<^P~ 6-c-v ^ " ptAb**! , /4 c^fn^ c IV o <*-l o IV(X_ C-oNn P o ^Vo/Vu-- <--*-( JY--X Y 1*- t~j c-ala^X . C&JlA Lx~"*--i*A~*r b*^A~ p fh+YrX^ CfjfeaA Ca'^-Caw^cj^^l*A a/L-o-*- jv^-3-A~ Yat'YLJ-, Y* ? w>--oX*--<*. / 'T^-i'VotXx^v' UYlte f-A- ^ J I "K cP-^Yr~ m X"" yi^py^Lx. (z ----<//<j/jd^/ L1 j/--Jy ^^ --- # ^ . l^C (&\r\.A*oP Jpv' H-''-''i-r*-'X ty'fc~L&r) j/^Yp i*-~cP--***" l-- &-^yX_ do~^xJL^i /^-v--o-a^ p/V- O-vYIh Y. VsY~%-P' ^ pp Cta*-J~ CeJk id^AstX* *X) kY~~*-^s. Ca^A ^/^l. JpU-A--- CLtrl iK^-t ficrcy ----^ ft. t Ca-^< J^d "A L-i,--a (svo~* ff7( ^LvCci<TUC' C-^-eJU 'J-'t'd^L-v1 tJ~ ->* \ ' *~ i // - Z ^4y</ Exnibit .rf ig-, Date AWR ENDOCRINE STUDIES IN TESTICULAR TUMOR PATIENTS WITH AND WITHOUT GYNECOMASTIA A Report of 45 Cases Antanas V. Stepanas, BMedSc, MB, BS, FRACP, Naguib A. Samaan, MD, PhD, FRCP, FACP, Pamela N. Schultz, BS, and Paul Y. Holoye, MD . Prolactin (PRL), human placental lactogen (tiPL), the 0-suhunit of human chorionic gonadotropin (0hCG), testosterone (T), estrone (<), and estradiol (E2) were measured in blood samples from 45 patients with testicular tumors, 27 of whom had gynecomastia at some stage of their disease. Forty-two of the 45 patients had at least one abnormal hormone level. The most common abnor mality was that of plasma estrone: it was elevated in 32 out of 42 (76%) patients in whom it was measured, suggesting a useful role for Ej as a testicular tumor marker. Prognosis was notably worse in patients with embryonal carcinoma, tcratocarcinoma, and choriocarcinoma, in those with gynecomastia and, partic ularly, galactorrhea. Such patients also had the highest incidence of hormonal abnormalities as well as (he most extreme absolute values. Hormonal mecha nisms were implicated in (he development of gynecomastia and galactorrhea. Prolactin, hCC, E,, and E) levels in all permutations correlated stgnficantly among patients with gynecomastia, but not among those without, while estro gen to testosterone ratios were elevated in patients with galactorrhea. ' Cancer 41:369-376, 1978. UNOKMAl. CONCENTRATIONS OF VARIOUS PEP- nde,M,6,9*33,w and steroid*'***031 M hor mones as well as nonhormonal lumor-rdaied antigensu n so are an established feature of paurnts with testicular tumors of germinal cell rigim In the present study, six hormones, prolactin f rom the Set lion of Endocrinology, Department of Mcdi< me. The University of Texas System Cancer Center M. D Anderson Hospital and Tumor Institute, Houston, Texas Supported by Grams CA 01831-16 and CA 16672-02, .warded by the National Cancer Institute, 1)HE\V, and AC'S PHT -tlE. awarded by the .\mchcan C'ancer ' - u'ty \ddrcss for reprints: \. A Samaan. M l)., Pit 1)., Chief, Viiion of Endocrinology. Depart mem of Medicine, M I). Anderson Hospital and Tumor Insiiiuie, 672.1 Benner Ave nue Houston, Texas 77030 \W are grateful to Douglas Johnson, M. I) , Chief, Section *I l lolugv. Department of Surgcrv, ai -M. D Anderson Husjmal. for referring his jr.iticnts to us for stud), and for valuable adviee in the preparation of this manuscript We aUu wish to thank Mi Atonao Gurrra. Mrs Socorro Caslilju. Mrs Elsa Pope. Ms Laura Smith, and Mrs. Carolyn M.ir>hafl for troaloable technical assistance. Wc arc in- hied to the British Medical Research Council for supply_ pmlio tin and rf-fiCG standards, and the National Pitui!.>j\ Agent) for supplving prolactin. 0-liCXi, and ihcir ..i.ui.udtci for ladininununoassa). Vttepird for publication May 18, 1^7 (PRL), human placenta! lactogen (hPL). the 0subunit of human chorionic gonadotropin (0hCC;), testosterone (T), estrone (E,) and es tradiol (Ej) were simultaneously measured in blood samples from 45 patients with testicular tumors. Twenty-seven patients had demon strable gynecomastia and four had galactorrhea as well. Our aim was to determine the preva lence of abnormal hormone concentrations in the various types of testicular tumors, assess the prognostic significance of abnormal hormone levels, gynecomastia and galactorrhea, and identify any hormone patterns correlating with the occurrence of gynecomastia or galactorrhea. Matehiai.s and Methods Patients Fasting, early morning blood samples for hor mone assay were drawn from 45 patients with testicular tumors at various Stages during the management of their disease Patient selection was strongly biased toward those with gynecomastia; its presence uas estab lished by palpation of glandular tissue, hpomasiia being ignored. Twenty-seven patients had gynecomastia at some stage of their disease, lour patients also had galactorrhea. Tumors were classified according to the tKKISo'UX-Ttt-UKKMUCi't-OOBS American (.`antcj Norim 369 C'Aisct.H January 1978 Vol 41 1 Ahi t- 1. Munalily related lo Presence or Absence of (lynecomaslia in Patterns with Testicular Tumurs Grutij. i Ealholugy T>'l* Seminoma II Embryonal carcinoma 111 Teratoma l\ 1 eraiocarcinoma \ (-honor aremoma 1 in ai No 9 16 2 10 8 4.3 Mean age & range ai diagnosis (years) 47 (29-6S) 35 (21-34) 24 27 (14-44) 32 (20-44) No < jynecomasiia No. Dead % Dead 5* 1 2(1 4 3 75 1 l KM) 6 3 30 2* 0 (1 18 8 44 Gynecomastia No. Dead V Dead 4 , 23 12' 8 67 |00 4 4 IOO 6 3 83 27 18 67 - i>n< patient living with disease I wo patients living with disease. scheme of Dixon and Moore.* Among (he 45 patients, there were nine seminomas (group 1), 16 embryonal carcinomas (group II), two tera tomas (group III), ten teralocarcinomas (group IV), and eight choriocarcinomas (group V). The primary tumors were all of testicular ori gin, and were treated by orchiectomy and radio therapy to melastases followed, in most cases, by chemotherapy using various drug regimens. Management details are beyond the scope of this paper. The charts of all patients were re viewed recently to determine current status. Fol low-up from date of diagnosis ranges from 10 to 52 months for patients still living and ? to 41 months for those who died.I Hormone Assays Serum RRL, hPL, jShCG, and plasma T, E(, and Ej were assayed by specific radioimmunoas says as previously described.'Blood samples were immediately spun after drawing, and serum or plasma was frozen at --20 C until the time of assay. Hormone measurements were made in several assays, but interassay variability below 10% ensured comparability of results. Resiu.ts Gynecomastia occurred in all tumor types (Table I). Comments on its prevalence are in- I I Mean survivot from diagnosis ot disease Meon survivo! tram onset of gynecomastia Uhl :& "A i Tumor Group I k. I. Survival duration m (Hiiit-nis with ;md without gynecomastia Number of |>atirms in rath nrouj> shown m (hr eight of the bars f Minor i\ |k*s: I. semi noma, H. embryonal car cinoma; HI. irrauuifa: IV. tcratocamnoma; V, chonot aumuma. I 1 Testicular Tumors Stepanai el al. Proloctin (ng/ml) 200 (A) HPL (ng/ml) 0HCG (ng/ml) 371 150 too 50 i n nev o No Gynecomastia Gynecomastia Galactorrhea Fiu 2 Peptide hormone concentrations in trslirular tumor patients l-V ~ testicular tumor types as in Fig I appropriate because the patients had been se lected for the presence of gynecomastia. The imntality was higher in patients with gyneco mastia (67%) than in those without (44%). The adverse influence of gynecomastia on survival duration is shown in Fig. 1. Survival was strik ingly shortened by the onset of gynecomastia. Conversely, the disappearance of gynecomastia correlated with a good prognosis and coincided with eradication of demonstrable tumor in four patients Five other patients are still alive with persistent gynecomastia. Two of these (with em bryonal carcinoma) also have persistent tumor, but three patients with seminoma are alive and ate now free of disease. The latter three patients represent a special case, since all had unde scended testicles and two demonstrated other features of feminization (sparse facial hair and redistribution of body fat), thus, persistent gy necomastia without evidence of disease in their vase may be attributable to factors other than their testicular tumor. The levels of peptide hormones PRL, hPL, and /ShC-G are plotted for the five tumor types (group I to V) in Fig. 2(a-c); those of steroid hormones T, E,, and E, are plotted in Fig. 3(a- c). High concentrations of PRL hPL, 0hCG, Ei, and Ej, and low T concentrations were found in all tumor types except for choriocarcinoma, in which hPL levels were normal, and teratoma, in which E, and T levels were normal. Extremely high levels of jShCG, El; and E, were found among embryonal carcinoma and choriocarci noma patients, while lowest T levels and highest PRL levels were found in teratocarcinoma pa tients (Figs. 2, 3). Although patients with gy necomastia tended to fjave the highest hormone values, high concentrations were not necessity associated with gynecomastia. A tendency for very abnormal hormone levels was noted among patients who eventually died: PRL >50 ng/ml: 7 dead (D), 2 alive (A); hPL >5 ng/ml; 4D, 1A; /ShCG >50 ng/ml: 13D, 2A; T < 350 ng/100 ml: 9D, 2A; E, >200 pg/ml: 80, 3A; E, >200 pg/ml: 5D, 1A. Because the timing of samples relative to ther apeutic events was variable, no attempt was made strictly to relate hormone levels to stage of disease. This will be done in a prospective study non1 under way ' o No Gynecomastia Gynecomastia Galactorrhea I k; 3. Steroid hormone concentrations in testicular tumor patients. I-V = testicular tumor types as in Fig. 1- ' . $ The percentage incidence of abnormal hor mone levels is presented in Table 2. E| Was the hormone most frequently elevated among all tu mor types; 32 of 42 (76%) patients in whom it was measured had high E| levels. The incidence of several abnormal hormone levels occurring simultaneously was higher in patients with gynecomastia than in .those with out (Fig. 4). Among gynecomastic patients, the mortality increased as the number of coexisting hormone abnormalities incieased, a trend which was slightly reversed in patients without gyneco mastia Features of patients with and without gyneco mastia and galactorrhea are examined in Table 3. Fourteen patients presented with '.gyneco mastia, while in 13 it developed subsequently. Those with gynecomastia and galactorrhea tended to be younger than those without. Sur vival duration was significantly shorter in pa tients with galactorrhea (p < 0.05) when pompared with those without. Factors possibly important in the genesis of gynecomastia were examined. Exposure to phenothiazinc antiemetics, which can elevate prolactin levels and induce gynecomastia, did not differ for patients with gynecomastia (96% exposed) and those without (89% exposed). Fur- Tabic 2 Percentage Jnrjdencf of Abnormal Hormone Levels According to Tumor Type, Presence or Absence of Gynecomastia or Galactorrhea, and Fate PR 1- 1 hPI. | 0hCG 1 T1 F-.l Pathological Type Gynecomastia Fate 1 it hi IV V GM - c;m + Galaa' Alive Dead 25 46 50 38 50 2S 55 10(1 41 59 14 20 so 33 0 10 33 23 18 33 23 69 30 30 88 40 61 ion 44 62 23 33 0 44 14 27 33 75 II 36 37 75 100 78 88 82 67 1(H) 76 76 14 38 0 V) 63 18 42 100 33 44 GM --: no gynecomastia; GM +: gynecomastia. ` Tumor types in patients with galactorrhea: I embryonal carcinoma. 2 leratocarcinomas, and 1 choriocarcinoma. t 4 j . / ] j v' 1 Testicular Tumors Sltpanas el al. 373 thermore, 52% of gynccomaslic patients had not , received such drugs prior to developing gyneco mastia. Similarly, there was no significant differ ence between gynccomastic and nongyneComastic patients in the incidence of obesity (our , patients as a group, were not obese) or pul monary metastascs. We were unable to demon ! strate a significant difference in the E|/T, Ej/T, l-wi/T ratios between patients with and with out gynecomastia. However, in those with galac torrhea. these ratios were uniformly higher, but significantly so only for the Et/T ratio (p < 0.05). Significant positive correlations were found between certain hormone pairs (Table 4). This was particularly marked between PRL, 0hCG, j E,, and E, in all permutations in patients with gynecomastia, but not in those without. Nota1 fiiy, E| or E levels >100 pg/ml were always associated with (JhCG >100 ng/ml in patients with gynecomastia, but not in those without. However, specific hormone patterns could not I be defined in relation to particular tumor type, gynecomastia, or mortality. | Discussion I The simultaneous measurement of serum 1 i'RL, hPL, (ShCG, and plasma T, Eh and Eiin a (large scries of patients with testicular tumors has not been reported previously. Our results I demonstrate that the concentration of any of these six hormones may be abnormal in any of the five tumor types of Dixon and Moore.* Of our 45 patients, 42 had at least one abnormal hormone concentration, this finding being withi out exception among the 27 patients with gyt necomastia. Abnormal hormone levels were most preva lent among patients with embryonal carcino- 0 ff/tiecpmesfm f ] Ahvt No. ol Abnormal Hormone Levels Fig. 4. CtmcurTtm Association of abnormal hormone levels in paiirnts with and without gynecomastia. Four patients with galactorrhea each had four concurrent abnormal hormones. mas, teratocarcinomas, and choriocarcinomas, which is a predictable consequence of these tu mors consisting of trophoblastic cells,* or multi potential cells that may differentiate along trophoblastic lines.* Multipolential cells are also found in teratomas, but the spermatogonial ori gin of seminomas* precludes speculation of a direct hormone-secreting function. On the other hand, even a small nest of choriocarcinoma cells may elaborate a considerable amount of hor mones," and an undetected focus or such cells may be responsible for the endocrine activity observed in some patients with seminoma. Rec ognition that testicular tumors have a predeliction for mixed histology* particularly in metastatic seminoma" supports this possibility. Recent investigations permit fairly confident speculation on the exact origin or abnormal lev els of the six hormones measured in our patients. hPL and (ShCG are natural secretory products of trophoblastic tissue in health and disease."''5" ; ' Ta&ix 3. Features of Patients with and without Gynecomastia and Galactorrhea Survival from Mean age diagnosis Prolactin- at of tumor inducing Lung * Diagnosis (months: drugs metastascs Et/T X 10"1 PVTXtp-* i.i.x ttr1 No. (years) 5 SD)' No. " * No (S SD) (s SD) (x i SD) .3 ncro V .3*113 tttcom.AMi* alaetorrhea 18 . 27 4 36 31 30 39 29* 22 27- 95 16 89 U 61 6.9 3.7- 4.2 5.6 r.5 tp s 26 96 20 74 6.8 6.V 4.6 4 .0 12 ' 12 8 4 too 4 100 52.6 43.5 34.? i 41.7 90.9 i H3.3 * p < 0 001 compared to patients with galactorrhea, 'li < OOS compared to palients wilt, galactorrhea v i SO = mean standard deviation- jj j fj i! , ; ; ' Testicular Tumors Slefxmas el at. 373 thermore, 52% of gynecomastic patients had not 0 0b n received such drugs prior to developing gyneco mastia. Similarly, there was no significant differ ence between gynecomastic and nongyneeo- j mastic patients in the incidence of obesity (our jl patients as a group, were not obese) or pul I monary metastases. We were unable to demon strate a significant difference in the Ei/T, E>/T, l',|,i#fT ratios between patients with and with It out gynecomastia. However, in those with galac torrhea. these ratios were uniformly higher, but significantly so only for the E|/T ratio (p < t 0.05). Significant positive correlations were found between certain hormone pairs (Table 4). This No.ef Abnormol Hormone Levels was particularly marked between PRL, 0hCG, Fic. 4. Concurrent association of abnormal hormone lev Ei, and E, in all permutations in patients with els in patients with and without gynecomastia. Four patients gynecomastia, but not in those without. Nota with galactorrhea each had four concurrent abnormal hor bly. Ei or E, levels >100 pg/ml were always mones. associated with ffhCG >100 ng/ml in patients mas, teratocarcinomas, and choriocarcinomas, with gynecomastia, but not in those without. which is a predictable consequence of these tu However, specific hormone patterns could not mors consisting of trophoblastic cells,* or multi be defined in relation to particular tumor type, potential cells that may differentiate along tro gynecomastia, or mortality. phoblastic lines.* Multipotential cells are also found in teratomas, but the spermatogonia! ori Discussion gin of seminomas' precludes speculation of a direct hormone-secreting function. On the other The simultaneous measurement of serum hand, even a small nest of choriocarcinoma cells I t'RE, hPL, /SliCG, and plasma T, and Eina may elaborate a considerable amount of hor large scries of patients with testicular tumors mones," and an undetected focus of such cells has not been reported previously. Our results may be responsible for the endocrine activity demonstrate that the concentration of any of observed in some patients with seminoma. Rec these six hormones may be abnormal in any of ognition that testicular tumors have a pre- the five tumor types of Dixon and Moore.* Of deliction for mixed histology* particularly in our 45 patients, 42 had at least one abnormal metastatic seminoma" supports this possibility. hormone concentration, this finding being with Recent investigations permit Fairly confident out exception among the 27 patients with gy- speculation on the exact origin of abnormal lev nrromastia. els of the six hormones measured in our patients. Abnormal hormone levels were most preva hPL and /ShCG are natural secretory products of lent among patients with embryonal carcino- trophoblastic tissue in health and disease.""" I apm 3. Features of Patients with and without Gynecomastia and Galactorrhea -Surv ival from Mean age diagnosis lYolact in- at of tumor inducing Lone Diagnosis (months: druef metastases FVT X I0-* E,/TXUI 5 L,,i'1XIII-' No {years) S SD)* No. ` * No. % (xiSO) (x SI)) tvSD) v'neco- 1ft 36 39 29* 16 89 11 61 6.9 37* 4.2 3.6 \~M IP 3 :..5stin rj D 1 * 'iicro. 27 31 22 27* 26 % 6.S i ft..S' 4.6 4 (1 13.' I2.f> mastia fialart- 4 30 95 4 100 4 100 53.6 43.3 >4.3 a 41.7 `Ml 0 i > orrhea * p < 0 001 compared to patients with gaUriorrbca. p < 0.05 compared to paiirnis with galactorrhea. ' v i SO = mean standard deviation. 374 Cancer January 1978 Vol. 41 Tari.* 4. Significant Correlation Cofficients (Positive except as shown) between Hormone Pairs in Patients with and without Gynecomastia Hormone pairs correlated* tjn. I'Rl./E, I'RL/E, fihCC./E, 0hOC;/PRL 0hGC;/T t/e, No Gynecomastia r' P 0.15 0.03 -0.11 075 0.35 -0.11 043 -0.38 n.s. n.s. n.s. <0.001 n.s. n.s. <0.05 <0.05 Gynecomastia rP 0.60 0.79 0.49 0.48 0.67 0.44 -0.16 -0.28 <0.01 <0.001 <0.05 <0.01 <0.001 <0.05 n.s. n.s. Correlations between T and E. T and PRL, and hPL and all other hormones did not reach significance in either group of patients. 1 r :correlation coefficient. The investigations of Kirschner rf a/, ""indicate that high circulating estrogen levels in testicular tumor patients are the result of in situ aromaliza- tion of Ci,Oj androgens, principally dchy- drocpiandroslcrone but also androstenedionr, produced by steroidogenically competent cells within the tumor tissue itself. Reduced Leydig cell mass as a result of or chiectomy, radiotherapy, and chemotherapy may account for the low T levels that we and others have observed. The high LH levels in testicular tumor patients, demonstrated by Cochran ri a!.,' may represent a compensatory adjustment by the pituitary to maintain T secre tion. Elevated circulating estrogen levels would tend to suppress pituitary secretion of gonad olropins so that LH levels, even though elevated, may represent a compromised pitui tary response that is inadequate to restore nor mal T secretion from the reduced Leydig cell mass. A report of low FSH levels in testicular tumor patients" lends support to this sugges tion. That the testicles of these patients arc re fractory to stimulation by the massive concen trations of circulating hCG, but are LH- responsive, was demonstrated by Kirschner et /." Elevated prolactin concentrations are the most difficult to explain. Although spurious elevation may result from administering pheno- thiazinc anticmctics, the possibility of estrogen- stimulated prolactin release at the hypotha lamic-pituitary level is supported by our finding of a significant positive correlation between PRL and both E| and E, in patients with gyneco mastia, while in two teratocarcinoma patients without gynecomastia extremely high PRL lev els (139 and 103 ng/m!) were also associated with very high E, levels (>100 pg/ml). How ever, prolactin secretion directly by multi potential tumor cells cannot be ruled out in the absence of data on testicular vein samples. Uniformly normal hPL concentrations in the presence or high 0hCG levels in all our patients with choriocarcinoma was an unexpected find ing. Elevated hPL concentrations have been re ported previously in patients with choriocarci noma.' However, the dissociation of /ShCG and hPL in early pregnancy," particularly in molar pregnancy and trophoblastic disease in women is well recognized." A similar situation might exist in our choriocarcinoma patients. The low incidence of gynecomastia in pre vious series (reported to be between 2.5% and 6% in patients with testicular tumors"'") may have precluded its recognition as an important prognostic marker in its own right. Among our patients with gynecomastia, its onset frequently heralded a rapid demise, while its dis appearance was often associated with eradica tion of disease. Abnormal levels of various hormones, particu larly PRL, hCG, and estrogens, or an altered estrogen to androgen ratio, are commonly sug gested in the pathogenesis of gynecomastia. In -our series, patients with gynecomastia had an overall greater incidence of abnormal hormone concentrations, in addition to a greater preva lence of exceptionally high /9hCG, E,. .and E (but not PRI-) levels. This was not a Specific finding, as some patients without gynecomastia had equally high levels oT these hormone^. and many gynecomastic patients had normal values. A striking feature was the significant positive correlations of PRL, (JltOG. E,. and E, in their various permutations among patients with gy necomastia, but not among those without. Clearly, it is not the mere elevation of one hor mone that is important in the development of gynecomastia, but a synchronized elevation of the several hormones maintaining a physiologi cal relationship to each other. The model for . such a situation prev ails in pregnancy in relation . to lactogcncsis in the female breast. The inter- * dependence of /JhOG and estrogens has been ' cited before. "*' but the statistical significance of this interdependence and the correlation with | PRL have not been demonstrated before in ei ther testicular tumor or gynecomastic patients. 4} The possibility that obesity, prolactin-elevat- 5$ ing drugs* or pulmonary metastascs*7 may play '4f a role in the development of gynecomastia was J| not supported in our scries Nor did we find^S evidence for an abnormal estrogen to andrugcn:s5 TESTICULAR Tumors Stepanas el at. 375 r.Tliu, palicnts both with and without gyneco mastia had almost identical mean EJT, E*/T, and E14^T ratios (Table 3), which were similar to those reported for normal men.*-" This con trasts with previous studies demonstrating high E/T ratios in patients with gynecomastia associ ated with puberty," Klinefelter's syndrome,Cir rhosis,' digoxin use,** and Graves' disease.' However, all three E/T ratios were elevated in .mir four patients with galactorrhea (signifi cantly so for Et/T), thereby supporting an etiological role for estrogen-androgen imbalance in the development of inappropriate lactation. Furthermore, it was noteworthy that four pa tients without gynecomastia but with gross per turbations of PRL, hPL, 0hCG, and estrogen levels had the highest T levels observed among oi.r patients (all >1000 ng/100 ml), suggesting lhat T may play a protective role against the development of gynecomastia. The search for markers useful diagnostically and prognostically or for following the effects of therapy in testicular tumor patients has recently established the value of the nonhormonal poly peptide, alpha-fetoprotein," particularly when measured together with cither dhCG,T or an other nonhormonal protein, carcinoembryonic antigen.*0 To these, we would suggest adding plasma estrone as a potentially useful marker. Estrone levels were more frequently elevated than any other hormone, being high in 32 out of 42 (76%) of our patients both with and without gynecomastia, and with all types of tumor. Its value as a marker will be more critically assessed in a prospective study now under way. Taking E, and |ShCG together, 37 of 45 (82%) patients had elevated levels. The prognostic significance of elevated uri nary hCG levels in patients with testicular tu mors is widely accepted.*""*! Except for the measurement of serum ffhCG,4 which is more sensitive than the urine measurement,' the prog nostic implication of abnormal hormone concen trations in blood had not been systematically studied. Although no prognostically significant "hormone profile" emerged from our series, it was clear that the incidence of abnormal hor mone levels, the most extreme absolute values, as well as increasingly complex hormone associ ations, correlated with gynecomastia and with mortality, all being found more frequently in patients with galactorrhea, and those with em bryonal carcinoma, leratocarcinoma, and choriocarcinoma. REFERENCES 1 Hiaunsirin. O. [). Vaiiukaitis. J I... Carbone, r P,, liitl Ross. (. T.: Ectopic production of human chorionic cmndoiropin bv neoplasms, .4rw. Intern. Mrd. 78:39-43, r>~v ` 2. Chopra. 1. J.. Abraham. (V E.. Chopra. U.. Solomon. U. II.. and Oddi. \V. D.; Alterations in circulating estradiol* l"d in male patients with Graces'disease. .V Eng/.J. Mrd. 286.124-129. 1972. . " V Chopra. I J.. Tulchinsky. I)., and Greenway. F. L.: }.*tf<ccn-androeen imbalance in hrpatic cirrhosis: Studies ;n It male patients. .4rm. Intern. Mrd. 79:198-203. 1973. (-t*(hran. J Walsh. P. C.. Porter. J. C.. Nicholson. I'. and Peters. IV C.: Clinical evaluation of human ' rnu gonadotropin level* in men w till testicular tumors. ' 25:542-343. 1974. ^ U.iuehadav. \V H.: The ndcnohvpophvsis. In Text- 1'tw.k nf Endocrinology. 3th rd . R. H. Williams. Ed. Phila delphia. W. B. Saunders Company, 1974: p. 49. 6 Dixon. F. j.. and Moore. R. A.: Testicular tumors: A Iiom opatholoeiral stud\. (an.n 6:427-454. 1933. * f urmama. S.. Mayes. J). M., and Nugent. C A. A f 'dinimnuinoassav fur plasma testosterone. Steroid* -t 1 --428. 1970. v (iabrilove. J. E.. Nirolis. G. L.. and Hausknecht. ' l rinarx testosterone, oestrogen production rate and - ..n\ estrogen in chromatin positive Klinefelter* svn- (iiumr Aila l.ntbvrinnl (fchh) 63:499-504. 1970. 0 CrccnwtMtd. S. M.. Goodman. J R.. Schneider. G., Borman. H IF. Kress. S. C . and Gelb. A. F.: Choriocarci noma in a man: The relationship of gxnecomastia to cho- r,nnk somatomammotropin and esirocens. H*v J. Mrd. M J|o-422. 19"|, JO. Hwang, P., Ouyda, H., and Friesen. H.: A radio immunoassay for human prolactin. Pior.JsatL Arad. Sn. I'SA 68:1902-1906, 197). . } |. Johnson, 13, E.. Appelt, G., Samuels. M. L.. and Luna, M.: Metastases lor testicular carcinoma. Study of 78 autopsied cases. (:iohgy 8:234-239, 1976 12. Kirschner, M. A., Cohen. F. B . and Jespersen. D.: Estrogen production and its origin in men with Ronadotro- pin-jM ixfutrng neoplasm. J. (/in Cndocnnnl. M/tab. 39:112-118, 1974. ` 13. Kirschner, M. A., Wider, j. A . and Ross. G T.: Levdig cel! function in men with gonadotrophin-producing testicular tumors. J. Chn. lindnrnnol. Mrtab. 30:304-51 1. 1970. ' (4 Kohn. J., Orr, A. H.. McElw/in, T J.. Beniall. M . and Peckham, M. J.: Scrum-alpha,-feioprotcin in patients with testicular tumours. I^tnrrt 2:435-436. 1976. Jfv Kurohara. S- S., George, F. W., Dykhuisen. R. F., and Lear)', K. L.: Testicular tumors: Analysis of 196 cases treated at the U. S. Naval Hospital in San Diego Carter* 20:1089-1098. 19(.7. 16. LaFranchi. S.. Parlow. A.. Lippc. If. Oiyoiupa. J . and Kaplan. S.: Pubertal gynecomastia associated with a transient elevation of serum estradiol. Chn. Hr*. 22:213. 19 4 (Abstract). 17. Lange. P. II., Mrlmyre. K. R.. Waldman. T A.. Hakala. T. R., and Fraley, E. E.: Serum alpha fetoprotein and human chorionic gonadotropin in the diagnosis and management of nonseminomatous Rcrm-ccll tesiivular can cer. ,V. Engl. J. Mrd. 295:1237-1240, 19"6 IR. I^Fevre, R. E.. Sirwarl. B H., Levin. If S-. Straflnn. R A . Banowsky, 1. 11 .. and Hewitt. C B ; Tr*ti* tumor* , * j i 'I I -j ;j ; : ; ; j j : V Cancer January 1978 Voi. 4i Review of 125 cases at the Cleveland Oink. Otology 6:588-593. 1975. to. Li, M. C Trophoblastic disease: Natural history, diagnosis, and treatment. Ann. Intern. Mrd. 74:102-112, 1071. 20. Lindenmcyer, D., Hornung, D., and Forner, F.: Hor monal changes in urine and plasma in patients with various testicular tumours before and after treatment. 1. Seminoma. /W. InlrrnnhnTMtl 28:127-134, 1973. 21. Lindcnmeyer, I)., Hornung, D., and Forner, F.: Hor monal changes in urine and plasma in patients with various testicular tumours before and after treatment. 11. Malignant teratoma of intermediate type B and malignant trophoblas tic teratoma. fiof. International 28:135-144. 1973. 22 Mikhail, C.. Wu, C. H., Ferin, M- and Vande Wielc, R. L.: Radioimmunoassay of plasma estrone and estradiol. .V/rrW* 15:333-352, 1970. 23. Reiter, E. O., and Kulin, H. E : Supressed follicle stimulating hormone in men w*ith chorionic gonadotropin secreting testicular tumors. J. Uw Endocrinol. Metob. 33737-961, 1971. 24. .Samaan, N. A., McRoberts, W. A., Smith, J. P.,and Myers, L. C.: Metabolic changes in women with tropho blastic disease and with intrauterine fetal death compared with metabolic changes during normal pregnancy. J. (Jin. Endornnol. Mrtab 33:521-529, 1971. 25. Samaan, N. A., Yen, S C. C., Friesen. H., and Fear- son, O. H.: Serum placental lactogen levels during preg nancy and in trophoblastic disease, j. Chn. Endocrinol. Mtlob. 26:1303-13<ffl. 1966. 26. Saxcna. B.: Scrum placcnial lactogen levels in tro phoblastic disease. Trans. 4ih Rochester Trophoblastic Conference, 1967, pp. 423-438. 27. Sbar. S.: Unilateral gynecomastia (letter) .V. Engl. J. Mrd. 280:1367-1368. 1972. 28. StofTer, S. S.. Hynes, K. M.. Jiang. N-S.. and Ryan, R. J.: Digoxin and abnormal serum hormone levels. JAMA 225:1643-1644. 1973. 29. Vailukaitis, JH. BraunMctn. ti 13., and Ross, C. T.: A radioimmunnassav which specifically measures human chorionic gonadolropin in the presence of human luteinizing hormone. Am. J Ob.uct. (iynmd. 113:751-758, 1972. 30. Wahrcn, B., and Edsmyr, K : Fetal proteins occurring in testicular tcraiomas. Int J. damn. 14:207-214, 1974. 31. Weinstt'in. R. L.. Kelch, R. P.. Jcnner, M R., Kaplan, S. L., and (Jrumbach. M. M : Secretion of uncon jugated androgens and estrogens by the normal and abnor mal human testis before and after human chorionic gonad otropin. J. (hn. IntH-st. 53:1-6, 1974. 32. Wilson, J. M., and Woodhead, I). M.: Prognostic and therapeutic implications of urinary gonadotropin levels in the management of testicular neoplasia. J. I'rol. p 108:754-756, 1972. . li-f ' if Mayo Clin Proc 43:570-573 (Ang.) if&i PRIMARY MEDIASTINAL CHORIOCARCINOMA Marlin E. Wenger, m.d., Resident in Internal Medicine* David E. Dines, m.d.. Section of Medicine David L. Ahmann, m.d., Section of Clinical Oncology C. Allen Good, m.d., Section of Diagnostic Roentgenology Extragonadal choriocarcinoma is an uncommon tumor, and to date only 14 cases of the primary mediastinal form of the disease have been reported in the literature. Because only one of these occurred in a female, it appears to be a disease almost entirely confined to males. A review was undertaken of the cases of choriocarcinoma occurring in males examined at the Mayo Clinic in the period from 1957 through 1967. Of the total of 17 cases diagnosed during this period, 1 was the primary mediastinal form of the disease and is discussed herein. REPORT OP CASE A 20-yeer-old man was seen in October 1967 because of nonproductive cough and chest pain of 3 months* duration. He had had no fever and no other systemic symptoms. Two weeks prior to his admission here, a thoracic roentgenogram had shown an anterior mediastinal mass. The mass had been explored and biopsied through a right thoracotomy incision. The pathologic diagnosis was undifferentiated carcinoma, and the patient had been referred to the Mayo Clinic for further evaluation. The slides from that biopsy were reviewed and a revised diagnosis of primer}' mediastinal choriocarcinoma was made. The patient had mild gynecomastia; otherwise, tbe physical ex amination gave normal results. |~he testicles were normal to palpation. Results of "routine laboratqry tests were normal except for a sedimentation rate of 88 mm in } hour (Wcstergren). Thp thoracic roentgenogram showed multiple metastatic pulmonary nodules in both lungs, with a large mass protruding from the mediastinum into the right lung Reid (Figure). The urinary chorionic gonadotropin level w* 6,485 international units/24 hr. The patient was seen by tbe*oncology consultants, and a program of treatment was outlined to include triple drug therapy with actinomycin D, methotrexate, and chlorambucil. DISCUSSION Primary mediastinal choriocarcinoma is characteristically seen in young Caucasian males presenting with the symptom triad of rough, chest pain, and gynecomastia. Most cases have occurred in males 20 to 30 years of age (Table 1). The cough and chest pain are often accompanied by other respiratory symptoms including hemoptysis, dyspnea, hoarseness, and 570 AUG. 1968 PRIMARY MEDIASTINAL CHORIOCARCINOMA 57! Chest roentgenogram, on admission at Mayo Clinic, shows multiple metastatic pulmonary' nodules in both lungs with large mass protmding from mediastinum into right lung Held. stridor. Horner's syndrome and dysphagia have been described. Gynecomastia has been reported in approximately half the rases. Nonspecific symptoms include generalized malaise, anorexia, and weight loss.,,,*`1* / Roentgenographically, primary mediastinal choriocarcino ma presents as a well-defined anterior mediastinal mass char acterized by rapid growth but without cavitation. It must be differentiated from other anterior mediastinal tumors including other gciminal tumors (teratomas), thymomas, intrathoracic thyroid adenomas, pericardial cysts, lipomas, lymphangiomas, and parathyroid adenomas (listed in order of decreasing frerjuency1). A roentgenogram revealing an anterior mediastinal . :* j j j j r I r.-V e< >* t sn MAYO CUNIC PROCEEDINGS VOL. 43, NO. 8 TWf i.--Symmirj of Reported Cue* of Primary Mediastinal Cborioardaem* Author Arendtl** Kastroorits4 Leipplr and Shipley* Hindi et a!.* Giroux and Desroeulest*-* Shlinumtt end V*b Bnwra* Zorzi end FiacentiJ*-* NielubsTyei*-** Fanger rad . MocAndrew11 Lvnch rad Blewett'* Magovera end Blades* Yurici and Ottoman1 Fine et al." Bennington et m\.u Date 1931 1934 Age, Frag- ex mastia test BOM Yet S2M No Pm 1946 I3M Yes Fm. 1946 B6M Ym Fm. 1947 IBM No Fos. 1950 S7M Ye* Fm. JP52 S9M Yes Pot 1952 MM 1952 44F Yes Po*. 1953 B6M Yes 1958 BOM ? Post 1960 SOM 19G2 49M 1964 44M No Ye* No Pm. Pm. Histology} Primary Metastasis Complex teratoma and chorio Complex teratoma and chorio Und IfTertsnbated celts and chorio Chorioepithelioma in a dyiewbryotna Chorio and chorio Complex teratoma and chario Seminoma, ambrycninl cell cancer, chario Cliorio Chorio Chorio Granulomatoot les:om typical of TB in beer rad mediastinal Irmph nodes Chorio Chorio > Chorio Chorio `This table is modification of that published by Yuritit and Ottoman.1 fChorio ~ choriocarcinoma. 1Cases abstracted from Migorm cod Blides.' {At autopsy. mass in a young male patient with tlie above triad of symptoms is strongly suggestive of primary1, mediastinal choriocarcinoma. The finding of a high titer iof gonadotropin in a male, as occurred in our case, is of itself diagnostic of choriocarcino ma, whether it be of gonadal or exlragonadal origin. The hormone is presumably produced by the trophoblastic element of the tuihor and is biologically similar to the chorionic gonado tropin of normal pregnancy in the female." Consequently a pregnane}' test is also positive in patients with choriocarcinoma. The gynecomastia observed in males with primary medias tinal choriocarcinoma is undoubtedly related to the production of gonadotropin. Circulating gonadotropin may stimulate the Leydig cells of the testicles to increase not only testosterone synthesis but estrogen production as well. The increased blood level of circulating estrogen could account for the adverse effect noted on the testicular germinal epithelium as well as the hypertrophy of the mammary glands. Leydig cell hyper plasia was reported to have been found in 30 to 40 cases of exlragonadal choriocarcinoma studied by Fine and co-workers." Much of the controversy concerning exlragonadal chonopjf v AUG. 1968 PRIMARY MEDIASTINAL CHORIOCARCINOMA S73 carcinoma regards the location of the primary site of the neoplasm. Certainly, gonadal origin of the primary lesion I must be excluded before one can conclude that a choriocardnoI ma is of extragonadal origin. Fine and co-workers1' and ; others5'1" have made a careful study of multiple serial sections I from each testicle and have advocated that this must be done before the testicle can be excluded as the primary site. The testicles should also be free of cysts, scars, or tumors. Some authors1'5'* question the spontaneous involution which these scars are said to represent. Fine and co-workers think that mediastinal choriocarcinoma can be metastatic as well as primary. There are those, however, who doubt the possibility of metastatic choriocarcinoma in the mediastinum.*'11 This controversy regarding exact criteria for the diagnosis of pri mary mediastinal choriocarcinoma has made the validity of ! case reports difficult to ascertain. The pathogenesis of this tumor has also been of con siderable interest. Several theories have been proposed in the literature, none of which has been totally accepted. The primitive germ cell rest theory has received the widest acceptance.1,5,51, This theory stales that, as the primordial germ cell migrates along the urogenital ridge to the primitive gonad, it either goes astray or does not complete-the journey. The theory is supported clinically by at least two observations. First, extragonadal tumors develop in midline structures such as the mediastinum, retroperitoneal space, and abdominal or pelvic viscera. Second, the appearance of these tumors in the second, third, and fourth decades of life can be explained by the fact that the primitive gonadal germ cell remains dormant until puberty. Other theories that should be mentioned are the included twin theory, the included zygote theory, and the somatic cell rest theory. Friedman15 does not think that the primordial germ cell originates from the urogenital fold. Rather, he believes that the mediastinal teratomas and cliui ioepilheliomas may arise from germ cell rests in the anlage of the thymus gland. This is based on his observation of similar histopathologic features in thymic teratocarcinomas and germinomas seen in the mediastinum. He suggested a scheme (Table 2) for the histo genesis of these tumors based on studies of testicular and extra gonadal teratomas and epitheliomas and their inetastases. This scheme of development could certainly explain the pre, ponderance of mixed teratomas and trophoblastic tumors seen clinically. The histogenesis of extragonadal choriocarcinoma remains an unsettled issue in need of further investigation. i j- [ -I V  j. -'.Kr? V-: y) ' *74 MAYO CLINIC PROCEEDINGS VOL. 43, NO. 6 TM* 2.--Origin of Teratonai aod Cboriocarclnwiu According to Filtdu Gtrminomi (germ cell) | nrihrymil (primitive cell) (hiphasic potency) Icniofmstt --) teratoma /. (aomatic) \ trophogenesis-----choriocarcinoma (trophoblastic) (From Friedman, N. B.:M The Comparative Morphogenesis of Extragenital and Gonadal Teratoid Tumors. Cancer *.-265-276 (Mar.] 1951. By per mission of J. B. Uppincott Company.) Prognosis with choriocarcinoma is very poor, and most patients die rapidly of metastasis. Surgical treatment is of little value because of the rapidity of the growth and the in vasive nature of the tumor. Deep radiation (cobait therapy) has been of little success because chorioepitheliomas are highly radioresistant.1 Methotrexate, although highly effective in female choriocarcinoma arising from_ fetal tissue,, is much less effective in primary mediastinal choriocarcinoma. To date, the most effective treatment is triple drug therapy with methotrexate, actinomycin D, and chlorambucil. Most patients have died in 4 to 6 months.1' $ $ i.f? 'i SUMMARY During the period 1957 through 1967, 17 male patients with choriocarcinoma were seen a) the Mayo Clinic. One, with primary mediastinal choriocarcinoma, is described, bringing the number of such cases in 'the literature to 15 (including only 1 female) for the primary mediastinal form. This pa tient presented with cough, dies! pain, and gynecomastia and had a positive pregnancy test and high chorionic gonado tropin "titer. Roentgenographically, primary mediastinal chorio carcinoma presents as a well-defined anterior mediastinal mass. Oonadal origin of the primary lesion must be excluded before one can conclude that the choriocarcinoma is of extragonadal origin. & I '.4i REFERENCES 1. Yurick, B. S., and Ottoman, R E.: Primary Mediastinal Choriocarcinoma. Radiology 75.901-907 (Dec.) 1960 2. Arendt, J.: Das Choriooepitheliom des Mannes. Fortsehr Roentgenstr *3.728-735 (June) I93f. 3. Magovem, G. J.. and Blades, B.r Primary Extragenital Chorinepithelioena in the Male Mediastinum. J Thorac Cardior Surg 35 378-383 (Mar.) 1958. 4. Kanlruwilz, A. R.: Extragenital Chnricnepithelioma ta a Male Amer J Path /0.-531544 (July) 1934. 5. Laimly. T. C., and Shipley, R. A.: Extragenital Choriocarcinoma in the Male. Am*1 J Path 2/ 921-933 (Sept ) 1945 6. HincK, O., Rabbin*, S. L., and Haughtoe. J. D t Mediacboal Chm-irtnapithelimni i> a Male: Case Report. Amer J Path 27.833-6*5 (July) 1946. - 7. Giroux, M,, and Desmeules. R : Dyaemhryome thornridoe et chorio-4pith(liome y- * t AUG. 1968 PRIMARY MEDIASTINAL CHORIOCARCINOMA 575 190.. ZNoirritui,bnanydf, PSia'ceCntli: dCbiteyd by MagoveGr.n,J-G, .aIn.d, BanladdeBsl,adBe.*s, B* 11. Ffnger, H., and MacAndrew, R.: Extragenital Choriooepithelioma in a Female Arising From a Mediastinal Teratoma. Rhode Island Med i J5 259-260 (May) 1952. 12. Lynch, M. J. G., and Blcwetl, G. L.: Choriocarcinoma Amine is the Male Mctfiastiaani. Thorax 1:157-161 (June) 1953. 13. Fine. G., Smith, B. W., Jr., and Pachter. M. R.: Primary Eimpninl Qw'autuiwpa ao the Male Subject: Cate Report and Renew of the Literature. Amer J Med 32:776 79* (May) 1962. 14. Bennington, J. L., Haber, S. L, and Schweid, A.: Primary Mediastinal Cbariocaraziamt. Dit Oiest 44.523-626 (Nov.) 1964. 15. Holt, L. P., Melcher, D. H., and Colqahmui, J.: Elxtra-gonadal Choriocamnoma in the Male Postgrad Mad J 4/.-134 198 (Mar.) 1965. 16. Friedman, N. B.: The Comparative Morphogenesis of Extragenital and Gonadal Teratoid Tumors. Cancer 4 265-276 (Mar.) 1951. 17. Miller, J., and Browne, F. J.: Extra-genital Chorionenilheliemata of Congenital Origin: With Report of a New Case of Chorionepitbelioma in a Male. J Obstet Gvaaec Brit Comm 29MS7, 1922. tr': ' - / !I