Document 3eM6ag5N20eK6wp10pVYok4jn

FILE NAME: Neighborhood Exposures (NE) DATE: 1967 DOC#: NE020 DOCUMENT DESCRIPTION: Medical Journal Article - Mesothelioma and Asbestos Exposure Mesothelioma and Asbestos Exposure Jan Lieben, MD, and Harry Pistawka, MDt Harrisburg, Pa IT H IN the past five years several arti cles have called attention to the association ctween mesotheliomas of the pleura and critoneum with asbestos exposure.1--' Wagner et al4 studied 33 cases of meso thelioma. All but one had probable exposure to crocidolite, the blue asbestos. Asbestos has become a ubiquitous materi al in our civilization. Cauna et al6 reported that asbestos bodies were found in the lung smears of 41% of 100 consecutive autopsies at the Presbyterian University Hospital in Pittsburgh. Similar findings were reported by Thompson87 in 500 consecutive lung smears from Capetown, South Africa, and Miami, Fla. Asbestos bodies were found in 30% of the m en and 20% of the women. As-bestos has been conclusively associated with increased incidence of lung cancer and other malignancies8- and an increasing number of studies associate its presence with malig nant mesothelioma of the pleura and perito neum . Pathology Mesotheliomas of the pleura and perito neum are rare neoplasms. Controversy in volves histological types, nomenclature, ori.gin, and their very existence. Recently, mesotheliomas as an entity have become generally accepted. Their morphologic vari ability makes classification difficult and dif. ferentiation from other malignancies is often a problem. Submitted for publication June 6, 1966; accepted Sept 13. From the Division of Occupational Health, De partment of Health, Harrisburg, Pa. Read before the Ninth International Cancer Con gress, Tokyo, October 1966. Reprint requests to PO Box 90, Harrisburg, Pa 17120 (Dr. Ueben). Sacconi and Coblenz10 give th e incidence of pleural mesotheliomas as 1.1 cases per 1,000 autopsies. Campbell reported four cases of pleural mesotheliomas in 3,533 con secutive autopsies.11 Mesothelioma occurs primarily in adults and is twice as common in males as in fe males.10-'2 Pleural mesotheliomas occur equally on the right and left though W eissman feels that pleural mesothelioma occurs on the right more frequently than on the left side.12 The criteria for diagnosis of pleural meso thelioma are presence of a firm pleural mass encasing the lung, histological structure compatible with mesothelioma, and absence of a demonstrable prim ary malignant neo plasm elsewhere. T he histologic architecture may be mesenchymal, "epithelial," or mixed. A complete autopsy is necessary for une quivocal diagnosis, b u t for the purpose' of this study, criteria were made less rigid in that unautopsied cases were accepted if a definite diagnosis of pleural mesothelioma had been made by biopsy, and malignancy elsewhere had been excluded clinically; chest x-ray examination, bronchoscopy, and cytologic studies of sputum or bronchial washing assisted in excluding the presence of bronchial carcinoma. Prim ary tumors of the peritoneum are among the rarest of tumors. Generally called mesotheliomas, they form large spreading masses over the peritoneum and histologi cally appear the same as pleural mesothe liomas. As with pleural mesotheliomas, ex clusion of a prim ary tum or is necessary. This study is an attem pt to learn the ex tent of the relationship of asbestos exposure with mesothelioma diagnosed in southeast ern Pennsylvania. Arch Environ Health.--Voi 14, April 1967 560 MESOTHELIOMA--LIEBEN & PISTAWKA M ethod Table 1.--Headings ol Consultant Paiho;og)t<| One hundred and aixty-two hospitals Serving a population o 6Vs million people were re quested to report all mesotheliomas diagnosed between 1958 and 1963. Replies were received from 152 hospitals. Hospital records of 62 re ported cases were reviewed and only mesothe liomas confirmed by operation, biopsy, or au topsy were included in the study. Forty-two cases satisfied our critera. There were 34 meso theliomas of the pleura and eight of the perito neum. Among the pleural mesotheliomas there was a definite preponderance for occurrence on the right side of the chest. Of 34 pleural meso theliomas only seven occurred on the left side, 25 on the right side, and two were not stated. Sections of as many of the tumors and lungs as possible were borrowed and reviewed by a single consultant pathologist familiar with mes otheliomas. In the 15 instances in which lung sections were available, they were examined for the presence of asbestos bodies. All slides were reviewed without the benefit of the complete history and autopsy protocol available to the pathologists who made the original diagnosis. Results of the 33 cases reviewed (Table) by our pathologist agreed with those of the outside pathologists in 17 cases; he rejected seven cases as unacceptable histologically, had serious doubts in nine cases (of these one slide wag read as metastasis and one Blide as anaplastic malignancy). Of the lfi cases'in which lung tis sue was available, asbestos bodies were iden tified in seven. The discrepancies between the original pathological diagnosis and that of our patholo gist .are reported to illustrate the difficulties and disagreements which are so frequent in the diagnosis of ibis tumor. For inclusion in this study the diagnoses, of the originally reporting pathologists have been accepted and cases re ported by them were investigated. Efforts were made to obtain a complete em ployment and residence history for each pa tient. Inquiry was also made into the employ ment history of family contacts. Data were obtained from the individual if alive, from fam ily members, or employers. Of the 42 patients, ten had definite occupa tional exposure to asbestos during lifetime, three were family contacts of asbestos workers, right either lived in the immediate neighbor hood of asbestos plants or had been employed next to an asbestos plant Ten patients had a questionable asbestos exposure and, in the oth er 11 patients, either no asbestos exposure could be elicited on direct questioning or no survivor could be located. Case No. Mesothelioma A sb esto s Bodies 1-0 3-0 ' 40 50 60 9 0 10-0 2-N 3 N 4-N 6-N 1 -F 2-F 3F 1-Q 2-Q 4-Q 5Q 60 7-Q 8-Q 9-0 10Q 1-X 2-X 3-X 4-X 5-X 6-X 7X 8-X 9-X 10-X Yes Not acceptable Probably not Yes Probably not Probably not Yes Yes Probably not Not acceptable Yes Yes Yes Yes Probably not Yes Yes Probably yes Not acceptable Yes Yes Probably not May be Metast Yes Yes Not acceptable Not acceptable Anaplastic malignancy Probably not No epithelial cells Mesothelioma must be Probably not Yes Yes proven No lung t is s u e Yes No lung ti s s u e Yes Yes No lung t i s s u e Yes No lung tissue No lung tissue No lung tissue 9 No lung tissue No lung tissue a No lung tissue 1 No lung tissue 9 No lung tissue M Yes 1 No No 1 No -1 No lung tissue 1 No No 1 No ;] Yes j No lung tissue 5j No lung tissue ^ No lung tissue No No No lung tissue No lung tissue No lung tissue Yes Exposure of Ten Mesothelioma Patients Who Worked With Asbestos.--Patient 1-0 worked 35 years in the textile department of a large as bestos plant. Patients 2-0, 3-0, and 4-0 worked more than 20 years in asbestos insulation plants and pa tient 5-0 worked in an insulation plant for only one year. Patient 6-0 worked 15 years in a plant manu facturing acoustic tile and linoleum. Patient 7-0 was a boiler maker in a railroad yard where, for 25 years, he worked on insula tion of steam engines. Patient 8-0 built bakery ovens in which large amounts of asbestos insulation were used. Patient 9-0 was a certified accountant who worked more than 30 years in the office of an asbestos textile plant. Patient 10-0 was a plasterer who came in contact with a large amount of asbestos in his work. Of these ten men, patients 1-0, 8-0, and 10-0 had mesotheliomas of the peritoneum; the oth er seven men had pleural mesotheliomas. Neighborhood Cases.--Patient 1-N was a 65year-old woman who never had any occupa- Arch Environ Health--Vol 14, April 1967 g nal asbt retarial [ e, in 3 text ^tien t 1-C 8 of 18 s om the l Sr 15 yea Patient i geath in V stos expi he lived fo { the insu nd 6-0 ha Jing workei Patient : fbeetos exp* ib is death, | the street 1 in the hist Patient < i street fron t. connection Patients [ tributor, 1 i family con within thr* plants in a mesothelio Patients storage ba plant and no asbestr p lan t is Um bestes text cases is q Patients tients 2-N pleural m M esotht tacts Exp* year-old engineer th at util,* a n d 1,500 ally. Patient a n y occuf ther had p lan t wb worked neighborb had work P a tie n t any aabe a n asbei worked years, prior MESOTHELIOMA--LIEBEN & PISTAWKA 561 [ asbestos exposure. Her work was always Patients 1-F and 3-F had peritoneal and pa etarial; she was born and lived until the age tient 2-F pleural mesotheliomas. 8, in the immediate neighborhood of an as- Mesothelioma Patients With Questionable ob textile and friction material plant where Asbestos Exposure.--A study of these ten men SBent 1-0 had worked for 35 years. From the elicited either a relatively minor or question 'e of 18 she lived for 30 years across the street able exposure to asbestos. the plant where patient 6-0 had worked Patient 1-Q was a welder for 35 years. Ac r 15 years. cording to a common reference,13 eight out of Patient 2-N, a clergyman from 1935 until his 12 welding electrodes contain asbestos, which is eath in 1961, never had any occupational as- used as a filler. stos exposure. Prior to becoming a minister Patient 2-Q was a self-employed Swiss-born e lived for 19 years within one half of a mile Swiss cheesemaker. A thorough study of the ' the insulation plant where patients 3-0, 4-0, processes of Swiss cheese manufacture revealed nd 5-0 had worked as insulation manufactur- no use of asbestos. During the study of the workers. manufacturing process a 500-gal boiler was no Patient 3-N never had any occupational as- ticed. This boiler was covered with a friable as- exposure except that, 20 years prior to bestos insulation which flaked off on contact. is death, he had worked for one year across Patient 3-Q, a 14-year-old boy with mesothe the street from the insulation plant mentioned lioma, had no occupational contact with asbes in the history of patient 2-N. tos nor did any of his family. On questioning, Patient 4-N worked for 26 years across the the boy's father told the authors that his boy street from the insulation plant mentioned in had lived with him and had helped him while connection with patients 2-N and 3-N. he had replaced most of the plaster board dur Patients 5-N, a nurse, and 6-N, a meat dis ing extensive remodeling of his house. Plaster tributor, bad no occupational exposure nor board contains a high percentage of asbestos. family contact with asbestos. They both lived Patient 4-Q is employed in industrial Bales within three fourths of a mile of two asbestos and never had any occupational asbestos expo plants in a town with the greatest incidence of sure. Extensive questioning revealed that, on mesotheliomas in this study. two occasions several years before, he applied Patients 7-N and 8-N were both foremen in a asbestos insulation to boilers in his home, mix storage battery plant. A careful check of the ing asbestos cement himBelf. His total exposure plant and their employment records revealed during these applications was only a matter of no asbestos exposure, past nor present. The hours. plant is located less than 1% miles from an as Patient 5-Q was a brewery worker for 20 bestos textile p lant The exposure of these two years. The brewery was no longer in business cases is questionable. when the case was investigated. Reviewing Patients 1-N and 4-N had peritoneal and pa the literature of beer production the following tients 2-N, 3-N, 5-N, 6-N, 7-N, and 8-N had paragraph was discovered: pleural mesotheliomas. Mesothelioma Patients With Family Con "When ready for .packaging the beer is fil tacts Exposed to Asbestos.--Patient 1-F, a 3- tered through pulp filters consisting essentially year-old child, was the daughter of a ceramic of cotton fibers and asbestos. After each filtra engineer who worked in an insulation plant tion this 'FILTERMASS' is removed, mangled, that utilizes 400 tons of Canadian chrysotile and washed in dear, warm water, then bleach and 1,500 tons of South African amesite annu eTdheanwdasstheerdilipzeudlpatth1e6n0 gtooe1s8d0irFecwtliythtochalopriande-. allPy.atient 2-F, a 40-year-old nurse, never had forming machine where it is compressed at 89 any occupational asbestos'exposure, but her fa to 90 pounds per square inch to form new filter ther had worked for 35 years in the insulation pads.14" plant where patients 3-0, 4-0, and 5-0 had Asbestos-containing pipe insulation is used in worked and which was also credited with three breweries. neighborhood cases. The nurse's brother also Patients 6-Q, 7-Q, and 8-Q were all steel had worked in this plant for one year. workers. Patient 6-Q was a crane operator; 7-Q Patient 3-F, a 67-year-old woman, never had a. forger; and 8-Q a foreman and supervisor. In any asbestos exposure nor had she lived near all cases the companies did not recall any as- an asbestos plant. She had two sons who 'bestos exposure for these men. Pipe insulation worked as insulators in a shipyard for six containing asbestos is extensively utilized by years. These sons lived a t home until 15 years steel companies. prior to their mother's death. Patient 9-Q was a spinner in a silk company Arch Environ Health--Vol 14, April 1967 562 MESOTHELIOMA--LIEBEN & PISTAWKA from 1925 to 1938, and later in a plastic fabri cation plant which utilized fiber glass; he also had been a welder for 25 years. He thinks he has used asbestos but could not recall when and where. Patient 10-Q, a 63-year-old man, was a core-maker all his life. He worked in two foun dries in one of which asbestos cement is used ip small quantities but, according to the plant manager, the core-maker did not have any con tact with this material. The son stated that his father had used asbestos pipe insulation for pipes in the basement of their home several years prior to the onset of his illness and that he had done some sawing of this pipe insula tion material. All cases in this group had pleural mesothe liomas. Mesothelioma Patients Without Asbestos Exposure.--In the other 11 patients (1-X to 11X) no occupational, familial or neighborhood asbestos exposure evidence could be elicited. Ten of these patients had mesothelioma of the pleura and one peritoneal mesothelioma. Comment This study presents a good deal of circum stantial evidence and many unanswered questions. Asbestos is a ubiquitous material used' much more frequently than is generally real ized. Some uses, such as in the brewery, were not previously known to the writers. There are undoubtedly many others. If we assume that asbestos may be the causative or trigger agent for malignant mesothelioma in some of the cases described above, we must admit th at the minimal dose-effect relationship and duration of a latent period are unknown. The occupation al exposure of the insulation workers or as bestos textile workers were certainly many thousand times higher than those of the neighborhood cases or family contacts. Simi lar findings have recently been reported from England.1 T he attack rate for mesotheliomas is ex- CWrgyman Patient 2-N Patient 3-N4-N 0_ 0- STREET Occupational, neighborhood, and family contact patients with mesothelioma associated with one insulation plant. Arch Environ Health--Vol 14, April 1967 , Nur* I Client 2-F d with one MESOTHELIOMA--LIEBEN & PISTAWKA m _ ,ely low. N ot all mesotheliomas were re nted to us by the hospitals, but, even if we uble the incidence, only a minute fraction the exposed population was affected. ,ere are precedents for this w ith beryllium which acts in a somewhat similar ite m ; occupational diseases, familial com ets, neighborhood cases plus a very low ttack rate, and a long latent period beeen exposure and onset of disease. Another question which arises is why ileural mesotheliomas are so much more 'requent than peritoneal mesotheliomas. The most striking finding of this study was th a t of the 42 mesotheliomas which came from a geographical area of approxi mately 30,000 sq mi, six were clustered in and around an insulation plant (Figure). These included two insulation manufactur ing workers (Cases 2-0 and 3 0 ) , three neighborhood cases (Cases 2-N, 3-N, and 4N) and one family contact (Case 2-F)--the 'daughter of an insulation worker. Summary Forty-two cases of mesotheliomas report ed from 162 hospitals over a five-year peri od, were studied with regard to exposure to asbestos. Survivors or employers, or both, were questioned regarding the possibility of asbestos exposure. T en patients actually worked in asbestos plants; eight lived or worked dose to an asbestos industry; three patients were family members of asbestos workers. In ten patients a history of as sumed exposure to asbestos was obtained after prolonged questioning. In 11 other p a tients no history of asbestos exposure could be obtained. References 1. Newhouse, MX., and Thompson, H.: Mesothe lioma of the Pleura and Peritoneum Following Ex posure to Asbestos in the London Area, Brit J Industr Med 22:261-269, 1965. 2. Hourihane, P.O.: The Pathology of Mesotheliomata and an Analysis of Their Association With Asbestos Exposure, Thorax 19:268-277, 1964. 3. SelikoS, I.J.; Churgh, J.; and Hammond, C : Exposure to Asbestos and Mesothelioma, New Eng J Med 272:560-563 (March) 1966. 4. Wagner, J.C.; Sleggs, C.A.; and Marchand, P.: Diffuse Pleural Mesothelioma and Asbestos Expo sure in N.W. Caps Province, Brit J Industr Med 17:260-271, 1960. 6. Cauna, D.; Totten, R ; and Gross, F.; Asbestos Bodies in Human Lungs at Autopsies, JAM A 192:371-373 (May 3) 1963. 6. Thompson, J.G.; Kaschula, R.O.; and MacDon ald, R.R.: Asbestos as a Modem Urban Hazard, S A ir Med J 37:77-81 (Jan) 1963. 7. Thompson, J.G.: Asbestos and Urban Dweller, read before the Conference on Biological Effects of Asbestos, New York, Oct 19, 1964. . 8. Doll, R.: Mortality From Lung Cancer in As bestos Workers, Brit J Induetr Med 12:81, 1955. 9. Lieben, J.: Asbestos and Malignancy, Arch En viron Health 13:619-621 (Nov) 1966. 10. Sacconi, A., and Coblenz, A.: Endothelioma of the Pleura, With Report of Two Cases, Amer J Clin Path 13:186-207, 1943. 11. Campbell, W.: Pleural Mesothelioma, Amer J Path 26:473-487, 1960. 12. Weissman, H.: Primary Endothlia of the Pleura, Die Chest 12:562-570, 1946. 13. Lyman, T. (ed.): Metals Handbook: 1. Prop erties and Selection o/ Metals, ed 8, American Socie ty of Metals, 1961, p 5, 14. Modern Chemical Processes, New York: Rein hold Publishing Co., 1952, vol 2, p 167. DISCOVERY OF QUININE Many of the drug sources known in ancient times were apparently discovered by acci dent For example, according to an old South American Indian legend, the curative power of cinchona bark (containing quinine) for malaria was discovered by a sick, fe verish Indian lost in the jungle. He quenched his thirst by drinking from a pool of water. From the bitter taste of the water, he recognized that it was tainted with the poison from the quina-quina tree. Although he shared this fictitious belief, he drank deeply so as to bring about a quick death. To his great surprise, ho recovered completely. When he returned to his village, he told the Btore of his cure and thereafter cinchona bark was used as a medicine for the fever prevalent in that region. The Incas later taught the Spanish conquistadors that malaria could be cured with cinchona extract--- Rossman, R.E.: The History and Significance of Serendipity in Medical Discovery, Trans Coll Physicians Phila 33:104-120 (Oct) 1965. Arch Environ Health--Vol 14, April 1967