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FILE NAME State of the Art Literature SAL DATE 1942 DOC SAL034 DOCUMENT DESCRIPTION Journal Article - Bronchogenic Carcinoma in Association with Pulmonary Asbestosis div Mtns tly. SS ve - 34 Pe) . ages pean wre gicampape Lie peaa . J : ie] te a, Official Publication of The American Association of Pathologists and BOARD OF EDITORS _ CARL V. WELLER EDITOR CHIEF \ TRACY B. J. HAROLD AUSTIN PAUL R. CANNON HOWARD T. KARSNER MALLORY . ASSISTANT EDITOR MALCOLM SODLE +... SCHOOL | WEALRREN SHIELDS HARRY M. " ZIMMERMAN SCHOOL SCHOOL SCHOOL ae SCHOOL . ta, SCHOOL SCHOL SCHOOL SCHOOL ot pacer s. Aaeeee ys OF vata! *50 OF anger . : . ao? aeeo% OF . . Sad VOLUME XVIII # OF &%,, - BRONCHIOGEN IC CAR CINOMA | N CARCINOMA IN ASSOCIAASTISONOASCSOCIATION IATION witiH PULMONARY ASBESTOSIS ASBESTOSIS ASBESTOSIS Herserr REPORT MD. (From the HERBERT REPORT HOLLEB TWO CASES CASES M.D. MD Alfred ANGRIST Hospital M.D. Department N. N, Y.) Frormeport "ence Following Department Pathology a Pathology of carcinoma the case of carcinoma lung in pres- pres- pres- Following pulmonary asbestosis asbestosis by Lynch Smith lung 1935 several several similar papers appeared in Lynch the same year = presented presented rapid succession carcinoma Gloyne Gloyne the cases squamous squamous squamous lung oc- oc- following presented asbestosis and the year case of oat carcinoma carcinoma Egbert the following case in 1936. celled #2, later Geiger Geiger recorded Two years years Nordmann Nordmann analyzed the cases adding adding of his his relationship own the literature recorded the between A diseasesrevealed His views on the his paper Der two two revealed Cancer of the Asbestos Berufkrebs der Worker The together an addi- an ye O = fa Stud warded yeuoyeut enti Kew ter aq d poya yoi protected 3. Kapo9 a a rs : beace vay: ge ences Wh pte venne ient rt ett twe 3S ni < ARPoi toe g, we cart: hach, ar them: awh: on 4. at x x Fy hlloan nhs He Aarne A" anu Oy yeswe saries ons. te BR ' 4 ar wien,eayeeSOSWARE RN AE 7 eo OR: = ire raRs ie ee bas S*> ur} pip at aia SakSsaTen Bre oo of pes For nasal operation at the age surgical or venereal continuously by conticnontiuuoslyously a continuously eee Se ya oe the past past 25 years patient products been products duties always tage patente silicosis asbestos ~ eae ing Nera breathing S48 SE -Of manufacturers manufacturers of ing steam and water workers had died of revealed asbestos fabric stated stated that fasbaestos bric He many cover~ 5 = emaciated white male breathing veins 2 Lyfe sud ita s3 PN Agu. cel f Pq) 2bb | Ban 123 eS a = - oot ea ite +. AS ares Pa : SheUNE 0 41g arn 4 Ne may re LE ae a ~ e < f Shae . . F<4 ie . Fa t ? eS nae STS O Io NS eEOL ue SER CRS hee ee oe ER seefe eesae . 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Onorodes 7 FeewSUEY Poae 0 BaeSE SLY ene mene Sey ee me The en ae Pye Postmortem 9 een Soe a Ligan ee a At. teh ree ee oe eee nye tee Fetihe se to : 7 oa 4 , - HOLLEB AND ANGRIST eee and white blood cells Blood count 4,800,000 red cells per mm and 11,000 white cells per mm of which 72 per cent were polymorphonuclear cells Hemoglobin 5 . *, 12.3 gm per 100 cc Venous pressure 140 mm of blood Ether circulation time -..1 " tissue * 15 sec Saccharin circulation time 3 min probably unreliable The sputum Ff was +, negative for acid bacilli A Kline test of the blood was negative a . vf wooeors Roentgenograms of the chest taken shortly after admission showed a large area 378 of ; diminished illumination involving the entire right upper lobe with patchy in- ans we filtration of the lower lobe The lower cardiac shadow was deviated to the right The left lung field presented prominent pulmonary markings which however could co day bronchoscopy not be regarded as definitely pathological On the fifth hospital Sy revealed a sessile mass protruding from the posterior wall of the trachea about 1.5 above the carina a narrow crescentic lumen about 2 mm in width . cm leaving 2 . Biopsy from this region showed branchial tissue with only an inflammatory reac- a tion During the next 12 days the patient received small daily doses of high The roentgen therapy to the anterior aspect the chest totaling 1,600 , ied voltage was of .. This accompanied by a marked improvement in respiration The intratracheal , * mass had now been reduced in size sufficiently to allow passage of the broncho- 43!scope into the right main bronchus where ulceration and constriction were noted .-" trac visu cept press only simila lowish o The 4 by 2 _ Biopsy from this region showed definite carcinoma _ via - - the br gradus -* .. During the first 4 weeks inthe hospital he had a grade fever which ally declined On the 30th hospital day his temperature rose to 105.2 F. and he complained of a sore throat Blood cultures taken at this time and repeated 5 days later showed the presence of hemolytic streptococci In spite of sulfapyridine ee later sulfanilamide therapy his temperature remained elevated 101 and --sant 104 to F He grew rapidly weaker and expired on the 36th a hospital day AS +3 we final clinical diagnoses were bronchiogenic carcinoma in the region of the carina pulmonary Streptococcus hemolyticus septicemia and terminal te edema ee TIT cortica oie; compos round : cellular erable \ multinu Findings The pertinent descriptive data are limited a8 essentially to the thorax 8 The right pleural cavity was completely obliterated by dense fibrou-s+ eryae adhesions The left pleural cavity contained approximately 200 cc of ear watery yellow fluid with numerous flakes offibrin A shaggy yellow sie aie coating covered the posterior parietal pleura Section of the right lung~ - ee Fig 1 revealed an irregular globular hard grayish white mass 5 cm in diameter The mass had completely eroded and encircled the right main bronchus Some portions of the mass were softened and had ag been partially excavated Grayish white neoplastic tissue was seen in-- filtrating beneath intact bronchial epithelium upward to a point 2.5 cm Ee above the carina and downward along the right main bronchus for a distance of 5 cm beyond the lower margin of ulceration The re- ie mainder of the right upper lobe presented several prominent grayish irregular white septa extending out to the pleura which measured 3 mm a = in thicknessin this region and was composed of firm opaque white S2e2 tissue The parenchyma of the right upper and middle lobes presentedoo numerous pneumonitic areas The cut surfaces of the right lower lobe ` and the entire left lung were grayish red and crepitant Within the mediastinum at the level of the bifurcation of the spindledefinite gave was pro plastic t respondi the lumin Small crotic we lobe the _ right kidney the substa Of inte thelium of mucous seen Stru nant chang Many se fibrosis qu and a mod These varie DRESS atest pert Se 2. a a S erty tee SAA, te ine taPaes mevee art a eee ud ny . EEN eS oe a - -~) 00" white Doglcbin, ion time, joo white ion time tum was he meht. erge area itchy he right a could Ty choscopy of bou a width iry of "@ 2,600 2 broncho- . te noted 2 gradu- and ror? Deated 1 of 101 m3. ct inetraspulombonparryhaagnucsh shaggy BRONCHIOCENIC CARCINOMA ann PULMONARY ASBESTOSIS yo 5 BRONCHIOGENIC BRONCHIOGENIC BRONCHIOGENIC CARCINOMA ussue 8 CARCINOMA nodular cm. in irregular irregular mass necrotic neoplastic neoplastic trachea there diameter nodular mass necrotic necrotic was compressed both tissue adherent compressed compressed mass trachea trachea and esophagus probably corresponded corresponded mass bronchoscopically ) The pulmonary intact ex- ex. visualized the bronchoscopically pulmonary vessels were com- cept for right lobe which com- com- probe was passed passed pressed difficulty difficulty , . - only Within the pericardial pericardial ssaaccthterheerwe aapproxis mately approximately cc fluid fluid fluid approximately thick ~ similar . - similar to found the pleural cavity yel- yel-_ pericardium gray coating covered covered parietal parietal lowish myocardium myocardium visceral was mm thick thick 4 The The only extrathoracic extrathoracic extrathoracic ventricle seen grossly a mass measuring measuring aa-"- 4 by metastasis metastasis metastasis right kidney Multiple sections of multinucleated : these cells and some were present In a few cells were- ve cells were regions There was . SF. spindle shaped tendency arranged invade in cordlike bundles occasionally a o. definite definite tendency along the alveolar walls Lymphatic occasionally a permeation Was resemblance to large glands superficial throughout throughout involved Lymphatic neo- was prominent tissue present areas bronchial epithelium , beneath intact bronchial cor- oye responding responding to picture seen lamina islands grossly Many in lal . I He oR ne f a ae: as ot ae . hs Soe, at | re ree fires a 2 : tf ee 24, i$ & Sys : oe on at BR ene : =e etre, Br tet eras me P28ephegs . ech roe ah este HE i" wf 42d toe idea S Fi Like oe : Ey ss peerH ne: te on thelium thelium thelium the right and several the a mucous gland ducts in srlieghgtliyon Distinct Distinct intercellular intercellular intercellular bbrroncihiald-gbreonchsial wie? was atypical seen seen Structure there definite malig- white nant change change metaplastic epithelium epithelium was DO diffuse metaplastic showed considerable interstitial sented 1 Many sections sections foamy mononuclear spaces fibrosis golden rlobe fibrosis numerous within the Fig the & and moderate rod yellow asbestosis asbestosis bodies " the These These varied shaped early forms beaded weathered from early forms to bead ed (Fiz, 3). weathered ? aiid. H . . i Pests; i Ais hee Tae 3 A eat oe ak fae is irees peop i. 3 Be meaten nnn sb ry perieseposer *- ta Bye : Ltt pate Ll? 2 and te Dag: E L a'r ill rere wat a ey ial c. . i Sou am ay poate : ere ot SAR irtea ok ., Lote; a WarX We aan) . as Mad bet ert aa thiFateal. - halted carer, Pad - Piel aibetametenenan Medea aaa ge er a SR NOR . 0? setete RAT Le pagg eHONE a . TON! SX sonic bia a ede SR oe AN 495 a eae ae my i 141 D pers pe at le Awe phat EIaSr , a Pace on aie e See an DOTS Cr 126 res) 0 KHOLLEB AND ANGRIST * >>forms Many were partially or completely engulfed by mononuclear = and multinuclear macrophages Sections treated with potassium ferro- cyanide gave positive results for iron In several regions the alveoli - were filled with polymorphonuclear cells and fibrin In areas of fibrosis marked obliterative endarteritis was present holon, of e a.w v re Chemical examination yielded 240 mg silicon dioxide per 100 gm . ae | of dried ludiagnn osesdiagg noses - were Ts yas 2 1 The final diagnoses were Bronchiogenic keratinizing squa- on right . celled carcinoma of upper lobe metastases to mediastina-l3 lymph nodes right kidney and to a cortical adenoma of right ad- renal gland pulmonary asbestosis right ventricular hypertrophy: ae squamous metaplasia of bronchus bronchopneumonia of right upper +)": and middle lobes left pleural effusion fibrinous pericarditis Strepto-- ~.) coccus hemolyticus with effusion --- 0 e wh ey waTshe history clots was obtained from the patient's son after the autopsy completed His knowledge of some details was admittedly in- accurate - . E. a white male 58 years old began to experience dyspnea on exertion ap- _ proximately 15 years before his death This progressed slowly but steadily so that .. during his last few years of life he was almost completely exhausted after climbing . a - only one flight of stairs He had frequent bouts of coughing which were especially <4we= Pei severe in the morning but occurred throughout the day and night This was pro- 2 ductive of moderately large amounts of sticky brown sputum which was never ~ eogs ssras streaked During the spells of coughing wheezing noises in his chest could 4 be heard many feet away After several years he was examined by a physician ae ~- tor who made a roentgenogram of his chest and told him he had asbestosis of the lungs There was no history of cyanosis orthopnea paroxysmal dyspnea angina7 * pectSoerviesraolr manoknltehsedbeemfoare his death the patient began to lose weight rapidly He we ae complained of continual fatigue and his cough became more frequent and more iS - severe There was no change in the character of his sputum A physician told the family that the patient had developed complications following asbestosis 45, expired He sank slowly became comatose and finally The patient had been employed by a manufacturer of asbestos products since the age of 23 years until a few months before his death During the first 25 years of this period he was employed as a coverer the same occupation as in case 1.x Although there was no known association between the two men the conditions under which they worked were essentially the same The patient's work called for covering steam and water pipes with asbestos He was seldom in the same place unventilated S25 for more than a few days or weeks but the the work usually was done in cellars Large amounts of powdered asbestos cement were used in addition to the asbestos fabric The patient's son worked with his father for a year but quit because the air was too dusty and because several of the employees were getting ena sick During the 10 years before his death the patient was employed as a sale<s2 -7 man and was not exposed to asbestos dust S she Micr large r There v varying There v fibrous true gla In the present tissue in remaind masses v tions I characte marked : less com rhage Section unevenly Fig 6 few were sium ferr Additic muscular endarterit fibrinous . ahaa tain ehwn pan ak rte AM Se Pee Ech aime a iclear terroclear ferro- gm t squa- stinal t phy . cL, IN eeA aes wa CST bik vac tac %. See Ps 3 % pet bts Rnae eR ete ei F BRONCHIOGENIC CARCINOMA AND PULMONARY ASBESTOSIS 127 BRONCHIOGENIC BRONCHIOGENIC Both pleural E Postmortem Postmortem Findings Both cavities cavities almost completely completely Postmortem Postmortem by fibrous adhesions cavities almost completely cut cut 3 obliterated right between between pleural surfaces firm white white be surface lung tissue presented a diffuse infiltration infiltration was replacing replacing most the lower the promi- promi- oo neoplastic encirclement encirclement the septa by the new new bronchi and invasion the the right upper upper primary bronchial large round considerable variation in > hyperchromatic with the size and shape of the There considerable considerable cytoplasm E T oy YE eae KL - Ate.o NEbas sak Es oy that 4 teas. on roers oe Sf sieee reyek see fats OT ak.<= red tae ezer few were seen within positive iron potas- potas- wey ew quit sium ferrocyanide ferrocyanide were lungs included treated with the we quit Additional Additional findings findings small large = etting muscular muscular coat coat recanalization recanalization bronchi obliterative pulmonary organizing sales- pulmonary me endendarteritis endarteritis recanalization edema organizing eys exudate ary EAS surfaces fibrinous fibrinous on exudate the s edema 4nd Organizing oly ji ne urfaces, Fe SPT RARE PRS Ai texto SS ~ eae m eres Ree Sat . Bae SSe ate . an . Bik atti oo aii) Tr ee, i ed Be Ea sane ir { uy TABLE I = Summary of Reported Cases of Pulmonary Asbestosis and Carcinoma= | Authors Scx Year and age Occupation . Duration ol exposure | Freedom from exposure | before death an a os +e 4 Nature of 7 tumor i Primary cs, Primary oa site OT mos + Metralasca J8 ge mo fuga | | maeis M Weaver 21 yrs 4 Imos Squamous Right lower Many nodules in os 1 Lynch and 1935 Tobe a soon . right lower lobe |, Smith . 57 btn | Right 2 Gloyne Satelit | HOLEB 3 Gloyne 1935 F Spinner 35 yrs 8 yrs Squamous -- upper Pleura ct E Tobc 7) ot L ; - | 1935 F Mattress and 19 mos 5 yrs Squamoustou Right Tloboe wer Noa n, e 7 opening depts . 4. Egbert and Geiger s Gloyne | | 1936 M | Weaver 41 17 yrs 1 yrs Glandular 2 - oo = . Left lower lobe Widespread | { AND 1936 M Packer stores 10 yrs mos celled 59 department ' : Left lower lube Left upper lobe and pleura ANCRIST | ] q --Squamous lower Liver kidneys - a 6 Nordmann 1938 F Carder spinner 7 yrs ms Jobe avte 35 weaver | | 7 Nordmann 1938 M 7'YIS yrs Squamous - Left lower Widespread . : labe spinning . 55 assembly room TES | We Smith | M Weaver 13 yrs 3 yrs Squamous with Right lower Pleura medi- os 8. Lynch and 1939 glandular features Tobe astinal nodes 50 sae | Lobe adrenal 9. Holleb and Angrist pataFIO to Ilolleb and Angrist 1941 M | Pipe insulator 51 1941 M [ Pipe insulator 58 25 yrs 15 yrs 9 wks | keratinizing ' squamous 10 yrs | celled : Right upper Mediastinal nodes kidney | Right lower Widespread In- . Sobc cluding brain Included in previous tabulation by Nordmann coneivab viduals bestois monary longed which fibers arable it which is case tion The and cytosis which celyimtionarabalestciiytossiiss 3 of histc chronseve has kno the bu da a 3 e mi > 4 C C C 3 73 is : | . 2 =\/ BRONCHIOGENIC CARCINOMA AND BRONCHIOGENIC BRONCHIOGENIC PULMONARY ASBESTOSIS 129 . of dried lung, CARCINOMA 4-5 Mg. of silicon Chemical Chemical per gm . gm. examination yielded silicon of dried lung . were were oat carcinoma The The . diagnoses diagnoses . Bronchiogenic Bronchiogenic large celled carcinoma carcinoma cere- the extensperiipancoreatnitoc right upper kidneys mmeetasta-tasta- metacesrtea-- nodes vertebrae pulmonary asbestosis thoracolumbar vertebrae vertebrae pulmonary pulmonary upper lobe lobe. * to portion portion the as- as. there- Determinations silica were theredemonstration definitely definitely in- confirmation the diagnosis diagnosis of there there no reason appreciable on suspect suspect appreciable Py egy anaes SF : as os HE eth ieee one gs 2 et ae rr Fi dpgad ne b fame f ee Te:$e afb eR 7 5 2hth Uae veins co oor ee Yt ae Nordman, by tabultion previous la *tnctuded pe and respiratory symptoms and severe exertional dyspnea dyspnea dyspnea productive without without cardiac disease 2.(3) histological histological findings in namely namelydiffuse interstitial disease pul- asbestosis macrophages and giant as- 2". 075 . showing of these indi- sae. fe: viduals * iy Su ce & Pale } e employed employed for unusually periods periods in occupations occupations an viduals were exposure exposure unusually long periods low is which which conceivable that extensiavesbdaemsagte odsamagwe as relatively as summationtherefefofercte could as conceivable conceivable extensive damage could It is therefore result as a summation ^'effect, gk ak EOE See ash Fae emt eee rereretad Ee SA Ee erPsRLS tiseSpo arene ernstSGApL Re & Seat! Ql a, 4 Oo. a zee ah ends AB, aotabted nee WAR ow AtSe 7 ' ^' ale . ai ~ te ah + eter cEedt d dine t, a4Le r me vg >. to : [At ts Sw Red mele e e moet add tb meme Me et Ole Tate le Neh fet 130 falc TA.- HOLLEB AND ANGRIST . _ without appreciable accumulation of asbestos in the lung at any one time The combination of both factors may account for the particu-- larly Oo . low silica content in case 2 in which there was in addition free- ~ dom from exposure for 10 years before death * ,.- Nordmann presentedin tabular form the relevant on his own two data " cases of pulmonary asbestosis and carcinoma and of the four cases :previously recorded After analyzing the results he came to the con_ - - clusion that pulmonary cancer is an occupational disease among asbes- ~tos workers Gloyne in a recent text stated that no definite conclu- : =. sions can be drawn on the relation between these two diseases until material is available Table presents a tabulation similar to... ~~ Nordmann'sNordmann's but brought up to date by the addition of four cases in | cluding the two here reported It should be made clear that the data | . - are presented merely as a summary and not - as . necessarily supportive for Nordmann's conclusions . boos evidence _ the incidence - It may be of interest to review briefly for comparison of carcinoma in the material examinedin this department The figures are derived from the autopsy material of a general city hospital forfor acute illnesses with 696 beds of which 498 are devoted to adults In total of 2,451 routine autopsies performedin a year period there were 401 instances of carcinoma of all types Thisis an incidence of 16.36 per cent Of these 59 were bronchiogenic comprising 14.71 per cent of all carcinomas and 2.41 per cent the routine autopsies It was striking although naturally of no statistical significance to find bronchiogenic carcinoma in the only two cases of pulmonary asbestosis seen here ae 7 CONCLUSIONS 1. Two cases of bronchiogenic carcinoma in association with pul- monary asbestosis are presented 2. An attempt to demonstrate unusual amounts of silicain the lungs of both cases was unsuccessful 3. An explanation for the absence of elevated silica values in the presence of asbestosis is offered 4. The relevant data of all reported cases of pulmonary asbestosis presented and carcinoma are in tabular form wish appreciation NOTE The authors to express Distler for the clinical data and their grateful to Richard Grimes and to Goodwin A. Howard W. Neail the of the Office of the Chief Medical Examiner for the autopsy material opportunity to study RIN ireSate : 2 mA . wiaiete Mpa 8 eS ae=rth Rae eR . A ate6 t REFERENCES REFERENCES silicosis t. CARCINOMACARCINOMA ca)B Lynch, K. M., and lung in REFERENCES REFERENCES REFERENCES A. Pulmonary asbestosis Carcinoma of of 1. Lynch Pulmonary M. asbestosis silicosis . asbestosis asbestosis Carcinoma : silicosis Am J. asbestosis Cancer Tubercle oat 2. Gloyne asbestosis Tubercle Tubercle asbestosis asbestosis Tubercle 1935-36 1935-36 , 17 5-10 cell carcinoma pf lunglung occurring occurring asbes- ashes. 3. Gloyne Tubercle Tubercle Tubercle 1936-37 18 necropsy necropsy findings Asbestarbeiter Martin Martin Der Asbestarbeiter Ztschr Asbestosisk^rperchen carcinoma Sundius Asbestosislunge Sundius Beschaffenheit epithelial epithelial metaplasia Bygden sogenannten V. report report Cancer of bron- bron. Cancer 36 567-573 567-573 Staubinhalt einer Gewerbe- die Beschaffenheit 8. path Gewerbehyg Gewerbehyg sogenannten sogenanten Asbestosisk^rperchen Arch Gewerbe- Gewerbe- tuberculo- McNally McNally McNally W. D. Silicon dioxdiiodxiede content of lungs health health disease Kettle and H. A. M.+ 1933 ArcherArcher H.H. E. The differential diagnosis . 1933 25 811-824 tuberculo- disease, J. M. asbestosis IV The asbestos body and similar ~ Ur, jects jects in R. A. 1937 109 1974-1978 ob- Gloyne Gloyne 19L3a8n2 za3, 8 A. Silicosis and AsbestosisAsbestosis Oxford 12. 12. Idem p University ~ ~ Z 4 tb < SINeK deagPs we ees te nes, ath be. ats Naony 4 Rt ^'s oO an i ate ( Pet gies, & TAO + . Eg xO : a a wes 0. 3 o ~ eae eT Te oF Bat) . . = Ks 2 aS Ace iae, ay, A Tea Ca Bg *, Ge 5 - * CAThen - MLSE ome ae : oot eet se atk w aed pee $8 m ie xt ane nae, ne a ate ne . > " Ss reais renitaRa Mg" ? be? . Je ve di z - ow q : o a, x Cas Sea eBS _ ~~. mB oe apn 24 4 ? ees a5 7 4 arene s + Verret st! }