Document 716Z5aNoY4MQV2XYmnvOO4L8o

Mesothelioma and Asbestos Exposure J-> " J**-. -v^-r^ ` Jan Llebrn, MD, and Harry pistauika, MD, Harrisburg, Pa Q 00 UJ O _J the past five years several arti- Sacconi and Coblenz10 give the incidence {--* u~ ij&ve called attention to the association of pleural mesotheliomas as 1.1 cases per mesotheliomas of the pleura and 1,000 autopsies. Campbell reported four fIrpW OA with asbestos exposure.1-3 cases of pleural mesotheliomas in 3,533 con Signer et al* studied 33 cases of meso- secutive autopsies.11 ~T) yS-erta AH but one had probable exposure s cocidolite, the blue asbestos. A&estos has become a ubiquitous materi- Mesothelioma occurs primarily in adults and is twice as common in males as in females.10-12 O c; O ia.our civilization. Cauna et al5 reported Pleural mesotheliomas occur equally on rsi asbestos bodies were found in the lung the right and left though Wetssman feels c/'> ,-7^rs of 41% of 100 consecutive autopsies that pleural mesothelioma occurs on the 5* Presbyterian University Hospital in right more frequently than on the left o Thdrargh. Similar findings were reported side.11 Thompson6-7 in 500 consecutive lung The criteria for diagnosis of pleural meso Is from Capetown, South Africa, and thelioma are presence of a firm pleural mass UJ o Vo-- Fla. Asbestos bodies were found in encasing the lung, histological structure 1% of the men and 20% of the women. As- compatible with mesothelioma, and absence a^s has been conclusively associated with of a demonstrable primary malignant neo iireased incidence of lung cancer and other plasm elsewhere. The histologic architecture sSghancies8- and an increasing number may be mesenchymal, "epithelial," or fsfedies associate its presence with malig- mixed. i=t mesothelioma of the pleura and perito- A complete autopsy is necessary for une tuny quivocal diagnosis, but for the purpose of m- Pathology this study, criteria were made less rigid in that unautopsied cases were accepted if a definite diagnosis of pleural mesothelioma ^Mesotheliomas of the pleura and peritofem are rare neoplasms. Controversy inwym histological types, nomenclature, ori- and their very existence. Recently, 5etheliomas as an entity have become Psoally accepted. Their morphologic vari ety makes classification difficult and difk^ntiation from other malignancies is often fproblem. 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. Primary tumors of the peritoneum are among the rarest of tumors. Generally called mesotheliomas, they form large spreading masses over the peritoneum and histologi AAmitted (or publication June 6, 1966; accepted cally appear the same as pleural mesothe s?* 13. liomas. As with pleural mesotheliomas, ex fj^ruai tba Division al Occupational Health, De- clusion of a primary tumor is necessary. fytnsent ot Health, Harrisburg, Pa. ^Saad before the Ninth International Cancer Con- - , Tokyo, October 1966. This study is an attempt to. learn the ex tent of the relationship of asbestos exposure tprint requests to PO Box 90, Harrisburg, Pa I (Dr. Ueben), with mesothelioma diagnosed in southeast ern Pennsylvania. `GC Arch Environ Health--Vol 14, April 1967 14695 vi ` M j i&.:' & | BB 0005521 ^ j - X 560 MESOTHELIOMA--LIEBEN & PISTAWKA __ _ MESO Method Table 1.--Readings of Consultant Pathotogfot One hundred and sixty-two hospitals serving a population of 6% 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 was read as metastasis and one slide as anaplastic malignancy). Of the 15 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 this 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, eight either lived in the immediate neighbor hood of asbestos plant* 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 Asbesto* Bodies 1-0 3*0 4-0 5-0 6-0 9-0 10-0 2-N 3-N 4-N 6*N l-F 2-F 3-F 1-Q 2-Q 4-0 5-0 6-Q 7-Q S-Q 9-Q 10-0 1-X 2-X 3-X 4-X 5-X 6-X 7-X 8-X 9-X 10-X Ye* Not acceptably Probably not Ye* Probably not Probably not Yes Ye* Probably not Not acceptable Yes Ye* Ye* Ye* Probably not Ye* Ye* Probably ye* Not acceptable Ye* Ye* Probably not May be Metast Yes Ye* Not acceptable Not acceptable Anaplastic malignancy Probably not No epithelial cells Mesothelioma must be proven Probably not Ye* Yes ` No lung tissu. Ye* No lung tissu. Yes Yes No lunr* ttv-u* Ye* No lu~ No lu -.-.ua No 1u *, ijf No 1 uf, * lis'tiis No lun*; No lung t'S*u No lung tissue No lung tissue Ye* No No No No lung tissue No No No Yes No lunr No lunr No lung ;i _,,u* 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 -i-- bestos plant. Patients 2-0, 3-0, and 4-0 worked more a 20 years in asbestos insulation plants ami tient 5-0 worked in an insulation plant for '<ni\ 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 !> worked more than 30 years in the office of asbestos textile plant. Patient 10-0 was a plasterer who came contact with a large amount of asbestos in hi- 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 55- year-old woman who never bad any oecupa- ^ JIG& D.GiWT DID _\NGIC0MLER0M^---'L^ I '^Mbestos exposure. Her' vlnBl; waS b0rn 3nd " It'ja the immediate neighb- textile and friction mat. 1-0 bad worked for 35 I ' j she lived for 30 years I the plant where patient ' * IS years. j^tfent 2-N, a clergyman ft Jj, in 1961. never had any exposure. Prior to bee ,elived for 19 years within < . fa insulation plant where 5-0 bad worked as insul jgworkers. Patient 3-N never had an exposure except that, * death, be bad worked f< 1 it street from the insulatic I * the history of patient 2 | p*fient 4-N worked for : i ired from the insulation * onnection with patients 2 { patients 5-N, a nurse, ai I ribntor, bad no occupat. I holly contact with asbest j rithin three fourths of a i ; plants in a town with the ; mesotheliomas in this stud Patients 7-N and 8-N wt dotage battery plant. A pint and their employm {\ asbestos exposure, pa j plant is located less than bestoe textile plant. The . I cues is questionable. , - '.Patients 1-N and 4-N h | Gents 2-N, 3-N, 5-N, 6-1 pleural mesotheliomas. l -Mesothelioma Patient bet* Exposed to Asbest. year-old child, was the . engineer who worked v that utilizes 400 tons c rod 1,500 tons of South tUy. ~-_r Patient 2-F, a 40-yea my occupational asbest tier had worked for 35 _ plant where patients worked and which was neighborhood cases. T lad worked in this pi V Patient 3-F, a 67-yet ;*ny asbestos exposure asbestos plant S I ^Worked as insulators ^'jears. These sons live flerw as-;' BB 0005522 | I-- \\jTtsbeslos exposure. Her work w*as always she was born and lived until the age the immediate neighborhood of an astextile and friction material plant where te3i 1-0 bad worked for 35 years. From the \jofi8 she lived for 30 years across the street J.a as plant where patient 6-0 had worked j Sr It years. , pitient 2-N, a clergyman from 1935 until his ! ttih-in 1901, never had any occupational as! exposure. Prior to becoming a minister 1 jiCved for 19 years within one half of a mile ; jinsulation plant where patients 3-0, 4-0, #15-0 had worked as insulation manufactur- ef workers. patient 3-N never had any occupational as- exposure except that, 20 years prior to ^ death, he had worked for one year across e street from the insulation plant mentioned ~ the history of patient 2-N. Pstient 4-N worked for 26 years across the (ieei from the insulation plant mentioned in "miction with patients 2-N and 3-N. Patients 5-N, a nurse, and 6-N, a meat disrxutor, had no occupational exposure nor 'rr.ilj contact with asbestos. They both lived irithia three fourths of a mile of two asbestos a town with the greatest incidence of oe^^Aomas in this study. TWrots 7-N and 8-N were both foremen in a mage hattery plant. A careful check of the ,~ant and theix employment records revealed to asbestos exposure, past nor present. The jnt is located less than 1V4 miles from an as* iotas textile plant. The exposure of these two t*s is questionable. ' Patients 1-N and 4-N had peritoneal and pa5=ai 2-N, 3-N, 5-N, 6-N, 7-N, and 8-N had Jwral mesotheliomas. . Mesothelioma Patients With Family Conbits Exposed to Asbestos--Patient 1-F, a 3* 7r-old child, was the daughter of a ceramic ciiieer who worked in an insulation plant Cist utilizes 400 tons of Canadian chrysotile *ad 1,500 tons of South African amesite annuaHy;.- Patient 2-F, a 40-year-old nurse, never had T occupational asbestos exposure, but her fa- bad worked for 35 years in the insulation plant where patients 3-0, 4-0, and 5-0 had nrled and which was also credited with three Bchborhood cases. The nurse's brother also lad worked in this plant for one year. -^Patient 3-F, a 67-year-old woman, never had .*ny asbestos exposure nor had she lived near a* asbestos plant She had two sons who *OTlr*d as insulators in a shipyard for six ^^^khese sons lived at home until 15 years their mother's death. Patients 1-F and 3-F had peritoneal and pa tient 2-F pleural mesotheliomas. Mesothelioma Patients With Questionable Asbestos Exposure.--A study of these ten men elicited either a relatively minor or question able exposure to asbestos. Patient 1-Q was a welder for 35 years. Ac cording to a common reference,13 eight out of 12 welding electrodes contain asbestos, which is used as a filler. Patient 2-Q was a self-employed Swiss-born Swiss cheesemaker. A thorough study of the processes of Swiss cheese manufacture revealed no use of asbestos. During the study of the manufacturing process a 500-gal boiler was no ticed. This boiler was covered with a friable as bestos insulation which flaked off on contact. Patient 3-Q, a 14-year-old boy with mesothe lioma, had no occupational contact with asbes tos nor did any of his family. On questioning, the boy's father told the authors that his boy had lived with him and had helped him while he had replaced most of the plaster board dur ing extensive remodeling of his house. Plaster board contains a high percentage of asbestos. Patient 4-Q is employed in industrial sales and never had any occupational asbestos expo sure. Extensive questioning revealed that, on two occasions several years before, he applied asbestos insulation to boilers in his home, mix ing asbestos cement himself. His total exposure during these applications was only a matter of hours. Patient 5-Q was a brewery worker for 20 years. The brewery was no longer in business when the case was investigated. Reviewing the literature of beer production the following paragraph was discovered: "When ready for packaging the beer is fil tered through pulp filters consisting essentially of cotton fibers and asbestos. After each filtra tion this `FILTERMASS' is removed, mangled, and washed in clear, warm water, then bleach ed and sterilized at 160 to 180 F with chlorine. The washed pulp then goes directly to a pad forming machine where it is compressed at 89 to 90 pounds per square inch to form new filter pads.14" Asbestos-containing pipe insulation is used in breweries. Patients 6-Q, 7-Q, and 8-Q were all 3teel workers. Patient 6-Q was a crane operator; 7-Q a forger; and 8-Q a foreman and supervisor. In all cases the companies did not recall any as bestos exposure for these men. Pipe insulation containing asbestos is extensively utilized by steel companies. Patient 9-Q was a spinner in a silk company o co tr"" c5 o oo r? Arch Environ Health--Vol 14, April 1967 , Hrn GG 'i r lw J * rtr e V1 fpgi _4*1------------ Ld from 1925 to 1938, and later in a plastic fabri cation plant which utilized fiber glass; he also whhhaeKasd,ouifobsreefednassaibbewwsieettollvddseeiburrulfttooccrroo2u2u55llddyynneooattrsriw. HHSU,*ee*isWttshh;hiinennnkekse,anhhlsdeeo sUTnhtiisasl tuedvyidPernecseeCnetosnm.dmgoemonadt n.dye.e.u! uatmceuewTMeM, pISent 104*. a 63-year-old man, was a BSSSsSrSSrSn.SXiA^bto.cn^*---- Asbestos is a ubiquitous mtiU-rml quriemstTioknesr, all his life He worked in two founized. Some uses, such as in the I,TM,, m^*ujgchthemexpionorcseieddfernepcqeou,peounnlatllytyioatnhnan is so are precedents for this small ' were not previouslv * ~i which acts in a son ^er,e:tr?f" * r-r" J g occupational diseeaasse: ^- n*-e*,i'rgfKhJb-uo'\rr-hrwo'Wod? cf^aqspe-ss; ft*iT fahds rate, and a long la hTl'I'TM' ,0 ,h` nonet of ^V'me !ev'rel Causative that <** l^sea exposure and onset v-a-- -* ss i:. * I ' jiDQtber question whic '* ft'g&iszaall, mesotheliomas are * "* ^ ^ -- -onto. MesotleUom. aJ sepo7,,re Jlf The ^ X) ,,mt* ra the other if p,(; au* ^estos bestos textile e msulation workcrj^ ,"n | bqusnt than peritoneal n vJhe most striking findir { e<'aa5a*i3',ec9t.thif`rr_aoo_tmm_-o_aa_f--_-gt_-h-_e-e-o-_-g-_4-r_-a2--pLh--m!i_ceas1lol . jBiety 30,000 sq mi, six Ten ?of fkTpoPsauHre'"e`>vidheandceL c"ofufMcd ,.<lS b'hocrfilteodi hnerighborhorvl io^fearmitIhyanJTMthn*. "v i1 | &jtgS&jejs,aearroiionnuuccnnllduudddaeeanddn titniwwnsoosuuliilannatsstiiouuonllia } if workers (Cases 2-0 The attack rat . e for mesothelif); IvOTf^' TUfO rnn 'u.w.M.ibDV. O... C. i;OuiWrftuS'.MNJ TUDlUlK"aitiWent r2 s COsvIit* FRGiVs>k/riiA.S FrnPnG FruILEf-S-- $ i i ttcnijgbfbaboorhrhoooodd ccaasseess ((CCaasset s (; { JSQ).aandd one family contact ft f&iraigzhHtierr ooff aann iinnssuulalattioi r j Sununa I I -nForty-two cases of me ttUlk------ I ad from 152 hospitals ov ! td, were studied with re; Patient 3-N4-N i j n. I Patient 2-0 3-0 o. o t&estos. Survivors or e (s*re questioned regardir .ssbestos exposure. Ten aorled in asbestos pin ( 'forked dose to an asbe . patients were family ir j ^workers. In ten patien Other Indus try 4*f>esto* Plant { ^turned exposure to ash ifter prolonged questioi of Pother [Brother P>tlent 2- Occup*tinal, neighborhood, insulation plant and f3miJy COftt^ patient* STREET with mesothelioma associated with one Arch Environ Health--Vol 14` April 1967 GG IA69G XT: ", Many of the drug dent For example, i power of cinchona verish Indian lost Xj-hV water. From the b poison from the c deeply so as to bris When he returnee fgi bark was used as taught the Span!? Roasman, R.E.: T Coll Physicians l I BB~0005S24' MESOTHELIOMA--LIEBEN & PISTAWKA 533 f circiu^nswertJ nal "aUy real. bre-.ve^ ; wr:'ten' ~rs. y be the lalignani Scribed Eninimaj on of a 'Jpatfon"3 or asy many of the S- Simispo ted > is ex- jpanely low. Not all mesotheliomas were re ported to us by the hospitals, but, even if we ^uble the incidence, only a minute fraction J the exposed population was affected. }beie are precedents for this with beryllium jgsease which acts in a somewhat similar pattern; occupational diseases, familial con tacts, neighborhood cases plus a very low ,ttack rate, and a long latent period be tween exposure and onset of disease. ..-Another question which arises is why pleural mesotheliomas are so much more frequent than peritoneal mesotheliomas, ;=.The most striking finding of this study ris that of the 42 mesotheliomas which came from a geographical area of approxi mately 30,000 sq mi, six were clustered in md 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 V"*r ; V Forty-two cases of mesotheliomas report~ed from 152 hospitals over a five-year perl'od, were studied with regard to exposure to .asbestos. Survivors or employers, or both, ;-^re questioned regarding the possibility of -'.asbestos exposure. Ten patients actually (Worked in asbestos plants; eight lived or c worked dose to an asbestos industry; three `patients were family members of asbestos .^workers. In ten patients a history of asi sumed exposure to asbestos was obtained R after prolonged questioning. In II other pa tients no history of asbestos exposure could be obtained. References 1. Newhouse, M.L., and Thompson, H.: Mesotbe? 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 Mesotbe* liomata and an Analysis of Their Association With Asbestos Exposure, Thorax 19:268-277, 1964. 3. Selikoff, I.J.; Cburgh, J.; snd Hammond, C.: Exposure to Asbestos and Mesothelioma, New Eng J Med 272:560-563 (March) 1965. 4. Wagner, J.C.; Sleggs, C.A; and Marcband. P.: Diffuse Pleural Mesothelioma and Asbestos Exposure in N.W. Cape Province, Brit J Industr Med 17:260-271, 1960. 5. Cauna, D.; Totten, R.; and Gross, P.: Asbestos Bodies in Human Lungs at Autopsies, JAMA 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 Afr 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 Industr 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. 1L Campbell, W.: Pleural Mesothelioma, Amer J Path 26:473-487, 1950. 12. Weissman, H.: Primary Endothelia of the Pleura, Dis Chest 12:562-570. 1946. 13. Lyman, T. (ed.): Metals Handbook: 1. Prop erties and Selection of Metals, ed 8, American Socie ty ot Metals, 1961, p 5. 14. Modern Chemical Processes, New York: Rein hold Publishing Co- 1952, vol 2, p 167. iw.' Q CO Oo 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, he recovered completely. When he returned to his village, he told the store 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 GG ^699 j | 1_BB 0005525*7 ' r