Document 93r8w0GK428Ka78Jv9oo063rq

Journal of Environmental Pathology, Toxicology and Oncology, 15(2-4):1U-I94 (1996) Malignant Peritoneal Mesothelioma Following Asbestos Exposure Osman Manauoglu,1 Biilent Orhan} Tiirkkan Evrensel,1 Tillay Ozqelik,s Ibrahim Yolcuf and Esra Kunt2 . Clinical, epidemiological, and pathological studies have demonstrated that asbestosis plays a major role in the etiology of mesothelioma. The direct exposure of workers in industrialized countries to asbestos fibers and nonoccupational household contact elevate the risk of malignant mesothelioma. An increased risk has been found in certain geographic areas of Turkey due to the presence of asbestos deposits and the use of the material known as "white soil" as an insulation. We present a malignant mesothelioma case from rural eastern Turkey with a history of asbestos exposure from using "white soil". We review the epidemiological aspects of asbestos as they relate to mesothelioma. KEY WORDS: malignant mesothelioma, peritoneal mesothelioma, asbestos exposure, asbestos and cancer, mesothelioma and asbestos exposure. Introduction Malignant mesothelioma is a tumor that arises from the mesothelial cells lining the body cavi ties.1 It can occur in any body cavity, most fre quently in the pleura and the peritoneum, but can also occur in the pericardium and tunica vaginalis of the testis.1-1 This tumor is difficult to diagnose and has a poor prognosis. The inci dence of mesothelioma appears to be increasing, and its relationship with environmental and oc cupational asbestos exposure has been docu mented.1 The relationship between asbestos fi bers and malignant pleural and peritoneal mesothelioma has been studied intensively since the original observation by Wagner et al.3 As bestos exposure continues to be the primary cause of pleural, peritoneal, and probably also epididymal mesothelioma.16 We describe a case of ma lignant mesothelioma, a rare disease in a 52- Depai Iment of Medical Oncology, Uludajj University Medical School, department of Internal Medicine, Uludag University Medical School, Bursa, Turkey. Address all correspondence to Prof. Dr. Osman Manavogtu, Department ofMedical Oncology, Uludag University Medical School, Goriikie, Bursa, Turkey.* 9 year-old woman. The diagnosis was, based on light microscopy, CT findings, hronchoalveolar lavage, and evaluation of the clinical course. Exposure to asbestos filaments was suspected because of the patient's history and traces of as bestos were found in the hronchoalveolar lavage. The case is reviewed here because of its rarity and its relationship to environmental factors that present a public health problem in Turkey. Case History A 52-year-old housewife from the village of Diyarhakir, located in southwestern Turkey, was admitted to the Gastroenterology Department of Ulnda'g University Faculty of Medicine with the chief complaint of abdominal distention and pain lasting 1 year. She described the pain as starting from the periumbilical region, radiating, through out her entire abdomen, and lasting for hours. During the last three months, she noticed a slowly progressing abdominal distention and, after this finding, was admitted to the hospital. Personal history: She grew up in Diyarbakir in the southeast part of Turkey and lived in that district until 30 years of age.. She gave a history 0731-3B9S/96HS,IH> 9 199 by Begeli Houee. Inc. 191 MANAVOGLU ET AL. of using "white soil" as an insulation material on her house walls. Her family history was unre markable for pathological findings. Physical ex amination'. Ascites and tenderness on palpation of the abdomen was found with no guarding or rebound tenderness. No other pathological find ings were found. Diagnostic work-up: CEA: 0.2 ng/rnL (N1 = 0.5 2), CA-125: 334 U/mL (N1 = 0-35), CA19-9: 20 U/ mL (N1 -1-37), CA 72-^: 1 U/mL (N1 = 1-4). Abdominopeluic ultrasonography: A 4-cm cyst with a thick wall was seen in the right ovary and a 14-mm solid mass was seen in the anterior part of the uterus.Abdominopelvic Computerized Tomography (CTJ: A large amount of ascites was found. Perito neal implants and infiltration of the omentum were noted in the anterior part of the abdomen. A mass 5 x 4 cm in diameter with cystic and solid compo nents was found in the right part of the uterine fundus. No pelvic or paraaortic lymphadenopathy and no metastases to the liver or other intraab dominal organs were identified. Bone scintigraphy revealed no evidence of bone metastases. Based on the radiological findings and the el evated CA-125 level, a probable diagnosis of ova rian cancer was formulated. At laparotomy there was a 2 x 2 cm tumoral mass in front ofthe uterus, invading the sacrouterine ligaments. A tumoral mass 4x4 cm in diameter was seen in the Douglas pouch and a tumoral mass 3 x 4 cm was seen in the mesocolon of the descend ing colon. Another tumoral mass 4x4 cm was found in the omentum. The subdiaphragmatic surface was studded with tumoral implants less than 1 cm in diameter. A total abdominal hysterectomy, bilat eral salphingoopherectomy omentectomy, and tu moral mass excision were performed. The histopathological examination of the tu moral mass showed a malignant mesothelioma. Her history of using "white soil" as an insulation material was thought to be the source of asbestos exposure. A thoracic CT scan was performed that revealed bilateral pleural thickening, calcifica tions, and linear opacities in the inferoposterior part of the right lung, probably due to asbestosis. A bronchoalveolar lavage produced a 12.4 mL asbestos clump, indicating high exposure to as bestos. The bronchial lavage cytology was benign. Discussion The word asbestos is derived from the Greek word asbestinon (incombustible), owing to its re sistance to heat and combustion. Asbestos is the commercial name for hydrated magnesium sili cate fiber, categorized as either serpentine or amphibole minerals,1*6 depending on whether they are curved or straight (Table 1). Asbestos miner als appear to provoke carcinogenesis because of their physical composition. The long rod-like fi bers with narrow diameter are thought to induce tumors in laboratory animals. After entering the airways, most fibers are eliminated by coughing or by swallowing and elimination in the feces. The remaining fibers in the lungs are ingested by macrophages, liberating free radicals and lysoso mal enzymes, which initiate an inflammatory and fibrotic process. Protooncogenes are upregulated from alveolar macrophages in the fibrotic lungs that enhances mesothelial cell proliferation.1*6-8 It is not known how asbestos fibers are trans ported into the peritoneum. It is thought that the fibers are transported from the lung via lymphat ics and that swallowed filaments are transferred into the peritoneal cavity across the gut mucosa. Peritoneal mesothelioma occurs only in patients exposed to amphiboles, probably because chrysotile fibers disintegrate in the abdominal tissue.7 The link between asbestos, asbestosis, and pleu ral and peritoneal mesothelioma are well estab lished. Asbestos-related diseases are seen in people exposed to asbestosis (Table 2).1*2*6*7 Asbes tos minerals adsorb hydrocarbons that may in crease the risk oflung cancer in people who smoke and are exposed to asbestos fibers. The risk of lung cancer in smokers with a history of asbestos exposure increases almost 60 times compared to smokers without asbestos exposure.9 A higher incidence of gastrointestinal and laryngeal can cer has been reported in individuals exposed to asbestos, but whether this is a direct or casual relationship is undetermined.6*10-12 TABLE 1. Classification of Asbestos Minerals. Serpentine minerals (curly and pliable) Amphibole minerals (straight, needle-like fibers) Chryeotile Crocidolite Amosite Anthophylite Tremolite Actinolite 182 JEPTO 1996. Volume 15, Numbers 2--4 MALIGNANT MESOTHELIOMA TABLE 2. Established Asbestos-Related Diseases. Asbestosis Pleural reactions Pleural effusions . Pleural thickening Malignant Mesotheliomas Pleural Pericardial Peritoneal Testieular Other Neoplastic Diseases Carcinoma of the bronchus ' Extrapulmonary carcinomas (gastrointestinal and laryngeal carcinoma) A diagnosis ofperitoneal mesothelioma depends mostly on the clinical evaluation and histopathological studies. There is no specific clinical or ra diological finding for this disease. CT findings may be important in evaluating pleural malignant mesothelioma. However, in peritoneal malignant mesothelioma, various nonspecific findings such as ascites, pancreatic masses, peritoneal nodules, and omental infiltrations may he seen.13-18 No spe cific tumor markers for malignant mesothelioma have been reported in the literature. Asbestos exposure continues to be the pri mary cause of pleural and peritoneal mesothe lioma.16,19-23 The risk is related to the duration and intensity of the exposure.6'18 20 21 Thus, those exposed at a younger age are at higher lifetime risk.2-24 Dust concentration, the duration of expo sure, and a person's cellular or humoral immu nity play a role in the progression of asbestosrelated disease. Occupational exposure is the main problem in Europe and the U.S.1,6,10,19,25 The fami lies of asbestos workers are also at risk because of the workers' asbestos-exposed hair and cloth ing.6 Asbestos items brought home from the work place also constitute a risk. Unlike malignant mesothelioma that is caused by occupational exposure in developed countries such as the U.S., malignant meso thelioma in Turkey is mostly caused by envi ronmental exposure.2,13,26 The type of asbestos responsible for malignant mesothelioma in cases of occupational exposure is chrocidolite or amosite, but environmental exposure-related malignant mesothelioma is usually caused by tremolite.26,27 Erionite, a natural fibrous zeo lite, has been shown to cause malignant mesothelioma in central Turkey. There are many asbestos deposits in rural parts of central and eastern Anatolia. The types of asbestos found in these regions, tremolite or chrysolite, have no economic value.2,26 Inhabitants use tremolite asbestos contaminated soil (called white soil) as a whitewash, a substitute for baby powder, or a plastering material used on roofs as insulation or to prevent water leaks. One of the most important routes of domestic exposure is the dust from the walls of homes whitewashed with tremolite-contaminated soil. Turkish and Greek villagers also used this soil in the past as a white stucco because of its brilliance and because it does not stain easily.2 The major occupations of the residents in rural central and eastern Anatolia are agriculture and livestock breeding. It is clear that in these areas there is no occupational exposure to as bestos or from the use of asbestos-contaminated products, so we can assume that cases of malig nant pleural or peritoneal mesothelioma are caused by environmental exposure. Our case was typical of environmental expo sure-related malignant peritoneal mesothelioma, because there is no history of occupational expo sure to asbestos. Our patient lived in a rural area in eastern Turkey and had no family his tory of occupationally asbestos-exposed family members. She did have, however, a history of using "white soil" to insulate walls. A latency period of about 30 years is the expected latent period of time reported in the literature for the carcinogenic effect of asbestos filaments to oc cur. The CT findings of benign asbestos plaques in the lung and the presence of amphibole asbes tos filaments in the bronchoalveolar lavage may support the diagnosis of asbestos exposure-re lated peritoneal mesothelioma. The elevated CA-125 level was an unexpected finding in this patient as this antigen has not been reported as a specific tumor marker for malignant peritoneal mesothelioma. In conclusion, malignant peritoneal meso thelioma, although a rare tumor, should be consid ered when evaluating a slowly growing abdominal mass in residents ofareas where asbestos-related malignant mesothelioma is endemic. It is impor tant to question patients about the possible expo sure to asbestos fibers, especially in countries such as Turkey where asbestos-related diseases are a public health problem. JEPTO 1996, Volume 15, Numbers 2--4 193 MANAVOGLU ET AL. References 1. Antman KH, Li PF, Pass HI, Corson J, Delaney T. Benign and malignant mesothelioma. In: DeVita VT Jr, Heilman S, Rosenberg SA, eds. Cancer: principles and practice ofoncology. Phila delphia: J B Lippincott, 1993; 1499-1508. 2. Barig YI, ed. Asbestos and Eritonite-related chest diseases. Ankara: Semih matbaacilik, 1987; 113-169. 3. Mirabella F. Pericardial mesothelioma. Evolu tion and update in the last decade (Italian). Pathologica 1993; 85:377-386. 4. Loire R, Tabib A. Malignant mesothelioma ofthe pericardium. An anatomo-clinical study of 10 cases (French). Arch Mai Coeur Vaiss 1994; 87:255-262. 5. Wagner JC, Sleggs CA Marchand P, Diffuse pleu ral mesothelioma and asbestos exposure in the northwestern Cape Province. Br J IndMed 1960; 17:260-271. 6. Antman KH. Natural history and epidemiology of malignant mesothelioma. Chest 1993; 103 (Suppi 4):373S-376S. 7. Passero MA, Calabresi P. Neoplasms of the me diastinum and the mesothelioma. In: Calabresi P, Schein PS, eds. Medical oncology. New York: McGraw-Hill, 1993; 625-648. 8. Rom WN, Travis WD, Brody AR. Cellular and molecular basis of the asbestos-related diseases. Am Rev Respir Dis 1991; 143:408-422. 9. Hammond EC, Selikof IJ, Seidman H. Asbestos exposure, cigarette smoking and death rates. Ann NY Acad Sri 1979; 330:473-490. 10. Sane M, Vujovif M. Malignant tumors in an area with an asbestos processing plant. Public Health Rev 1994; 22:293-303. 11. Fischbein A, Luo JC, Pinkston GR. Asbestosis, laryngeal carcinoma, and malignant peritonea] mesothelioma in an insulation worker. Br J Ind Med 1991; 48:338-341. 12. Albin M, Jakobsson K, Attewell R, Johansson L, Welinder H. Mortality and cancer morbidity in . cohorts of asbestos cement workers and refer ents. Br J Ind Med 1990; 47:602-610. 13. Erzen C, Eryilmaz M, Kalyoncu F, Bilir N, ahin AA, Barig YI. CT findings in malignant pleural mesothelioma related to nonoccupational expo sure to asbestos and fibrous zeolite (eritonite). J Comput Assist Tomogr 1991; 15:256-260. 14. Smith TR. Malignant peritoneal mesothelioma: marked variability of CT findings. Abdom Imag 1994; 19:27-29. 15. Sans N, CnuddeF, ChevallierJ, MathieuS, Giron J, Railhac JJ. A rare peritoneal tumor; malig nantmesothelioma (French). Ann Radiol (France) 1993; 36:118-124. 16. Suzuki Y. Diagnostic criteria for human diffuse malignant mesothelioma. Acta Pathol Jpn 1992; 42:767-786. 17. Guest PJ, Reznek RH, Selleslag D, Geraghty R, Slevin M. Peritoneal mesothelioma: the role of computed tomography in diagnosis and follow up. Clin Radiol 1992; 45:79-84. 18. Weidner N. Malignant mesothelioma of the peri toneum. Ultrastructr Pathol 1991; 15:515-520. 19. Spirtas R, Heineman EF, Bernstein L, Beebe GW, Keehn RJ, Stark A, Harlow BL, Benichou J. Malig nant mesothelioma; attributable risk of asbestos exposure. Occup Environ Med 1994; 51:804-811. 20. Leigh J, Rogers AJ, Ferguson DA, Mulder HB, Ackad M, Thompson R. Lung asbestos fiber con tent and mesothelioma cell type, site and sur vival. Cancer 1991; 68:135-141. 21. Roggli VL. Malignant mesothelioma and dura tion of asbestos exposure: correlation with tissue tissue mineral fiber content. Ann Occup Hyg 1995; 39:363-374. 22. Saitoh K, Muto H, Hachiya N, Takizawa Y. As bestos body and fiber concentrations in patho logical autopsy tissues of patients with malig nant peritoneal mesothelioma. Bull Environ Contain Traded 1993; 50:325-332. 23. Davis JM, Bolton RE, Miller BG, Niven K. Mesothelioma dose response following intraperitoneal injection ofmineral fibers. Int J Exp Pathol 1991; 72:263-274. 24. Andrion A, Bosia.S, Paoletti L, Feyles E, Lanfranco C, Beilis D, Mollo F. Malignant peritoneal mesothelioma in a 17-year-old boy with evidence of previous exposure to chrysolite and tremolite asbestos. Hum Pathol 1994; 25:617-622. 25. KarjaLainen A Meurman LO, Pukkala E. Four cases ofmesothelioma among Finnish anthophyllite ' miners. Occup Environ Med 1994; 51:212-215. 26. Selfuk ZT, Qijplii L, Emri S, Kalyoncu AF, f?ahin AA, Bari? YI. Malignant pleural mesothelioma due to environmental mineral fiber exposure in Turkey. Analysis of 135 cases. Chest 1992; 102:790-796. 27. Sjahin AA, oplu L, Selfuk ZT, Eryilmaz M, Emri S, Akhan O, Bari$ YI. Malignant pleural meso thelioma caused by environmental exposure to asbestos bodies or eronite in rural Turkey: CT findings in 84 patients. Am J Roentgenol 1993; 161:533-537. 194 JEPTO 1996, Volume 15, Numbers 2--4