Document 9z3bRZB3ELw9pwnYZwVeLOZD

FLEUR. CALCIFICATION AND MESOTHELIOMA FOLLOWING EXPOSURE TO ASBESTOS Bv S. J. Steel andJ. Boyd Tlie London Cbesl Hojjjiial, London, E.a., and The Romford Chcit Clinic, London In i960 Kiviluoto investigated 126 eases of pleural calcification in Northern Karelia, Finland, and found that the majority lived in the vicinity of two anlhophyllite mines. He attributed the pleural calcification to non-occupational qndcmic anthophyllitc asbestosis. | During the same year Wagner, Slcggs, and Marchand, in South Africa, described 33 cases of diffuse pleural mesothelioma, all but one of whom had pro bably been exposed to crocidolitc asbestos in the North Western Gape Province, j This article describes a patient with pleural calcification followed by meso thelioma of the pleura. Ten years previously, after twenty years in charge of the stores of a firm engaged in distributing a variety of asbestos insulating materials for industry and the building trade, he was transferred to the office and had no further contact with asbestos. Case Report A 63-year-old man with a history of intermittent winter bronchitis was admitted in March 19G4 for investigation of six months' persistent cough and sputum, increasing dyspnoea on exertion, and loss of weight. He smoked 40 cigarettes a day. His father had died of bronchial carcinoma, j On examination lie was thin. There were no enlarged glands Or clubbing of the fingers. Movement, percussion note, and breath sounds were diminished on the left side of the chest. There were no abnormal physical signs in the abdomen or cardiovascular system; B.P. 140/90 mm. Previous chest X-rays in 195c, j'954, and 1959 had shown bilateral calcified pleural plaques (Fig. 1) and the dresent X-ray showed left-sided pleural thickening and effusion (Fig. 2). Investigations showed the E.S.R. raised to 35 mm. (Westergren) and the Mantoux test 10 T.U. was strongly positive. The sputum was negative for neo plastic cells, tubercle bacilli, and asbestos bodies. Other investigations which vrere normal included full blood count, scrum proteins, electrolytes, calcium and phosphorus, liver function tests, electrocardiograph. X-rays of the spine, and bronchoscopy. Respiratory function tests showed a one-second forced cixpiratory volume of 1220 c.c. and a forced vital capacity of 1300 c.c. Aspirat on of the effusion produced straw-coloured fluid which was sterile on culture lor organisms and tubercle bacilli. In view of the strongly positive Mantoux test and raised erythrocyte sedi mentation rate, it was concluded that the a:tiology was probably tuberculous, and treatment was started with anti-tubcrculous drugs. He was allowed to go home, but was re-admitted in June complaining of progressive dyspnoea and ){Rntwtdfar publication. May 1965 "'t nvu UiOVU 1U* mi imcKcnmg displacement of the mediastinum to the right. Bad^Twnllow and showed some delay in oesophageal emptying, but no < abnormality. A percutaneous biopsy through the sixth left intercostal space in the axillary line, using a high-speed compressed-air drill, was performed by o us (S.J.S.). The histology showed the appearances of mesothelioma o pleura (Fig. 3) with an asbestos body present in the adjacent lung (Fig Asbestos bodies were subsequently found in the sputum for the first time He was anxious to return home, where he died a month after the bit Unfortunately no post-mortem examination was performed. Discussion The association between asbestosis and bronchial carcinoma has been rt nized for many years since the first case reported by Lynch and Smith (t; More recently attention has been drawn to the development of other typ neoplasm in patients exposed to asbestos. Keal (i960} described 19 men and 23 women with asbestosis, of whe man and 9 women died of peritoneal or ovarian cancer and 10 men ai women died of lung cancer. Enticknap and Smither (1964) reported 11 cas diffuse abdominal tumour in association with exposure to asbestos. Houri) {1964) studied the pathology of 34 cases of primary mesothelioma of the pfi and peritoneum, of which 17 were pleural, and confirmed the associatio both groups with asbestos bodies in the lungs. Owen (1964) studied 17 ca*< diffuse mesothelioma in the Merseyside area, of which 16 were pleural, found a history of exposure to asbestos in 14. In 7 out of 10 specimens of J tissue examined asbestos bodies were seen. Fowler, Sloper, and Warner (ij described 2 cases of mesothelioma of the pleura in whom the lungs contai asbestos bodies and there was an occupational history of exposure to asbsi ex C^Sclikoff, Ghurg, and Hammond (1965) found that of 307 deaths am ^Jasbcstos-insulation workers in New York and New Jersey, U.S.A., 10 wfre c i Uto mesothelioma, 4 of the pleura, and 6 of the peritoneum. Eimes, McCaugl c --jand Wade (1965) obtained a history of occupational exposure to asbestos ii ,,'.'out of 42 patients with mesothelioma of the pleura in Belfast. In 42 mate rvl j control patients of the same age and sex a history of exposure was obtai v ; in only 9. As originally observed by Wagner et ai, an interesting feature of man C;. the reported cases, in common with the patient described above, was that exposure to asbestos was slight in degree and remote in time. *x 'J, Wagner et al. stated that in all the histological sections of pleura exami -Jjin cases of mesothelioma, no asbestos bodies or fibres were observed beyi L j - - the pleural elastic laminae. The section shown here (Fig. 4) demonstr; that asbestos bodies may be found in the adjacent lung. FI Jacob and Bohlig (1955} first described calcified pleural plaques occurr m in asbestos workers in 5 per cent, of 343 cases of asbestosis. Frost, Georg, t 001 OJ Flemming Moller (1956} exapained 31 workers engaged for 20 years or mon different kinds of insulation' work and found g with pulmonary asbesto c J BB 0005544 I /JrU- J O/S. At.S-> ........v-j ui till. jJiiuiti, hiui i.aii.jm.uLiuil 111 II C3SCS, Of w...h..i--cirS- w---e-r-e---j-*---c---c--r-a-l-. Hurwitz (1961) described a cliaractcristic pattern of sclerotic plcu^ft presenting in the form of calcified pleural plaques among asbestos workc^in South Africa. Lawson (1963) reviewed the previously re ported radiological features of asbestosis and drew attention to the value of calcified pleural plaques as an additional sign of long-standing asbestosis. One of the 3 eases he described died of a peritonea! tumour, possibly a mesothelioma, Enticknap and Smithcr mentioned pleural calcification in 2 of their eases who developed diffuse abdominal tumours. ! The question arises whether the development of pleural calcification in a subject exposed to asbestos is of any prognostic significance in anticipating the eventual development of pleural mesothelioma. The answer will probably have to wait until the long-term follow-up of a large series of patients with pleural calcification, such as Kiviluoto's, is published. However, the sequence of events in the case reported would indicate that it is advisable to enquire care fully into the history of exposure to asbestos in all patients with pleural calcifi cation, and to keep them under observation. Summary j The ease is described of a 63-year-old man with pleural calcificadon who developed mesothelioma of the pleura 10 years after exposure to asbestos as a store-keeper. The clinical and radiographic findings are reported and the chest X-rays and the histological appearance ofa biopsy performed with a highspieed compressed-air drill are illustrated. The literature relating to the association between exposure to asbestos and pleural calcification and mesothelioma is briefly reviewed and discussed. The question is raised whether pleural calcification has any prognostic significance in the development of mesothelioma. Comment is made on the slight degree and remoteness in time of the exposure to asbestos in the case reported, and on the finding of asbestos bodies in the biopsy specimen. 1.--Chest X-ray, 38.5.59, showing bilateral calcified pleural plaques. ACKNOWLEDGEMENTS We wish to thank Dr. E. I I. Hudson for his kind permission to publish details or this cascf-- wtfilc under his care, and Dr. K. Hinson for his report and photographs of the histology, Thanks arc also due to the Photographic Department of the Hospitals for Diseases of the Chest for reproduction of the chest X-rays, and to Mrs. Malone for her secretarial help. REFERENCES Elkes, P. C., McCauciiey, W. T. E., fit Wade, O. L. (1965). Bril. med.J., 1, 350. Enticknap, J. B., fit Smither, W. J. {1964). Brit.J. induitr. Med., ai, ao. F >vler, P. B. S., Sloper.J. C., fit Warner, E. C. (1964). Brit. med.J., a, at 1. C~~) Frost, J., Georg, J., fit Flemming Moller, P. (1956). Dan. mtd. Btdl., 3, aoa. cn Hqoiuhane, D. O'B. (1964). Thorax, 19, a68. Hurwitz, M. (1961). Amer.J. Roentgenol., 85, 356. i,., -- O ;;T*- Jacob, G., fit Uoiiuc, H. (1955). Fortschr. Rdntgenitr., 83, 515. KIvee^alL,, Efc.. EW.. (t1ig9uGo0j).. LLaonnecttti,, iisi,, traanil. Kiviluoto, R. (19G0). Ada radial. Supplt, 194. -- -d zh Lawson, J. P. (1963). Clin. Radiol., 14, 414. Lynch, K. M., fit Smith, W. A. (1935). Amr. J. Cancer, 34, 56. Owen, W. Glyn. (19G4). Brit. mtd. J., a, a 14. Seukoff, I. J., Ciumo, J., fit Hamsiond, E. C. (1965). Flew Engl. J. Med., 373, 560. .*HL 3.--Air-drill biopsy showing the histology of **mesothelioma of the pleura. 1 Wajoner, J. C., Sleccs, C. A., fit Marciiano, P. (19G0). Brit.J. ini dustr. Med., 17, ado. i f BB 000551*5 f o Ui o