Document DVzd7Nv84xjpX4kMVO4VELbn

V c) . \o> 't Article by H.C.M VAN DER SCHOOL " ASBESTOSIS AND PLEURAL TUMORS I"t June 7. - NETHERLANDS JOURNAL 70R MEDICATE. VOL : 1E2,( I ) 23, p 1125-1126 M Since Lynch and Smith, in 1935, published the first case of lung cancer in a victim of asbestosis, numerous communicationshave appeared in. the literature on the concurrence of both processes. The carcinomas thus described appear generally to have had their origin in the peripheral branches of the bronchu_ and could be classified histologically as epidermoid`carcinoma , oatcell adenocarcinoma or as anaplasticjcarcinoma, with epidermoid carcinoma predomir.-. in this series. In the literature only one case is mentioned of the combinati. of asbestosis and pleural tumor, without an account of the localization or histological detail. During the past year we encountered this combination ( of asbestosis and pleural tumor ) twice and to which we now can, through the courtesy of Dr SCHORNAGEL,add a third case. In all three medical histories we are concerned with workers who were for a protracted period iga^ed lin the occupation of M insulator V Their work consisted in part disassembling old insulation, which (involved? often/ per:..' of work in poorly ventilated spaces in which a great amount of dust>with a high concentration of asbestos fibers^ was released. - A . Pa.tientV-7as a man of 67 years who had worked for 41 years with asbestos.__ 0ne'7eaf before his death he was admitted for a/nemorrnagic pleuri&is (^right's. No tumor cells were detected in repeated aspirates of the exudate. After two months^the manif est2tion of pleuritis disappeared. Eight months later the patient was readmitted in moderately ill condition, wd. severe dyspnea. On fluoroscopy a considerable pleuraythickening was seen on right side together with a lung picture which suggested asbestosis. No asb*t bodies were however found in the sputum. While the patient was being studie; he developed a bronchopneumoniatfrom which he died. ( At autopsy a very large tumor was found which envelopedthe whole lung and wr.w had infiltrated through'the diaphragm. On microscopic examination numerous asbestos bodies were found in both lungs,with only slight fibrosis of the . lung tissue. The tumor showed the characteristics of a mesothelioma and in . probability had arisen from the pleura . Patient B also was an insulator aged 67 years, who had worked with asbestos 13 years, and who had experienced symptoms of cough and shortness of breath 8 years prior to his death. After these symptoms had endured for five year; a diagnosis of pulmonary asbestosis was made on the basis of the medical hi? a and the X-R2y picture end he was determined to be 100 per cent incapacitates wear later a left-sided pleural exudate appeared, in "hich were detected. This exudate disappeared later, but on the/x^ray increasing onati *ic2::ion of the lower left lung fiel^ves observed. Tf'c years later the patient died with the status of increasing respiratory fails At necropsy the pleura of both lungs was "ound to be markedly thic`. each, ant a tumor mass , which had er.vcloncd the 1c cr lobe of the Is *t i-ng and uhic had infiltrated the diaphragm, '.us found . Microscopic analysts vcrittec^n, -cser.ee of asbestosis "hicr. "as or as marked degree. Them s t c : on--- tore less PLAINTIFF'S EXHIBIT O VAN DhR SCHOOT O- "e 2 ?aciencC( Dr Schorr.agel1 s) was an insulator 5? years for whom it was not 'determined ho*..' long he had worked in the insulation industry. His hict is shorter and shows little correspondence with that of the ocher two cases. Half a year before his demise the pstisac complained of severe pain in the upper right abdominal region, for which no organic abnormality was initially detected. There were no respiratory system complaints. During his stay in the hospital, however, opacification of "the lower portion of the right lung fie?, arose and a tmor became palpable below the right costal margin . A little-, fluid was aspirated from the right pleural cavity in which malignant neoplast' cells of undiagnosable origin were demonstrable. The patient expired after several months in a state of cachexia. 1 At autopsy a fibrosarcoma was found. It had surrounded the lower and middle ' lobes and had grown through the diaphragm deep into the liver. Only a moderan* number of asbestos bodies were present in the lungs. bronchus A long series of anecdotal reports on the concurrence of ^cancer and asbestosis has * finally lead to the universal acceptance of the ojinion ( point of view ) that asbestos should be regarded as one of the/factor.- in the -genesis of lung cancer. Asbestos, which ^promoting / etiological consists of magnesium silicate, does not contain any carcinogenic material, sothat the carcinogenic`action of asbestos fibers must be ascribed to the chrc mechanical irritation. In conformance herewith,the lungcancer tends to devel<: in lung regions where the asbestos fibers occur in greatest concentration, ic_ general thus in the lower lunc lobes, particular in the vicinity of the diaphr. and the lung periphery where the asbestos fibers exert their strongest irritv because the greatest ventilatory excursions occur here. . r? From the fact that in pulmonary asbestosis pleural thickening, including plaque formation ,seldom is lacking, one can assume that mechanical irritatiL by the asbestos fibers contributes at the very least to the chickening c: the pleural layers. - lumen of C; In the above described cases no asbestos fibers were detected in the/bronchi brochioles in any of the numerous sections. lletaplastic deviation of the bronchial epithelium, su~h as that --hich had been demonstrated^ clearly by HAMPE in 1952 in a oatient who suffered from asbestosis and lunrcarcinoma, al; W2S lacking. If one assumes that the dimensions of inhaled asbestos fibers a. of such a sice that they tan pass . ' . . unhampered through the respiratory tree sothat their irritating action would take place in the peripheral pore:. .. of the lungs, it is comprehensible why pleural chi ihening dominates the picc-- TheseI considerations lead to drawing' the line of correlation between . lungcancer and asbestosis at the level of the pleural thickening. We are f- . in /his the investigations of DOL'D, published in 1955. in which he sho*-*- ' statistical rrounds that the average chance of lung cancer in asbestos work:-' who have practiced their profession for 20 or more years, is ten times as r : as temper td with the population in genera 1. His table, which only mentioned histologi cal diagnesi s, included one case of p 1 cu ral- er\sdothel i cma , end he : mentions this pleural tumor in the same b reath vi th lungutumors According to the data of the central serv ice of t he labor serv * 0 , asbestu- occurs by far most fr ecuentiy in the west or our country/ where ** * n> i r. s u 1 a 11. industry is establish ^ ' Q - ^ ^ v f% ur.drccs of w'or::ers . free c one erni r. g the prove 1.cr.cc o asbestosis t! -- a sy r- tresen11v 5v::i 1 ' b ;. c. but 12 r. n * 'i a * , '.v ."S3 \ 7- q r* zr.cz c d 0 c z 20 0 c r cent 01 the verb. 2 rc K ` VAN'dER SCHOOT ARTICLE : Page 3 QS ,, lesser or greater decree from asbestosis. Pvvention of asbestosis ' ' a difficult technical . problem. . appe DISCUSSION: . Dr VAN DER ZAL21: drew attention to a case of mesothelioraa of the pleural cuv which was detected next' to silicosis with pseutomor formation. Are there.in ^ literature more similar cases? DR VAN DER SCHOOT:( response ) : The literature which I have reviewed has nc ' revealed any publication which establishes a link between pleural tumors and any form of pneumoconiosis. The relationship between silicosis and canc?: is decidedly less clear. DrSCHOPClAGZL: Recently I performed and autopsy on yet another deceased patie:: with asbestosis, who, however, had a mesothelioma of the peritoneum. Would \ be able to establish a connection between this asbestosis and the ` ' peritoneal tumor? The patient was an insulator -3nd worked temporally in an atomic factory in Australia. DR VAN DER SCHOOT ( Answer ): If it is established that there was no tumor ti. ' within the thorax and that the tumor had not grown through the diaphragm, it would seem to me difficult to establish a connection between the two disease processes. COMMENT BY TRANSLATOR: ' (0 Dr Van Der Schoot did apparently not recognise that asbestos fibers are transferred from the pulmonary system via the lymphatics and through swallows . sputum to the intestinal lymphatics and peritoneum: GWHS >) Dr Jan Hampe studied for a period at Saranac Lake with Dr Vorwald and had a particular interest in asbestosis of insulation workers since he was a pathcl. at the University of Amsterdam, where he frequently saw asbestosis in insulati workers of the industries of Western Holland. I visited with Dr Hampe in Amsterdam in August-September of 1950, en route back from the USA. We reviewed our mutual observations on the tumor manifestations in asbestos workers in the USA. Since Hollanders generally have a long lifespan, unless they drink too mu-. . BOLS ? it is possible that Dx Hampe may still be around. He could be about 70 y- old. He may still .have recollections of relevance. I last communicated with hi., in 1953 when I tried to recruit him for the Pneunoconiosis Bureau of South Aft. When he declined the position we gave it to Dr Webster. GWHS Note that D& Van Der Schoot says that by 1953 the relationship between lung cu asbestosis had been universally accepted. GWHS ) M <1 *i >c si n aI d :t i; t i v:m .lc darmiv.md fmnden in flit g*hird rn>lgr nrr ul.ilir. xiik>riitvvf'ii. in lie * n tn u Idelgmt i: tnkki'tt v*in art* rm mrvnn-riea iirTtr*r Ix'sinmi tromlxwr mrt orgnnbulir, wraarhij rm vuatrtjk wrrfscl was prnnml, tbi dc vatru `opvuldc* JUndweefscl curt hUiedv.v.ujcs, van buiten het vat nnnr binnrn grnrirml, drorg bij aan etc vorming van Jit ,,vul\vrfsrP\ IV artcrtYwamlrn waren ontstoken, vooral de iniim.i m de advnititia. A;m do omirek dcr thrombi werden rm/cncr!h`M van het ty|)C*I.anghnus grvnodcn cn iti do thrmnbi rrilf-n mrt kenmerken van cpuliclioutc ccilcti. Dc advent ilia was vrrdikt en in hnar builcnxtc Inug sclerotivh. Rrmdom dr nrirricn bevonden zich uilycbfcidc ontstekingsirtlihraten. Ook tie wantJen van cnige klcine adernn tufindm ontsieking. Dc afxvijking word bochouwrl nls thrombangtids obli* ternns. op grond van do Imiulogische overeenkomst met dc door ]'ueri:i:k bearhrevon vernndcrmgcn aan dc extremi- teitvaten bij thromhangiitis obliterans. Dc punter) van over- ecnkomst waren: obfiteranr van dc lumina dcr artcricn door cri vaatrijk hituKvecisci of cen thrombus met organi* jade. In deze thrombi hcvnndcn zich ccllen, geiykcnd op cptthcio7de ccHcn (do atypische angioblastcn ran Buerger) cn aan dc |>cnTcrie rruxmccilen; voortx dc onisickingsin- fihraten in <lc media en adventitia, met atrofic van tic media; de vascularisuic van tie media van de adventitia uict de sclerose \an dc adventitia: tie peri-arteriole fibrosis en de peri-arteriole onutckingsinfiltraicn en de omsteking ook vau de adenvanden. * Hr zijn slechts 14 gcvallen beschreven van thromhangittis obliterans \an dc mescntcriale vaten; in hoofdzaak betrof* fen doze de artcria mcxcntrriea superior. In ctn gevai was ook de arten'a mrsentcrica inferior aangetast. Het klinischc ondcrzock van het hart, dc nicren, dc ledemaren en de ogen guf grot aanwijzingcn voor throat* bangiitis obliterans van dc vaten van deze organen. Dacuuie: Dr. Straw: Is er kenmerkend verse hi! met dc verandrrin- gen bij artrriitis tcmjxjralis, die ook aan andcre vaten mecr gcgcncraUsccrd kan voorkomcn? KootKra antwoordt: Ja. Bij aricrutw temporalis komcn dc reuzcnccllrn voor in dc wand van dc vaten, niet in dc pcri/cric van dc in orgnnisatie zijntic thrombusmassa. 7.c tonen bovmdicn cen rriatie 10c de elastics interna cn bcvac- ten brakstukken van het vlastischc wecfsrl. Dr. Dijkstra: Met thrombnngiiiis obliterans heeft U blijkbaur dc ziektr van Buerger bedodd. Maar er is a Been cnigc mi'TOscofiischc grfiikrnix, dc 2icktc van Jiuerger is immers cen bqnnkl r.iVktebceld cn dat was bier nirt: dc beenvatrn warm ni*t aamjetast. Itovrmlicn heeft U os cigcniijk allvvn rrn thrombartvritiix cn gren thrombangiiiis latrrn zicu: dr atlrrcn waren vrijwirl nirt aangrtasi. KfKKv.H. nutwoonU: Dc zickte van Uucrgvr :ls mi hr* jvaaicl zirkirbcrkl, tint g'-kcnntrrkl is door a.antnxtim; <lrr brenvatm cm df<r brt brstaatt van voorkrur voor rin be* jcuihjc Icrhijd. grslachl, ras cn gcwoomcil, wrrri liirr nirt betiocid. (w-irarlil need, aan te tonen dat <lx: iii.'ioingisrhc vrrandrrinijcn /n.ils lh'i'Uf:p.R dcv.c iuc-l't brvcim*\ct\ hij tiiromij.nic'iii.N ohliicranN van dc bcriivanm cn <iu-. /oai-. nit dr lurraimir N kind aJ/.oulrrlijk kiiimni viu ki mirtl .n amn-rr va.iie' hn iir:i. hrj dr/e naiu ni br-NiinidcM in nicM-nlff!:i|r v;ucn. He /iektr van i'urrgrr in dr l*>vrnl>r- doriti': ?m n in ' nnv ;uc;, ma.tr \m-; /im er lie kennicrkm van tlirnrnii.uiimni' i>i<lii'T:in.s. l}r .miii.mhij van dr aiieirn r.j ;craig, taaa.' " ,-r wri. .Ah in ; nroecs <i: bx-rnvaien gelijkr mate hoi gwal te '/.ijn. Vi.iuki.sk: y.i\n rr ook rnkclzijcligo ,.roKicr',*arht;r v infimHvmlikkingrn itt tie arirrien qnvoridm /m.jLs Iwschrrvc zijn bij dg ziektc v:m Huenjer, cn die onafhankrlijk ziju v.. tlmunbi? Kootkkji antwoordt: Nent. Deze vcrrlikkim^ru, di: . ` fibrinoid zoutlrn brstaan. wrrdrn cvcnmin gr/irn als door UuKJtm:)i brschrewn purulrnt*: foci. f: zoud cvcnwcl brhoren tot dc vrorge venutderingen i;ij hv.c aa;* doenlng. Atmgvzicn vie klachicn reetis cen jaar bevtondev* is-he: omlrirkcn van dt*zc vrranderimpm te verkhircn het reeds geruime tijd bevtaan van het proc*rs. Dr. Vowr.N*AAt: Hij ihrombnngiitis oblitrrans ornate^ de erTste nfwijkingcn in de ailcren. Deze zijn Incr minima' aangetast. I let lijkt nnj, dat daardoor de diagnose mitv. waarsehijidijk worth.. KootKtx antvvoorth: Dit gc!dt voor de ziektc van Hoer Het behoeft niet te gelden voor dirombangiiiis oblitc:; zoals reeds in cen voorafgaand antwoord w-erri uiteengr- C H. C. M* vat dkr SextoOT, Asbeslosu en platrtigrzu't!- Sedert Lvttcn cn .Smith in 1935 het eeme gircai publio.T; .. van longkankcr bij cr.n fijticr aan asbotovg, zijn tnlr'' metlrdch'ngcn over het samengoan van bride zivkicprccv'v in dc lileratuur vcrscliencn. De hierbij bNchrcvrn earci--; men blijkm in den reggJ uit te gaan van jxtrifrrc bronch.-. vcnakkingcn.cn liwtoiogischals plavcisclrpuhcrb, Itavcrrcl*, adenocarcinomen of anapiastiscHc carcinnmen te kitnnc worden geelassificeerd. In weJkc reeks het aancal plaveisc' cdcnrcinotnm aanzienlijk overheerst. In dc lileratuur wi. slechts cfn geval vcrmcld van cen combinatie mi asber. cnecn pleurageawel, zondcr opgavc van lokafisaiic eu tologivche details. In dc algcioprn twee jaren rage tvveemaal cen dergelijk samengaan. waaraart wij, det. vrtvndciijke betniddeling van Dr. Schornacm^ ecu t- geval kunnen toevoegen* Bij allc dric ziektcgesch/cdcnisscn bet reft het nrhr.\`.. die gedurende eett lange periode als ..isolccrder" werkt*. zijn gewerst. Hun wrrk bestond voor cen dor! uit bet tier; - term van oude leidiugcn, waarbij vaak in sictlu gev c Icerdc ruimten werd gewerkt cn veel stof met cen > * concentratic aan asbestvezeitja werd verjprcid. Patient A was cen man van 67 jaar. die 41 j:tar met a. \ had gewerkt. Hij wertl cen jaar voor zijn flood opgi-ncn.w . wegens cm rerlus'/.ijtligc hemorragbehe pfniritix wanrve.:; geen oorzaak wertl gevonden. In het exsudnat. dat he. - haaldcliik werd gcputtctcerd, werden g**t:n mnwrrx . aanRctry/rm. Na twee maanden waren dc vrrschijr.?: van plcuntb vertiwenen. Acht iTiaantlrn Inter werd j>ati;nt wnlefom iijn:' >. ; in matig zirkc I'jctCmd. met stt:rkc dyspno*:. Itij doorlit ; ~ wrrtl rvn aanzienlijkr pl'*uravcrdikktig aan dr rrrliii-. . gevonden hij rvn longiiecld, dat tierti drnkrn a:m :i-!n- .. hi hrt spiKum wrrili u erhter geen a.'liesiliclia.nni't' ' :\y c* trofirn. Trjtlenx dt: oljM-rvatic {>ntwikkr!de zidi cm on- purumomr waarrsan tie patient ovcrlvcd. Hi I t$* nlifinctitt wvnl erti grotr tumor > gvhrh* rrrhicr iong fimgai'en in hrt ili.ifi-:ii;"'-i 1! grifcul. l*n imiciiiu'oiumJj ontirr/ork wrrum 111 J e:t talrijkr asiirsificliaamojes grt'oudr'.. *' 'h i his [iiinr van het iougweebci. D-` tumn'' :oou<" *** kf nr'- ' rr> 'an cen nir7'>ih<-iioom e:i v. a> r.r.r.r zfle .lar-m'iijni^ _:a iiiiia'cann c.m lie jiieura. i'atirnt IS was eveuec::> cen ..Cceer.lrr van j** - .:,r I up 'SIC >\mi ' i i v, _ ;'G) - USS CUO ;oq .1.10 \3 * `t .~u: j* -_1JK IUJC A V) ' .>ui ;>u.\ :?is o pjnoiousS UOJxnrj t:spuo.\y.t'. uusnpqo np fiq npv tjnpj.*>A\ u.xlsuib ! s/.up 1!J 5>.|<iJtiiOO ;/{)! ).nst IJ.'.nuixIiA'jC Aiisoui-xl .11115',' jmu u^u.Miwi us \ijojiiin.) til.ui 5.mi n..nm>ii "iv .uj miduil OUOSil tJOjqO IUU1 U.MU.'l!.-i n5!o 1 U.I1U.M SI 1 yup U.UUA\ jy| usp.>|j:)AO su.n jind' a|)j[.v/i.h( ui .''ip ui 'wm imt[sn( DNflpJj tl.l JlpU|vSj> lr j.ljl UCA .11]! 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