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FILE NAME Talc TALC DATE 2019 DOC TALC219 DOCUMENT DESCRIPTION Journal Article - Mesothelioma Associated With the Use of Cosmetic Talc ORIGINAL ARTICLE Mesothelioma Associated With the Use of Cosmetic Talc Jacqueline Moline MD MSc Kristin Bevilacqua MPH Maya Alexandri JD and Ronald E. Gordon PhD Objective To describe 33 cases of malignant mesothelioma among indi- viduals with no known asbestos exposure other than cosmetic talcum powder Methods Cases were referred for medico evaluation and tissue digestions were performed in some cases Tissue digestion for the six cases described was done according to standard methodology Results Asbestos of the type found in talcum powder was found in all six cases evaluated Talcum powder usage was the only source of asbestos for all 33 cases Conclusions Exposure to contaminated talcum powders can cause mesothelioma Clinicians should elicit a history of talcum powder usage in all patients presenting with mesothelioma presence of three different types of asbestos fibers in 22 of 22 talcum products tested tremolite anthophyllite and chysotile However talcum powder is still widely produced and consumed with a reported 58.3 million adults using body and baby powder in the United States in 2017.26 While the relationship between occupational exposure to asbestos and mesothelioma is well established multiple studies have shown that not all individuals who develop mesothelioma can pin- point exposures to asbestos Among women occupational expo- sure explains less than half of malignant mesothelioma cases Some studies have focused on conventional exposure categories that Downlade for women only reflect take home exposures from male family members who worked in one of the selected occupations In one such from BACKGROUND study data on home or personal use exposures were not collected yet sbestos in all forms is recognized by the International Agency for Research on Cancer IARC as a human carcinogen and all increased amounts of tremolite asbestos fibers noted in the lungs of women with MM with no identified source of asbestos contact led htps:/journal.wcme forms of asbestos are recognized as the primary risk factor for study authors to that the tremolite could be related to hypothesize htps:/journals.lw.com/joem malignant mesothelioma By the 1950s over 60 cases of talcum powder use 28 The high prevalence of unexplained or idio- htps:/journal.wcme asbestos lung cancer had been published in the literature In pathic mesothelioma among women necessitates further inquiry into by 1955 Doll,,p"ublished a seminal paper describing the increased risk potential occupational exposures such as exposure to asbestos- BhDMf5ePHKav1zEoumtQfN4a of lung cancer among exposed workers In 1960 Wagner et al published a study of 33 cases of malignant mesothelioma among individuals who were exposed to asbestos in and around the contaminated talcum powder In light of these gaps in the existing literature we present 33 cases of individuals with malignant mesothelioma who were BhDMf5ePHKav1zEoumtQfN4a crocidolite mines in South Africa By the 20th century as exposed to commercial talcum powder products Of those cases BhDMf5ePHKav1zEoumtQfN4a asbestos use rose in the industrialized world diseases associated we present six in detail where the individuals had no other known kJLhEZgbslH04XMi0hCywCX1AWnYQp with its use also began their upward 3,8,11,12 On average exposure to asbestos and for whom tissue studies show the presence kJLhEZgbslH04XMi0hCywX1AWnYQp between 2003 and 2008 1.05 cases per 100,000 of malignant of asbestos commonly found in talcum powder such as tremolite kJLhEZgbslH04XMihCyw1AWnYQp mesothelioma MM were diagnosed in the United States and in 2015 2597 deaths resulted from the disease and anthophyllite For all 33 cases other potential exposures to asbestos were considered with no identified source apart from the The presence of asbestos in talc and talcum powder consumer products including body powder baby powder facial cosmetics and kJLhEZgbslH04XMiCyw1AWnYQp pharmaceutical talc was first discussed in the medical and scientific kJLhEZgbslH04XMihCyw1AWnYQp literature beginning in the 1940s Asbestos contamination of talcum powder The cases were referred to author J.M. for medicolegal evaluation as part of tort litigation and tissue digestions were performed by author R.G. as part of this litigation In every case a pathology report confirmed the diagnosis of malignant mesotheli- IQrHD3ctd talc products is understood to occur during the mining process in which talc deposits overlap or lie in close proximity to naturally occurring asbestos deposits The natural presence of asbestos oma This study was conducted with approval from the Northwell Health Feinstein Institute for Medical Research 18-0225 FIMR within talc deposits makes selective or the extrication of mining asbestos from mined talc nearly impossible During application in DsFBzQTMK its commercial talcum powder form asbestos fibers become air- MATERIALS AND METHODS Case Histories IfVrSzj5ui06vflsg borne and can be inhaled In 1968 Cralley et 25 found the Data gathered for all 33 patients were gathered from each individual's medical records and sworn testimony deposition tran- IfVrSzj5ui06vflsvg From the Northwell Health Department of Occupational Medicine Epidemiology scripts of individuals All cases were reviewed by an occupational JIKqupoH5c and Prevention Dr Moline Ms Bevilacqua Donald and Barbara Zucker School of Medicine at Northwell Hempstead Ms Alexandri physician with experience evaluating asbestos exposure in thousands of patients Data abstracted included medical diagnosis 01/320on Department of Pathology The Icahn School of Medicine at Mount Sinai review of pathology reports confirming the diagnosis of malignant Dr Gordon New York New York Funding No funds or external assistance were obtained by any outside source in mesothelioma and clinical course Exposure data was obtained the development writing analysis or conclusions of this manuscript from sworn testimony by the cases which included extensive Conflicts of Interest Authors J.M. and R.G. have served as expert witnesses in asbestos litigation including talc litigation for plaintiffs Supplemental digital contents are available for this article Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site www.joem.org questioning regarding all sources of asbestos exposure This included family occupational histories parents and anyone cohabitating with the patient for all cases to assess potential asbestos exposure hobbies that included use of products that might contain Clinical Significance This manuscript is the first to describe mesothelioma among talcum powder consumers Our case study suggest that cosmetic talcum powder use may help explain the high prevalence of idiopathic mesothelioma cases particularly among women and stresses the need for improved exposure history elicitation among physicians asbestos such as ceramics residence in an area that might have had asbestos industry leading to possible environmental exposures known abatement of asbestos while the patient was in school home renovations that might have used asbestos containing materials and Address correspondence to Jacqueline Moline MD Northwell Health Great Neck NY jmoline@northwell.edu jmoline@northwell.edu Copyright '2019 American College of Occupational and Environmental Medicine any other potential sources of asbestos exposure Additional data related to family history of cancers was obtained from the sworn testimony Any data related to potential genetic mutations such as DOI JOM.0000000000001723 BRCA1 associated protein was collected if present JOEM e Volume 62 Number 1 January 2020 11 Copyright '2019 American College of Occupational and Environmental Medicine Unauthorized reproduction of this article is prohibited Moline et al JOEM e Volume 62 Number 1 January 2020 Talcum powder exposure histories were reviewed based on sworn testimony by patients and in some cases family members with hand knowledge of the use of talcum powder such as parents who recalled using talcum powder while diapering the patient Data including type of talcum powder used Appendix 3 http://links.lww.com/JOM/A651 age at first use of talcum powder and duration of use was obtained to ensure adequate latency from first exposure was present In some cases individuals were also interviewed in person and these data were merged with the data obtained in medical records and deposition transcripts The six cases described below also had tissue digestions performed by author R.G. These case reports are presented in greater detail their clinical course was similar to all 33 cases evaluated and the same rigor with respect to obtaining information related to any asbestos exposure was applied to all 33 cases Case 1 Case 1 is a year woman who presented to a physician with shortness of breath and chest pain in January 2015. A chest xray revealed a small pleural effusion with left basilar atelectasis In August 2015 a CT angiogram showed development of two subpleural nodules anterior to the lingula and a pleural based mass a pleural effusion was still present A thoracentesis was done and the cytology showed large clusters of cells suspicious for mesothelioma A positron emission tomography PET scan showed pleural thickening and focal intense uptake inferiorly and posteriorly on the left side of her chest In September 2015 she underwent thoracoscopic surgery The pathology showed epithelial malignant mesothelioma with invasion of the visceral pleura and pulmonary parenchyma with tumor present at the stapled margin Case 1 applied loose face powder on a daily basis from the 1940s to the 1970s Her mother also used the same loose face powder and Case 1 cleaned residual powder from her mother's dresser and clothing every other week from 1994 to 2012 Electron microscopic analysis EMA of the lung tissue revealed anthophyllite fibers in a calculated concentrations of 3286 fibers per gram weight There was also significant amount of fibrous and platy talc and aluminum silicates Case 1 was treated with four cycles of combination chemotherapy with cisplatin and pemetrexed for four cycles Case 2 In August 2015 Case 2 a year woman presented with exertional dyspnea and dry cough A chest ray a showed large left pleural effusion A chest CT scan in September 2015 showed a movable volume left pleural effusion nodularity ulation of the left pleura left lower lobe atelectasis three nodules in the left upper lobe and no hilar or mediastinal lymphadenopathy A thoracentesis showed carcinoma cells A PET scan on September 22 2016 reported showed abnormal deposits of tumor in the left pleura There was no reported disease outside the chest Case 2 underwent a bronchoscopy in October 2015. Pathology showed malignant mesothelioma biphasic mixed type 50 sarcomatoid 50 epithelioid A second opinion confirmed the diagnosis She underwent two cycles of chemotherapy with doxorubricin ifosfide and mensa and completed treatment in November A PET scan showed no response to the chemotherapy In December Case 2 underwent left radical pleurectomy tion resection of left hemidiaphragm and one lymph node dissection Surgical pathology showed residual biphasic malignant mesothelioma with negative nodes and negative margins In January 2016 radiation oncology recommended adjuvant radiation therapy to the left chest which she received in February and March of 2016 As of April 2016 Case 2 had no evidence of disease recurrence Case 2 reported starting to use talc around age eight or nine and would apply powder after her daily shower or bath She would also use talcum powder when visiting her grandmother because she enjoyed the scent and would apply the powder before going on a date She continued to use powder after getting married and used baby powder with all three of her children In the early 2000s she began to regularly apply a fragrance and its matching talcum powder in the morning and at night describing it as her signature scent She also sprinkled the powder in her lingerie drawer and traveled with the powder which she would rub on her suitcases and other surfaces EMA of the lung tissue revealed anthophyllite fibers in a calculated concentration of 8625 fibers per gram wet weight with a limit of detection of 2875 fibers per gram wet weight A significant amount of fibrous and platy talc was seen EMA of the lymph node tissue revealed anthophyllite and tremolite fibers in a calculated concentrations of 34,500 fibers per gram wet weight with a limit of detection of 11,500 fibers per gram wet weight They were seen in a ratio of 2 anthophyllite All fibers counted were ...mor greater in length with aspect ratios greater than 8 There was also some amount of fibrous and platy talc noted in the lymph node tissue Case 3 In September 2014 Case 3 an year woman developed shortness of breath a cough and chest tightness A chest ray in November 2014 showed a large left pleural effusion A CT angiogram showed a large left pleural effusion with compressive atelectasis of the left middle and lower lobes and ground glass opacities in the left upper lobe and right lung A thoracentesis showed carcinoma cells Case 3 underwent a video thoracoscopy with pleural biopsy and evacuation of a pleural effusion Pathology revealed a malignant epithelial neoplasm consistent with malignant epithelial mesothelioma Case 3 then underwent a left pleurectomy and decortication in June 2015. The mesothelioma had spread to the lymph nodes and chest wall and the pathology now showed malignant biphasic mesothelioma Case 3 entered hospice care in September 2015 and died in late October 2015 Case 3 worked as an elementary school teacher with no known occupational exposure to asbestos Case 3 used talcum powder before she was 12 and 13 years old applying it under her arms and in her shoes daily She shook the powder out of the can and applied it onto her body She noted that her mother also used talcum body powder and they shared a small bathroom She used talcum powder beginning in the 1940s and continuing for decades until her preferred brand was no longer available for purchase EMA of the lung tissue did not reveal any asbestos fibers above the limit of detection of 6900. However there were a number of very small chrysotile asbestos fibers Analysis of the lymph node tissue revealed tremolite asbestos fibers in calculated concentrations of 9409 fibers per gram wet weight with a limit of detection of 9409 All fibers counted were 5 ...mor greater in length with aspect ratios greater than 20. There was also a significant amount of aluminum silicates silica particles and both fibrous and platy talc Light microscopic analysis revealed a calculated concentration of 409 asbestos bodies per gram wet weight of lymph node tissue by phase contrast light microscopy Case 4 In August 2014 Case 4 a year woman developed abdominal pain and had a CT scan of the abdomen and pelvis that showed omental caking ascites a fluid pocket in the right lower quadrant and enlarged diaphragmatic lymph nodes She underwent a paracentesis and an omental biopsy in August 2014. The cytology revealed atypical mesothelial cells She then underwent a laparotomy appendectomy omentectomy and left oophorectomy The pathology showed malignant epithelioid mesothelioma In September 2014 a PET showed increased uptake in the abdomen consistent with malignant ascites omental metastatic disease and cardiophrenic 12 '2019 American College of Occupational and Environmental Medicine Copyright '2019 American College of Occupational and Environmental Medicine Unauthorized reproduction of this article is prohibited JOEM e Volume 62 Number 1 January 2020 Mesothelioma and Cosmetic Talc nodules A thoracoscopy showed tumor covering the right hemidiaphragm She was treated with multiple rounds of chemotherapy with cisplatin and pemetrexed and therapeutic paracenteses due to persistent ascites Her tumor progressed and she died in February 2016. She was 68 years old Case 4 grew up in a home where her mother used talcum powder for as long as she could remember She recalled personally using talcum powder starting around the age of 9 or 10 applying the powder to her armpits groin and around her body using a powder puff She applied talcum powder to her body for approximately 40 years Case 4 had additional exposure to talcum powder in the 1960s while working as a licensed cosmetologist applying talcum powder on clients necks after a haircut She shook the talcum powder onto the client's neck and would wipe off the excess with a brush or blow dryer She also used talcum powder inside the gloves that she donned prior to applying hair color EMA of the peritoneal tissue revealed chrysotile type asbes- tos fibers in a calculated concentration of 920 fibers per gram wet weight with a limit of detection of 920 fibers per gram wet weight Fibrous and platy talc was also observed Also seen were nonasbestiform tremolite and silica crystals Case 5 Case 5 was a year woman who developed chest pain and fatigue in September 2015 and was diagnosed with viral pericarditis A CT scan in October 2015 showed mild pericardial thickening and mild perihepatic ascites She was treated with steroids for viral pericarditis In late fall 2015 Case 5 developed decreased appetite weight loss tenderness around the umbilicus and abdominal pain In December 2015 she had an abdominal ultrasound that showed a mild to moderate amount of ascites An abdominal CT scan showed slightly bilateral pleural thickening with minimal linear atelectatic change There was copious perihepatic ascites extending to the right and left paracolic gutter and deep pelvis nodularity at the paracolic gutter and a right sided deep pelvic mass A paracentesis was done and showed atypical epithelioid cells and tissue fragments with an inflammatory background A laparoscopy showed peritoneal carcinomatosis with a diffuse miliary excrescence a moderate sized pelvic mass and ascites In January 2016 she underwent an exploratory laparotomy and resection of the omentum spleen resection of abdominal tumor and resection of the abdominal wall tumor The pathology showed malignant mesothelioma involving the omentum spleen colon and mesentery as well as the fibroadipose tissue of the peritoneum Malignant mesothelioma also involved the parietal peritoneum as well as the appendix with fibrous obliteration of the appendiceal lumen Case 5 died in October 2017 Case 5 had daily personal use of talcum body powder from the 1950s to the 1970s She would pour the powder onto her hands and pat it under her arms in her genital area between her toes and on her legs When she was menstruating she would apply talcum powder on her feminine napkins and her underwear She also applied talcum powder to her shoes Case 5's husband also used talcum powder Both Case 5 and her husband applied the powder in the bathroom She shook the bathroom floor mat and cleaned up residual powder from the bathroom sink EMA of the omental tissue did not reveal any asbestos fibers above the limit of detection of detection of 651 fibers per gram wet weight EMA of the lymph node tissue revealed chrysotile and anthophyllite asbestos fibers in a calculated concentrations of 20,700 fibers per gram wet weight with a limit of detection of 10,350 fibers per gram wet weight All fibers counted were 5 ...mor greater in length with aspect ratios greater than 20. There was also a significant amount of fibrous and platy talc as well as fibrous and platy aluminum silicates Case 6 Case 6 is a year man who developed chest pain after playing hockey in 2012 and was evaluated in the Emergency Department A CT scan that showed no pulmonary abnormalities Case 6 continued to have chest pain over the next 4 years and underwent multiple cardiac evaluations A CT scan in February 2016 showed increased pleural thickening or calcified pleural plaque along the right major fissure and anterior right hemithorax along the right upper lobe A PET scan in March 2016 showed unilateral hypermetabolic pleural fissural and fissural soft tissue abnormalities suspicious for malignancies involving the pleura There were specific tiny parenchymal lung nodules Case 6 underwent a tissue biopsy in March 2016. The pathology showed malignant epithelioid mesothelioma with invasion to the skeletal muscle Case 6 underwent adjuvant chemotherapy with pemetrexed cisplatin and bevacizumab in April 2016. In May 2016 Case 6 underwent a mediastinoscopy which showed metastatic spread to the level VII lymph node Additional chemotherapy was administered which was not well tolerated In July 2016 a parietal pleurectomy was done along the fissure between the upper and lower lobe There was spread to the site of previous inferior right chest tube site Case 6 developed acute thrombus in the right upper extremity In September 2016 a chest ray showed unchanged right pleural thickening versus a small right pleural effusion Three additional cycles of chemotherapy were recommended A PET CT scan in November 2017 showed a persistent hypermetabolic focus in the right anterobasal pleura and a slight increase in a right pleural effusion Case 6 was exposed to talcum powder beginning when he was an infant His mother applied it to him after his bath until he was able to apply it himself starting around the age of six Case 6 recalled using the powder in the bathroom and in his room and that there would be powder on his floor He applied the talcum powder directly to his torso groin legs and back often twice a day after showering He played hockey as a youth and used powder in his hockey gear before donning the equipment He recalled getting mouthfuls of powder during the application He often applied talcum powder once or twice a day after showering He had no occupational exposure to asbestos EMA of the lymph node tissue revealed anthophyllite and tremolite asbestos fibers in a calculated concentrations of 17,250 fibers per gram wet weight with a limit of detection of 3450 fibers per gram wet weight They were seen in a ratio of 3 anthophyllitremolite All fibers counted were 5 ...mor greater in length with aspect ratios greater than 14.7 or greater There was also some amount of fibrous and platy talc along with platy aluminum silicates and magnesium aluminum silicates Tissue Sample Analysis Tissue samples from six patients were analyzed a lung and lymph node tissue from four of the patients diagnosed with pleural mesothelioma and b lung and lymph node from two of the patients diagnosed with peritoneal mesothelioma The tissue samples had been preserved in paraffin blocks or as formalin fixed tissues Tissue Digestion Protocols Paraffin Blocks The tissue was extracted from paraffin blocks was done according to the methodology described in Heller et al0and Wu et al.31 The tissues were cut from the paraffin blocks and deparaffinized by melting and xylene treatment They were brought to water blotted and weighted The tissues were digested with KOH and the inorganic pellet cleaned with distilled water by multiple centrifugation steps on an asbestos locator grid coated with formvar In '2019 American College of Occupational and Environmental Medicine 13 Copyright '2019 American College of Occupational and Environmental Medicine Unauthorized reproduction of this article is prohibited Moline et al JOEM e Volume 62 Number 1 January 2020 addition 250 ...Lsamples were prepared using a cytocentrifuge onto a standard glass slide to identify ferruginous bodies and longer fibers by phase contrast microscopy Formalin Fixed Tissue This protocol is similar to above without the deparaffinizing step as described in 39. Controls for both the paraffin and formalin fixed tissues included looking at the paraffin if from blocks the formalin if from fixed wet tissue or any other materials used to process the tissue to view the remaining inorganic material on the grids Asbestos Fiber Counting The grids were analyzed two ways a transmission elec- tron microscopy TEM using a standard counting protocol 23,40 on 800 grid openings and b phase contrast light microscopy on two cytocentrifuge preparations per tissue type in accordance with a standard asbestos counting protocol 23,40 Asbestos fibers were evaluated to determine whether they met the definition of a fiber which includes having at a 5 length width ratio and parallel sides and at least 5 min length The fibers were also analyzed by Energy Dispersive Spectroscopy EDS to determine the ratio of elements contained in the fibers and by Selected Area Electron Diffraction SAED to confirm the crystalline structure of the fiber to confirm that they were asbestos To evaluate for potential contamination control samples were prepared from the same distilled water used to wash the samples and the paraffin surrounding the tissue Verification techniques of fiber counting were used for quality control and quality assurance All fibers regardless of size were counted in 800 grid openings Calculating Asbestos Fiber Concentration TEM and PCM Asbestos fiber concentration in the samples examined with transmission electron microscopy was calculated see Appendix 1 http://links.lww.com/JOM/A649 The 250 Lsamples centrifuged onto standard microscope slides were examined using phase contrast light microscopy Appendix 2 http://links.lww.com/JOM/ A650 The asbestos fiber concentration in these samples was calculated see Appendix 2 http://links.lww.com/JOM/A650 Control Samples Background control samples were obtained at autopsy or from surgical specimens from pulmonary or obstetrical and gynecologic pathologists Samples included lung thoracic mesenteric and abdominal lymph nodes abdominal tissue ovaries fallopian tubes uteri and mesentery tissue Exposure histories had been obtained by treating pulmonologists or surgeons from all individuals all were screened for asbestos exposure from personal use family exposure and personal or family use of talcum powder For those patients in whom there was any question of asbestos exposure from any source the pathologists conferred with the treating clinician to ensure there was no known asbestos exposure If there was potential asbestos exposure the specimens were not included in the group As a result the background control specimens reflect only asbestos exposure from the overall community RESULTS The data associated with the exposure history of all 33 patients is presented in Table 1. The table identifies talcum powder as the only asbestos exposure these patients have experienced No individual identified any asbestos exposure apart from contaminated talcum powder from workplace or household exposures Table 2 provides the results of the fiber burden analyses for the six cases in which asbestos fibers were identified in the anatomic vicinity of the patients mesotheliomas Uniformly the tissue fiber burdens reveal the presence of the following talc aluminum silicates aluminum magnesium silicates silica crystals and asbestos fibers The asbestos fibers are all anthophyllite tremolite and chrysotile These three types are typical contaminants of talcum powders They have been identified as contaminants in talcum powders in repeated laboratory testing at numerous institutions The tissue fiber burdens contained no amosite or crocidolite commercial amphibole asbestos fibers Testing results of talcum powders have failed to show the presence of commercial amphib- oles Table 3 presents the asbestos fiber burden results from background controls in tissues from autopsy and surgical population with no evidence of ovarian cancer or other malignancy and with no known asbestos exposure The lung and lymph nodes sampled showed only chrysotile and commercial amphibole asbestos in a small percentage of control samples of the 35 control samples or 17 All women with asbestos present were over 60 years of age While asbestos is present at extremely low con- centrations in the ambient air in the control samples presented in the study there was no evidence of asbestos in women under the age of 60 years of age Two fibers were seen in two specimens and one fiber was seen in four samples all under 1 ...min size The asbestos fiber burdens in the six talc exposed patients were all greater than the control population No aluminum silicates aluminum magnesium silicates and silica crystals all components of talcum powder identified in our patients were not found in the control population that did not use talcum powder DISCUSSION This paper provides the first large case series to identify cosmetic talcum powder contaminated with asbestos as the cause of malignant mesothelioma in cosmetic talc users In 1960 Wagner presented 33 individuals exposed to crocidolite asbestos from occupational and environmental exposures providing the first large case series of individuals diagnosed with mesothelioma with clearly identifiable exposure to asbestos.Since then the high prevalence of idiopathic mesothelioma cases suggested other possible exposures including exposure to asbestos contaminated talc Like Wagner we present 33 cases predominantly of women who had no known exposure to asbestos other than prolonged use of talcum powder This is consistent with the distribution of talcum powder usage in the United Sates with greater numbers of women using powder than men Furthermore the six case histories detailed years or decades of talcum powder use as well as tissue analysis that showed asbestos present in either tumor tissue or lymph nodes In all six cases asbestos fibers consistent with those identified as contaminants in repeated laboratory testing of talcum powder samples across several institutions were identified Notably the fiber types found were consistent with the types of asbestos found in talc Amosite and crocidolite asbestos fibers that are encountered in cases of indus- trial and occupational exposure not cosmetic talcum powder were not found in any of these cases This paper is also the first to the authors knowledge to utilize background controls for which an extensive exposure history was elicited and for which no known asbestos exposure had occurred Background controls are the best comparison when analyzing tissue of asbestos exposed individuals however one of the biggest challenges is to choose a population of patients with no history of environmental or occupational exposure to asbestos apart from ambient air concentration of asbestos Previous fiber burden studies of occupationally exposed individuals have compared the asbestos content in their tissue to workers in the same commu- nity where asbestos mines or asbestos containing factories were 14 '2019 American College of Occupational and Environmental Medicine Copyright '2019 American College of Occupational and Environmental Medicine Unauthorized reproduction of this article is prohibited JOEM e Volume 62 Number 1 January 2020 Mesothelioma and Cosmetic Talc TABLE 1. Description of 33 Mesothelioma Cases Talcum Powder Exposure Case Sex Year of Diagnosis Age at Diagnosis Mesothelioma Site Histology Talcum Powder Brand Estimated Years of Use Occupation s **** F 2015 **** F 2015 **** F 2014 **** F 2014 5* F 2015 6* M 2016 road M 2016 road M 2016 road F 2016 10 F 2015 11 F 2018 12 F 2017 13 M 2016 14 M 2017 15 F 2016 16 F 2015 17 F 2015 18 F 2015 2222222222222 F 2009 2222222222222 F 2016 2222222222222 F 2013 2222222222222 F 2018 2222222222222 F 2016 2222222222222 F 2016 2222222222222 F 2017 2222222222222 F 2016 2222222222222 F 2017 2222222222222 F 2016 2222222222222 M 2015 2222222222222 F 2016 2222222222222 F 2017 32 F 2017 33 F 2017 70+ Pleural 65 Pleural 82+ Pleural 66+ Peritoneal 75+ Peritoneal 43 Pleural 65 Peritoneal 76+ Pleural 66+ Pleural 80 Pleural 73 Pleural 57 Peritoneal 56 Peritoneal 56 Peritoneal 40 Peritoneal 30 Pleural 80+ Pleural 64 Pleural 62 Pleural 69 Peritoneal 34 Peritoneal 59 Pleural 27 Peritoneal 38 Peritoneal 64 Pleural 83 Pleural 41 Peritoneal 79 Peritoneal 46 Pleural 88+ Pleural 2258 Pleural 2258 Pleural 2258 Peritoneal Epithelial Biphasic Biphasic Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Biphasic Epithelial Epithelial Epithelial Epithelial Sarcomatoid Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial A CHV C C C D U C F CV ADGHI D DJ DKLM N C C G C CD D D DGJ CDI ACT RU ADCI D D 30 Medical technician 50 Homemaker 70 Teacher 30 Hairdresser 25 Teacher 40 Finance 62 None provided 38 Accountant 35 Hair dresser 30 Administrative assistant 30 Flight attendant 40 Medical technologist 15 Maintenance worker 50 Molding press operator 12 Retail worker 19 Retail worker 40 Office worker 40 Real Estate agent 15 Teacher and fitness instructor 30 Hair dresser 10 Teacher 42 School custodian 10 Not provided 18 Social services 27 Mathematician 60 Not provided 30 Computer programmer 21 Not provided 15 Informational technology 80 Administrative worker 23 Cleaner 17 Rehabilitation coordinator 25 Clerical worker Tissue analysis presented done by author Tissue analysis might have been done in some cases by other investigator these results are not presented in this paper Deceased as of writing vital status of many individuals is currently unknown present Autopsy studies have been performed in individ- uals without a specific history of workplace asbestos exposure full exposure histories were not obtained Langer measured asbestos fiber burdens in New York City residents with no known history of asbestos Roggli and Longo47 measured tissue burdens for indi- viduals who had bystander or household exposure from family members who directly worked with asbestos in their work such as laundering clothes However that type of exposure does not truly reflect background or unexposed individuals Lee and Van Orden measured background air exposure in and outside of buildings They found short chrysotile tremolite and actinolite fibers but no anthophyllite or crocidolite and very small levels of amosite Lee and Van Orden's results are consistent with the background asbestos fibers found in the older women the present study While fiber burden studies are rarely undertaken in the course of clinical treatment and are used primarily for medico purposes the findings of various fibers in the lung tissues can provide guidance as to potential prior asbestos exposure whether from occupation residential or occupational exposure to asbestos Attention to true background rates for fiber burdens is critical Our findings strongly suggest that asbestos exposure through contaminated cosmetic talc explains cases once deemed idiopathic or spontaneous and underline the importance of TABLE 2. Tissue Digestion of Six Mesothelioma Cases Mesothelioma Case Sex Site Asbestos Type Site Found Concentration Fibers Lung Lymph Limit of Detection Lung Lymph Asbestos Bodies 1 F Pleural Anthophyllite Lung 2 F Pleural Anthophyllite tremolite actinolite Lung lymph node 3 F Pleural Tremolite Lung lymph node 4 F Peritoneal Chrysotile Peritoneum 5 F Peritoneal Anthophyllite Lymph node 6 M Pleural Anthophyllite tremolite Lymph node 3,286 8,625 34,500 0 9,409 920 20,700 17,250 1,643 2,875 11,500 6,900 9,409 920 10,350 3,450 0 0 0 409 0 0,0 0 '2019 American College of Occupational and Environmental Medicine 15 Copyright '2019 American College of Occupational and Environmental Medicine Unauthorized reproduction of this article is prohibited Moline et al JOEM e Volume 62 Number 1 January 2020 TABLE 3. Current Levels of Asbestos Fiber Burden Observed in Digests of Tissue From Autopsy and Surgical Population With no History of Asbestos Exposure Controls Tissue Type N Asbestos Type Mean Fibers Wet Weight Range Fibers Wet Weight Lung tissue 35 Chrysotile Tremolite Chrysotile and tremolite Asbestos bodies Paratracheal or parachronchial lymph node tissue 35 Chrysotile Tremolite Chrysotile and tremolite Asbestos bodies Peritoneum + gynecological tissue 10 Chrysotile Tremolite Chrysotile and tremolite Asbestos bodies 892 84 35 < bodies wet weight 225 225 < bodies wet weight 0 0 0 0 0-30,000 0-1,552 0-1,208 0-6 0-1,1035 0-552 0-828 0-5 0 0 0 0 All fibers that were counted were always 1 ...mor less in length collecting detailed exposure histories that incorporate these find- ings in patients presenting with mesothelioma Several factors may hinder the collection of comprehensive exposure histories among individuals diagnosed with mesothelioma Minimal training in occupational medicine and exposure taking practice among medi- cal students may contribute to a lack of or incomplete exposure history elicitation on the part of clinicians Secondly long latency periods between exposure and illness pose a challenge both to individual recall as well the ability to establishing causality Due to the relatively short period between diagnosis and death among mesothelioma patients patients are often too ill or are deceased before being able to provide a full history Furthermore though the presence of asbestos in talc and talcum powder was first discussed in the scientific literature in the 1940s individuals may not be aware that the products they used contained asbestos Few clini- cians are aware that this is a potential exposure Typically patients with mesothelioma will be simply asked whether they worked with or around asbestos rather than being providing with a listing of potential sources of the types of exposure in which one might encounter asbestos Cases of mesothelioma among hairdressers characterized as idiopathic also underscore the contribution of an incomplete exposure history the potential failure to identify the use of talcum powder exposure in their work would prevent the linking of occupational exposure to asbestos to their mesotheli- oma In our paper there were three female hairdressers who regularly used talcum powder in their work It was unclear from any of the histories noted in the medical records that these women were asked if they used talcum powder as part of the hair cutting process In a report from the National Mesothelioma Registry of Italy staff noted a cluster of mesothelioma due to unknown exposure among hairdressers but only examined hairdryer use as a potential exposure There was no discussion of the occupa- powder tional use of talcum 51 However McDonald et al noted that a barber's occupational exposure to asbestos to talc could explain the increased finding of tremolite in the individual's lung fiber burden The case series presented should be understood in the context of its limitations Data were obtained from medication records and transcripts of depositions rather than structured person interviews However the information solicited during the course of the patients depositions were thorough and included exhaustive questioning about alternative sources of asbestos exposure including household exposure exposures from external industrial sources occupational exposure and potential exposure from family members While deposition testimony is by definition report depositions were given under oath and the potential for recall bias noted would be presented whether patients completed a structured interview or were asked questions during sworn testimony Furthermore the utilization of medical records allowed the authors to corroborate important medical information and confirm the pathological diagnosis In March 2019 the Federal Drug Administration FDA released a statement as an update to their 2017 finding confirming asbestos contamination of certain cosmetic products marketed and sold to young girls and outlining new steps to work with manu- facturers to ensure the safety of their products While such public acknowledgment of the potential for asbestos contamination in cosmetic talc marks an important turning point manufacturers are not legally obligated to register cosmetic products with the FDA The results of this study coupled with the widespread use of such products underline the continued risks posed to consumers through common household and cosmetic products While these products remain unregulated and on the shelves the use of talcum powder must be incorporated into standard exposure history practice in order to promote earlier detection of asbestos related disease among occupationally exposed individuals This paper provides evidence that mesothelioma cases once considered idiopathic may be attributable to contaminated cosmetic talcum powder usage and that the elicitation of a 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