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FILE NAME Household Contact HC DATE 2007 DOC HC039 DOCUMENT DESCRIPTION Journal Article - Mesothelioma You Do Not Have to Work for it Mesothelioma You Do Not Have to Work for it Elizabeth J. Ampleford PD and Jill Ohar M.D.1.2 Asbestos pollution is a global problem Asbestos exposure induced mesothelioma does not require an occupational type of exposure Bystander exposures may result in earlier age of disease onset and more aggressive disease progression as described in the following 3 case reports Diagn Cytopathol 774 777'2007 Wiley Inc Key Words mesothelioma asbestos bystander exposure Bystander exposure can occur through contact with asbestos contaminated occupationally exposed individuals or their belongings through contact either with fibers resulting from the erosion of asbestiform rocks or exposure to products made with asbestos such as gaskets brake pads clutch pads floor tiles ceiling tiles roofing shingles sheet rock putties insulation and cement Innocuous tasks such as laundry home remodeling or auto repair can result in bystander exposure to asbestos Bourdes et al provides a summary of asbestos levels in various environments The levels near a US asbestos cement plant 0.6-2.2 fibers are notably lower than the range for ambient air in several US cities 150 fibers and less than that accompanying urban expressway pollution 3.3 fibers It is striking that a small number of New York air samples immediately after the World Trade Center Disaster showed levels in excess of the EPA haz- ard alert level of 70 fibers i.e. 7 ^ 10 fiber which represents a million fold increase over those listed above Ordinary vacuum cleaning sweeping or dusting is not effective at removing asbestos fibers which frequently become airborne when disturbed The presence of Center for Human Genomics Wake Forest University School of Medicine Winston North Carolina Department of Internal Medicine Wake Forest University School of Medicine Winston North Carolina Contract grant sponsors Selikoff fund Saint Louis University MARFthe mesothelio" raapplied research foundation Correspondence to Jill Ohar ALD Wake Forest University School of Medicine Section of Pulmonary Critical Care Allergy and immuno- fogic Diseases Medical Center Boulevard Winston NC mail johan ubric.edu Received 24 April 2007 Accepted 18 June 2007 DOI 10.1002dc.20766 Published online in Wiley InterScience www.interscience.ww.wintersciience.lwiley.ceom yww.in.tersccienceo.wilemy.com 774 Diagnostic Cytopathology Vol 35 No 12 og. MIVILEY asbestos fibers in ice from Greenland or on the moors of Yorkshire demonstrates the worldwide extent of asbestos pollution. Bystander asbestos exposure is a common but infrequently recognized risk for mesothelioma Magnani et al provided formal epidemiologic evidence for increased risk of pleural mesothelioma both from environmental 10fold increase and household fold increase exposure to asbestos over the risk in nonexposed controls Bystander exposure is often sustained by women and children who may be at increased risk for mesothelioma compared with men Recent analysis of a large population of asbestos exposed individuals revealed a significantly larger proportion of women in the mesothelioma group compared to the proportion of women in other asbestos induced dis- ease categories. Relatively little has been written about bystander exposure to asbestos in the U.S. Only 1 of 15 studies involving bystander exposure was conducted in the US with relative risk for mesothelioma ranging from 1.3 to 182. Five of 10 mesothelioma cases presenting in patients under age 40 represented household exposure to ashestos with median age at first exposure of 10 yr and median latency to diagnosis of 19 yr Bystander types of exposure can provoke mesothelioma with variable age onsets Recently Miller described a bystander exposure group household members of asbestos exposed workers consisting of 32 US cases of mesothelioma presenting after 1990 which were obtained from the records of law firms Age at diagnosis ranged upwards from 43 yr with half of the cohort older than 60. First exposure to asbestos in this group ranged from birth to 30 yr with almost half of the populations first known exposure between birth and age 20. The very nature of bystander asbestos exposure implies contact of variable duration However short exposure is not equivalent to low exposure or to low risk In fact Hillerdal suggests that fiber concentration during domes- tic exposure maybe as high as that sustained during occupational exposure De Vuyst demonstrated that bronchial lavage fluid contains asbestos bodies AB at concentra- tions of less than 1 AB in individuals without occupa- tional or known environmental asbestos exposure How- & 2007 WILEY INC Diagnostic Cytopathology DOI 10.1002 MESOTHELIOMA FROM BYSTANDER EXPOSURE TO ASBESTOS Fig 1. The posterior lu anterior PA chest ray of Mrs. X at the time of presentation Note the asymmetric pleural scarring ^ndor effusion A pleural effusion with or without evident pleural seaming is almost always apparent at the time of presentation of a thoracic mesothelioma This is frequently mistakenly treated as pneumonia or congestive heart for months causing delay in diagnosis ever he found 1.2 AB 80 of the AB formed on aruosite and the remainder formed on crocidolite in the wife of an asbestos spray insulator responsible for the weekly laundering of her husbands work clothes Fiber burdens within the lung are reflective of individual variability in alveolar retention and fiber dependent differences in biopersistence Some differences in alveolar retention arise from cigarette smoking chronic obstructive pulmonary disease COPD and other airway abnormalities In addition there may be genetic differences leading to alteration in alveolar structure function or inflammatory response The fact that high levels of asbestos exposure are not nec- essarily correlated with increased risk for mesothelioma probably reflects the fact that high fiber burdens may lead to pulmonary insufficiency well prior to any possible expression of mesothelioma Below are the case records of three women with bystander exposure to asbestos Case 1 Mrs. X was a old woman who worked from 19522002 as a clerk auditor courier and dispatcher without known occupational asbestos exposure She resided in a neighborhood containing a cement factory from 1939 through 1961 1962 through 1967 and from 1996 until her death in 2004. The asbestos containing cement pipe known as Transite pipe was manufactured at this facility located Fig 2. This CT cut illustrates the tendency of mesothelioma to the ungAlthough the tumor may have a lumpy bumpy configuration on CT it can also present as seen in this illustration as a unilateral smooth concentric increase in pleural thickness with or without a pleural effusion within two blocks of Mrs. X's residence Crocidolite asbes- tos was the fiber type primarily used in the manufacturing process which in full operation gencrated 0-20 tons of waste Mrs. X's father worked at the manufacturing facility for 30 yr primarily in the storeroom handling all sorts of asbestos containing materials such as pipe covering wallboard and raw asbestos As a child Mrs. X would routinely visit her father at the job site and take him his lunch sometimes sharing his lunch and riding her bicycle around the plant grounds She helped with the laundering of her dad's work clothes by age 12 13 Mrs. X presented with a right pleural effusion in March of 2002 Figs 12 12 and was treated for a community acquired pneumonia Four thoracentesis procedures were performed between March and September 2002. The pleural fluid was exudative with a cytology examination negative for malignancy She was admitted to hospital in mid September 2002 for possible thoracoscopic decortication and was found to have a markedly thickened pleura that was adherent to the underlying lung Therefore Mrs. X underwent a right thoracotomy with biopsy of the pleura which was markedly thickened to 1 cm and white finn and rubbery Attempts at separating the lung from the pleura resulted in multiple areas of air leak The patho ogy report revealed malignant mesothelioma epithelial type At the time of hospital admission Mrs. X complained of a 30 pound weight loss over the last yr Her family history was significant for cancer Three uncles Diagnostic Cytopathology Vol 35 No 12 775 Diagnostic Cytopathology DOI 10.1002 10.1002 AMPLEFORD AND OHAR had been diagnosed with cancer stomach Jung and the third an unknown primary An aunt was diagnosed with cervical cancer All four relatives worked in the asbestos plant Case 2 Ms. Y was a old female who began working as a medical associate from 1986 until the time of evaluation in 2001 performing EKG's assisting patients drawing blood and completing forms Her father worked for a can factory and she did not help launder his clothes He did a small remodeling project when she was 10 installing floor tile and sheetrock The entire project took about 6 mo She was married to an electrician from 1987-94 however she did not launder his clothing at home Ms. Y resided in close proximately to Mrs. X for most of her life She recalls the grass in her yard the tomatoes in the garden and the cars in the driveway constantly having a white dust on them As a child she remembers wiping the white dust from her bicycle and how the silt would build up on her bedroom fumiture She smoked up to 1/2 pack of cigarettes beginning at 17 and ending at age 45. She never regularly used pipe cigar or chewing tobacco Two of her seven siblings had no known occupational exposure to asbestos but were diagnosed with asbestosis In addition another brother also reported to be unexposed had a history of asbestosis and asbestos induced pericarditis In February 2000 Ms. Y complained of chest pain and a chest ray revealed a 1.5 cm nodular density in the right mid lung field which was suspicious for a primary lung carcinoma Also noted was linear left lower lobe atelectasis or scarring A PET scan performed in March 2000 revealed a nodule in the right central lung field that measured 1.7 ^ 2 ^ 1.4 cm consistent with primary lung cancer In April 2000 a thoracotomy was performed with a right upper lobectomy and node dissection A palpable 2-3 cm pleural mass in the inferior aspect of the right upper lobe was excised Also noted at the time of surgery were pleural plaques on the parietal surface of the chest wall A fiber burden analysis was performed and crocido- lite asbestos fibers were found at a concentration consis- tent with an occupational exposure The fiber burden analysis on Ms. Y reveled levels con- sistent with occupational exposure even thought Ms. Y's exposure was clearly environmental Given the shared environment between Ms. Y and Mrs. X similar lung fiber exposures would be predicted Asbestos bodies are frequently found in those who have sustained a bystander exposure Dodson found asbestos bodies in 13/15 and uncoated asbestos fibers on lung digestion in all 15 women with mesothelioma who had sustained a bystander exposure An increased number of ferruginous bodies compared 12 to the general population was seen in 4/15 The high incidence of cancer in close relatives sharing the same environ- 776 Diagnostic Cytopathology Vol 35 No 12 ment of Mrs. X is remarkable Vianna and Polan,,reported that the frequency of a parent with malignancy was 17/52 33 in a cohort of women with mesotheliomna resultant from a bystander exposure Ohar et al also found a similar increased frequency of first degree relatives with cancer anong both bystanders and primary exposure mesothelioma subjects 68 and 63 respectively Mrs. X and Ms. Y sustained a bystander exposure to asbestos and the source of the exposure is irrefutable Chrysotile was the most frequent asbestos fiber type used in US manufacturing Less than % of asbestos imported for manufacturing in the US was crocidolite The cement factory used crocidolite The presence of crocidolite fibers in the Jungs of Ms. Y at levels consistent with an occupational exposure link her exposure and that of Mrs. X by inference to the cement factory These individuals have atypical medical histories More often the source of exposure is much less apparent which is illustrated by the case of Miss S. Case 3 Miss S was a old woman whose primary asbestos exposure stemmed from exposure to her fathers work clothes Mr. S worked with asbestos as an electrician an insulator a mechanic a machinist a miller a pipe fitter a plumber a steel worker and as a welder while being employed by an aluminum can company In 1978 Mr. S worked as a furnace operator In 1979 he worked with the labor pool making wooden pallet boxes He also put coils of metal in the furnace In 1980 he installed asbestos ther- mal couples into furnaces Also in 1980 he worked as an equipment operator at the can recycling division He ran a high He worked in the vicinity of the furnaces and refractory material which he swept up and hauled away daily He used an air hose to clean up refractory material In 1981-2002 he worked as a mechanical craft specialist Over that time interval he continued to work furnace tear downs an activity performed quarterly where a jackhammer and pickaxe were used to remove and repiace refractory material from the furnace He reinsulated furnaces He removed insulation from pipes and reinsulated them He mixed anud from water and asbestos powder He used asbestos gaskets and packing material several times per wk Miss S's father believes that asbestos abatement began at the can company in 1992. He related that specially trained asbestos crews worked with the removal of asbestos at that time Mr. S's work clothes were laun- dered at home Both he and his wife laundered his clothes Mrs. S recollected dust debris on the floor of the laundry room where his clothes sat before washing Miss S on occasion would help with the laundering of these clothes Miss S worked as a nursing assistant without known asbestos exposure There was no remodeling performed while she occupied the family home Diagnostic Cytopathology DOI 10.1002 MESOTHELIOMA FROM BYSTANDER EXPOSURE TO ASBESTOS Miss had been born prematurely at 28-30 wk of ges- of onset suggest that neo natal or childhood bystander cx- tation and had a three month neonatal stay in the hospital posure may result in a more aggressive tumor type She had a patent arteriosis that was surgically Tighter regulation and controls over industrial uses of closed Bilateral chest tubes were placed at the age of 4 mo because of a pulmonary infection She had mild asbestos has helped protect and prevent occupational ex- posure in industrialized nations The current shift towards cerebral palsy and hydrocephalus treated with a ventriculoperitoneal shunt In June 2002 Miss S had a routine bystander exposures in countries which acted promptly to reduce exposure risk reflects both the effectiveness of the physical examination At that time she was noted to have occupational regulation und weaknesses in environmental a history of depression heavy menstrual cycles anemia hydrocephalus mild cerebral palsy and asthma She was control and remediation Asbestos pollution is a global problem It may be of academic interest only as to reported to have smoked half pack of cigarettes off whether individuals in industrialized societies could be and on for 6 yr Diabetes reportedly an in the family found not to have sustained some level of exposure to and a maternal grandmother suffered with heart disease asbestos Physicians may need to consider mesothelioma Physical examination revealed a pelvic mass and CT of among the differential diagnoses without regard to occu- toe the abdomen performed in August 2002 revealed exten- pational asbestos exposure in women and in individuals in sive abdominal ascites with subtle suggestion of possibly the 40+ age category who present with unexplained chest early peritoneal implants The left ovary appeared com- pain fatigue weight loss unilateral pleural effusions or plex in its configuration Also noted was an elliptical area asymmetric pleural thickening of soft tissue thickening anterior to the pericardia Miss S was admitted to the hospital in August 2002. At that time she was a old white woman with a history of hydrocephalus and mild cerebral palsy She had complaints of increased abdominal girth and a mass in the pelvis A chest ray performed at hospital admission revealed scarring and a rib abnormality The scarring was most prominent in the lingula She underwent an exploratory laparotomy on the day of admission to the hospital At the time of surgery extensive omental caking was noted and the pathology report retumed positive for malignant mesothelioma epithelial type The mass affected the rectovaginal septum the desac almost all peritoneal surfaces including the junction of the small bowel mesentery and the bowel Anderson et al reported four new cases and summarized 33 published cases of mesothelioma after a bystander exposure Twenty seven of 33 81 were women and 11 of 22 were diagnosed before the age of 50.14 A report by Vianna and Polan showed that the mean age of the 52 women with mesothelioma resultant from a bystander ex- posure reported was 60.2 yr The mean age of mesothe- References 1. Bourdes B Boffetta P Pisani P. Environmental exposure to asbestos and risk of pleural mesothelioma review and analysis Eur J Epidemiol 2000 411 414711 417 2. Landrigan PJ Lioy PJ Thurston O the NIEHS World Trade Center Working Group Health and environmental consequences of the world trade center disaster Environ Health Perspect 2004 731 739 3. Hillerdal G. Mesothelioma Cases associated with occupational and low dose exposures Occup Environ Med 505 55 05 51 13 3 4. Magnani C Agudo A Gonzalez CA et al Multicentric study on malignant pleural mesothelioma and occupational exposaure to asbestos BrJ Cancer 2000 104 111 5. Ohar J Howard S. Ampleford EJ Sterling DA Identification of a mesothelioma phenotype Respir Med 2007 503 509 6. Boffetta P. Epidemiology of environmental and occupational canicer Oncogen 5392 5403 7. Kane MD Chahinian A~ Holland FF Malignant mesothelioma in young adults Cancer 1449 1455 8. Miller A. Mesothelioma in household members of asbestos workers 32 United States cases since 1990. Am J Ind Med 2005 458 462 9. 9. De Vuyst P Dumortier P Moulin E Yourassowsky N Yemault JC Diagnostic value of asbestos bodies in bronchoalveolar lavage fluid Am Rev Respir Dis 1987 1219 1224 lioma diagnosis in both of these reports was less than that of asbestos tradesmen with primary exposure which was 66.9 -11.6 mean -SD Haque et al have documented the presence of asbes- 10. De Vuyst P Dumortier P Geverois PA Analysis of asbestos bodies I BAT from subjects with particular exposures AmJ Ind Med 1997 699-704 11. Pass HL Vogelzang N Hahn S. Carbone M. Malignant pleural mesotliclioma Cuir Probl Cancer 93 174 tos fibers in digests of placenta from healthy newboni infants in addition to finding fibers in lung liver skeletal muscle and placenta from stillborn infants In addition there was a suggestion that mean gestational age for infants positive for asbestos fibers was younger than that of infants negative for asbestos fibers.15 It is reasonable to suggest that Miss S was exposed to asbestos not only in her youth but also in utero The extensive invasion of the mesothelioma on peritoneal surfaces and the early age 12. Dodson RF O'Sullivan M Brooks DR Hammer SP Quantitative analysis of asbestos burden in women with mesothelioma Am F Ind Med 188 195 13. Vianna NJ Polau AK occupational exposure to asbestos and maliguant mesothelioma in females Lancet 1061 1063 14. HA Lilis R Daum SM Fischbein AS Selikoff IJ Anderson asbestos contact neoplastic risk Ann N Y Acad Sci 1976 Household 311 323 ; 15. Haque AK Vrazel DM Uchida T. Assessment of asbestos burden in the placenta and tissue digests of stillborn infants in south Texas Arch Environ Contam Toxical 532 538 Diagnostic Cytopathology Vol 35 No 12 777