Document JvvrBQ7KkZDDgv80v4rjLGjR2

6/6/7? PU8LJSHE0 SOUTHER MEDIC ASSOCIATICU June, 1955 ' Carcinoma of the Lung in Asbestoses: Report of Two Additional Cases* KENNETH M. LYNCH, M.D., and H. R. PRATT-THOM.VS. M.I)7 Charleston, S. C. The possible relationship of pulmonary carcinoma to asbestosis is as yet unsettled. Statistics would indicate a probable association. . As carcinoma of the lung has assumed a foremost position in the field of neoplastic disease, both from the standpoint of incidence and causation, it appears desirable to describe two additional cases involving the coexistence of an external irritant, asbestos. Since the original report from this department in 1935.* the number of reported cases with autopsy C a has gTown to twenty-one.- That form N-ot pneumoconiosis produced by the asbestos fiber and blown as asbestosis has probably been die subject of more comment and in vestigation in relationship to carcinoma of the lung than any of the odier dust diseases. This appears to tie related to the fact that the incidence of coexistence of asbestosis and carcinoma is fairly high when compared to the incidence of carcinoma of the -lung J autopsies at large, as well as its incidence in such other diseases as silicosis and tidierculosis. The average of five analyses of the inci dence of asliestosis and carcinoma of the lung as recorded in the literature is 13.* per cent.5 The incidence of carcinoma of the lung in routine necrojwies ranges from to if |>er <ent. Daw compiled by Mere-wether* ami die Miners Phthisis Medical Hurcau of South .Africa4 disclosed an incidence of carcinoma of the lung of 1.32 anti 0.7 i>cr cent in a large series of patients widi silicosis. We have had *1Uad txture (he smion on Patimkivs, StMiilmn MisiSol As. fnm-lic/KJi Annual Meeting. M. I^wo. Mo., November 4*11. J954. *fronj the Ik-oartmeot at Pnhokxr of hc Unikai Cut. t of South Carolina. CharteMon. ,S. G. four iii;tames ol cartiitoma of the lung in :m autopsy scries of 19 cases from wuiUets iu ;u a.slx*s(o?> manufacturing plant who `houi-d demonstrable deposits of asbestos in tlieir lungs. This is an incidence of 3.2 per cent of carcinoma and asliestosis in ibis series. The iyrnerai incidence of carrinonia of die lung in the hospital service during die same jieTiod ami in the same age range as the cases of nsljotosi* was 1.5 jxrr cent. I Ids in cidence ol 821 per cent is by fat die hmest incidence recorded among the live significant series relating to this problem. Meiewether5 found 31 instances of carcinoma ot the lung among 235 patients with asbestosis oi an incidence of 13.2 jjcr tent. UedJer' hail 92 patients who died with nslx-nosi* aiming whom there were 15 with carcinoma ol die lung or an incidence of IG.3 ]>er cent. At the present moment the available e\ idence i.s not eoiu'lusive as lo whether asbestosis mav pluv an etiological vole in the omineuct* oi iarcinoina ol the lung. However, die evideme at least docs not allav the suspii ion, cimllv Ironi statistical esiileme. that dieic* may >c a cause ami efFeri relationship. Case Reports (_4.se 1. \ Hi wai oiit white mail, who hmi Ikvii as :i lainit foiimait hn g` in mi ,)sJ*nins plain ';i.% .aJmilltsI u> the lu*s|iitdl in |imc. UM3, i< jm ,uul mucucss in the 'clt suic ( his chest. AIwmii III >*veks pievimisls lie taught (oii which wu.s aoniufentitai hi .1 li.utnw OKigli [>i<hicti<- <>l j mii.iII .mtottiti ol iniaimil' blackish s|miui. He nwamni about Hu* nuu- mini t i* 566 SOUTHERN MEOIOt JOURNAL JUNC 1955- tlirer w--t Iwf.nc uliiiwinn when he nutued sore* ness ^ml ;>ain throughout !>nth tides nf )m chest ami lie ImJ io jp* 10 bed. He remained essentially the , uiml four davs before admi-vhon when he ikuoI ihat ihe jutti had localised in ihe left side { hi*. I lie rough had improved. I'hv -it ul examination revealed signs which were liniiiiil u. Ihr k'lt -ide of the thorax. Breath rounds iH.T 1 lu- li-it Ium' were decreased and there was dvoruMvl x-Mxiance in the same area. * roentgetuv gram un.-ahil a bilateral increase in lung markings >>< .1 iMH* ^i.imilat i'[ie. There was partial atelectasis .{ ill.- i.-tt i.mvci l*n< jml a definite eniaigemem of 1 In- l,-it ini.11 u-gion. the left with a marked increase in lil'UMIV . ItiiiiuluMufiv rescaled a tumor in the left lower iium Mini inom bus. A biopsy of this ledou revealed j mMikciaant/iug cpiiiermnid carcinoma 1 Fig. I). Manual axpirated Irom (he bronchial tree at the mm* luomltu-Hopt as well as a subsequent specimen uf 'nutiun it".t-jf uumernus typical as(>e*KM bodies iKig. `J1. FIG. 1 The patient was discharged on May 2. \<HX. He returned to the hospital on June 10 with storr ih, his legs began to give away aitout three *eett previously and it the present time he could mm-e them scarceiv at ail. At (he same time be also Ixgan having trouble urinating and. had been comtinaiej Examination revealed paralysis of both legs fmi,, j,|m hips downward. He was examined by 3 consultant who found a markedly distended M.itWcr and gave the opinion that this was a rout l.(jwt.T due to carcinomatous involvement of the .pi*,,-. v, v ere pain, increasing dyspnea and oattods *-- . ami he pursued a ucadv downhill rouiM* .nui .;,ot im July 1". 11MS. 2. * .Vi vear old white man had !>cvt v),,. pioveti as a spinner in an asbestos factor. i... proximatelv Jfi yean, during the wimer of ,lc experienced several respiratory infections ,im>m|W,n| Uv pleuritic pains and cough. The cuugh iu-.pt cleared and became productive of rather large <|ii3u. lilies of grayish sputum which was orudmuiiv flecked with hlood. Increasing weakness. 3ftcni<i fever, severe night sweats, exertional dyspnea amt orthopnea followctl. He had lost 33 [xmmls in wnght during the last two yean. Some thortness of breath had been picsenr lor 2d 'cars. Eld 3 N.M.ittatmwmt -.namriMV <vtl uniitwm in btnnthiai bt*c iumh .i**- 1. llanuMu'cviin jmi mtin uam. AJmhmm ant earfemt panW k-i in wwum tmmi uli innwiim lu.timnte iro* I. UiiMaim-tl. Xtft*. Ill-defined. *irwdi. nodular AeoeUatw mass ia the veoer and rmdille loOes fmot case S. .r . - . V0l.2JM . - CAJ1C1N0MA Of THE tUN<3 IN A3BESTOS1S Lmeh t*4 Pfjft-THom** 567 muled into ilw lium-n ni ihc imitacJin* ! ih? lower IoIk* cm fhc It'll mi ihui Hit* [hiiiii ni - dun iiiv|Miiti (iron liviofl cMeiidcd imwuiiK ift*- i rat hrsilirnurhiai litlurcatuitt. C.iMit ai ililim-ti alveoli were jiremat in HKidcrahi miuiix-is. pani<nlaih in tin- light lung and ntmi maited in n\ ujijy-r loi*; .Kig. *i. Hi.yloltif'it M/niv. 1 vto iHiiMCjiiiiing Icaimo ivrte imimtiijiclv appaicm inn Mrs. <i)ii< i. \amuiaiiti. These toiiMMttl <U i-Mnasttf iiilijhanuii )! differentiated <{iiuniaiii\ iuiciiuhiu null (i>iis|.iiioii- U-mimi/uiinn and |H*aiI l.Mu.uioti ,ht m. I he Spia*m of hilar rrfton o< left lung with pericardium and hart of xmd case. imn Roentgencgraphic examination revealed a diffuse granular infiltration of the lungs with a lesion in the right middle lobe which was thought to he either carcinoma nr chronic bronchiectasis ami pneu monitis. 3roncho*topic examination was negative, but cytologic udy of the sputum revealed neoplastic /cdli as well -4S asbestos bodies. His vitai capacity "vtwras. 48 per cent of nonnai and exercise produced marked dyspnea so that the thought of pneumonectomy was abandoned and he received x-ray therapy. The diagnosis had been definitely euablisheri by exami nation of 'he sputum <m July 1, 1952. and the patient died, on Detcnilier 12. 1952. AVtTOpry. I hear wen dense plonra) adhesion* present dial the lungs were removed with difiicuitT. The pcrtcirdial sac was also paniallv obliteraied. 'Die lung* iigeHicr weighed Ififlll (nit. They held their diap' well and on palpation had an ir regular uodulai jihI leatiacry quality. Att ill-deiim-d neoplastic mass wa* presetu in the lower (bhimmi of the fight upjwr lolie ami in titc right uiiritifc* lobe 'Ftg, J).-Iii iltc Hilar region-of (lie left long -there was a ocotdawic mass 5 cm. in diameter width obliterated the inmicfai to the upper ami lower W^b** with the exorpium of the superior branches lo Htew.* lobes (Tig. 4). T his extended into the periraitltaJ .*- and involved the puMeroiatcai asperr of the left riculat wall. A polypoid uwtgtte of mmoc jn Ptetirai thickening and ouiicd mtdnwma >n <ac i. flG. 6 PVvifurm BtumtBMts iHI uiumnna hula giunn < j^imiwi Tbb1ii~ Inan rase "i. Heniji<>s*lin amt limn nani. \l*yt. i8 SOUTHERN MEDICAL JOURNAL JUNE 1955 - ... - mnwn wj* jm-M-m tx< .mlv in ihe hilar rrqnro of ' ilu left Inns: ami ihe non of ihe right lung. I>tii <a jm-w-ni in liter jUenli in tnativ area* where ilie idle lav either in riu.iow m iWmcii 3 -.m it aUritiar liniiie. 1 In* <rmri notable framre H3 ihc exieoriv e fihnm* Uih 1.4-mott n( ihe alvmilar w.ilK with rlum|ie anti Jwil* <4 HI.nun iiut<* ami I'.iuvvuttiiaKi^ Kttttj in live aivotlai mww Numerous ,i-jh-s'< iHniio w-tv rmiieihiisl in (In* fihrnm tissue ami were also present hi tin* alveolar "pace* riiljcr a* -Migiv IxhIJcw or in duster*. Discussion The tissue reaction produced by xebextm dim is believed to be due to the physical nature-of the- asbestos" particle nuher-than to any chemical constituent. The asbestos liber causes desquamation of the bronchiolar epithelium ami ;m outpouring; of numerous macrophages in an attempt to phayocytize the lilter* (Fig. 7). Fibroblastic proliferation ami collagen deposition in the walls of al veoli and about the terminal bronchioles billow at a later Mage. Theoretically it is an attractive hvpnthesi'* to Itelieve that the merhauual irritation of the a*4jestos fibers produces hyperplasia of bronchiolar epi thelium which esenttiaih estapes Irom the realm <d normal biologic control ami becomes neoplastic. There i* at least come histologic evidence ol epithelial hvj>erpl:ista (Fig. 7). but experimental proof >l progression from h\{>erp!:isia to neoplasia is difficult to pro* (hue. Tlie extjertmeutai animal in this case, a* in mans others. <loC> not iu*re>sarifv re* qxmd in a tu>hton that is comparable to human t issue*. I W>*;?or- V*u?- exj>.-ser? jo- con- f3. 7 ctmiratious ol ;jsI>cmoj dust having the proper qx*t ificnium* as regards particle volume ami M/e do not develop asixrsiosis or "arcinoma, although the ubiquitous pulmonary adenoma is frequentlv present. In Inc; bronchogenic carcinoma of man has no counterpart in oilier animals. It :ipj>c:irs lhat the puiinonarv tissue of dogs jnav reqxmd to a.sl-us dust in a manner somewhat more closely analogous to man. l.'niil a valid biologic experiment ran lie evolved, it appears that the evidence for or against the possible carcinogenic effect of die asbestos fiber will rest primarily on statistical evidence and personal opinion. Conclusions -- We have described two additional cases of asliesiosis and bronchogenic carcinoma. A total of lour cases showing the coexistence of these diseases have occurred in our series of *19 cases having asbestosis at necopsy, an incidence of 8,2 per cent. Statistical inference from this and other series doe* not allay the suspicion that there may be an associa tion between the two conditions. Animal ex perimentation has not yet provided any con clusive evidence of this. Sibil?raptor 1. L'mfo. ft. M.. and smith. W. A.: Puitaanarr Astefrou* <ii. ( imimmi ot Lunf ia Asoesco-SilieoMi. aa. J. Cjb>-r J lIM3. i. l.il>4<l)cr. K. Klaus. H.. sad Hardv, H. U. Aitxstosss slid MronrhMcnK C.Jrtinonia: Rfport st One \uioptird c, snU Rfs-ntw ot the Available Lticranu*. Am. ). \icd. i vrai. i.t. Mfiew-rtlwr. V. St. Aa Snmul Rcbott os the Chief In- fK Faueriet. I nndMi. 1P4T. H. \t. Sudcnerr N4. oRieliepur.m PbthHi* Medical Bureau. Ufuoo SmUs Alnta. Prt-cona. j. UniUi. II. U.: Aheoe and Luneerureb*. Oeucse&e *nl. Wilvtvwhr. "AorS, T9AS. Abu. Buii. Hvf. 19U63. H*H. Discussion (Abstract (MWonm i(.j4jtub I.Ih*v in-)ltnuM durt. Nme mnw uiI'<iImiii wtivicv wmJ nt Mum hwilai cl*- r lirliauit. itm imiil. Hrim>iiy liw .<k4 <*mu *4in. \ Ho*. Dr. ('" u hrti r. Squires. Prns/ieoh:. Fla. I wouU lil. fo Hr. Pi-air-Thomas, what is rhe present iiiiiiiMriai i<mipeiiutioti <tanui of the coexistence of tiu-v ! iiiM.-4M.-ii- As patliolo^ists we aie quite fie- ,.<ik*ii upon to ^ive an opmior. in an in- dinn.ii iiMi)|)oi<4iiuii ru\c on such iiuiividuais '! haw i.n'vwuii <ii.xase. /)*. pmtt-T^omu*. Mv inipmsion i? that it m.-' uw maucr what o^nniem \nu pve as l have testified quin* \<>iui)h on one si*le nr the other, and the indu*trial toinmioMtin aiwavs ilecades in the opposite dii<xiLtii. I liev wMtfti mneh rather listen u> a doctor wi;. has ixwer itime an amopey hut who has had 7* u*3is of (linirai ex^wictice render an opinion which iliew will alwav. "Imiv." rariiCT than to a so-called 'jwviaiist. Serinti-dv. iu our experience wc hate seen cases in which at Itsm panusi rnmpeusaiion lias been allowed. VOLUME *4 MALIGNANT TUMOW Of THE SUPERIOR MAXILLA--Lw* 569 It wa thongin thrv might mu hast* hied guiic a' fa** if ihev bad uoi gotten urnimma ami iNat (he mi* denee for astwxoou producing cuiwer. not proven. wa* *uffkientfv quesi inuaiilo >o ihe rase* were judgrd in favor ( the piaimiU. or at !om partially . - Dr. All>rt E. Cmer. lUmtiuuiiaitt, A In. ! umild like to aL Dr. l'ratt-Thumav. what is the imideme of jsbrttovii uwrr the rwimrnr- I am ulraid >*r hate been aiming >onie in Birmingham, . I luive, if it is is itituh 3* vou rqwn there. Alsu ! a.Li whether the effect of a carrinngcit with a ii<n-|>crific foreign body reactor might not lie the an*.*er to the increased iiuulcnec. Another question is. what is your autojny routine for dmmMrating adioinwar Dr. Fmtt-Ti-vittas (Waring). 1 take it \<m Jo mu have any aabe*o* plants in Birmingham. Well, that's our misfortune. We hapjjcn to have t|utie a big fabricating plant outside of Charleston ami. >>( imirv. that is the teason Dr. Lvmh ungjnalh Iks aim* interested in the problem ami did rmuh .if the lint and lusic work which has been done im ihtt par* ticuiar form of jmeurnonoconuwia.' ' ' . *'` It is estimated (hat there arc ai*mt I (rt hj [*oplc in the United States who arc at the purcm moment jaitt'ituullv mdit't i ijJh i iittiiH-iisaiiie as i.i i ,i\ .is- Ih-.(iss is iiiiiii IIK'iI 111 miIii'I ninil.v tlll'i .ill la nig l'\IHxst In lilt >lllM III .41J* i It II In i Ms* I' I Ml III I IlL* I'lllllli [Ill'll' .jii- jppniwtu.ni'iv I In t.t w * * mhets in iln' Itnii'h Ul-s wins m- is|i*ol to (his lio/ani at the pu-u-m Mine. I hough I iuimiiiI .iiisiii'i urtii ,|iis'Mii,ii in iii ci.ill stuttMOs. !Iris ^iu-s w*n .hi isti.a .is in liir imiiliiue. will mil si' H hiiIi'ws mu an* in ,i mmiiiihiiiiM nr :iu*j m is h<> It iln'H' i eilbei niming * IjImh.iIimii nl ihe jii>aim i. the 3>Im-si<s IiIh'i is ipiitc i'jm ih IuhI hi pHimii. One llv."* Ihe simple -aliiiiii nr |mt.ismHit hsilmwdc liipii-lus lion in hois will* i .nm lii",n i.m ;u<( studs liir* > <<<M rill laics. In ss *i 11* ii is fliev >linw up luMintliiiit ami tht not ici[iiiii' ant >|s-i mI s(aiuitig irt lmii|in .. t !u onlv imutU* is ih.it thru* .nr -aannual ihnig* ihm liaA like JsIksHis IiIh'Is llimigll liit't .lit- .u*l. I ll.lt . I.f IIHIISJ', is .1 -illi|i'i I within liv'd ,.S III III! jimp I liiililitii 4li*i. Hill the liassiui ,i-lsiis IiIm-i ..hi il'llaillh la' iliitilisl hi (lie spsiiiiin viiv Minpls .is Ms*il as in i issue -wi i imis. Ol mm**'. t |>n-ss-m< nl asiiotos la.iies ill lisMH* .... ........is du imiI iincssdilh mean dial Hie jiatit-iH is n-alls siiitenm* Imm imm- asla*M<sis. i hr* ni;]\ haw an i< annual .hh* m.iI irtial jmiinii ,ntd uu iraiimii in h . Malignant Tumors of the Superior Maxilla* MERCER G. LYNCH, *Wu/ Orlmns. I.a. Recent advances in anesthesia and radiarian-Hierapy, aionq with the antibiotics, permit a radicai attack upon malignant lesions of the superior maxilla not possible in the past. In scanning the medical literature o the past 15 years one finds more ami more about malignant Itrsiocn of die heud and neck and less aixiut the medical and surgical trcatnieru of iniertious (onditions. There are two main reasons for this. Oser a peiiixl of years the technical difficulties of, and inditatinns lor surgical prrxedurei have Iwen Rcmrndly and in most instances sjoetilicafly ironed out. Aiv, the principles and tationaic of mtwiiral therapy and the availability 'if antibiotic* have greatly decreased tic indirtniom lot tod before (he Sectwo >m DohihuiimOotv smi CHnisrin |oiev, aowiAem Medical iiwinmn, ivhtS Annual Ummf, u. Loon. * U. ]<r>l. ifma (J DcmiumM of Ou>iiuaarwMtiaofT. fxMnr* CUak. New rnkam. U. surgimf treatment of iid'crtiotts. I lius die j>endiilum Itas swung tuoie nearly to dicT***` {acnciirular in regard to die mlcriioiiv ioikIitions. Secondly, with die ini rcav in life ex pectancy ami die additional Ia(ilm<^ loi (iiagmtti.s. malignant disease is beiMining in* (re^isingly a umic pioiiiiueni piMiiicm m mesfiraf pr.uticc. Witfl die advances dial have lut-n made in unciti)esi<dogy au<i in picojxMame ami jxsi* Of;xative aie. sntguai pun etlures aw being dorte uxlay dial wete noi possible t<ameil>. Ihe radiraf surgirai piori'dmes neicsvns in dealing widi malignant nutiois are now leasibfe in many inMati<4*s, and the jaosw'bdit\ of