Document MMQ2610omZGDMqLbQ26MVvXjy

/tecK Vd88; 93i -Ss4 ^j Case Reports ASBESTOSIS ASSOCIATED WITH BRONCHOGENIC CARCINOMA ; . '. . ROGER STOLL, M.D. RICHARD BASS, M.D. AH O' ALFRED A. ANGRIST, M.D. JAMAICA, N. r, ' ' HOLLEB and Angrist1 in 1942 reported two cases of bronchogenic carc;noma in association with pulmonary..asbestosis. The first case of carcinoma of the Jung in association with pulmonary asbestosis was reported in 1935 by Lynch and Smith.* In that year Gloyne reported two cases and in 1936 another.' Egbert and Geiger * reported one case in 1936. Nordmatm * presented two cases ir I93S. One year later Lynch and Smith * added another. Of these, six were of squamous cell carcinoma, one of squamous-cell carcinoma with glandular features, two of oat-ccl! carcinoma, one of glandular carcinoma, and another of squamous^cell non- kcratinizing carcinoma. The age of the patients ranged from 33 to 71 years, and the duration of exposure, from 19 months to 25 years. All but two had metastases. Freedom from exposure before death varied from four months to IS years. We haw 'und four additional cases not mentioned in the report by Holleb and Angrist.' ` Two cases reported by Koelschr in 1940 were in an oral communication, and no details are known. Two more cases were reported by Linzbach and Wedler * in ' 1941, one of which was of a squamous-cell carcinoma in a man 61 years old, exposed . for at least three years to asbestos; of the other, no details were known. Ir. 1941 also Desmeules 3 added two more cases to the literature, one of a man 37 years old in whom alveolar-cell carcinoma was found and who had been exposed . From the Departments of Pathology and Ifedicine (Dr. James R. Reuiing, Director), Queens General Hospital. ' .. . ' v 1. Holleb, II, aid Angrist A.: Rronchiogcnic Carcinoma in Association with Pulmonary Asbestosis: Report of 2. Cases, Am* J* Path. 18:123-1.13. 1942. ' * 2. Lyndi, K. M.. and Smith, IV. A.: Pulmonary Asbestosis: HI. Carcinoma of Lung in Asbcsto-Silico*!*. Am. J..Cancer 21:36-64, 1935, . '. . s-,3. Gloyne, S. R.: .Two Cases of Squamous Carcinoma of the Lung Occurring in Asbestosis. Tubercle 17:3-10. 1933; Case of Oat Cell Carcinoma of Lung Occurring in Asbestosis,'ihUL . 18:100-101, 1936. ` 4. Egbert D. S. and Geiger, A. J.: Pulmonary Asbestosis and Carcinoma: Repvt of ._a Case with Mccropsv Findings, Am. Rev. Tnbcrc. 34:143-130, 1936. . k 5. Nordniann, M.: Dcr Bcnifskrcbs dcr Asbcstarixitcr, 7.t<tehr. Krebsfnrsch. 47:2Rf! 3ft2. 1934 ' ` ` .. ' - I.ynch, K. M.. and Smitli. W. A.: Pulmonary Asl>usti*i: V, A l\c|irt of Bronchial . Carcinoma and Kpilhcliat Metaplasia. An:. J. Cancer 36:567-573, 1939. ` 7. Knctscb: t.nngcnkrchs unil iloruf. abstracted in Zcntralhl. Gewcrbehyg. 27:32-33, 1940. 14 Linzbach. A. J, and Wedler, H. \V\: Deitrag zum Bcrufskrebs dcr Asbcstarbcitcr, . , Arch. path. Anat. 307:387-409. l'Ml. ' . .' U.-9. Desmeules. K.- Rousseau, L: Giroux, M, and Sire. A.: Amiatitosc ct careers pulmouaircs, Laval nvd. 6:97-lW, 1941. . 83i SCF-FA-4000 to asbestos for 25 years. The other was of a man of 50 with squanious-cdl carcinoma who had been exposed for 22 years. .Both had metastases to the pleura. Since 1941, a number of similar cases has been reported. In 1942 Homburger19 reported three cases in men 45, 43, and 49 years of age. In two, squamous-cell > ^ Physi. lying in note witl lung. T Laict carcinoma was found; in the other, an anaplastic carcinoma.- One had been exposed ' blood pr to asbestos for five years, another for 20 years. The duration of exposure in the fj.Tk per 100 third was not known. AH three had metastases. In Homburger's laboratory from *1,: 1918 to 1938, in 4,137 autopsies, asbestosis was diagnosed in eight cases. Pulmonary carcinoma was found in four of these. . ' polymori were wit cells. - A A cfc fti Wedler11 in 1943 collected 92 postmortem reports of cases of asbestosis from different parts of the world and found an incidence of 16% with associated pulmonary carcinoma. . _. In 1947 MerewetherlJ reviewed the accumulated data over a period of 22 v' oval shai A bone parietal urograpi findings. m iw* years (1924 to 1946) in the "Annual Report of Chief Inspector of Factories in v Thro England." In 235 cases asbestosis was found, and in 31 of these pulmonary card-' noma was also present, an incidence of 13.2%. The incidence of pulmonary carcinoma in the general adult population was 1.0%. Lynch and Cannon in 1948,11 reported that among 40 cases of asbestosis over.' .-r.*>..* On the i of the ri A spinal The cell 10Q cc. \ :/vv r.vi piS V ./.-v a period of 18 years in.their postmortem series a total of 3 cases of carcinoma of on the i . the lung was encountered, an inadence of 7.5%. Each of these three cases showed medium to advanced grades of asbestosis. . ' Wyers in -1949*1* reported on a series of 115 cases of asbestosis. Pulmonary earemoma was present in 17, an. inadence of 14.8%. Squamous, carcinoma was present in nine cases, oat-cell carcinoma. in five, and columnar-cell cardnoma in one. " Af (methylwithout day. ' The onknowt Posh pi pleural : ' BEPOET OF CASE . I>. I_, a white man 40 yean old, was admitted to Queens General Hospital- complaining of cough, fever, and weakness oi two weeks' duration. For four to five months prior to n admission he felt weak and slightly anorectic,jivith a weight loss of about 10 lb. (4.5 kg.). ' Two weeks prior to admission his weakness became more marked, and he began having a dry spersistent .cough which was nonbtoody. He visited his local physician at that time and was - T/>>J v.-.'.V -is* yeltow, : these no rigiit lanecrotic Inter addition, - r found to be febrile. A roentgenogram was taken, and he was told he had viral pneumonia. He . dark red 05 wat treated with penicillin,' sulfonamides, chloramphenicol (chloromycetin*), and aureomycin gross, bt without a fall in temperature, aqd with persistence oi the cough. His local physician then , advised hospitalization. There was no history of previous illness. ' . - . From 1925 to 1940 he had worked as a plumber but did not use asbestos in his work. In 1940 he obtained a job with the Works Progress Administration as a pipe coverer' in which he worked with asbestos exclusively for one and a halt years. For the next four and a half years he continued to work as a pipe coverer in a shipyard, where he again used asbestos .-A1` pole of t rouaded, Sereral In ea small he surround K*. oaly. During this time he was told to wear a mask while working but neglected fo do so In tl ., and complained that the smell always made him sick. . measurct The t/10. Homburger, F.t Ca-.tncMcr.ec oi Primary Carcinoma oi Lungs and Pulmonary Asbestotis: Analysis of Literature and Report of 3 Cases, Am. J. Path. 19:797-807, 1943. v- 11. Wedler, H. W.: Ashcstofu und I.ungcnkrehs, Deutsche mcd. Wchnschr. 69:575, 1943-,. abstracted. Bull. Hyg. 19:343. 1944. . ' 11 Merewether, E. R. A.: Annual Report of the Chief Inspector of Factories, London, , Baa. Majesty's Stationery Office, 1*147. . l E3L Lynch, K. M.. and Cannon, \V. M-.: Asbestosis: VI. Analysis of 40 Nccropsied Cases, DiL Chest 14:874-880, 1948. ^ M. Wyers, H.: Asbestosis. Post-Grad. M. J. 25:43145.38, 1*149. .tfien shape, Y regular manner were no1 Typii ' and out: . Meta inckulmi t 1. > STOLL ET AL.--ASBEST0S1S-BR0NCH0GEN1C c'aRCIHGMa' 833 Physical examination revealed a well-developed, well-nourished, moderately 111 white man lying: in bed and coughing. Examination of his chest disclosed a- slightly- diminished percussion note with depressed breath, sounds and occasional expiratory wheezes at the base of the right lung. There were no unusual findings in the heart, abdomen, extremities, or venous system. Laboratory Data.--The temperature was 102.4; the pulse rate, 104 per minute, and. the blood pressure, 120/76. The urine was normal. The hemoglobin concentration was 1S.5 gm. per 100 cc. and the white blood cell count 10,000 per cubic millimeter, of which 75% were polymorphonuclear cells. The Wassermann reaction was negative, and blood chemical values were within the normal range. Examination of the bone marrow revealed clumpj of malignant cells. An electrocardiogram was nqrraal. A chest roentgenogram taken shortly' after admission showed generalized,' Urge discrete : oval shadows of increased density throughout both lung fields indicative of pulmonary metastases. . A bone survey revealed multiple osteolytic lesions in the cranial vault In the frontal and ` parietal regions. The long bones and pelvis showed no lesions. The appearance on retrograde urography and on- a gastrointestinal series was normal. Proctoscopy revealed no. abnormal findings. .' _. ;' \ . . Throughout.the patient's hospital stay the temperature continued to range from 101 to 104 F. On the ninth hospital day he complained of numbness of the right arm, with'definite weakness . of the right peripheral facial nerve. There were no definite motor changes in the extremities.. A spinal tap performed at this time revealed crystal-clear fluid under-no increased pressure. 1 The cell count was 0; sugar measured 72 mg, proteins, 28 mg,,and chlorides, 11S mg, per 100 cc. On the 28th hospital day the patient displayed Babinskfs sign with hyperreflexia on the right side. On the 31st hospital day a course of treatment with nitrogen mustard (metliyl-iiz or friz[2-chloroethy1]amine hydrochloride) was started, and given for'three days without improvement. His condition went gradually downhill, and he died on the 54th hospital day. .` ". - ' The final clinical diagnosis was metastatic carcinoma to lung and bone, primary rite' unknown. . '. Postmortem Observations.--There were no adhesions or fluid in either pleural space. The . pleural" surface of the lung was studded with nodules varying to 2 cm. in diameter. These were yellow, slightly raised, and roughly rounded in outline. The cut surface of the lung showed these nodules to be scattered throughout both lungs and varying to 4 cm. in diameter. The right tower bronchus opened into a cavity about 2 cm", in diameter which was filled with necrotic material. The right Upper, bronchial site of tumor tissue was not discovered. Interstitial fibrosis was present throughout the lung, with areas of chronic pneumonitis. In addition, there wai an area in the upper part of the middle lobe of the right lung which was dark red and noncrepitant, measuring about 2 cm. in diameter. This resembled infarct in the gross, but on microscopic section it was seen to be atelectasis and pneumonitis. At the upper pole of.the right kidney, a nodule measuring 2 cm. in. diameter.was noted. This was raised, . rounded, firm, anti yellow. A similar nodule was observed in the lower pole of the left kidney. Several swollen* nodules were seen scattered through tire remainder of- both kidneys. ' In each frontal lobe of the brain was seen an oval-shaped area, 2. cm. in diameter, containing small hemorrhages, which was slightly-paler than the surrounding tissue. "These areas were surrounded by a jinall area of softening.''' ". **. '- In the Iiyer occasional small, white, discrete nodules were noted. * The largest of these measured 0J cm. in diameter. -' The other organs appeared normal. . . . Microscopic Study.--The neoplasm'was composed of loosely arranged cells, irregular in shape, varying in size, and staining quite markedly. Many mitoses were seen. There was no regular arrangement of these cells into any pattern. These cells were mingled in an unusual manner with plasma cells, lymphocytes, and fibroblasts, and many .giant muhinudear cells were noted. Large areas of necrosis were seen throughout the lung. Typical club-shaped brown asbestos bodies were seen throughout the- lung "in the tumor and outside the tumor areas. . ' . Metastases observed in the kidneys, brain, and liver showed a similar histological appearance, including extensive areas of necrosis. . o 9 0 n n ii i! II 1! II S3-* A. 31. ARCHIVES OF INTERNAL MEDICINE Chemical examination yielded 80 mg. o( silicon dioxide per 100 gm, at tissue. ' 'a . -;*s . " V (!'. -.Mi The final diagnoses were (1) anaplastic carcinoma at the lung with possibility of multi* '"""{.fSto-i centric origin, with 'metastases to kidney, .brain, and liver, and (2) pulmonary asbestosis, ` ' ' 1'' ' . .. .. COVIUENT ' *, . , Tltc diagnosis of pulmonary asbestosis is based primarily on a history o a long- i*.'J AS exposure to asbestos dust. The most consistent complaint is dyspnea. Other synip- ... toms are a chronic cough, weight loss, fatigue, and occasionally chest pain. Ejcamt- nation of sputum may disclose asl>cstos bodies. A roentgenogram may reveal little or show a haziness only. ` . In regard to*tlie mechanism of the malignant change in asbestosis, it is question- he.fr^gj&'Jgffl able whether the silicate in asbestos itself is directly carcinogenic or whether the silicate causes bronchiectasis with metaplasia due to irritation of the bronchial 1 epithelium, thus leading to carcinoma. The former mechanism seems significant/ since this high an incidence of carcinoma does not occur in other forms of silicosis, though they do tend to produce an equivalent degree of hronchitis and bronchiectasis. \.SM: > < rj'jxjSw t .. CONCLUSIONS .- ' A case of bronchogenic carcinoma in association with pulmonary asbestosis 'is ' :: ) presented.. '. ' The importance of tills association of carcinoma in cases of asbestosis is indicated . '-.'A v1-- I. :Vfrom the review of the literature presented. . This association emphasizes the hazards of industrial exposure, the compensa- - bifity of the cancerous process as well Is the asbestosis, and the need of careful preventive measures. ' ' ' :.v; . **.tl . *-tl ''".v-.ti: * 'tli3. ;r. s' 'u ,% Vj v'-<H r ,.-V t Jl* : : '* ! i- v - " t-.; Vi oat G thro reported hypertens fluctuatio patient; t cerebral s Thefi both cljni (f'e5 1 Kj rt F;: Mrs. N Dr. H. Zot The fan heart disea: The pat menorrhagi no mention after this J the age of of certain ' ' pressure ir episodes oc weeks, Ev . .of nuchal feeling of i nausea, vot From t 1. () Anatomic i . Schwalbe, . Fischer, 19 Coarctatioi General D; J. Clin. In 2. Wa IS:30-35, ! 3. Stei tIt)