Document Raq32K9JOLmEKgpj2LjMm7VLX

CLINICAL INVESTIGATIONS Presence of Asbestos Bodies in Organs Other than the Lung* Oscar Auerbach, M.D., F.C.C.P.,*0 Alfred S. Conston, Lawrence Garfinkel, Verta R. Parks, .S.; Haven D. Kaslow, B.S.;j [ and E. Cwjler Hammond, Sc.D.fi This study was designed to test the hypothesis that subjects with many asbestos bodies in their lungs at autopsy would also have asbestos bodies in various other organs. The subjects included 19 cases with diagnosis of asbestosis at death (two of these had mesothelioma, five had lung cancer) and 18 with pleural plaques but not asbestosis. Occupational his* tories were obtained from relatives. In subjects occu pationally exposed to asbestos, large numbers of asbestos bodies were found in the lungs, and in most of these, asbestos bodies were found in many of the other organs examined. In the 18 cases with only pleural plaques found at autopsy, considerably fewer asbestos bodies were found in the lungs. The number of other organs with one or more asbestos bodies ranged from 32 percent to 62 percent of the sites examined. The findings seem to confirm the hypothesis of the study. Then asbestos fibers are inhaled, some of those T which are entrapped in the lungs become coated, by biological processes, with a material con fining iron. These coated fibers have a unique ap- For editorial comment, see page 129 pearance under the microscope. Unlike some or ganic materials with which they might be confused, they are resistant to ashing, as well as to digestion by mild alkaline hydrolysis. These coated fibers are usually called asbestos bodies; the more general term, "ferruginous bodies," is sometimes preferred because objects of similar appearance can be formed by the biological coating of certain other types of mineral fibers.1- From the Veterans Administration Medical Center, East i ge' NJ; the Department of Pathology, Somerset MediCenter, Somerville, NJ; and the Department of Epide- auotogy and Statistics, American Cancer Society, Inc., New 'Distinguished Physician, Veterans Administration Medical and Professor of Pathology, College of Medicine >^Dentis`.-y of New Jersey, New Jersey Medical School, tDirector of Laboratories, Somerset Medical Center, and j'n,cal Associate Professor of Pathology, Colleec of Medi ae and Dentistry of New Jersey, Rutgers Medical School, ^iscataway, NJ. 'statist President, Department of Epidemiology and Biologist, SMI Laboratory, Veterans Administra- lE MeicaI Center. t-_.^arc" Biochemist and Consultant. Department of 'vgj"milology and Statistics. |in. .es`dent, Department of Epidemiology and Statistics, flej. . cnP* received March 2-S; revision accepted Mav S E<wn Dr. Auerbach. V.\ Medical Center, loin, UranUc, Kctc Jersey 07010 CHEST- 2, FEBRUARY. 19S0 Until recently, little attention has been given to the possibility that asbestos bodies might be present in locations other than the lungs. We became alerted to this possibility when we found one embedded in a tumor of the brain; at scientific meetings, several investigate have reported verbally that they have found asbestos bodies in other organs. Godwin and Jagatic3 reported that they found asbestos bodies in mediastinal lymph nodes, spleen, and small in testines. The purpose of this study was to ascertain whether persons with a great many asbestos bodies in their lungs are likely to have asbestos bodies in various other organs. As it turned out, some of our subjects did not have many asbestos bodies in the specimens of pulmonary tissue which we examined. Materials and Methods Our plan was to confine the study to autopsies of persons whose lungs were likely to contain a large number of asbestos bodies. With this in mind, we reviewed die records of all autopsies performed by one of us (A.S.C.) at Somerset Medi cal Center, Somerville, NJ, during 1970 and selected all of the cases in which asbestosis or mesothelioma had been recorded in die final diagnosis. Since many people in the area worked in an asliestos factory (and asbestos workers often develop pleural plaques), we also selected all cases in which pleural plaques had been recorded. A total of 37 such cases were found (34 men and three women). Asbestosis was recorded in 19 of the subjects, and all of these also had pleural plaques; two of these subjects died of mesothelioma, and five of them died of cancer of the lung. Pleural plaques but neither asbestosis nor mesodielioma were recorded in the ASBESTOS BODIES IN ORGANS OTHER THAN LUNG 133 remaining IS subjects; one of them died of lung cancer, and one died of pulmonary fibrosis of unknown etiology. Specimens of pulmonary tissue and renal tissue taken at autopsy (fixed in a solution of formaldehyde 1 formalin 1 and embedded in paraffin), were available from all of the 37 subjects. Similarly, preserved specimens from the heart (36 subjects), liver (35), spleen (34), adrenals (33), pancreas (30), brain (22), prostate (14), and thyroid (6) were also available, as well as a few from other sites (mediastinal lymph nodes, stomach, duodenum, colon, etc). Relatives of the 37 subjects were interviewed to ascertain whether the subjects had ever been employed in an asbestos factory or plant in which asbestos was extensively used or had ever been employed as an insulation worker or were likely to have been exposed to asbestos in some other way, eg exposure to asbestos dust in making home repairs or living with an asbestos worker. In some cases, the interview indicated that exposure to asbestos dust in any of these ways was unlikely; however, since a major asbestos factory is located not far from the Somerset Medical Center, some of the subjects may have been exposed occasionally without being aware of the fact. Moreover, electron-microscopic ex amination of samples of air from some modern cities and industrial areas has shown that at least a few asbestos fibers are often present.'1 Prc]>aration of Specimens As described in a previous study, a measured volume (20 cu mm) of pulmonary' tissue was cut from a paraffin block with a sliding microtome and was placed on a glass slide on which an 18 X lS-mm grid (design by E.C.H.) had been printed by the chrome sputter process.5 The grid contains let ters and numbers by which the location of microscopic objects can be specified from their coordinates. Tire lines of the grid make it easier to focus on the surface of the slide and also make it far easier to ensure the examination of all of an area of known size. Paraffin was removed from the specimen with xylene, after which the slide was placed in a low-temperature asher. In tins way, most of the organic material was burned off, leaving the residue including any asbestos fibers and as bestos bodies. A drop of mounting media was applied, and a cover slip was set in place. This procedure is satisfactory for pulmonary tissue which, because of air spaces, is not very dense; it is not satisfactory for the more dense tissue of other organs. Therefore, an improved procedure was developed by one of us (H.D.K.) for &e purpose of this study. The approximate surface area of the paraffin-embedded tissue was measured and the thickness and number of sec tions necessary to yield 20 cu mm of tissue calculated. The paraffin block was sectioned in increments of 25 to 40 mm as necessary, using a sliding microtome. The sections were transferred to a 25-ml Erlenmeyer flask and were extracted twice by decantation with 5-ml portions of xylene, finishing with 3 ml of acetone, and were then evaporated to dryness on a warm plate. Washings of xylene were decanted cautiously under a magnifying glass. Infrequently, when particulate matter failed to settle properly, the washings were filtered separately and examined for asbestos bodies. Five ml of a 5 percent aqueous solution of potassium hydroxide was added to the deparaffined tissue in the flask. The flask and contents were heated at 85 degrees C to 90C under reflux conditions for one hour. After cooling, the alkaline suspension was diluted with about 5 ml of water and was filtered by suction in a Pyrex microanalysis filtering device (Millipore) using 134 AUERBACH ET AL Ml' paper (mixed esters of cellulose) of 25-mm diameter anj a pore size of 0.4." miernmeters. The filter paper i23-nun ^ anieter) is damped between the base of the filter and tlJe j-* ml funnel (diameter. 15.5 mm at the base), resulting ' round filter cake approximately 16 mm in diameter. (\\'he properly centered, no fibers or asbestos bodies occur outsjj the boundaries of the grid.) The flask and filter were \vashej down with several portions of water. The microscopic slide with the grid was prepared with a light coating of a water-soluble adhesive; then the paper was removed from the filter, blotted lightly on the clean side, and centered, coated side down, on the grid. The water-soluble adhesive was a commercial glue (Elmer's glue) diluted 1:1 with water just before use and appljecj with a swab. (Trials using either albumin or gelatin adhe sives at various dilutions showed inferior performance). The paper was blotted and dried in warm air. The slide was then transferred to the asher and ashed for two hours at 200 ty and 250 ml/min of a gas mixture of 10 percent oxygen and 90 percent helium, at 1.3 mm Hg of vacuum. Under these conditions the ashless filter paper and the upper surface adhesive were oxidized away, leaving fixed on the slide any asl>estos bodies, fibers, and other resistant solids present in the tissue. Examination of Slides In a previous study, we found that when a slide contains under 100 asbestos bodies, it is usually possible to count them accurately.5 When a great many are present, there are usually dumps consisting of asbestos bodies, fragments of asbestos bodies, and uncoated fibers. An individual clump may contain only a few intact asbestos bodies, or it may contain dozens of them. Under these conditions, accurate counting is impossible; therefore, the following plan was used. The grid is divided into 18 rectangular areas. These areas were examined microscopically one at a time until over 100 definite asbestos bodies were counted. If and when over 100 were found, the remaining areas were scanned for the pres ence of dumps and individual microscopic fields containing many objects which resemble asbestos bodies. When these were found, they were carefully studied to determine wheth er the objects were actually asbestos bodies. If die examiner concluded that the slide probably contained a great many more than 100 definite asbestos bodies (probably hundreds or even thousands of them), then "TMTC," meaning "too many to count," was recorded. Otherwise the examiner recorded more than 100. If no dumps were found and the slide appeared to contain not many more than 100 definite asbestos bodies, then all of the 18 areas were examined as described subsequently, and an actual count was made. Each slide was examined microscopically by one of us (V.R.P.) under phase contrast using a 25 X objective (Neofiuor) (N.A. 0.60) and 12.5 X wide-angle eyepieces. Every object found at this magnification which even slightly resem bled an asbestos body was studied carefully at a higher magnification using a 40 X objective (N'eofiuor) (X.A.0.75) under both phase contrast and ordinary illumination. When ever an object was considered to be a "definite'' asbestos body or "probably" an asbestos body, a sketch of it was drawn on die record sheet, and die coordinates were noted. (The coordinates together with the sketch made it easy to find the object again for review or photography.) Some of the bodies may have been formed around a nonasbestos mineral fiber. When indicated, more than 100 or TMTC was re- CHEST, 77: 2, FEBRUARY, 1980 nd di. 15- V oe ed t ia ter the "he 2r's ied he*he ten \V 90 ese ace my in dns em are of mp na; reas j 100 I 100 j resiing iese sthiner any s or any ded lide stos .bed f us \'eo\'ery .em* zher .75) lenstos was te y tw ' Hie4 rdod. The time ivqtiiTcd varied considerably. with tin* r;ijjc* bring about four hours per slide. fro"' the reeimled findings a count was made of the total number of `'definite'' asbestos bodies and the total number of "probable" asbestos bodies for each slide. The distinction jjctwrcn "definite" asbestos body and "probable" asbestos body was only a matter of certainty in tlie mind of the cxamincr. Often, lack of certainty was due to inability to see jjie feature of an object clearly. This can occur in any one or a combination of the following circumstances: (1) the object is partially obscured by particles, fibers, or asl>estos bodies; (2) die object is not parallel to the surface of the slide; or (3) the object is so small that the critical features arc barely xvjdiin the resolving power of the microscope. In sections with many definite asbestos bodies, there are usually also jnany objects which are probably pieces of broken asbestos bodies. Such fragments arc difficult to evaluate, and to count all of them would result in overestimating the number of intact asbestos bodies originally present. Finally, sometimes an object is seen which looks very much like one of the sorts of asbestos bodies typically found in die lungs of people with known heavy occupational exposure to asbestos dust; but it somehow "docs not look quite right." The examiner has a choice of calling it "probably" an asbestos body or not an asbestos body. That difficult choice is at least better tiian being forced into a definite answer of "yes" or "no." It should be noted that when and if a fairly large number of definite asbestos bodies were found on a slide, then the examiner stopped recording "probable" asbestos bodies. Lung Results Two different analyses were made, one confined to definite asbestos bodies and another in which no distinction was made between definite and probable asbestos bodies. Except for absolute numbers, the two analyses yielded essentially the same results. Therefore, to save space and to be on the conserva tive side, we have confined this report to "definite" asbestos bodies. Many definite asbestos bodies were found in each of the specimens of pulmonary tissue from the 19 subjects with asbestosis (TMTC in 12 cases and more than 100 in seven cases). Interviews with relatives revealed that 17 of these 19 subjects had been employed in an asbestos factory, and one had worked in a factory where asbestos is used extensive ly. The remaining man was a welder and had worked in a plant where printing presses were made. In 18 cases, pleural plaques were found at au topsy, but asbestosis had not been noted. Perhaps some of these subjects had asbestosis but to such a limited degree as not to come to attention in a routine autopsy. These 18 cases fell into two distinct ly different groups in respect to the number of as bestos bodies found on the slides prepared from pulmonary tissue. In eight cases, more than 100 asbestos bodies were found. The information from interviews on these subjects was as follows: four had worked in an .980 CHEST, 77: 2, FEBRUARY, 1980 Table 1--Ten Subjects inl/i Less limn 1UO Asbestos lUxIicx in Scclions of l.ting Case, Ago :it Sox Doaili M 40 M 08 F 46 F 45 M 49 M 53 M 54 M 02 M 50 F 45 No. of Asbestos bodies in Lung 48 38 25 22 17 10 9 5 3 0 Information from Interview Laborer; no evidence of asljestos exposure Plumber in factory where asWstos used extensively Housekecjjcr and worker in bakery Owned auto business; worked briefly in asbestos factory when young Auto mechanic Service station employee Mechanical designer and draftsman Inspector in factory where aslx-stos is used extensively Laborer in lumber yard; handled asbestos siding Nurse; never occupationally exposed to asbestos dust; died of pulmonary fibrosis asbestos factory', and one had worked at a factory where asbestos is used extensively; one was a plumber who also insulated pipes; one was a furnace repairman; and one was a machinist. In the remaining ten cases, less than 100 asbestos bodies were found in the pulmonary specimens. A description of these cases is shown in Table 1. Four of them probably had slight or brief occupational exposure to asbestos dust. The automobile mechanic may perhaps have repaired brake linings containing asbestos. Some of the others may perhaps have been exposed to asbestos dust in some way without our informants being aware of the fact. Other Organs Findings in slides prepared from nine different organs are summarized in Table 2. The top part of Table 2 includes all of the 37 subjects. The second part is confined to the 12 subjects in whom a very' large number of asbestos bodies (TMTC) had been found in the slide prepared from pulmonary' tissue. The third part of Table 2 is confined to the 15 subjects in whom more than 100 definite asbestos bodies (but less than TMTC) had been found in the slide prepared from pulmonary tissue. The fourth part of Table 2 is confined to the ten subjects in ASBESTOS BODIES IN ORGANS OTHER THAN LUNG 135 Table 2--.1sltrslitx Itntlirs Fount! in .Yin/- HifJt'Trnt Orgimj i JMniitm 1> Number Found in S/m/fl Sitrriiiirn of l>ulnionttrr Tissue Group ami Organ No of No. of A>Ik\*1o> liodios Subjects Subjects with with 1 + Total Tissue Asbesfos Defi Mean Maximum Avail Bodies nite No. JKT pi-r able (|K*reeiit) Bodies Subject Subject All subjects (=*37) Kidncv Heart Liver Spleen Adrenals Pancreas Brain Prostate Thvrokl TMTC in pulmonary t issue (n= 12)** Kitlncv Heart Liver Spleen Adrenals Pancreas Brain Prostate Tltvroid >100 Bodies in pulmonary tissue. (n*15)t Kklnov Heart Liver Spleen Adrenals Pancreas Brain Prostate Thyroid <100 Bodies in pulmonary tissue Cn --10) Kidney Heart Liver Spleen Adrenals Pancreas Brain Prostate Thyroid 37 36 35 34 33 30 22 14 6 12 11 12 0 12 9 4 5 4 15 15 13 15 13 13 11 6 2 10 10 10 10 8 8 7 3 0 14 (38) 13 (36) 16 (40) 21 (62) 16 (48) 14 (47) 5 (23) 6 (43) 6(100) 132 218 84 660* J7S 272 30 42 517* 3.0 6.1 2.4 19.4 5.4 9.1 1.4 3.0 86.2 82 ss 26 >100 29 no 20 12 >100 9 (75) 7 (64) 9 (75) 9(100) 10 (S3) 9(100) 3 (75) 5(100) 4(100) 122 204 70 469* 123 246 24 41 370* J0.2 1S.0 5.8 52.1 10.3 27.3 G.O 8.2 92.5 82 88 26 >100 25 116 20 12 >100 3 (20) 5 (33) 5 (38) 10 (67) 5 (38) 5 (38) 1 (9) 1 U7) 2(100) 5 12 11 187 26 26 2 1 147 0.3 0.8 0.9 12.5 2.0 2.0 0.2 0.2 73.5 2 4 4 47 14 14 4 1 134 2 (20) 1 (10) 2 (20) 2 (20) 1 (12) 0 1 (14) 0 0 5 2 3 4 29 0 4 0 0 . 0.5 0.2 0.3 0.4 3.6 0 0.6 0 0 4 2 2 2 29 0 2 0 0 *In one specimen of spleen and two of thyroid, more than 100 asbestos bodies were found, but exact number could not be determined. We have arbitrarily assumed that 150 were present. *TMTC, Too many to count (asbestos bodies). fDoes not include specimens showing TMTC. 136 AUERBACH ET AL whom loss than 100 definite asbestos bodies fiatf been found in the slide prepared from pulmonary tissue. The number of asbestos bodies refers to ' def inite" asbestos bodies only; objects described as "probable" asbestos bodies are not included in th{s table. As shown in the first part of Table 2, the pvopor. tion of slides with one or more definite asbestos bodies varied from six out of six (thyroid) down to five out of 22 (brain). In the six organs for which 30 to 37 specimens were available, from 3S percent (14/37) to 62 percent (21/34) of the slides had one or more asbestos bodies. We were very surprised at how many asbestos bodies were found on some of the slides; for example, 8S were found on one slide prepared from the heart, and more than 100 were found on one slide prepared from the spleen. The last three parts of Table 2 show that there was a definite relationship between the number of asbestos bodies found in pulmonary tissue and the number found In tissue from other organs. That is to say, far more asbestos bodies were found in other organs when a very large number (TMTC) were found in the pulmonary specimen than when rela tively few were found. The fourth part of Table 2 is confined to the ten subjects described in Table 1. They had pleural plaques but neither asbestosis nor mesothelioma; and only 48 or fewer definite asbestos bodies were found in slides prepared from pulmonary tissue. From interview's, it appears that three had had some occupational exposure to asbestos dust; and perhaps a fourth (the auto mechanic) had repaired asbestos brake linings. For the remaining six subjects, inter views provided no evidence of exposure to asbestos dust. At least for these six subjects, it seems very unlikely that the lesions described as pleural plaques (because of their gross appearance at autopsy) were caused by asbestos. Furthermore, in the absence of proof of exposure to asbestos dust (and by lightmicroscopic examination alone), it is impossible to say whether an object having the appearance of an asbestos body was formed about an asbestos fiber. Some of them may have been "ferruginous bodies" formed about a fiber of some other sort As previously mentioned, a few specimens were included from each of several sites other than the nine organs listed in Table 2. Other tissues in which one or more asbestos bodies were found include mediastinal lymph nodes, bone, duodenum, stom ach, colon, omentum, and spinal cord. The number of organs in which definite asbestos bodies are found depends in part upon how many and which organs are examined for asbestos bodies. This is taken into account in Table 3. Twenty-five ` CHEST, 77: 2, FEBRUARY, 1980 had narv this >porestos vn to hich rcent ^ one ed at ie of slide were there er of d the : is to other were rela te ten leur^l tissue. . some irhaps bestos inter* bestos s very .'agues j were :ice of light, .ble to of an 9 fiber, iodies* s were an the which ncludc stom- 3--\ittuber of Different Orsons hi IT Iih h Our or More Axhextos Filters Were Found \ i i Group :uul Orjnnis No. of Orsniiis will) + 1 Hmlv No. of _ . ,, _ *^ Stmiiol Subject* 0 12 3 15 0 7 8 AHsu!>j<vi* m37> 6 ..-jxY'j/it* cr^ui.-.* Any 7+ organs** 25 20 6-12343300 6 33323234 <fyfTC in pulmonary tissue (n -- 12) (3 specific w/r.uis* Any 7+ organs** 7 9 000202300 000001224 >1C0 Bodies in pulmonary tissue (n*15.5f 6 specific organs* Any 7+organs** Ii 12 3 1114 10 0 0 30 1 3220 1 0 <100 Bodies in pulmonary tissue to-10) 6 specific organs* Any 7+organs** 7 g 331000000 332000000 Slides from six sjx'cifie organs (kidney, heart, liver, adrenal glands, spleen, and pancreas) were examined for each of these subjects. Slides from seven to ten different organs were examined for each of these subjects. fDoes not include specimens showing TMTC subjects had tissue examined from all of the follow ing six organs: kidney, heart, liver, spleen, adrenal glands, and pancreas. In six of the subjects, no def inite asbestos bodies were found in any of these six organs; and in three subjects, definite asbestos bod ies were found in all six of these organs. As shown on the first line of the second part of Table 3, a very large number (TMTC) of asbestos bodies were found in pulmonary tissue from seven of the same subjects. In these subjects, asbestos bodies were found in three to six of the specified organs; in three of the nine subjects, asbestos bodies were found in all six of the specified organs. The following is presented only to give an idea of how widely asbestos bodies may be distributed. Twenty-nine subjects had specimens of tissue from seven to ten different sites examined. These sites include the nine organs listed in Table 2, plus stom ach, duodenum, colon, and mediastinal lymph nodes. There were very few subjects in whom more than nine sites were examined. The findings in the subjects are shown on the second lines of each part st many ityV - Y, 1980 CHEST, 77: 2, FEBRUARY, 1980 of Table 3. It is sufficient to say that in one subject, definite bodies were found on slides from each of the eight different sites examined. Discussion One should not draw too-sweeping conclusions from findings in so few as 37 subjects, all of whom came to autopsy in the same hospital and many of whom had worked in an asbestos factory in which chrysotile was the principal type of asbestos used. Nevertheless, the findings strongly suggest that when people have such a degree of exposure to asbestos dust that a great many asbestos bodies are formed in the lungs, then asbestos bodies are very likely to be present in one or several other organs as well. There are two different possibilities concerning the presence of asbestos bodies in other organs: (1) they may have been formed in the lungs and then migrated to another organ; or (2) asbestos fibers may have migrated to another organ and have been coated there, thus forming an asbestos body. We are inclined to favor the latter possibility. Electron-microscopic studies have shown that only a tiny proportion of the asbestos fibers present in the lungs of asbestos workers become coated, with the resultant production of asbestos bodies.6 Assum ing that this is also the case in other organs, then the finding of even one or two asbestos bodies in a fragment of tissue from an organ suggests that the entire organ contains a very large number of as bestos fibers. References 1 Gross P, Cralley LJ, de Treville RTP: "Asbestos" bodies: Their nonspecificity. Am Ind Hyg Assoc J 28:541*542, 1967 2 Churg A, Wamock ML, Green N: Analysis of the cores of ferruginous (asbestos) bodies from the general population: II. True asbestos bodies and pseudoasbestos bodies. Lab Invest 40:31-38, 1979 3 Goodwin MC, Jagatic J: Asbestos and mesothelioma. Envi ron Res 3:391-416, 1970 4 Langer AM, Selikoff IJ, Sastre A: Chrysotile asbestos in the lungs of persons living in New York City. Arch Environ Health 22:348-360,1971 5 Auerbach O, Hammond EC, Selikoff IJ, et al: Asbestos bodies in lung parenchyma in relation to ingestion and inhalation of mineral fibers. Environ Res 14:286-304, 1S77 6 Langer AM: Inorganic particles in human tissues and their association with neoplastic disease. Environ Health Per ' spect 9:229-233, 1974 ASBESTOS BODIES IN ORGANS OTHER THAN LUNG 137