Document Xz24X0wB66akpJX5vNNq7rdNd

% * INDUSTRIAL HYGIENE FOUNDATION OF AMERICA, INC. MELLON IISSTlTUTe. A4QO FTh AVENUE Memorandum to: . Cr. Kenneth W, Smith* Medical Director Johns-ManviUe Corporation 4>l East 4Qth Street New Turk 16* New York . Re: Case of Waller Burek IKE Dab. No. Aft-6 From; Irani Cross, M.D., Research f'aihotogist Date: January 7. 1959 ' . INTRODUCTION - The data and material lor study, pertinent to the above case, received by the Industrial Hygiene Foundation laboratory consists of the following: * . .' * 1. A letter dated October 31, I95w, which gave the employment and medical history of Mr. Burek. This letter was signed by D. T. LuSow, M. L. * i. Ror:lono of both lungs fixed in formalin. 4 *6i**t rowNOArteN'er a*kchca i*c. *i .** -jcuipati^n*l Hirr^nv * Mr, fiurek wai 6c year* old At the time ol death and had been retired from JvhuJ-MaavilU fur 6 year*. He was first employed by Johns- Manvllle on November 5. Prior to that time his employment had bees the following: ' farming - id years hard coal minps (inside) - 6 years * woolen mills 6 years dye works 6 years ' At Johns^Manville, Mr, fiurek worked almost ? years as miscel laneous handler tn the Magnesia department, during this time, he was assigned tu cleaning dust bins where he was exposed to diatomUe and Asbestos oust. On October J, he was transferred Cu another depart- e meat where he worked as sweeper sad janitor. This job lasted about i yvars ana during this time he was exposed to Asbe'stos dust. The tt'tal period of potential exposure to Dlatomlts dust was approximately ? years and to Asbestos dust, approximately 1- years. 4 5UMM/-.K Y vj;- l HI?SfwT%Y In June, l/5c, Mr. Burak was hospitalised because of pain in the lateral portion of the right chest ina the upper right nuadrant of the abdwmen. Following bis discharge, a thoracentesis la early July resulted . la clear, yellow fluid. This was negative for aclu-faet organisms and tumor cells. Because his condition became progressively worse, Mr. Burek was again hospitalized la October. l9Sof Another tap of his right chest again yielded yellow fluid. He was broachoscoped with negative results and died 4 days later on jetnber 31, 195ft. The x-ray diagnosis was 'pulmonary emphysema with changes consistent with fibrosis and chronic bronchiectasis.' **At autopsy, performed by Dr. Cewaster, there was obvivu* ex tensive diffuse pulmonary emphysema with fibrosis predominantly la the lower lobes, markedly thickenu and adherent pleura with extensive effusloo at the right base. In addition, thers was definite thickening of the right ventricle and widening of tbs pulmonary artery. * ' .REPORT OF FINDINGS Grui Inscription: Right lung weighs Sod gms. and measures 4 x l.. 5x17 cm. The specimen appears to represent somewhat less than one-half -:l the lung as judged by its thickness. The pleural surface is greatly thickeneu a ad leathery. Its thickness varies from 1 to 1 mm. The interlobar fissures * '' * o'lMAMh rewnOATiON . *MiMiCA tNC. . ` * are obliterates The u^vr lobe is compoecc of crepitant, *p'<'gy gray tissue. Beneath the thickened pleura, there is marked enUrf;en)Bt "ii the blr apace** up to diameter* of 5-t> mm. Similarly, enlargv- air spare* are found la Isolated small foci scattered irregularly over the upper lobe. The rest o( the right lung la largely solidified* firm to bare in consistency, and composed of a dense, compact gray tissue* mottled with small black r foci. Gray fibrous streaks and thick vessels as well as bronchi are visible a * ' upon the cut surface. . Left lung weighs 3b 1 gms. and measures 4 x 9. 5 x 16 cm. This specimen also appears to represent less than one-half of the lung. The pleura Is irregularly thickened to a maximum of C mm. The Interlobar fissure Is obliterated. Only the upper one-half of the upper lobe la com posed of crepitant* spongy tissue. The remainuer of the lung is composed of solidified, firm to bard* grayllghtly mottleu with black tissue in which * gray strands, vessels* and bronchi are prominent. *ln addition, at the lateral portion of the lower lobe* there is a triangular area, the apex of ' which is directed upward and begins immediately beneath the pleura. This ar^a extends 9 cm. down to the base to a maximum width of i. S cm. and then exleods across the base to fwrm a aubpleural sun- 3 cm. thick. These tones are hooey combed with greatly dilated aaci tortuous branchial pas* sages which are filled with thick, gelatinous pus. Between the pus-filled cavities* dn* connective tissue Is present. 4 No lyrr.pn noaei are represented in either ipci.nfn. No tnaj-.r or bronchi are present. Microscopic Description: Right Lung* Tumor lu the form of aae&ocarcinoma is fouaa in o of 10 sections* The tumor Is composed of deeply staining columnar epithelium which Unea existing air spaces and bronchioles and thereby + forms glandular structures* These*tumorliaed air spaces form llldcinad masses, some of which occupy about one-fourth of the section in several instances. Small aggregations of such tumor*-med air spaces are also found irregularly scattered throughout the right lung inclusive of the greatly thickened pleura* Tumor tissue Is found within the lumen of a number uf pulmonary veins and in the lumen of lymphatic vessels. There is generalized atelectasis and the effectiveness of many of the partially collapsed air spaces is further reduced by masses of asbestos bodies and debris or frank pus filling ths lumen* -- Tbs alveolar walls are irregularly thickened by relatively acellu lar collagen* More nodular or fusiform septal fibrous thickening Is also present. Such foci tenu to be more cellular and contain also fine dust granules. Many of the granules appear to be of translucent, crystalline character and appear greenish. . In some sectluns. very few alveoli are found. There is much * i: . dense fibrous tissue, poor in cells. Amag this connective tissue are Count: Ml !(*" *W ftm. yWMWrigM Ml* *K,*ltCA il^C. c. &umer;ui irregular, very lung channels `j! varying caliber, ihose c ..ivicu; pus and are Used by bronchial-lyps epithelium. Bronchi arc greatly on* larged aad filled with pus. In e^me sections, these pusfUleo bronchi an- bronchioles alternate with bronchioles and air spaces that are Ulicawah foam cells. . Emphyeematous change* are present but are ovuranadewea by . the fibrosis aad alelectaela. Ia adaltioa to asbestos bodies* which generally occur in sizable clusters, aad the greenish crystalline particles, more massive deposits of dense black pigment are present* These are generally perivascular in position. Much of this black pigment is extracellular and there ia associated perivascular fibrosis. The blood vessels show considerable sclerosis. I he pleura is enormously thickeAed by a hyaline, acellular connective tissue, which contains compressed rumur glands in some regions. No hyperplasia of alveolar Uniag eells is noted. There Is no gradual*transition from normal to tumor lining ceils. Left Lung. Many of tne sections show the presence of tumor* This luir.wr Infiltration is more insidious than is the case in the right lung. The lunur masses are much smaller and more widely dispersed. a Ih# fibrosis Is extensive and Is similar t>> that on the other side. There are relatively few air spaces capable of function. Most air spaces are rendered useless by tumor investment* or by an Inflammatory exudates vary. Xa turn* placet, the six spaces c-T.tuin pus only. In .ti;er placet. eh exudate U largely fibrinous or fibrino-purulcnt. There It extensive bronchiectasis. The lumen f tnsse eniar**3 . bronchi It filled either wish frank put or muco-purulmt material, A number of emphysematous f*ci are founu. These are sur prisingly few aad small. They are surrounded by thick fibrous tissue. There la a large nodule with a scalloped periphery which It apparently competed of smaller cenfluenDnoduies. U contain* irregularly distributed gray dust granules and appears typically silicotic. ThU nodule la adjacent to a Urge pulmonary artery and teems to have been originally a lym* i node, . One section contains a sharpie circumscribed mass of cartilage with tome fibrillary ttroma. This fibrillary stroma it infiltrated on the periphery by small or narrow tumor glands which are present la mweserat* numbers elsewhere about the periphery of the cartilaginous mass. This natt of cartilage shows no feature of malignancy and is considered to be haems rtomt. DIAGNOSIS 1. Asbestosl*. severe. s) Diffuse interstitial pulmonary fibrosis, b} Wsural fibrosis, severe, c) hmphyterna. focal. Adenocarcinoma <*' ' * 3. NuruUnt brncniecta*;*. 4. Cartilaginous haemartoma of left apex. . 5. Mixed pneumocunloelc, slight. a) SUieosts, focal. b) Aathracosls, slight. 6. Focal bronchopneumonia. COMMENT The moat Important and significant feature in these lungs is the severe reduction in air spaces capable of function. Only In the apical por tion* of both lungs Is spongy lung tissue to be found. The main involvement Is due to severe diffuse interstitial fibrosis associated with the presence of many asbestos bodies and asbestos fibers. Contributing also to this impair ment Is the replacement of normal alveolar lining by carcinomatous ceils. The question arises whether this tumor is primary nr secondary. Against th view that this Is a primary tumor are the following observations. The tumor occurs diffusely scattered as innumerable foci of microscopic sis No grossly visible tumor nodule* are recognisable as primary foci. Micro scopically, the foci show no transitions between non-lumor and tumor cells. The turner cells are smaller and darker staining than the usual alveolar coil carcinoma. It must be admitted, however, that this dlstinctljn between primary and secondary tumur Is not without an element of error.  tj* *mIOiCa inc. I. lvzlx'.js u.LU5n<> n ?ns i> \g tGran appearance of lungs. 'Ihe jr-.it thickening vt th pleura covering the right lung and the *biUera:ioA of the tnterl.-bar Futures ers eaeily recognised. Fla. . .(SLOP) - Severe ecnphyssirt* associated with irregular fibrous thicken ing of eeptal walla. 5-me pigment la present. There are many aabuatws bwdiet to be f-ud among the pigment* .fig. 3.(S6>),>) Dilated, Irregular bronchiole* Increased La cumber and filled with pus. Very great fibrous thickening of aeptal walle with greatly reduced alveolar lumens* Many jf thus* are .plugged by brown pigment ana masse* A asbestos bodies* Some black pigment, much of which is perivascular. Vet* eels are greatly thickened* Fig. 4.(5604) - Diffuse alveolar fibrosis with air spaces renuced to .ners slits. Many of these allt-Uks air spaces plugged by debris, pigment, and asbestos bodies. Vessels are gruatly thickened. Fig. 5,(S60M - m-.Xe extensive region of acellular, hyaline llbrusle in up per right. In lower left. Irregular sllt-llke spaces are lined by tumor cell*. Emphysema in the center, acme anlhracotic pigment and many asbestes bodies are present. Fig. 6. - Many tortuous bronchioles fiUsd with pus or a mixture of pus sod mucus. A small br-.nchu* (below center) shows focal squamous rnetplaala In lnWrt.*r portion. There is severe fibrosis throughout and severe vascular . sclerosis. ._ Flq. 7 (560-) - There Is severs uUfuse flhroois with obliteration of sir spaces. Some air spaces contain fibrin ana polys. Brcnchl contain pu*. A bronchiole 1a center near top shows squamous metaplasia. Vessels are markeuly tmekene ru, ^(aAll) - A lymph node near a large branch of the pulmonary artery *nuw. repla-cineiit of much of the lymphoid tissue by silic./tlc hyaline tissue. Some smhracotlc pigment is alsc present. Fiq, i(S603) - /Mr spaces are Uncu by carcinomatous epithelium forming many papillary projections. A large space above center c /ntulas many long asbestos bodies in cellular debris. 4 > I J H i KJ /*n ieolatci cluster o' turn a r Citlfi air space* near a l*r vpiael. ru l l (^oOS) Thickened pleura infiltrate;: by ^lanUular tuci*'r structure*. Tumor replacement jC lung tissue in lower ri^ht j^raer. ,T1<. I (35^4) - A pulmonary artrry containing a tumor thrombus.