Document ZnnedBNqkaGVVkbrM0wmZRZ1L

fi \ 'J v ^ ; j m /ttae, i% & u<! fir*. < Ciirni/O'na t* -.iratvAr---,\ * l\/f i':^ i V; f, t < M ESOTHELIOM A ASSOCIA TED W IT H AS1STOSIS A R eport oj 3 C ars R x h v r d H . M a n n . m d . J o h n L . G h o s h , m d , a nd W'akd M . O D o n n h .i . m d \f I..: ovaries. A f t J (, Hume. \f f /(. Jut . M*ri. j, Ji n p c jp : a - ;i ,; 111-:. A t ; , / . Ov . : Carcinoma <, * tnu.ru . f ' j , - let. b \ 122* l j - j . - ij Tumor R 'j u t v . ipubli-hed j l . j[ 3. J.: Procmou.-; f j ma. Obst et . <_, j A studs of 51 au top 'ic. of patients d 'in g u iih pulmonarv asbestosis disclosed i casts of peritoneal m esotheliom a, one of uhirh v.as tornplirated hi a m eso t h e lio m a of the p leu ra . In 2 of the 3 p a tie n ts there v*as an o c c u p a tio n a l cxjxtsu te h isto n of 20 and 3} stars in an a-besios textile plant. Although the rem ain in g patient had c la s h e d a-bestosts of the lungs at autopss. there ssas no known h iston of industrial exposure to asbestos. Tfie authors think asbestos tan pro d u c e m e s o t h e l i o m a o f e i t h e r j r e r i t o n e u m or p l e u r a : t h e \ p r e s e n t .3 ca ses to s u p j x i r t t h e c o m e . : >! , . o s a i t i l a t i o n s h i p T h e in c r e a s e d u t i l i z a t i o n o f asbestos material and the recent dem onstration of asbestos bodies in the lungs of urban dwellers mas hase significant implications for cancer epidemiology in the future. rowitz. W'. E : f J /. .U frf. 62 iT24-_`: > j vitz. M : Enden.? n-_ \cretiou in w.in. 1961. U.S. Census of Po, rmtio-- New \r i. gton. D.C., IMS. C< v i f I j tion o f diabetes r-v m e tm u n . A n . J. 0 sioffen en her cu- i Oenecsk. 10< 322-'* j i 2 . No. 01*173. E-- i : A cUological view * ea. Cancer ]S*43u- ' * \\ tel, S. I.. ami Mo-. le corpus-- A >tu.`\ .' ami Hospital. H`-- a 073-10S2. 1932. of caicinouia of rArmee. Ha;, l.ruv u. lion: EpitiemioK>C'.c.. 150-204, 1i>57. J.. Shroff. P. D '.w i io n in e m a l taci* ' . j Obitet. Gyiee. t" | f [ ; i j ! I j j { ! ci cent cone anuntiH of olnl number plie able anil THE A ssOCI \TION OF MESOTHELIOMA OF T HE petitoneum and pleura with asbestosis mesothtlioinas of the peritoneum and one had associated mesothelioma of the pleuia. .is been lecognired recently. T h e n u m b e r of T h e 3 patients w ith mesothelioma h a d been ...ses reported to date has been small and the a dm itted to the medical or sutgical s e n ice of ..iusal re lationship requires a d d itio n a l con- the Lancaster General H ospital. T w o of the 3 rotation. individuals had been emplored in the same Recent reports ftom South Africa,1- - 14 p la n t involved in the textile pha-e of the (.teat B rita in 2 3-5- -11 a n d this countn,- asbestos industrv. W e do n o t know the m a n .we in a in iin a te d pulm onats asbestosis in a ner of exposure of the third patient. ijttsal role with respect to pleural and peri- 'meal m esothelioma. W a g n e r et al.14 dexribed 33 cases of pleural mesothelioma, C ase R eports 'nich thev related to asbestos exposure. Case I (S.B.. D-f'5820.. A 53-\ear-old m ale Thomson12 associated 7 cases of mesothelioma. 1 in the pleura and 3 in the p eritoneum w ith ulntonarv asbestosis. Selikoff. C h u rg and H a n tm o n d ;' desciibed 1 cases of pleural mesotheliom a and 6 of c-iitoneal mesotheliom a in 307 consecutive vaths am ong asbestos insulation workers from i m iian 1013 th ro u g h August 1004. T h e same nithors found asbestos bodies in 12 of the 45 factors w orker was adm itted to the hospital in O ctober 1964 with a chief c om plaint of a b dominal distress and distention of 2-week d u ration. He gave a histon of smoking a pack of cigarettes duih for most of his adult life. On phisical examination, the patient ajv peared to be chronicnlh ill. Rales and coarse rhonchi were heard throughout both lung fields. T h e abdom en was distended: shifting dullness was present in tile flanks and urn- aesotheliomas in the A rm ed Forces Institute panic percussion was elicited over the a n te tio r '( Pathologv m aterial u p o n review. T hese in- p ortion of the abdom en. T h e r e were no 1litigators emphasised the im p o tia n c e of a 'iligent search for asbestos bodies in the lungs ''1autopsied patients tcho h a r e mesothelioma. In a studs'1 covering 1040 th to u g h 1005 au'psies were perform ed on 54 patients with 'athologic eviilence of aslx'stosis at the Lana'ter G eneral H ospital: 22 patients hail `(onchogenic carcinoma: 3 individuals had palpable organs or masses in the abdomen. The bowel sounds were normal. T h e blood count, urinals sis am i blood in dices were within normal limits. An x-rav of the colon was not remarkable except for evi dence of ascites. Infiltration of the bases of both lungs, blunting of the costophrenic an gles and adhesions to the diaphtagm wete present on x-rav studv. Calcification over tire tight diaphragm atic and mediastinal ateas was ^ ftotn the IV p n iin u tu s of M ofum o am i l\u h o !o g \, J 'c .is ttr <3onet.ll H o s i'iia l. 1 .u u .i 'i e i . I'a. Rtxt-ivovi fo r p u W u a in m VugU'i 27. lfVC>. present. 1 lie x-rav hnding> were interpieted as compatible with the fibrous associated with asbestosis. A histotr of expostne to asbestos 521 t TM ttu.;.. ;i . UJIIM, qgJWTJWI.*11 HJW C.ANl'lK J:> !96o fi . '* i i 1 Ii ^ -i. 1-. i f>4 _ " */ ''?- V*!P.' - "J Fig. 1. Cjm: II. Section of II showing 2 asbestos bodies in . bronchiole. f , J`. Cdsc I. ho^in th ^ ow v Z ri , mopt-KU Us ' juUt'tn. .* __ "j ^ *"**' ^ L- ,,, ' *V-* " ' -*,,> --*_ - _. . - a ^ , .* -- '-. s r vJ<W :* 1 1i i I I C: ^ ****" ` * - * - j- . v - "T- '/ ' - i` **i dust was obtained. He had worked in an as bestos p la n t from 1926 to 1946. A clinical diagnosis was made of nsbestosis with mesothelioma of the peritoneum. An a b d o m in a l paracentesis \ie ld e d 5.100 cc of ascitic fluid, which contained clusters of atypical cells thought to be malignant. One week later a laparotomv disclosed generalized a b d o m in a l carcinomatosis: 3.9ud cc ot ascitic fluid were ltmoved. An omental biopsy showed a malignant neoplasm with a papillary pattern which could be either a mesothelioma or meta static carcinoma. Tw o weeks following surgery the patient again was distended m arkedh: a paracentesis was d one <6 nun c o and nitrogen m ustard was instilled into the peritoneal ca\itv. Nine dn\s later, prior to discharge, a final paracentesis was done and 2no cc of fluid were obtained. Following the patient's discharge, the ascitic fluid gradualls reaccumulated: the patient be came weaker and expired 4 months after dis charge from the hospital. Po<!"iOT'^rr>* i . ' 'nr i'S B . .1-<~~t / On external examination, there was marked atrophv of the Teletal musculature of the bodv. T h e abdom en seas di-tended greatly anci had a 0 cm healed rnidline surgical scar. A b dom en-- A bout 4.000 rnl of vellow gela tinous fiuici was present in the greater peri toneal space. T h e peritoneum was partial!', rose-red bv grav-v.hite nodules a n d plaques whicli varied from a few millimeters to 6 cm in length. T u m o r ti-sue s e -ten in the serosa of the me-'enietc large and bowel, li'.er a n d spleen. T h e User weighed 2.500 C,m anci o'.er half of its col urine was replaced bv grav- white. coalescing neoplastic nodules. T he in dividual nodules were 6 to 8 cm in diametv and im olved both lobes. T h o r a x -- T h e left lung weighed 350 Grr and the right weighed 400 Gm. T h e parer, chyma was gra\-brow n a n d of increased cor, sistenev. H istopathologic e x a m in a tio n -- T h e serosj, reiis of the pc-moneum showed marked pin liferation and formed sheets a n d strands o: tu m o r o \ e r tire spleen, pancreas, colon, ap pendix. om enium and liver. T h e neoplas;:. cells had eosinophilic ectoplasm and vesicuh' nuclei and mans had vacuolated cytoplasn T h e overall arrangem ent of the neoplasm vupseudo-glandular. M uch of the liver substane was replaced bv msothlial cells which mai: tained an adenom atoid pattern b u t in so:: areas thee formed a spindle arrangem ent s,.: rounded bv fibrous tissue. Where the m plasm invaded the muscularis of the anjx . dix. the pa tte rn was tubular. Several of t: parapancreatic h m p h nodes contained rne: tatic payflarv lesions. T h r 'wsCeral pleura wm fihnuic and ' lung uarench'.ma was replaced extensive!' 1 hvalinized fibrous connective tissue. T: bronchioles contained manv asbestos bodiT h e respiratorv svstem was free of neoplan Essential pathologic diagnoses were as v lows: diffuse m alig n a n t mesothelioma of t' peritoneum: neoplastic extension into f liver a n d appendix: tu rn e r mtastass to tpara pancreatic Ivmph nodes: moderateh- S'; vanceci puiroonaiv asbestosis: acute p u r u h 'b r o n r h ith : recent mixed coagulation t'--'' embolus in a medium-sized pulm onary artcra-fir^s and cachexia. (av ell R.B gloved in an -, admitted t ;.:I in lu n e 1 mitis involv i :>f comnlain . _ the lower a u u u d a tlv ac mansion and :_ He h a d a i > admission, ''lin e d s m o k i On p h w c a l ahrile and i eg fields on v >' interprte cr portions :< tliought ' -t films sho a b'r'.u a n d i .,-besg,- wc ' '-loved. lire wiogv were in March 1 o, a 5-wcek 'n anorexia ' lope:: as ' '.b-.-tco ; edar rales, bedh anc 1 - bio-' i co ' ere not tge-m An ' ederable c ' d e le:: lu: armed fr ' " not V'il I', S., 1 M !.-><<.. if i IOM v A v / x i \ it h v. n u \ i- 1 >ro- :- IS t i II. -action rjf lu: _ i h bodies in j i }K,. 2. Cav_ JJ. Section from ..Icen sho'Ain? the mcsotheJi`.,3 rrouir<2 on the capsule I;.e mopla^rn hus an adenoma. .<1 pattern. * t ' f *- an i t a /. .3* J 4; 7l r :-v JJ ^ - >:~7 V-' ' f V y 5 i *1 ** *V% eri_ odules. T he in- Case II iR.B.. D-57201 i. A 49-vear-old male. cm in diameter j Linploved in an asbestos m a n u fa c tu rin g plant, eighed 350 Gin 5 m . T h e paren>f increased cum vis admitted to the Lancaster General Hos:.ital in J u n e 1962, w ith a diagnosis of p n e u monitis involving the base of the left lung. His diief complaint was fever and distress involv } ing the lower a n te tio r chest. T h e p ain became o n --T h e serovil ! mirticuladv acute a b o u t one week p rio r to ved marked pro idmission a n d was aggravated by deep b re a th , a n d strands oi 'l l . He had a cough until a b o u t 4 weeks prior creas, colon, ap '.a admission. T h e cough subsided when he . T h e neoplasm mpped smoking cigarettes. sm and vescula On phvsical exam ination the patient was dated cvtopl.nm febrile and moist rales were h e a rd in the :he neoplasm to' ' nig fields on auscultation. T h e ches! x-ray le liver substam- os interpreted as showing fibrosis in the cells which main over portions of b o th lungs a n d the changes ern b u t in son'' ere th ought to represent asbestosis. T h e arrangem ent sm first films showed no change from those taken 5Vheie the m * 1960 and in 1961. T h e p a tie n t h a d been iis of die appc n asbestos worker since 1929 and still was so ir. Several of t!'- ; nploved. Brondioscopv. sp u tu m culture and contained met - tology were essentiallv negative. fibrotic and f red extensiveh j tive tissue. T v asbestos borla' In March 1964 the p atient was readm itted >ith a 3-week historv of swelling of the a bdo men. anorexia and malaise. Cough and dyspnea 'eloped as the abdom en distended more, hhvsical exam ination disclosed bilateral free of neoph'" noses were as ! sothelioma of t tension into : mtastass to ' s: moderateb 'dar rales. T h e abdomen was distended ukedlv and signs of ascites were present. ` ' blood counts, blood indices and urinalv' were not remarkable. T h e heart was not ' finged. An x-rav film of the chest showed widernble elevation of the diaphragm . Mul- is: acute p u n 1, coagulation *' pulm n a rv a t- '< densities were present in the lower lobe 1 die left lung: otherwise, the chest film was hanged from the one taken in 1962. T h e w>rt was not enlarged. O n the io u n h hospital dav, paracentesis was attempted. A small am ount of tiiick mucinous material was ob tained, which on cvtologic examination showed clumps of malignant cells. O n the tenth hos pital dav the patient had exploratory suigerv. T h ere was extensive carcinomatosis with "sheets" and "cakes ' of tum or tissue over the mesenterv. peritoneal and omental surfaces. The pathologic report on the biopsied mate rial was poorlv differentiated carcinoma. T he patient was discharged, but was seen for pe riodic removal of ascitic fluid. O n J u n e 14, 1964 the patient was readm itted for term inal care: he expired 5 davs later. Postm ortem exam ination (R .B., A-6Jt-152e The external examination showed marked atrophv of the skeletal musculature and pitting edema of die lower extremities. There was a healed right rectus scar of the abdomen. T horax--T here was an extensive adhesive pleuritis in the right chest and. in die left, a marked fibrous pleuritis with focal loculation of about 606 ml of brown serous fluid between the pleural membranes. Both lungs were of increased consistence- and the parenchyma was reddish-brown. An S cm white fibrous plaque covered the lateral aspect of the lower lobe of the left lung. T he visceral pleura of both lungs was thickened and opaque. Some hilar lvmph nodes were replaced bv grav tissue. Abdomen-- T h e abdominal contents had to be removed en masse because die viscera! or gans were matted together bv tumor. T he peritoneum covering the stomach, intestines, liver, spleen and mesenterv was studded bv the neoplasm distributed as sheets, plaques and nodules of grav-white or pale pink tissue. T h e plaques varied fiom 0.5 to one cm in . mu 1-- -fri -* - - -- -- ^'arifc^,tfha^^*i>^^nfrarfriaa,HrnttlBiifa i B B i ? a r t f c ^ a r t M r t M ^ iiil humr i i i k 1 - f M i n i i f a rrlritoliirf' flu 31M C.ANCtR A p 'd 19Gl> \ o i \,< 4 X thickne and in sorao ureas die neoplasm was seen as rubbers nodules measuring u p to 8 etn in diam eter. Gov ei ing the in te iio r su tt.u e ot the diaphragm was giuv -white tissue ab o u t one o n in thickne". some of the para-aoitie lvruph nDales weie enlarged a n d replaced by neoplasm. Gras-white nodules scere present on the parietal peritoneum . T h e t e seas no evidence ot gross invasion of visceral organs although both liver and spleen scete encased almost completelv bv the tumor. Histopathologic examination-- Sections of stomach, intestines, diaphragm, mesentery and spleen revealed neoplasm in the serosal sur faces. T h e diaphragm and colon were the onlv organs invaded bv tumor. M uch of the serosa ot the abdom en showed hvpertrophv and pro liferation of its cells. T h e neoplastic cells formed papillary excrescences which consisted ot connective tissue coies covered bv cuboidal msothlial cells. In some areas the tu m o r was solid, consisting of large cells with eosinophilic ectoplasm and oval, vesicular, bland-appeuring nuclei. Manv of these cells had vacuolated cv toplasm. In the colon and d ia p h ra g m tire neoplasm invaded the muscular lasers and the pattern which the cells assumed was pleo morphic. pseudoglandular. solid and papil lary. T h e capsules of liver and spleen were thickened and invaded by papinurv mesothelial tissue. T h e re was m oderate hvpertrophv and hvperpla-ia of the serosal cells covering the visceral pleura. At some levels the neoplastic cells had proliferated into clumps. A similar change was seen in the parietal pleura and in some of the alveoli. X o neonlasm was found in the bronchial epithelium or walls. Manv asbestos bodies v\ere seen in the bro n chioles and there was a moderate degree of diffuse fibrosis of die lungs. Hilar and paraortic abdominal lvmph nodes contained papil lary neoplastic mtastass. Essential pathologic diagnoses included the follov. ing: diffuse m alignant mesothelioma invob. h' g d `e , pf-citun^urn and pi ' ra: neo plastic invadon of the colon, diaphragm and lungs: neoplastic mtastass to hilar and parsonic abdominal lvrnph nodes; palmonarv asbesto-is: bilatetal chronic adhesive fibious pleurius: rachexia and rnarkc-d edema of the lower extremities. Cave I I I ffJ.M., C-G5G1 ;. A GO-vear-old laundrv worker was admitted to the hospital in ]05o He had an acute onset of right upper qu ad ran t and right ov.er chest pain with chills and fever. O n exam ination a onc-urnonitis in the lower lobe of the right lung was indicated. Chest x-rav ievt-alc-d an elevated light diaphragm and mottled abnormal den-i- tie> hirrg above a n d posteriorly, lir e patier Disci ssu improved on antibiotic treatment and discharged. These a patier In Novem ber IHAS this p a tie n t was rea : , (voths'liomas. lu m ilte d because of lig h t u p p e r q u a d r a n t di v.itcii to the al tress. Gallbladder x-ray and intraveno, urogram weie negative. A stomach and d oden.il x-rav showed a small d uode na l ulec j in die duodenal cap. T h e chest x-ray reveale I elevation of the right d ia p h ra g m a n d scan in. ; of the right lowerlung field. T h e patier j improved on anulcerprogram a n d was dr j charged. ; .raitiguruiion of ti , vcpi tot the spin . seen in the hvei In tire second pa ururilv a p e iito r eungement was fc ,.t solid masses of I n January 1959 the patient was admitu- ' .enom.uoid patte again because of right up p er q uadrant dr i ,i was involved tress. O n phvsical exam ination the patient vw j vxTtrophic a n d obese a n d h a d generalized a bdom ina l tende: I ne mot phologic ness. X o palpable masses or organs wet- j e hbrotic pleura found. j -.renchvma small O n January 20. 1959 an exploratory lap. sie present in sc rotomv was done and extensive carcinom ato ; was seen over the om entum , gallbladder ar. j liver. Several litets of serous fluid were r j nance, we think rated independent moved. T h e pathologic study of the biop-- ,-lv in the serosal material disclosed a p apillate m alignant nee 1 ml pleura. T h e plasm, probablv a mesothelioma. T h e patier i cognized onlv in was discharged and had multiple abdomina i The third patien paracenteses as an outpatient. H e was read { wsothelioma whic m itted in June 1959 for term inal care an ,'topathologic pat expired J clays later. s ,e onlv organ inv o Postm ortem e x am ination (G.M .. A-59-15v j com was confined T h e bodv was fairlv well developed. A 15 cr j U1 3 patients 1 scar was seen in the right upper quadrant c | the abdomen. j A b d o m e n --A b o u t 400 ml of tu rb id flu; | Manv asbestos bodi< ".(1 diffuse fibrosis was present in the greater peritoneal spue ! rase individuals. T h e a bdom inal viscera were encased bv tunvv ' Xo asbestos bode tissue. Both visceral and parietal peritonea- ' 1>neum. tire perito vvere studded widely with gray plaques ar. ' 1 pleura, h ila r o; nodules. Similar masses were seen in the sero 1 :t-e structures wc covering liver, spleen, gallbladder, stomar ; "cstinal tract. In intestines and urinarv bladder. Omentum w 'ra of asbestos bod replaced bv solid grav-white tissue. T h o ra x -- Grossly there was a moderate: rag parenchyma. advanced bilateral fibrous pleuritis. Th lungs we: a i eddish-brown an d ot increaw- j O consistency. Histopathologic exam ination-- T h e serr cells which made up these tum or masses !r a mixed pa tte rn -- papiilarv, adenom atoid a: \ ; dhe exact perioc 1 -'t is known for ' ' b ) had been em; sol id masses of mc-sothelial relis. T h e n( ' 20 rears (192G tc plasrn was confine', to the capsules or cem* ` dj-vear exposure of all visceral organs except the colon. In t.: :ornas were rtc< organ the m alignant relis invaded the out' ; m u-z ula r laver. Asbe-tos bodies were c-vidt' I in the fibious tissue w-en in the lungs. _ ; E-sc-ntial pathologic diagnoses included l" , follov.ing: diffuse malignant peritoneal me theliorna. neoplas.tic extension into the wall the colon: old bilateral fibrous pleuritis :,r' : pulmortarv a-bc-stosis. .ractively, after t ere is no inform1 our third pa tic ' local asbestos p! Hie patients with an asbestos texih '-'ration since the 4 \ol. i l ; N M m o i u h i o m A i i ' K i ' i M ) w i m \ - ; ; j - i i i I-, M ' u i u * t /.!, JlC Jj.iticjn t and v.,, . was jeaii adrant dh ntra\enoi]. ch and dn denal ul< rat revealed m d scartirp The patient m d teas div ,'as admitted u a d ra n t div e patient tsas ninal teneleiorgans eeete , , , i oratory lapa- ` arcinomatosn llbladder and j lin'd were re- j of the biops', talignant neo- t t. T h e patient ! ale abdominal \ H e teas lead- j .inal care and .M., A-59-I3S). opetl. A 15 cni er q u a d r a n t of af tu rb id fluid i rritoneal space i teased bv tuiuot tal peritoneum j rv plaques and j ten in tire seroo j adder, stomach j . O m e n tu m tea' issue. ,s a moderate!' pleuritis. The nd of incre.i'ed D l s C t , S I O \ ' O f J' U H O I O O t These 3 paiienK had malignant diffuse ;IieiOthelionia'>. in <ase i the neoplasm teas united to the abdomen. T h e rnoi phologic lonfiguration oi the tumor teas adenomatoid except toi the spindle ceils in a fibrous stroma as seen in th e l i t e r substance. In die second patient the mesothelioma teas pi manly a peiitoneal giowth. T h e structural .inangement teas for the gieater pait papillary but solid masses of large eosinophilic ceils and adenomatoid patterns teere seen. T he pleura .ho va s in v o k e d and the serosal cells teere htpertiophic and shoteed focal htptipiasia. The moiphologic pattern teas tabulai vhere the fibtotic p leura teas in ta d e d . In the Jung paienchtm a small d u m p s of msothlial cells teeie present in some of the alveoli. In this instance, v e think the mesothelioma origi nated independently and perhaps siinultaneousls in the serosa] m em branes of p e tito n e u m and pleura. T h e pleural im o h e m e n t teas recognized onlt in the microscopic studs. The thiid patient had a diffuse abdominal niesotlielioma tehich teas also seen as a mixed histopathologic pattern. T h e colonic wall teas the only organ invohed b\ invasion. T h e neo plasm teas confined to the abdomen. All 3 patients had pulm onart asbestosis. Main asbestos bodies teeie seen in bronchioles and diffuse fibrosis of the lung teas present in these individuals. Xo asbestos bodies teere found in the peri toneum. the peritoneal mesotheliomas, pari etal pleura, hilar or abdom inal h m p h nodes. These structmcs teere not seen in the gastro intestinal tract. In our experience the pres ence of asbestos bodies has been limited to the lung parenchtma. Comment on-- T h e serosal amor masses had : ldenom atoid and j cells. T h e neo- j apsides o r serosa j the colon. In the nvaded the outer j dies tvete etidenc > the lungs. ] loses included the j t peritoneal mew- j nr in to the trail ot tons pleuritis and T h e exact periods of exposure to asbestos 'lust is knotvn for 2 of our patients. Case I had been em ploted in an asbestos mill bar 20 te a r s (1926 to 19ltV>. Case II iR.B.) had a el-year exposure (1929 to 196;!':,. T h e meso theliomas were recognized 58 and 33 tears, tespectit elv. after the first knotvn exposure. There is no in formation available to confirm that our third patient had been em ploted in fie local asbestos plant. The patients with knotvn exposure worked :r* an a>bestos texile mill which had been in operation since the tuna of the cenmrv. This plant was concerned v. itii wearing, carding and ^pinning of axbesto-,. In the eari;. tears the potential danger o; inhalation o; a-bestos dust teas n o t l.notwi. `J o e concentration of `'asbestos dust" before the niid-193'i's as of 'uch degree that set era! departments were re ferred to as "dust holes. ' I t has been sa id that indit duals wot king in this atmosphere ` could not see beyond an aim's length." In 935 as bestos was recognized as a cause of pne-mnonoconiosis and measures then teere initiated to minimize the enrironmemal pollution. We think mesothelioma of the peritoneum is a definite pathological entity as seen in these I paiivtus. M e ta sta t'c malignant'- rnimicing mesothelioma is not likely in the absence of a dem onstrable p iim a it lesion at autopst. M esothelioma of the peritoneum is >o infre quent. except in association with asbestosis, that a causal relationship seems acceptable. In our hospital tee Irate not seen a case of mesothelioma without asbestosis. T h o m s o n 1-' and Selikoif et aid have pointed out that asbestosis frequently nrav be over looked in mesotheliomas. This occurred in our third case. Initially, the pulm onarv asbestosis had been overlooked. On reviewing the lung sections, definite evidence of asbestosis was present. In 2 of the 3 cases the patients, when seen, were no longer in an occupation associated with exposure to asbestos dust. T w o patients had x-ray changes sufficiently characteristic to suggest asbestosis but the third did not, even to radiologists who see m anv cases of pulm o nary asbestosis. A high index of suspicion is needed in i elating asbestosis to mesothelioma. T he frequency with which occupations are changed, as well as the widespread use of asbestos, necessitates a detailed history of pos sible exposure. At autopsv the presence of pulmonary asbestosis raav be overlooked verv easily. O u r 3 patients had extensive fibrosis of tire lung parenchyma and characteristic asbestos bodies, presenting the tvpical changes of pul monary asbestosis usually seen as a result of occupational exposure. Recently, however, several investigators have presented evidence th a t asbestos fibers may be air-bom e a n d ns such present a modem urban hazard. Reports from Cape T o w n ." M ia m i10 a n d P ittsb u rg h 1 showed 26.4. 27.9 and 41%. respectively, of the subjects studied to h ate asbestos bodies in the lung tissue at autopsv. T h e implications in cancer epidemiology are significant since iwy *j JPtf1 V_Y< C a n c e r I p i t l lfh>U ' 1 19 there h.rs been a m a ik e d increase in the utilization of asbestos in the past generation. Pleural or peritoneal mesothelioma max be seen in increased freejuenev as a result of noiloccupational exposure on the basis of em iron- mem contamination. Since asbestosis is primal ily a pulm onary disease, an explanation is needed for its car cinogenic relationship to the peritoneum. The h m p h atie \essels of the diaphragm form 2 plexuses--one on the thoracic and one over the a b d o m in a l surface. ~l hese plexuses com municate freeh midi one another on the parts coiered bv the pleura and the peritoneum.4 Asbestosis involves mainly the bases of die lungs. It is postulated dia t a carcinogenic sub stance is released in asbestosis. which. through access to the h m p h a tie channels in the dia phragm. mav produce mesothelioma of die peritoneum. The South African and B ritis h reports deal m im a rih with the crcnidolite txpe of asbestosis. Chixsotile t\:x' asbestos fiber is used prim arih b\ the United States asbestos industrv. O u r findings support the concept of Selikoif et ale tha t mesothelioma is a hazard of asbestos exposure in general, rather than one t\}>e of asbestos fiber in particular. ; ' j ! ( > A ddendum Since the preparation of this report, a fourth case of pulmonarv asbestosis with pleural meso thelioma has been seen in a patient at surgery. , It occurred in a patient with a history of occupa- j tional exposure to asbestos. Since a primary bron- ! chogenic carcinoma cannot be excluded completely 1 at this time, die case has not been included in this j report. . REFERENCES 1. Cattna. DZidra Totter. Robert S.. and Gross. Paul: Asbestos bodies in human lungs at autopsc. J A M A 192371-373. 1963. " 2. Entich nap J. G.. and Smither. W . J.: Peritoneal tumors in asbestosis. Brit. J. I ndust . .\Ied. 21:20-31. 1964. 3. Fou ler, P. B., s]0 per, J. D ,, and Warner. E. D.: Exposure to asbestos and mesothelioma of the pleura. Brit. M e d . J. 1:211-213. 1964. 1. Goss. C. M . Giav's Anatom v, 26th ed. P h i l a delphia Lea and Febicrer, p. 793. 3. H ourihane. D. O B.: P a th ologe o f m eso theliom a and analysis of association utth aslx-stos exposure. T/ . o r c x 19:265-275. 1961. 6. Mann Richard H.. Grcsh, John L., and O 'D on nell. Ward M : Unpublished data. 7. O u e n . W. G.: Diffuse m eso theliom a and exposu re to asbestos d u n in the Merseyside area. Bn t. M e d. J. 2.214-dls. 1964. ' 5. Selikoif. I. J. Churg. J., and H a m m o n d , E. Cc Asbestoses explosure and neoplasia. J A M A 155.22-26. 1964. y ----------. C h u m . J.. and H a m m o n d , E. C.: Relation between exposure to asbestos and m eso theliom a. -\V_ r.~. J. M e d . 272:560-563,1965. 10. T h o m so n . J. G.: Asbestos and urban dweller, L'npublished paper from Conference on Biological Effects of Wbe-tos. New York, Oct. 1964. 11. ----------: Exposure to asbestos dust and ditfuse pleural mesothelioma, Brit.Me d . J. 1:123, 1963. 12. ----------: M esotheliom a of pleura or peritoneum and lim ited basal asbestosis. S. At r . M e d . J. 36:759-76c 19*32. 13 ----------. Kuschula. R. O. C., and MacDonald R. R.: Wbostos as a m o d e m urban hazard. I b i d . 37 77-51. 19*33. 14. Warner, J. C., Slesgs. C. A., and Marchand. P. Ditfuse p.eurai m esothelioma and asbestos expesur-. in north ue-tem Cane Province. Brit. J. Indu.:!. Mes 17 260-271.1960. ' | i , j . ; t METAS " as inai lion the gen tina] unti' O RKABLE T T ha\e bee Lasrieman, I\e plasms of the ognized micros agement usua although sxsren quired as hema uons a n d my a ascribed to die rence in associa: has been report terv infrequent pleural inxasioi nancy. Castlema that appeared ; years after s' mediastinum fo and renal metas found at nectoj oncerns a pat growing, periph 's.'rich was d e te r ' ;'i'i'na. A separ. cioma was disco h o m the De-par* '"-Jery, Wadsworth T ' " r , Los Anpel-.s ;T-.a I.os Are*::** r-irt.-r.or.Ti ,,f , u r -_- scdr'vs for r*-pri ' '000:0 Pari o'oer* ' ar.d S:.>. * Lhict I hora etc ' ' = . ar.d C.ir..oaI ' m rr .a. L o ; f-r-.': o f I ho:c* * ' 1 ';*:i-ar.t P r o f 's - of California, Io c Mjy mrp !fug11