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FILE NAME: Talc (TALC) DATE: 2019 DOC#: TALC219 DOCUMENT DESCRIPTION: Journal Article - Mesothelioma Associated With the Use of Cosmetic Talc ORIGINAL ARTICLE Mesothelioma Associated With the Use of Cosmetic Talc Jacqueline Moline, MD, MSc, Kristin Bevilacqua, MPH, Maya Alexandri, JD, and Ronald E. Gordon, PhD Objective: To describe 33 cases of malignant mesothelioma among indi viduals with no known asbestos exposure other than cosmetic talcum powder. Methods: Cases were referred for medico-legal evaluation, and tissue digestions were performed in some cases. Tissue digestion for the six cases described was done according to standard methodology. Results: Asbestos of the type found in talcum powder was found in all six cases evaluated. Talcum powder usage was the only source of asbestos for all 33 cases. Conclusions: Exposure to asbestos-contaminated talcum powders can cause mesothelioma. Clinicians should elicit a history of talcum powder usage in all patients presenting with mesothelioma. 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Tashepacratsoesf twoertrelitriegfaetriroend, taondauttihssoureJ.dMig.efsotiromnsedwiceroe ppearthfoorlmogeyd rbeypoarutthcoornfRir.mG.edasthpeardt ioafgtnhoissislitoigfamtioanli.gnInanetvemryescoatshee,lia oHmeaal.thThFiesinsstutediyn wInasstitcuotnedfuocrteMdewdiicthalaRpepsreoavraclhfr(o#m18t-h0e22N5oFrtIhMwRe)l.l MATERIALS AND METHODS Case Histories individDuaalt'as gmaethdeicrealdrefocor radlsl a3n3dpsawtioernntstewsteimreognayth(dereepdosfirtoiomn teraacnh pschryipsitcs)iaonf winidthiviedxupaelsr.ieAncllecaesveasluwateirnegreavsbieewsteods beyxpaonsoucrecuipnattihoonual rseavnideswooff ppaatthieonltosg.yDreaptaortasbcstornafcitremdinignctlhuededdiagmnoedsiiscaolf dmiaaglingonsainst, mfroemsothsewlioormn at,esatnimdocnlyinibcyal tchoeurcsaes.esE,xpwohsiucrhe idnactlaudwedas eoxbtetanisnievde qinucelsutdioendinfagmirleygaorcdciunpgatiaollnalsohuisrctoersiesof(paarsebnetsstoasndeaxnpyoosunree.cohTahbisietxaptionsgurwe,ithhotbhbeiepsatthieant ti)ncfolurdaeldl ucsaeseosftporoadsusecstss tphoattemntiigahl tacsobnestatoins aassbbeessttooss (sinudcuhsatsrycelreaamdiicnsg), troesipdoesnscieblien aennvarireoantmhaetnmtailghetxhpaovseurheasd, krennoowvnataiobnastetmhaetnmt oigfhatshbaevsteousswedhialesbtehsetopsatcioennttawinaisnginmscahteoroial,lsh,oamnde raenlyateodthteor pfaomteinlytiahlisstoouryrceosf ocafnacsebresstwosaseoxbpotasiunreed. Afrodmdititohneaslwdoartna tBeRstCimAo1nya.ssAoncyiatdeadtaprroeltaetiend-1towpaosteconltlieacltgeedn, eitficprmesuetnatt.ions such as JOEM Volume 62, Number 1, January 2020 11 Copyright 2019 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited Moline et al JOEM Volume 62, Number 1, January 2020 sworn Tteasltciummonpyowbydepraetixepnotssuarnedhiisntosroiemsewcearseesr,evfiaemwielyd mbaesmedbeorns pwairtehntfsirswt-hhoandreckanlolewdleudsgiengoftatlhceumusepoowf dtaelrcuwmhilpeowddiaepre, rsinugchthaes phatttpie:/n/lti.nDksa.tlawwin.ccloumdi/nJgOMtyp/Ae 6o5f1t)a, lacguematpfoirwstduesreuosef dtal(cAupmpepnodwixde3r,, afinrdst deuxrpaotisounreowf ausseprweassenotb.2t9aiInnedsotmo eencsausrees,aidnedqiuvaidteuallastewnceyrefarolsmo ionbttearivnieedweind minedpiecraslonre,caonrddsthaensdeddeaptoasiwtieorne tmraenrsgcerdiptws.ith the data performTehde bsiyx acuatsheosr dRes.Gcr.ibTedhesbeelocwasealrseopohratds atirsesuperedsiegnetsetdionins gevreaaluteartedd,etaanild; ththeesiramcelinriigcaolr wcoituhrsreespweacst tsoimobiltaarintiongailnl fo33rmcaatisoens related to any asbestos exposure was applied to all 33 cases. Case 1 with shCoarstneelssi soaf b7r0e-aytehaar-nodldchweosmt paaninwihnoJpanreusaernyte2d01to5.aAphcyhseisctiaxnrAauygruesvtea2l0e1d5a, samCaTll palneguiroaglreafmfussihoonwweidthdleevftelboapsmilaerntatoelfetcwtaosiss.ubIn pplleeuurraall enfofduusiloens awnatsersitoilrltporethseenlti.nAgutlhaoarancdenatpesleisurwaal sbadsoende manadsst;hea coymtoa.loAgyposhsiotrwoendelmarigsseiocnlutsotmeros goraf pcheylls(PsEuTsp)icsicoauns sfhoorwmedespoltehuerlail tlhefict kseidneinogfahnedrfcohceaslti.nItnenSseeputpetmakbeerin2f0e1ri5o,rlsyheanudnpdoesrwteerinotrltyhoornacthoe tshceolpioicmsaurgweirtyh. Tinhveaspiaotnhoolofgytheshovwisecdereapl itphleeluiaral maanldignpaunlmt moneasroy parencChyamsea1waipthpltiuemd oloropsreesfeancet aptotwhedesrtaopnleaddmaialrygibna.sis from the p1o9w40dsertoanthdeC1a9s7e0s1. cHleearnemdotrheesridaulaslopuosweddetrhefrosmamheerlomosoethfearc'es dresserEalencdtrcolnothminicgroesvceorpyicothaenralwyseiesk (fEroMmA1) 9o94f ttohe20lu12n.g tissue r3e2v8e6alefidberasntpheorphgyrallmitewfeiibgehrts. Tinhearecwalacsulaaltseod scigonnicfiecnatnrattiaomnsouonft of fibroCuassean1dwpalasttyretaatlecdawndithalfuomuirncuymclessiliocfatceos.mbination chemo therapy with cisplatin and pemetrexed for four cycles. Case 2 exertioInnalAduygsupsnte2a0a1n5d, Cdrayseco2u, gah6.5A-ycehaer-sotlxd-rwaoymshaonwperedsaenlaterdgewlietfht pfrleeeulrya-lmeofvfuasbiloen,.laArgec-hveosltumCeT, lsecfatnplienurSaelpetfefmusbioenr,2n0o1d5ulsahriotwy/elodbauthlaetlieofnt oupf tpheer lleofbtep,laenudran, olehftillaorwoerrmloebdeiaastteilneacltalysmis,pthhardeeennoopdauthleys. iAn tbheorr2a2c,en2t0e1s6isresphoowrteedd schaorcwinedomabancoerlmlsa. lAdePpEoTsi-tCsTofstcuamnoorninStehpetelmeft pleura.CTahseer2e uwnadsernwoernetpaorbterodndchisoesacsoepoyuitnsidOecttohbeerc,h2es0t1.5. Pathol osagrycosmhoawtoeidd, m50al%igneapnitthmeleiosoidth).elAiomseac,obnidphoapsiicniomnixceodnftyirpmeed(50th%e doiraugbnriocsiins,. iSfohsefiudne,dearnwdemntentwsaoancydccleosmopflectehdemtroetahtmeraepnyt inwiNthovdeomx- bDeerc. eAmbPerE,TCascsean2 suhnodweerdwennot lreefstporandsiecatloptlheeurecchteommoyt/hdeercaopryt.icaInttiioonn,. reSsuercgtiicoanl ofpalethftohloegmyidisahpohwraegdmr,easnidduoanl ebliypmhapshicnodmealdiigsnsaenct m20e1s6o,thraedliioamtioanwoitnhconleoggaytivreecnoomdemseannddendeagdajtuivveanmtarragdiinast.ioInn Jthaneruaapryy tAosthoef lAefptrcihl e2s0t,16w,hCicahsesh2e hreacdeinvoedevinidFeenbcreuaorfydainsedaMsearrecchuorrfe2n0c1e6.. and woCualdsea2pprleypoprotweddesrtaarfttienrghteorudsaeiltyalschaorwoeurndorabgaethe.igShhteowr onuinlde aelnsjooyuesde ttahlecusmcenptowandderwwohueldn vaipspitliyngthheerpogwradnedrmboetfhoerrebgeocianugseosnhea bdaatbey. pSohwe dceorntwinituhedalltothurseee poofwhdererchaifltderregne. tItinngthemeaarrrileyd2a0n0d0sussehde binegthaen mtoorrengiunlgaralnydaaptpnlyigahft,radgersacnrcibeianngdititassmhaetrcshiignngattaulrceusmcepnot.wSdheer tahlseopospwridnekrlwedhitchhe sphoewwdoeurldinruhberolninhgeerrsieuidtcraasweesraannddottrhaevresluerdfawceitsh. calculaEteMdAconocfetnhteraltuionngotfis8s6u2e5refivbeearlsepderangtrhaomphwyelltitweefigibhetrws iitnh aa laimmoituonft doeftfeicbtrioounsoafn2d8p7l5atfyibtearlcs pwearsgsreaemn.wEeMt wAeoigfhtth.eAlysmigpnhifincoadnet tciossnuceenrteravteiaolnesdoafn3t4h,o5p0h0yflliibteersanpdertgrerammolwiteet fwibeeirgshtinwiathcaallciumlaitteodf rdaettieoctoiofn2o:1f 1a1n,5th0o0pfhibyellristep:terregmraomlitew/aecttwineoilgihtet.. TAhlelyfwibeerres sceoeunnitneda wTheerere5wmams aolsrogsroemateeraimnoluenntgothf fwibitrhouasspaencdtprlaattiyostaglcrenaoteterdthiannth8e. lymph node tissue. Case 3 oped shInortSneepstseomfbberrea2t0h1,4a,cCouagseh,3a,nadnch8e4s-tyteigarh-tonledssw. oAmcahne,stdxe-vrealy ianngNioogvreammbsehro2w0e1d4 ashlaorwgeedleaft lpalreguerallefetffpulseiuornalweitfhfucsoiomnp. rAessCivTe aotpealeccittiaessisinofthtehelelfetftupmpiedrdlleobaendanldowriegrhltobluensg.anAd gthrooruancdengtelassiss wshiothwpeldeucraarlcbinioopmsay caenldlse. vCaacuseati3onunodfearwpleenutraal veifdfuesoiotnh.orPaactohsocloopgyy reepvitehaelelidalammeasloigthnealniot mepai.thCealsiael 3nethoepnlausnmdecrownseinstteanltewftitphlemuraelicgtonmanyt alynmd pdheconrotdiceastioanndin cJuhneset20w1a5ll.,Thanedmethsoethpealtihoomloaghyadnsopwreasdhtoowthede mSeaplitgemnabnetrb2i0p1h5asaicndmdeiseodthienliolamtea.OCctaosbee3r 2e0n1te5r.ed hospice care in knownCoacsecup3atwioonrkaledexapsosaunreelteomeansbtaersytoss.chCoaoslete3acuhseerdwtiatlhcunmo phoerwadremrs``abnedfoinreh[esrhseh]owesasda1il2y.anSdhe1s3hyoeoakrsthoelpdo,'w' adpeprloyuint gofitthuencdaenr taanldcuamppblioeddyitpoowntdoerh,earnbdodthye.ySshheanreodtead stmhaatllhberatmhrootohmer. aSlhsoe uusseedd tuanltciulmhepropwredfeerrrbeedgibnrnainndg winasthneo1l9o4n0gsearnadvaciolanbtilneufinogr pfourrcdheacsaed.es, above tEhMe lAimoitfotfhedeltuenctgiotnisosufe69d0i0d. nHootwreevveera,lthaenrye awsebreestaosnufmibbeersr toisfsvueeryresvmeaalleldchtrreymsootliilteeaassbbeessttoossffiibbeerrss. iAnncaallycsuilsatoefdthceonlycemnptrhatnioodnes oAfll94fi0b9erfsibceorusnpteerdgwraemrew5emt mweoigr hgtrewaittehrainlilmenitgothf dweittehctaisopneoctf r9a4t0io9s. gsirleicaateterst,hasnili2c0a. pTahrteircelews,asanaldsoboathsigfnibifriocuasntaanmdopulnattyoftaallcu.mLinigumht masibcersotsocsobpoicdieasnapleyrsigsrarmevweaeltedweaigchatlocuf llaytmedphconnocdeenttirsastuioenbyopf h4a0s9e contrast light microscopy. Case 4 abdomIinnalApuagiunstan2d01h4a,d CaaCseT 4s,caan 6o6f-tyheeara-bodldomweonmaannd, pdeelvveislotpheadt qshuoawdreadnto, manednetanllacragkeidngd,iaapshcriategsm, aaticflluyimd pphocnkoedtesi.nSthheeurnigdhertwloewntear preavreaacleendteastiyspaicnadl manesoomtheenlitaall cbeilolsp.sSyhienthAeunguunsdte2rw01e4n.t Ta hlaepacryottoolmogyy, papatpheonldoegcytosmhoyw, eodmmenatleigcntoamntye,paitnhdellieofitdsmalepsiontghoe-loioomphao.rIencStoemptye.mTbheer 2w0i1th4,maalPiEgnTa/nCtTasschiotews,eodminecnrteaalsmedetuapsttaatkice dinistehaesea,badnodmceanrdcioonpshirsetnenict 12 2019 American College of Occupational and Environmental Medicine Copyright 2019 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited JOEM Volume 62, Number 1, January 2020 Mesothelioma and Cosmetic Talc ndoiadpuhlreasg. mA. Sthhoerawcaossctorepaytesdhowwitehdmtuumltioprlecroovuenrdinsgotfhceherimghotthheerampiytwoithpecrsisisptleantitn aasncditeps.emHeetrrexteudmoanr dprthoegrraepsseeudti,c apnadracsehnetesdeiesdduine FebruaCryas2e0146.grSehwe wupasin68ayheoarmseolwd.here her mother used talcum ppoerwsodnerall`y`foursinags tlaolncgumaspo[wshdeercosutaldrt]ingremareomunbder.t'h'eSahgee roefca9lleodr b1o0d, ya,pupslyiningg athpeowpodwerdepruftfo. hSehre aarpmppliietsd, tgarlociunm, apnodwadreoruntod hheerr btoodtaylcfuomr appopwrodxeirminattehlye 41906y0esawrsh. ilCeawseor4kihnagdaasdadiltiicoennasledexcpoossmuree tSohloegsihsot,oakptphleytianlgcutamlcpuomwdpeorwodnetor othnecclliieenntts''s nneecckk,saanfdtewr oauhldaiwrciupte. pooffwtdheer exincseisdse wtihthe aglborvuessh tohratbloswhe drdyoenrn. eSdheprailosro utosedaptpallycuinmg hair coEloMr.A of the peritoneal tissue revealed chrysotile type asbes twoesigfihbtewrsitihn aa lcimalcituolafteddeteccotniocennotrfa9ti2o0n foibfe9r2s0pefirbgerrasmpewregtrwameigwhet.t Fasibbreosutisfoarmndtrpelmatoylittaelcanwdassiliaclasocroybstsaelrsv.ed. Also seen were non- Case 5 and faCtiagsuee 5inwaSseapt7e6m-ybeearr-2o0ld15woamndanwwashoddiaegvneloospeedd wchitehst vpiarianl ptheircikcaerndinitgis.aAndCmT ilsdcanpeirnihOepcatotibceras2c0i1te5s.shSohweedwmasildtrepaetreidcarwdiitahl dsteecrroeiadssedforapvpieratiltep,ewriceaigrdhittilso.ssIn, tleantedefranlels2s0a1r5o,uCndastehe5 udmevbeilloicpuesd, aunltdrasaobudnodmtihnaatl sphaoiwn.edIna Dmeicldemtobemro2d0e1ra5teshame ohuandt aonf aasbcditoems.inAanl ambidnoimmainl allinCeTarscaatenleshctoawtiecdcshliagnhgtely. bTihlaetreerawl pasleucorapliothuisckpeenriinhgepwatiithc paseclvitiess, nexotdeunldairnitgy taot tthhee rpiagrhatcoalnidc gleuftttepr,araancdoliac rgiguhtttersiadnedd ddeeeepp plieolivdiccemllassas.ndAtipsasruaecefrnategsmisenwtsaswdiothneananindflsahmowmeadtoartyypbiaccaklgerpoiutnhde. Amilliaapryaroesxccorepsycesnhcoew, eadmpoedreitroanteeaslizceadrcpienlovmicatmosaisss wanidthasacidteifsf.usIne Jtiaonnuaorfyt2h0e1o6mshenetuunmd,erswpleenetn,anreesxepcltoiorantoorfy alabpdaormotionmalytuamndorr,esaencd rmesaelicgtnioannt omf ethsoethaeblidoommainianlvowlvalilngtutmheor.omTehnetupmat,hosplolegeyn,shcoowloend, Manadlimgneasennttemrye,soatshweleiollmaas tahlesofiibnrvooaldviepdostehetispsaureieotaflthpeeprietorintoenuemumas. wluemllena.s Cthaeseap5pdenieddixi,nwOitchtofbiebrro2u0s17o.bliteration of the appendiceal the 195C0asseto5thheadmdiadi-l1y9p7e0rss.oSnhael uwsoeuoldf tpaolcuurmthbeopdoywpdoewr doenrtofrhoemr hananddosnahnedrpleagtsit. uWnhdeenr hsehreawrmass,minenhsetrrugaetninitgalsahreewa,obueltdwaepepnlyhetarltcouems, papopwlideedr toanlcuhmerpfoewmdinerinteo nhaeprksihnosesa.ndCahseer5u'sndheurswbaeanrd. aSlshoe uaslesod tthalecubmathproowomde.r.SBhoethshCoaoske t5heanbdahtherrohoumsbfalnodorapmpaliteadntdhecpleoawnedderuipn residuaElMpoAwodferthferoommethnetalbatitshsruoeodmidsninokt.reveal any asbestos fibers awbeoigvhett.heEMlimAit ooff dtheeteclytimonphofndoedteecttiiossnuoefr6e5v1eafliebderschpreyrsgortialme awnedt a2n0t,h70o0phfyilbleitres apsebresgtroasmfiwbeetrswienigaht cwalicthulaateldimcitonocfednetrtaetciotinosn ooff g1r0e,3at5e0r finibleernsgptehrwgirtahmaswpeetctwreaitgiohst.gArellatfeibrethrsanco2u0n.tTedhewreerwea5smalmsooar psilgantyifiaclaunmt ianmumounsitliocaftfeisb.rous and platy talc as well as fibrous and Case 6 playingCahsoec6keiys ain442-y0e1a2r-oalnddmwaanswehvoaldueavteeldopiend tchheesEt mpaeirngeanftceyr DCaespeart6mceonnt.tiAnuCedT tsocahnavtheatchsehsotwpeadinnoovpeurlmthoenanreyxatb4noyremaarslitiaensd. u20n1d6erwsheonwt emd uinltcipreleasecdardpilaecureavl athluicaktieonnisn.gAorCnTons-ccaanlciifnieFdepblreuuarrayl palloaqnugethaelornigghtthueprpigerhtlombea.joAr fPiEssTu/rCeTansdcaanntinerMiorarrcighh2t0h1e6msihthoowraexd utinssiluaeteraablnohrympearlimtieetsabsoulsicpicpiloeuusraflorfismsuarlailgnaanndciensonin-fvisosluvrinalg stohfet pClaesuera6. uTnhdeererwwenetreantiosns-usepebciiofpicsytiinnyMpaarrecnhc2h0y1m6a.lTlhuengpantohdoulolegsy. sskheolweteadl mmuaslicglne.ant epithelioid mesothelioma with invasion to the trexed,Ccaisspela6tinu,nadnedrwbeevnatcnizeuom-aadbjuivnaAntprcihl 2em01o6t.hIenraMpyayw2i0th16p, eCmaseet6heunldeverewl eVnItIalymmepdhianstoindoe.scAodpdyitwiohnicahl cshheomwoedthmereatpaystawtaics sapdrmeaidnitso tpelreeudr,ecwtohmicyh wwaassdonnoet waleolnlgtothleeraftiesds.ureInbeJutwlyee2n01th6e, uapppearrieatnadl lcohwesetrtulobbee.siTteh.eCreaswea6s dsepvreelaodpetod tahceutseittehroofmpbreuvsiionusthienfreigrihotrurpigphert pexletruermalityth.iIcnkSeneipntgemvbeerrsu2s01a6, asmchaellstrxig-rhatypslheouwraeld uefnfcuhsaionng.edTrhigrehet aCdTditsicoannalincyNcolevsemofbecrhe2m01o7thsehraopwyedwaereperrescisotmenmt ehnydpeedr.mAetabPoElTic/ pfolecuursailnetfhfuesriiognh.t anterobasal pleura and a slight increase in a right an infanCta.sHei6s mwaostheexrpaopspeldietod ittatlocuhmimpoawftedrehribsebgaitnhnuinngtiwl hheewn ahseawbales tuosianpgptlhyeitphoiwmdseerlfi,nsttharetibnagtharroooumndatnhde iangehiosfrosioxm. ,Caansed 6thraetctahlleerde twoohuilsdtobrespoo, wgrdoeinr,olneghsis, aflnodorb.aHcke,aopfptelinedtwthiceetaalcduamy apfotewrdsehrodwierericntgly. bHeefoprleaydeodnnhioncgketyheaseqauyipomutehnat.ndHeusreedcaplolewddegretitninhgismhoouctkhefyulgseoarf poonwcedeorr dtuwriicneg tahedaayppalifcteartiosnh.owHeerinogft.enHeaphpalidedntoalcoucmcuppaotiwodnearl exposuEreMtAo aosfbethsteosl.ymph node tissue revealed anthophyllite and tfriebmeroslpiteer agsrbaemstowsetfiwbeerisghint waitchalaculilmatietdofcodnecteecnttiroantioonfs34o5f01f7i,b2e5r0s ptee:rtrgemraomlitwe.etAwllefiigbhetr.sTchoeuyntwederwe esereen5imnma roartigoreoafte2r:3inalnetnhgotphhwyliltihaamspoeuctntroatfifoisbrgoruesaatenrd tphlaanty t1a4l.c7aloornggrweaittherp. laTthyearleumwiansumalssoiliscoamtees and magnesium aluminum silicates. TissueTisSsaume spamleplAesnfarolymsissix patients were analyzed: (a) lung and lmymespohthneloidoemtais;saunedf(rbo)mlufnoguarnodfltyhme pphatnieondtes fdroiamgntwosoedofwthitehppalteieunratsl bdeiaegnnporseesderwveitdh ipnepriatoranfefainl mbleoscoktsheolrioams af.orTmhaelitnisfsiuxeedsatimsspuleess. had Tissue Digestion Protocols ParaffTinheBtlisoscukeswas extracted from paraffin blocks was done aect caol.r3d1inTghetotisthsueems wetehroedcoulot gfryomdetshceripbaerdafifninHbelloleckr setanadl30deapnadraWffiubnliozettdedbyanmdewltienigghatnedd.xTyhleenteistsreuaetsmwenerte. TdhigeeyswteedrewbitrhouKgOhHt toanwdattehre, ignaotirognansicteppselolent calneaansebdeswtoisthlodcisattiollredgriwdatceorabteydmwuiltthipfloermcevnatrr.ifuIn 2019 American College of Occupational and Environmental Medicine 13 Copyright 2019 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited Moline et al JOEM Volume 62, Number 1, January 2020 aadsdtiatinodna,r2d50glpasLs ssalmidpeletsowiedreenptirfeypafreerdruugsiinnoguas cbyotdoiceesntarinfdugleonongteor fibers by phase contrast microscopy. Formalin Fixed Tissue step asTdheisscrpirboetdocinol23is'39s.imCoilnatrrotolsafboorvbeowthitthhoeuptatrhaeffidnepanardafffoirnmizailning ffioxremdaltiinss, uiefsfrionmclufdiexdedlowoektintigssaute,thoer paanryaffoitnh,eirf mfraotmeriabllsocuksse,dthtoe pthreocgersisdst.he tissue to view the remaining inorganic material on Asbestos Fiber Counting tron mTichreosgcroipdsy w(TeEreMa)nuaslyinzgedatswtaondwaaryds:fib(ae)r-tcraonusnmtinisgsipornoteolceocl m(2i3c.r4o0s)co2p3y'3o2notnw8o0c0ytgorcidenotrpifeunginegpsr;epanadrat(ibo)nsphpaesretiscsounetrtayspteliignht a(2c3co.4r0d)anc.2e3'3w2 iAthsbeastsotsanfidbaerrds wasebreesetvoaslubaoteddy-tocoduentetirnmginperwothoectohler tlheneygtmh:ewtitdhteh draetfiioniatinodnpoafraallfeiblesri,dweshiacnhdiantclluedasets5hamvminignaltenag5th:1. T(EhDeSfi)bteorsdweteerremailnsoe athnealryazteiod boyf eElneemrgenytDs icsopnetrasiinveedSipnecthtreosfciboeprys tahned cbryysStaellleincetedstrAurcetuareEloecfttrhoen fDibieffrratocticoonnf(iSrmAEtDha)ttothecyonwfiermre awsebreestporse.pTaoreedvaflruoamte ftoherposatemnetiadlisctoilnletadmwinaatteironu,sceodnttorolwsaasmhptlhees tseacmhpnlieqsueasndof tfhiebepr acroauffnintinsgurwroeurenduisnegd tfhoer qtiussauliet.y Vcoenritfrioclataionnd q8u00aligtryidasospuernanincges..All fibers, regardless of size, were counted in Calculating Asbestos Fiber Concentration TEM and PCM transmAisssiboensteolsecfitbroenr cmoinccroensctroaptyionwains cthaelcusalamtepdle(sseeexaAmpipneenddiwxit1h, hotnttpo://sltiannkdsa.lrwdwm.cicormos/JcOopMe/Asl6id4e9s).wTehree 2e5x0ampiLnesdamupsilnegs cpehnatsreifucgoend tAra6s5t0)l.igThthemaicsrboessctoospyfib(Aerppceonndciexnt2ra,tihotntp:i/n/litnhkess.elwswa.mcopmle/sJOwMas/ calculated (see Appendix 2, http://links.lww.com/JOM/A650). Control Samples or fromBascukrggriocuanl dspceocinmtreonls sfarmomplepsulwmeornearoybtoarinoebdstaettriacuatlopansyd gmyenseecnotelorigcicandpaathbodloomgiisntasl. lySmamphplneosdeisn,claubddeodmilnuanlgt,isstuheo,raocvica, rriieess, hfaadllobpeieann toubbteasi,neudterbiyantrdeamtiensgenptuelrmy otinsosuloeg. iEstxspoosrusruerhgeisotnos pfreormsoanlallinudsiev,idfuaamlsil;yalelxwpeorseusrcer,eeanneddpfeorrsaosnbaelstoors efaxmpoilsyuruesferoomf toaflcausbmesptoows deexrp.oFsourrtehforsoempaatnieynstosuinrcwe,htohme pthaethreolwoagsisatnsycoqnufeesrtrioend wexipthosthureet.reIfatthinegrecwlinasicpiaontetnotieanl sausrbeetshtoesreewxpaossnuorek, nthoewsnpaescbimesetnoss wspeerceimnoetnisncrleufdleecdt ionntlhye agsrboeuspt.oAs seaxpreossuulrte, tfhreombacthkegroovuenrdalclocnotrmol munity. The data associated RwEiSthUtLhTeSexposure history of all 33 pasattiheentosnislyparessbeensttoeds einxpToasbulere1t.hTeshee ptaabtileenitdsehnativfeiesextaplecruiemncpeodw. dNeor tianldciuvmidupaolwiddeenrtiffrioemd awnyoraksbpelasctoesoerxhpooususerehoapldaretxfproomsucreosn.taminated the sixTcaasbeles i2npwrohivcihdeassbthesetoressfuibltesrsowf tehree ifdibeenrtibfiuerddeinnthaneaalnyasetosmfoicr bvuicridneintys orfetvheealpatthieentpsr'emseenscoetheolfiotmheas.foUllnoiwfoirnmg:ly,tathlce, tiaslsuumeifniubmer tsoilsicfaibteesr,s.aTluhme iansubmestmosagfinbeesrisuamresaillilcaanteths,opsihliyclalitcer,ytsrteamlso, laitned, aansbde/osr pchorwydsoetrisl.e1.9 TThheesye hthavreeebteyepnesidaernetitfyiepdicaasl ccoonnttaammiinnaannttss oinf ttaallccuumm p7owTdheerstiisnsureepfeiabteerdblaubrdoerantsorcyontetsatiinnegdant onuammeorsoiutes ionrstcitruotcioidnosl.i3t3e-, pcoomwdmeersrchiaalveamfapihleidbotloe sahsobwesttohse pfirbeesresn.cTeeosftincogmremseurlctsiaol famtaplchuibm oles. Table 3 presents the asbestos fiber burden results from bwaicthkgnrooeuvniddecnocnetrooflsoivnatriisasnuecsanfrcoemr oaruottohpesrymaanldigsnuarngcicya,lapnodpwuliathtionno kshnoowwend aosnbleystocshryesxoptoilseuraen. dTnhoen-luconmg manedrcilaylmapmhphniobdoelse saasbmepslteods isnamaplsems,allorpe1r7c%en.taAgell owf ocmonetnrowl istahmapslbese--stossixporefsethnet 3w5erceonotvroerl 6ce0nytreaatiros nosfinagthe.e Wamhbilieenatsabiers,3to8sinisthperecsoenntrt oaltseaxmtrpelmeseplyrelsoewntecdonin tohfe6s0tuydeya,rtshoerfeawgea.sTnwooevfiibdeernscewoefreassbeeesntoins itnwwoosmpeecnimunendseratnhde oagnee ffiibbeerr wbuarsdseenesninintfhoeusrisxamtalpcleesx, paollsuedndpearti1enptms winerseizael.lTghreeaatsebretshtaons tshiuemcosniltircoaltepso,paunldatsioilnic.aNcorysatlaulms,inalulmcosmilpicoanteesn,tsaolufmtailncuumm mpoawgdneer tihdaetntdifidiednoint uosuer tpaalctiuemntsp,owwedreer.not found in the control population DISCUSSION cosmetTichitsalcpuampepropwrodveirdceosnttahme ifniarstetdlawrgiteh acsabseestsoesriaessthtoe ciaduesnetifoyf pmraelsiegnntaendt m33esiontdhievliiodmuaalsinexcpoosmseedtictotalccroucsiedrosl.itIen a1s9b6e0s,toWs afgronmer ocacsceupseartiieosnaolfainnddivenidvuiarolsnmdieangtnaolseexdpwosiuthrems,epsroothveidliionmg athweiftihrsctlelaarrglye iiddieonptiaftihaibclemeexspootshuerleiotmo aascbaessetsoss.u2gSgienscteedtheonth,ethrephoisgshibplereevxapleonsucereos,f pinrcelsuednitng33excpaosseus,reptroedaosbmeisntoasntclyonotafmwinoamteedn,tawlch. oLihkaedWnaognkenro, wwne eTxhpisosisurceontosisatsebnetswtoitshoththeedristhtraibnuptiroonloonfgteadlcuumsepoofwtdaelcruumsagpeowindtehre. Umnenit.e2d6 FSuarttehse, rwmiothre,gtrheeatseirxncuamsebheirsstoorfiews odmeteanileudsiynegarpsoowrddeercathdaens porfetsaelcnutminpoewithdeerr utusemaosrwtieslsluaes toisrsulyemanpahlynsoisdtehsa. tIsnhoawlledsiaxsbceassteoss, raespbeeasttoeds lfaibbeorrsatcoornystiesstetinntgwoifthtaltchuomsepiodwendteifriseadmapslecsonactaromsisnsaenvtserianl iwnestrietuctoionnsisstwenetrewiidthenthtiefiteydp.es'of'as'besNtoostafboluyn,dthien tfaiblce.rAtympoessitfeouanndd tcrrioaclidaonlditeo,cacsubpeasttioosnafilbeerxspothsautrea,renoent ccoousnmteerteicd itnalccuasmespoofwidnedru,4s0 were nToht ifsoupnadpeirn iasnyalsoof tthheesefircsats,etso. the authors' knowledge, to uwtailsizeelbicaictkedgroaunndd cfoorntrwohlsicfhor nwohickhnoawn nextaesnbseisvteosexpexopsuorseurheisthoaryd oanccaulyrzreindg. tBisascukegroofuansdbecsotonstreoxlspoasreed tihnedivbiedsutalscohmopwaerviseor,n owneheonf thhisetobrigygoefset ncvhiarlolennmgeenstaisl toor cohcocuopseataiopnoapluelxaptioosnuroeftpoaatisebnetsstowsitahpanrot fsrtoudmieasmobfiennotn-aoircccuopnacteionntraaltliyonexopfoassebdesintodsi.viPdrueavlisouhsavfeibceormbupradreedn tnhietyaswbheesrtoesacsobnetsetonst imn itnheesir otirssausebetostowsorckoenrtsaiinninthge fsaacmtoericeosmwmeure 14 2019 American College of Occupational and Environmental Medicine Copyright 2019 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited JOEM Volume 62, Number 1, January 2020 Mesothelioma and Cosmetic Talc TABLE 1. Description of 33 Mesothelioma Cases Talcum Powder Exposure Year of Case Sex Diagnosis Age at Diagnosis Mesothelioma Site Histology Talcum Powder Estimated Years Brand of Use Occupation (s) 1* F 2015 2* F 2015 3* F 2014 4* F 2014 5* F 2015 6* M 2016 7 M 2016 8 M 2016 9 F 2016 10 F 2015 11 F 2018 12 F 2017 13 M 2016 14 M 2017 15 F 2016 16 F 2015 17 F 2015 18 F 2015 19 F 2009 20 F 2016 21 F 2013 22 F 2018 23 F 2016 24 F 2016 25 F 2017 26 F 2016 27 F 2017 28 F 2016 29 M 2015 30 F 2016 31 F 2017 32 F 2017 33 F 2017 70y Pleural 65 Pleural 82y Pleural 66y Peritoneal 75y Peritoneal 43 Pleural 65 Peritoneal 76y Pleural 66y Pleural 80 Pleural 73 Pleural 57 Peritoneal 56 Peritoneal 56 Peritoneal 40 Peritoneal 30 Pleural 80y Pleural 64 Pleural 62 Pleural 69 Peritoneal 34y Peritoneal 59 Pleural 27 Peritoneal 38 Peritoneal 64 Pleural 83 Pleural 41 Peritoneal 79 Peritoneal 46 Pleural 88y Pleural 53 Pleural 76 Pleural 46 Peritoneal Epithelial Biphasic Biphasic Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Biphasic Epithelial Epithelial Epithelial Epithelial Sarcomatoid Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial Epithelial A C, H, V C B, C C D D U C, E F C, V A, D, G, H, I DD, I, S D, J D, K, L, M A, C, N C C D, G C C, D D, O D, I D, G, J C, D, I D A, C, T, D, R, U A, D, C, I D D, C D 30 Medical technician 50 Homemaker 70 Teacher 30 Hairdresser 25 Teacher 40 Finance 62 None provided 38 Accountant 35 Hair dresser 30 Administrative assistant 30 Flight attendant 40 Medical technologist 15 Maintenance worker 50 Molding press operator 12 Retail worker 19 Retail worker 40 Office worker 40 Real Estate agent 15 Teacher and fitness instructor 30 Hair dresser 10 Teacher 42 School custodian 10 Not provided 18 Social services 27 Mathematician 60 Not provided 30 Computer programmer 21 Not provided 15 Informational technology 80 Administrative worker 23 Cleaner 17 Rehabilitation coordinator 25 Clerical worker `^TDiescsueaeseadnaalsysoisf wprreistienngt;edvidtaolnsetabtyusauotfhmora.nTyisisnudeivaidnualaylssisismciugrhretnhtalyveunbkeneonwdno.ne in some cases by other investigator, these results are not presented in this paper. puarelssewnitt.4h1o,4u2t Aa usptoepcsifyicsthuidstioesryhoavf ewboerkenplpaceerfaosrbmeesdto4s3-e4x5pionsuinred;ivfiudll efixbpeorsbuurerdehnisstoinrieNsewweYreornkoCtitoybtraeisnideden. tLs awnigthernomkeansouwrendhiasstboerystoosf avsidbuesatloss.w46hoRohgagdlibaynsdtaLnodnergoo4r7 hmoeuasseuhroelddtiesxsupeosbuurerdefrnosmfofraimndiliy maselmaubnedrseriwnhgocldoitrheecst.lyHowwoerkveedr thwaitthtyapseboesfteoxspionsutrheeidrowesonrko,t tsruuclyh rOerfdleecnt32bamckeagsruoruendd boarck`g`uronuenxdposaeird''exipnodsiuvrideuainls.anLdeeouatnsdideVaonf bfiubieldrsi,ngbsu.t nToheaynthfooupnhdyllsihteorotr cchrorycsidootilliet,e,traenmdovleitrey, samnadllalcetvineolsliotef bamacoksgitreo.unLdeeasbaensdtosVafinbeOrsrdfoenu'nsd riensuthltes oalrdeercwonosmisetenntthewpitrhesethnet cstouudrys.e32ofWclhiniliecaflitbreeratbmuerndte,nansdtuadrieesusaerdeprraimrealyriluynfdoerrmtaekdeincoi-nlegthael ppruorvpiodseesg,utihdeanfciendaisngtos pooftevnatriiaolupsrifoibrearssbeinstothseexlupnogsurteis,suwehsetchaenr farsobmestoosc.cuAptatetinotnio, nretosidtreunetiabla, ckogrropuanrad-orcacteuspaftoior nfaibl eerxbpuorsduernes tios criticalO.48ur findings strongly suggest that asbestos exposure through aidsiboepsatothsi-ccoonrtam``sinpaotnetdanceoosums,e't'icantadlcuenxdpelraliinnes ctahseesimonpcoertadneceemeodf TABLE 2. Tissue Digestion of Six Mesothelioma Cases Mesothelioma Case Sex Site Asbestos Type 1 F Pleural Anthophyllite 2 F Pleural Anthophyllite, tremolite, actinolite 3 F Pleural Tremolite 4 F Peritoneal Chrysotile 5 F Peritoneal Anthophyllite 6 M Pleural Anthophyllite, tremolite Site Found Lung Lung, lymph node Lung, lymph node Peritoneum Lymph node Lymph node Concentration (Fibers/g) (Lung, Lymph) 3,286 8,625, 34,500 0, 9,409 920 20,700 17,250 Limit of Detection (Lung, Lymph) 1,643 2,875, 11,500 6,900, 9,409 920 10,350 3,450 Asbestos Bodies 0 0 0, 409 0 0, 0 0 2019 American College of Occupational and Environmental Medicine 15 Copyright 2019 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited Moline et al JOEM Volume 62, Number 1, January 2020 TABLE 3. Current Levels of Asbestos Fiber Burden Observed in Digests of Tissue From Autopsy and Surgical Population With no History of Asbestos Exposure (Controls) Tissue Type N Asbestos Type M ean (Fibers/Gram Wet Weight)* Range (Fibers/Gram Wet Weight) Lung tissue 35 Chrysotile Tremolite Chrysotile and tremolite Paratracheal or parachronchial Asbestos bodies 35 Chrysotile lymph node tissue Tremolite Chrysotile and tremolite Asbestos bodies Peritoneum + gynecological tissue 10 Chrysotile Tremolite Chrysotile and tremolite Asbestos bodies 892 84 35 <1 bodies/gram wet weight 72 29 24 <1 bodies/gram wet weight 0 0 0 0 0-30,000 0-1,552 0-1,208 0-6 0-1,1035 0-552 0-828 0-5 0 0 0 0 *All fibers that were counted were always 1mm or less in length. cinogllseicntipnagtiednettsaipleredseexnptionsguwreithhismtoersioetshethliaotminac. oSrepvoerraatlefathcetosersfminady hinindidveirdtuhaelscodlilaegcntioosnedofwcoitmh pmreehseonthsievlieoemxap.osMurineihmisatlortireasinaimngonign ocaclcusptuadtieonntaslmmaeydiccoinnetriabnudteextopoasulraecktakoifnogrpirnaccotimceplaemteoenxgpmoseudrie hlaitsetonrcyy peelircioitdastiboentwoenentheexppoarsturoefacnldinililcniaesnss.p4o9s'5e0aScehcaolnlednlyg,e bloonthg ttoo itnhdeivreidlautaivlerelycaslhloarstwpeelrliothdebaebtiwlietyentodeisatganbolissihsianngdcaduesaathlitaym. Donuge bmeefsoorethbeeliionmg aabpleattioenptrso,vpidaetieanftusllahriestoofrtye.nFtuorothielrlmoorraer,ethdoeucgehastehde pinretsheencsecioefnatisfbicesltiotesriantutarlec ianndthtealc1u9m40ps,owinddeivr iwdausalfsirsmt adyiscnuostsebde aciwanarseatrheaatwthaerepthroadt uthcitss itshaeypoutseendtiacloenxtapionseudrea.sTbeysptiocsa.llFy,ewpatcileinntis woritahromuensdotahsebleiosmtoas,wrialtlhbeer stihmanplybeaisnkgedprwohveidthinegr thweiythwaorlkisetdinwgiothf penocteonutniatelrsoasubrceestsoso.f Cthaesetsypoefsmoefsoetxhpeolsioumreainamwohnigchhaoinrderemssigehrst cinhcaoramcpteleritzeeedxapsoisduiroephaitshtiocrya;lstohuenpdoetresnctoiarel fthaielucroenttoribiduetinotnifyofthane ulisnekionfgtaolfcuomccuppoawtidoenrael xepxopsousruereintothaesirbewstoorsk two othueldirpmreevseontthethlie roemgau.laIrnly ouusredptaaplecru,mthpeorwe dwererien tthhreeire wfeomrka.leIt whaaisrdurnecssleearsr fwrohmo awneyreofasthkeedhiisftothreieysunsoetdedtailncuthme mpoewdidcearl arescpoarrdtsotfhathtethheasier wcuotmtinegn pItraolyce, ssst.aIfnf anorteepdorat fcrloumstethreoNf amtieosnoatlheMlieosmotahedluioemtoa R``eugnikstnroywonf easxpaopsuorteen''tiaaml oexnpgohsauirred.reTshseerres,wbaust noonlydisecxuasmsiionnedofhathiredroycecruupsae ttihoantaal ubsaerboefrt'aslcoucmcuppoawtiodnear.l51eHxpoowseuvreer,toMacsDbeosntaolsd teot atal,l5c2 cnoouteldd efixbpelraibnurthdeeni.ncreased finding of tremolite in the individual's lung of its liTmhietactaiosenss.eDrieastapwreesreentoebdtasihnoeudldfrboemunmdeedrsictoaotidoninrtehceorcdosntaenxdt tvriaenwssc.riHptoswoefvedre,ptohseitiinofnosr,mraattihoenr stohlaincitsetdrudcuturirnegd,thine-cpoeursrosen oinfttehre ptiaotnieinngts'adbeopuot saitlitoenrnsawtivereestohuorrcoeusgho,faansdbeinstcolusdeexdpeoxsuhraeu,stiinvceluqduiensg hooccuusephaotilodnaelxepxopsuorseu,ree,xapnodsuproetsenfrtioaml eexxptoesrunrael firnodmustfraimalilsyoumrecems, bers. While deposition testimony is by definition self-report, bdieapsonsiotitoednswwouelrde bgeivperneseunntdeedrwohaetthhearnpdattihenetspocotemnptilaeltefdora rsetrcuacll tFuurretdheirnmteorrvei,ewtheourtiwliezraetioanskoefd mqeudeisctaiol nrsecdourdrisngallsowwoerdn thteestaimutohnoyrs. tpoathcoolrorogbicoarlatdeiagimnopsoirst.ant medical information and confirm the releaseIdnaMstaartecmh e2n0t1a9s atnheupFdeadteertaol thDeriurg20A17dmfinindiisntrga,ticoonnfi(rFmDiAng) asosbldesttoosycoounntgamgiinrlastiaonndoof uctelrintaining cnoeswmesttiecppsrotoduwctosrkmwarikthetemdaannud faaccktnuorewrsletdogemnesnutreotfhethseafeptoyteonfttihaleirfoprroadsubcetsst.o5s3 Wcohniltaemsuincahtipounbliinc caroesmneotticletgaalcllymoabrklisgaatend imtoproergtaisnttertucronsinmgetipcoipnrto, dmucatnsufwacitthurtehres FsuDcAh .pTrohdeurcetssu26ltsunodf etrhliisnestuthdey ccoonutpinleudedwriitshktshpeowseiddetsoprceoandsuumseeorsf tphrrooduugchts croemmmainonunhroeugsuelhaoteldd aanndd ocnosthmeetsihcelpvreosd,utchtes.usWe hoifletatlhceusme pinowodrdeerrmtuostpbreominoctoerpeoarraltieedr idnettoecsttaionndaordf eaxsbpeosstuorse hreislatoteryd pdriascetaicsee avmidoesngevnidoenn-coeccthuaptatmioensaoltlhyeleioxmpoasecdaseinsdoinvcideucaolsn.siTdherisedpiadpioepr apthroic pmoawydebreuasattgriebuatnadbltehattothaesbeelsictoitsa-tcioonntaomf ianahtiesdtorcyosomfestuicchtaulscaugme pisreismenpteirnagtivweitthomoebstoatihneinligomaaf.ull exposure history in all patients REFERENCES 1. 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