Document g2rgG5VLVv4ywR3gX6OLNKEJa

) /, * (i<f.t if*LtV * l<I.Ki:KAI. CAt.CIKICATlON AND MKSOTJIKUOMA KOI.I .OWING KXPOSURK TO ASBESTOS Itv 5. J. Smi. andJ, Boyd THr tawtlnn diet lli|nial, IanImi, R.S., and TV RndW Qrt QUr, LomW Is 19G0 Kiviluoto investigated 13O rai of |4rural calcification in Northern.^ Karelia, Finland, and found that (he majority livrd in (tie winity ofhro anlhophyttiie mines, lie attributed the pleural calcification to noo-occupationaU endemir anthophyllite asbestosis. During (fie same year Wagner, Stepp, and Marchand, in South Africa, dcscrilietl 33 ravn of diffuse pleural mesothelioma, all hut one ofwhom had probably lievn exposed tncrncidolite asliestos in (lie North Western Cape ftovincer- This anicle describes a |>a(ient with pleural calcification followed by moo** thelmma of die pleura. 1 en years previously, after twenty years in charge ofther- stores ofa firm engaged in distributing a isriety ofasbestos insulating materials .. for industry and the building trade, he was transferred to the office and had no further contact with asbestos. Case Report A 63-year-old man with a history of intermittent winter bronchitis was admitted in March 1964 for investigation of six months' persistent cough and sputum, increasing 'bspnoa on exertion, and has of weight. He smoked 40 cigarettes a day. His father had died of bronchial carcinoma. On examination lie was thin. There were no enlarged glands or dubbing of the fingers. Movement, percussion note, and breath sounds were diminished on the IcQ ide of the chest. There were no abnormal physical signs in the abdomen - or cardiovascular system; B.P. 140/90 mm. Previous chat X-nyi In 195r, 1954, and 1939 had shown bilateral calcified pleural plaques (Fig. l) and the present X-ray showed left-sided pleural thickening and effusion (Fig. a). Investigations shgwrd (lie E.S.K. raised to 33 mm. (Watcrgnen) and the Mantoux JgfclbT.Zwas strongly positive. The sputum was negative for neo plastic ccBni rch bacilli, and asliestos bodies. Other investigations which were ooriitf firffwdrd full blood count, serum proteins; electrolytes; cakhim and plwNffera; MVer ftifiction tests, electrocardiograph, X-rays of the spine, and broochnsrnpy. Respiratory function tests showed a one-second forced expiratory volume of tssn e.e. and a foiled vital capacity of 1300 C.C. Aspira tion of the effusion produced straw-colourtdJHiid which was sterile on culture for organisms and tubercle bacilli. In view of the strongly positive Mantoux test and raised erythrocyte sedi mentation rate, it was concluded that the etiology was probably tuberculous, and treatment was started with anti-tuberculous drugs. He was allowed to go home, but was re-admittrd in June romplaining ofnfMMtjwi|Mmi|mnd (*!**& aft, isfiil^PUUNnFF^^I || EXHIBIT I] DOW-262 I I OOUJ 0598 rll,rir' *rrifr<nw ASM MMMIUHIW IlMHH l> pli.iiti.t. *1 hr * b-t X-ray Oifiwnl lnrrravd Ifft plural lliklfnin^ and lisjj.* m# *f if*' i>* iMMintim to the right; Barium iwalto** and meal v|i<ml Hay in o ophain-al emptying, lint no other almormalily, A luop.y through the sixth Ifft intrrtostal space in tin* mW* 4tiH.it v !, n'ii'K a high-s|wed i unprearthair drill, was performed ly rme #/ us fS-J.N.). The histology showed the. appearances of mesntlteliwna of tle plrttt t 'I n*. will* an .islw-stm Imdy present in the adjacent lung (Fig. 4). Ad* If-li's were Mihstipiniity ftumrl in the sputum fnr the first time. II*- '' " ' Him Itome, wlierr hr dirrl a month after tin* biopsy. rii|.iMim.i I) no post-mortem examination was performed. DismsiiM *1 It* .iw i.uion Itri-A-rrn asltestous ami bronchia! carcinoma has been feeng niml fr iii.my yr.m vnrr the first case reported by l.ynch and Smith (1935). M'i< * oily iiitmtion has brrn drawn to tle development of other types of ( nrojil.iMn iii patients exposed to aslirstris. K*al (t/*i) rlrv-rilirit 19 men and S3 women with asbestmb, of whom-1 nun ami y women dird of prritoncal or ovarian cancer and 10 men and 4 women died of lung earner. Kntirknap and Smither (1964) reported 11 cases of diffuse af*lomin.il tumour iv association with exposure to asbestos. Ilourihane studied ill*- [uih'tlogy of 34 cases of primary mesothelioma of the pleura and |terittiiruiu, of whirh 17 wrre pleural, and confirmed the association in both groups with aslirstos Itodies in the lungs. Owen (19G4) studied 17 cases of diffuse mesothelioma in the Merseyside area, of which t6 were pleural, and found . hi .t.ry of ex|insure to asfirsira in 14. In 7 out of to specimens of lung tiv.u*- -i.Miiiti-d aslirMot Indies were seen. Fowler, Sloper, and Warner (1964) de-.rfiijrd j rases of mevttlirlioma of the pleura in whom the lungs contained ad*- f*.: Iirali* s anil there was an occupational history of exposure to asbestos. I Srhtofl, flung, and Hammond (ifjfi'j) found that of 307 deaths among aslK-.io.-iusiil.itKin workers in New York and New Jersey, U&A., to were due to m*-.ntIi<'fiom.1,4 of the pleura, ami Gof the peritoneum. Fifties, McCaughey, and \V.de (ir/iy obtained a bistory of ornipational exposure to asbestos in 3* out #,f p |Mti( ut% with mevulielioma of the (tlrura in Belfast. In 4s matched "inir'il |Mti'nis if the same age ami sex a history t/exposure was obtained ! tnoi.ly.,. As mii'inally iitfiii if by Wagner rt /., an interesting feature of many of the r*|*atrt| rases, Jjk common with the patient described above, was that the exprr.iirr to asbestos Wk% slight in degrrr ami remote in time. Wagner ft d, stated that in alt the histologicaFjrctinns of pleura examined in t\ ,f mevithelionta, no asljestos bodies or fibres were observed lieyoml th* |.l uial elastic lamina*. Hie section shown ne*^)(Fig. 4) demonstrates that i'Iimm bodies may lie found in the adjaernt lung. I J-c*a* .iml llofdig (19.*/,) first deserilied ratr ificrl pleural plaques orrurring ( <0 * U workers in *, per rent, of 343 rases of asliestosis. Frost, CJeorg, ami , H*numu| Muller f 19*/,j examined 31 workers engaged fin *0 years or more in ,,t kinds nf insulation work and found 9 with pulmonary asla-stmis. c/> --H a - 'rta40* aw. - DOW 05982 mrw am> NiiKirrn showed alnmuliiitii nf Uia*|M^&wilk<akUkalinif 11 taut, of uhich n mu hfrur.l Itnrwta (fj)filfBlfWlTl)iit cfthfaeteriitlc patternof clrroir pbwrisy presenting in the faWiirf wMfaii plemral jitaqiin among aslmtm worfcm ill South Afiira. IjuSih(1963) reviewed the |irrvinusly re. ported radiological Irature* nf nboMUlod drew attention to the value of calcified pleural plaques as an additionall^gn oflongstanding asbrstmis. One of tle 3 cases he drscrilird died ofa pt ritdncwtTumour, pnalUft mesothelioma. F.nticknap and Smither mentioned pleural calcification In a of their cam who developed diffuse abdominal tumour*. The question arises wltether the development of pleural calcification in a subject exposed to asbestos is of any,prDgnoitic signifuancc in anticipating the esvntual development ofpleural mcaothefibmmThe tmnrcturig'probahly have to wait until the long-term folkjuMtp of a large sericaof patlcnta.srith pleural calcification, such as Kiviluoto's, b published. However, Ad sequence of events in the case reported would indicate that it is advisable to enquire care fully into the history of exposure to asbestos in all patients with pleural calcifi cation, and to keep them under observation. The case is described of a 63-year-oki man with pleural calcification whodeveloped mesothelioma of the pleura 10 yean after exposure to asbestos as a store-keeper. The clinical and radiographic findingr are reported and the chest X-rays and the histological appearance ofa biopsy performed with a high speed compressed-air drill are illustrated. The literature relating to the association between exposure to asbestos ana pleural calcification and mesothelioma is briefly reviewed and discussed. The question is raised whether pleural calcification has any prognostic significance in the development ofmesothelioma. Comment is made on the slight degree and remoteness in time of the exposure to asbestos in the case reported, and on the finding of asbestos bodies in the biopsy specimen. ACKNOWLEDGEMENTS W wi* thank . P- II. Ifwdm fee Mi Und ndee hi* cam, and Ur. K. Himan Ihr his rrpart sad plwia awhd--wmfhawgiphliit>pswnii mrfllsUmhUi liirtlagti riojQw&s. and Mm Mihw tar her met tef tfcfeow sf iIm Mnofagy. references tSSLm.0.wj,inusw Motuta,r. (1991 (tjdth.Tlnm, o,i r fftvnmx, M. (tgii). _ J*noa, O., 4 Inmn, II. (mj). Fmisrdr. IUi{n#, Kui, F. F. (ifh). LmrttUt ttii. Kmuma, It. (igfio). Am add. Stfftl, iw. AM., tya, )hv AML,ty,fe. STOOI I lid . .I i I I I i !*. I < X-t.lV. .-!t vv*. |4 nut Ilibtrral Fm. j. (Hint N*. i J-j.**. i #v ' i-. V **r^ % * / . " ir *& i Airlrill Iw^ny ihtMint ihr Imtt4iy / nwothrliimM id thr |*lnra. Vw. 4. * btofm *hu*int an alaM* bl> in thr fane arfjarrnt h l icttrr 3. 1*t--* #* DOU 05984