Document o9aOwoK4JvXb4DEGkJr6Be61E

t mcr SJ cOPCfc' Y~ Vo I. 3.*; emaciated. His chief "stomach," right sid breath. PULMONARY ASBESTOSIS III; CARCINOMA OF LUNG IN ASBESTO-SILICOS IS History: Prior to 1! no time was lost from i lie had noticed some sh KENNETH M. LYNCH, MJ), as*d W. ATMAK SMITH, >U>. but except for that ha (from the Department* of Pathology and Medicine, Medical College of the State of South Carolina) v from work on account the three lower ribs, pains occurred involvi Primary carcinoma of the lung has attained a position of major in terest in malignant neoplastic disease, through at least a more common . recognition, if not more frequent occurrence, within recent years.. Likewise asbestosis has assumed a rank of considerable importance in industrial medicine. 'Workers in the mines of the Era Mountains, on both the Bohemian and the Saxon sides, have suffered heavily for some centuries from pul monary disease now recognized as carcinoma and well known as Schnee- berg and Jachymov (Joaclumstaiy lung cancer. * Pirchan and Sikl (1), in a report upon a series of these cases, state that "there were only moderate degrees of anthracosis," and they are not inclined to attach any particular importance to the degree of pneu- . monoconiosis as a cause of the cancer, but consider that "the question may bo somewhat different with regard to the quality of the forciga substance deposited in the lung." Chemical analysis in one of their cases revealed "only calcium, magnesium, aluminum, silicic acid, chlo rides, and phosphates; notrace *of arsenic,.bismuth, cobalt, nickel, or uranium was .found." They lay suspicion, as others have done, upon radium emanatiou and upon arsenic, both factors being encountered in the Schnceberg and Jachymov mines. Rostoski, Saupo and Schmorl (2) found severe "anthracosis" in Schneeberg miners the subjects of lung cancer and are inclined to at tribute the causation of the enneer to tlie autliracosis, while Simpson (3) states that pulmonary cancer is a rare complication of silicosis in South African miners. Schulte (4) has reported lung cancer in pneti- monoconiosis among coal miners, and Saupo (3) has recorded two cases in arsenic miners. There appears to be no previous report of its oc currence in asbestos miners or mill workers, although the record of autopsy examinations of cases of asbestosis is not large. As worthy of record in the interest of both diseases, as well as their possible relationship, the following case of pulmonary asbestosis with associated carcinoma of the lung is reported. ,. Java. Except for the : toms until Nov. 7,1933, ing the right shoulder, The pain occurred abc It seemed to be more sc quite weak and seemed work and seek mediea'. medical care, he grow aggravated, and a coup veloped. On Jan. 8, d blood mixed with mucc The family history Occupational llisto occurred when the pat in a cotton mill as a i doors and window?, an did not consider the ah work as a weaver in vr a job as a weaver at an to hospital admission, ponded ho did odd jobs, ginning in 1913, bo woi of the fact that window. About 1923 a humidify! vevy inefficient, thougl winter the heating sys, mottling of dusty particl air from the forced drill side the plant, entered last five or six months stead of dry weaving, : 1 omed to work overtime This man, then, woi Case Report twenty-two years and a years, which may accou A white man, fifty-seven years of ago at the time oF his death, first in addition to those of came under observation at the Shirras Dispensary of the Roper Hos Course: Throughout pital on Jan. 10, 1934, at which time1 h1,e0 apl>pPeparedu very olidu, weeaaikcenantli i lu..com pin in of per.'isle NOTE: THIS DOCUMENT DiOso THIS DOCUMENT WAS NOT A RECORD OF ' j ~ jSJOT COME FROM P&G F LESPPG I-ND.U...S..T..R.IE^S,aIwNiCm.oDTIBDENAOUTTHCEONMTEICFARTOESM) - - ^ !--t r-r\ * v* i. 1^3LSjfi^OXANNOT BE. BY-PPG INDUSTRIE^IftCr BB 0007292 | 1530 3;isXOXA OF LUNG IN uae sirrrir, m.d. tcdical College of the State of iod a position of major infli at least a more common ice, within recent years, onsidcrable importance in ins, on both the Bohemian c some centuries from pul* and well known as Schnec?r. series of these cases, state uthracosis, " and they am ace to the degree of pneu>nsider that "the question hemiality of the foreign 1 sis in one of their nrnffTtm, silicic acid, chlolismuth, cobalt, nickel, or s others have done, upon tors being encountered in severe-"anthracosis" in er and are inclined to atilliracosis, while Simpson amplication of silicosis in rted lung cancer in pneu3) has recorded two cases previous report of its oe- although the record of s not large. . diseases, as well as their ulmonnry nsbestosis with he time of his death, first nsary of the Itoper Hosured very old, weak, and NOTCTHtS-DOCU^TOP NOT COME FROM Ptu FILES PULMOXAnr ASBESTOSES 57 emaciated. His chief complaints were pains in the right side of the "stomach," right side of the back and shoulder, and shortness of breath. History: Prior to 1931 the patient's health was good and practically no time was lost from work as a result of illness, although for five years he had noticed some shortness of breath. He had had influenza in 1918, but except for that had always been well. In 1931 he lost three days from woi-k on account of sharp pains in his back, extending down over the three lower ribs. Nino mouths later intermittent sharp shooting pains occurred involving his right shoulder. These lasted about ten days. Except for the shortness of breath, there were no further symp toms until Nov. 7,1933, when there were renewed attacks of pain involv ing the right shoulder, axilla, and the three lower ribs on tlve same side. The pain occurred about even' hour and lasted about thirty minutes. It seemed to be more severe dm*ing the night: The patient also became quite weak and seemed to lose weight. He was now compelled to quit work and seek medical aid. During November and December, under medical care, he grew weaker and lost more weight, his dyspnea was aggravated, and a cough, productive of win', white mucoid sputum de veloped. On Jan. 8, during a spell of coughing, lie expectorated fresh blood mixed with mucoid material. The family history was not significant. Occupational History: The first exposure to a dusty atmosphere occurred when the patient was about sixteen, when he began to work in a cotton mill as a weaver. Ho first worked in a place with open dooi's and windows, and later a humidifying system was installed;.he did not consider the atmosphere excessively dust laden. He continued work as a weaver in various cotton mills until 1913, when he obtained a job as a weaver at an asbestos factory, which he held until just prior to hospital admission. During times when his work there was sus pended he did odd jobs, with apparently no occupational hazards. Be ginning in 1913, he worked in an extremely dusty atmosphere, in spite of the fact that windows and doors were kept open as much as possible. -About 1923 a humidifying system was installed, but this he considered very inefficient, though it improved the atmosphere somewhat. In winter the heating.system kept the air in the plant too dry to allow settling of dusty particles. In summer, when all doors were kept open, air from the forced draft from the " preparation room," emptying out ride flie plant, entered the room in which the patient worked. The last fivir.or_six months of his employment he was at " wet work " in stead of dry weaving, reducing the exposure to dust. He was accus tomed to work overtime, since lie was paid by the yard. This man, then, worked as a cotton mill weaver for approximately twentv-two years and as an asbestos mill ivoaver for some twenty-one years, which may account for certain features of silicosis in the lungs, 1,1 addition to those of nsbestosis. Course: Throughout his stay in the hospital the patient continued to complain of persistent pain along the right costal border and right I ;0 -`C I BB 0007293 f T / 58 KEXXETH M. LYXCH AND IT. ATMAR SMITH .ide of the abdomen. The cough, -with expectoration of a large quantity of mucopurulent sputum, continued and became more aggravated. There was anorexia, with progressive loss of weight and strength. For the first three weeks after admission there was an irregular afternoon elevation of temperature. In the latter weeks of the illness fever of remittent type was constantly present (993-101), rising on the day of death to 104The pulse rate ranged between 90 and 100. The res piratory rate was constantly above normal and on the slightest exertion there was dyspnea. Examination: In general appearance the patient looked much older than fifty-seven. He appeared exhausted and was extremely weak and row tom presented no ahnormalit previously noted. X-ray examination of tin who reported as follows: a generalized fibrosis throiu There is generalized inereas< by pleural thickening. In areas through the lower hnl * `Impression: Pulmonm right base), and bronehiect some irritant material," >* *, *- - *. & HEUSSENTdid 50;0rPGFILES - * rv^ - V V^'l IT, Fig. J. Boextoeitogram Showing Pclitoxart Aebesto-siucosjs axd Cakcikoua or Lower Eight Lobe A ?\- .emaciated. The finger nails and toe nails were clubbed and somewhat t cyanotic. 1%. The bony thorax was of the emphysematous type. Expansion was '{ equal but poor. Dullness was present over the bases of both lungs, be ing more marked on the right. The upper levels were resonant. Breath sounds were suppressed over the right base. Hides of all varie- ties were present in the lower posterior and axillary aspect of the chest, : though less numerous over the right base than the left. They were in- creased by cough. There wore numerous coarse, dry, "squeaking" sounds over the upper lobes as well. Tlio heart was normal in size and position; the sounds were good. There were no murmurs. The pulmonic second sound was accentuated. . The systolic blood pressure was 100, diastolic GO. The superficial ves sels were thickened and tortuous. The nbdomcn, muscles, bones, joints, extremities and nervous sys- Fia. 2. Asbes The tuberculin (Me No tubercle bacilli were Asbestosis bodies were pus. Tests for fungi mal. Blood counts we cent (Dare), leukocyte mononuclears 3, ncutr (Dare), leukocytes 13, neutrophils 7G, cosino- The admission dia effusion. The final t pneumonia. Autopsy (B.G.) X ologienl diagnoses: 1 GG 15303 I BB 0007294 | MXK SMITH ii of a largo quantity more aggravated, v'cig. and.strength. Foi ls an irregular afternoon ka of the illness fever of )1), rising on the day of en 90 and 100. The res* .1 on the slightest exertion >atient looked much older t \ras extremely weak and l'UI.MOXAUY asbestosis 50 tom presented no abnormalities except for the clubbing of the fingers previously noted. X-ray examination of the chest was made by Dr. Hillvcr Budisill, who reported as follows: " First examination, Jan. 12, 1934: There is a generalized fibrosis throughout both lungs, particularly in the bases. There is generalized increased density in the right base probably caused by pleural thickening. In addition I believe there ai*e broncliicctatic areas through the lower halves of both lungs. "Impression: Pulmonary fibrosis, pleural thickening (particularly right base), and bronchiectasis, probably the results of inhalation of .some irritant material." 3-shjcosis axp Carcinoma or re clubbed and somewhat us type. Expansion was o bases of both lungs, bor levels were resonant, base. Bales of all variecillary aspect of the chest, n the left. They were inoarse, dry, "squeaking'" n; the sounds were good, id sound was accentuated. : GO. The superficial ves- emities and nervous sys- Fja. 2. Asbesto-biucosis with Carcinoma or Lower Lobe The tuberculin (Mantoux), and Wassermanu tests were negative. Xo tubercle bacilli were found in the sputum on numerous examinations. Asbestosis bodies were present in unconcentrated viscid, tough mucopus. Tests for fungi were negative. The urinary findings were nor mal. Blood counts were as follows: Jan. 11, 1934: hemoglobin 80 per cent (Dare), leukocytes 15,525, small and large lymphocytes 11, large mononuclears 3, neutrophils 86; Feb. 20, 1934: hemoglobin 72 per cent (Dare), leukocytes 13,250, small lymphocytes 18, large mononuclears 4, neutrophils 76, eosinophils 2. The admission diagnosis was pulmonary fibrosis and pleurisy with effusion. The final diagnosis was asbestosis and chronic indurative pneumonia. Autopsy (B.G.) No. 20514-34-58, March 17,1934; Summary of path ological diagnoses: Fibrosis of lungs; pulmonary asbestosis; epidcr- CG 15304 L*]?_0007295~j CO KENNETH M, LYNCH AND W. ATHAR SSHTH mold carcinoma of right lung; bronchiectasis; purulent bronchitis; acute pleurisy; chronic myocarditis. The body is extremely wasted as to adipose tissue and musculature, all muscles, including the interosseous, are quite shrunken. The distal phalanges of the fingers and toes are broad and rounded. The chest is quite prominent anteriorly. The right lung is densely adherent over its whole surface, but par ticularly over the lower lobe and at the base, over the diaphragm and toward the spine. The left is adherent rather lightly at the apex and very densely over the lower lobe, particularly over the base and dia phragm. The left pleural cavity over the middle three-fourths con- P Tlie right lung has a s: and in the midportion is lung is of nodular, hard, lower aspect, at the spirn debris, ruptured in remo to the spine. The inner and the surrounding sub; or less into heavy trab "pocking," as in the opi The lymph nodes at t moderately enlarged bla Fig.'3. Silicotic Htauxe and Calcareous Nodule in Luxo, with " Asbestosis" Bodies. X 210 ^ ___ tains about 300 c.c. of turbid fluid and there arc no attachments here to the outer pleura. The pleura of the right lung is thickened as a whole and is of car tilaginous and even partly calcareous quality over tlio base. That of the left lung is likewise thickened, but over the free portion it is rough, congested and " furred," with small nodules in the surface. The apex of the left lung is composed of a globular mass of light balloon-like emphysematous bullae with intervening fibrous trabeculae, and sub-apieallv there is a group of small caseous and calcareous hard nodules. The raidportion of this lung is light, spongy, dry, and of a mottled dark slaty bluish-gray color. Beginning at the apposition of the interlobar pleura, the lower part of the lung is densely tough, with gross fibrous traheculutiou fusing with the thickened pleura, and at the base honeycombed by rounded cavities about the size of bird shot. if' 't! The entire hilar edematous. The heart is not t pale and flabby, the t Other organs and appearances. Pathological Diag berculosis of right ltu bronchiectasis. Microscopic Findi cellular fibrosis of t small mononuclear c pliied and also degei carditis. I C-G 15305 T'bB 0007296 it SMITH l'ULMOKAny asbestosis 61 : punr dent bronchitis; | The right lung has a similar group of balloon-like bullae at tlie apex ! and in the midporlion is similar to its fellow. The lower third of the id musculature, ' lung is of nodular, hard, solidified consistence. Occupying the inner shrunken. Tlie distal I lower aspect, at the spine, is a honeycombed cavity containing caseous l rounded. The chest debris, ruptured in removing the lung because of its dense adherence to the spine. The inner aspect of the cavity is quite rough, nodular, hole surface, but pur and the surrounding substance lumpy and caseous. This merges more er the diaphragm and or less into heavy trabecnlated fibrous induration and small cavity ghtly at tlie apex and ver the base and dia- "pocking," as in the opposite lung. The lymph nodes at tlie root of the lungs are not conspicuous, a few Jle three-fourths con- moderately enlarged black nodes being found. *a, 'wttb "Asbestosis" no attachments here whole and is of car;r the base. That of ;c portion it is rough, lie surface, lobular mass of light ng fibrous trabeculae, * and calcareous hard pongy, dry, and of a at the apposition of s densely tough, with icd pleura, and at the i'/.c of bird shot. .* , ;v\ Fia. 4* Chronic Bronchitis and Bronchiectasis: "Asbestosis" Bodies in Bronchiole. .. X130 : The entire hilar and mediastinal tissue is quite fibrous and if edematous. The heart is not enlarged, but is of rather small size, the muscle pale and flabby, the right cavity moderately dilated. Other organs and tissues are apparently normal in relations and /,, . appearances. Pathological Diagnoses at Autopsy: Fibrosis of lung; chronic tu berculosis of right lung; chronic fibrous pleurisy; tuberculous pleurisy; bronchiectasis. Microsco-pic Findings: Examination of the heart shows quite marked cellular fibrosis of the myocardium, accompanied by some large and small mononuclear cell infiltration. The muscle fibers are hypertro phied and also degenerated. The histologic diagnosis is chronic myo carditis. 4 4 i CC 15306 I BB 0007297"] 62 KXXXETH M. LYXCH AXD W. ATMAU SMITH Iu the spleen young fibrous elements awl large mononuclear cells iucrease the thickness of the sinus walls. Polymorphouuelear leuko cytes are conspicuous. Here and there are small groups of largo ** foam ** cells, the cytoplasm full of rather large, clear cut vacuoles. In these and other mononuclear cells is a brown granular pigment. A club-shaped asbestosis-like body is seen, whether embedded in the tissue or merely upon it, from transfer from other tissue in cutting, it is dif ficult to say. The histological diagnosis is chronic splenitis, asbestosTish(ef)k.idney is approximately normal, save for congestion. The liver shows fibrous thickening of the capsule; fibrosis and lymphocytosis of moderate grade in the interlobular framework; patchy t/i O,, c o o .[ -gemm -J no. 5. Epidermoid Carcinoma op Bronchus and Lvno. X 125 fatty, vacuolization of liver cells. Many nuclei of the liver cells are large and envitated, with a bluish fluid substance within. There are congestion and brown pigmentation of the central venous area. The histological diagnosis is passive congestion, fatty degeneration, portal cirrhosis. There is chronic fibrous thickening of the pleura, with lymphoid col lections, involving both visceral and parietal layers, with an internal covering of leukocytes and fibrin. The histologic diagnosis is chronic fibrous and acute fibrinous pleurisy. In the peribronchial lymph nodes are heavy deposits of large mononuclear cells containing a black and brownish granular substance in the pulp, with moderate associated fibrosis and deposit of asbestosis bodies, generally of shorter clubbed, rod, and dumb-bell forms. There is engorgement ot* t clear leukocytes, lymphadenitis. , In the lung thui along the bronchi ; generally old and 1: formation, arc disp< alveoli. Bronchiole there is much defoi alveoli are large nu jointed, clubbed, am large mononuclear j in the fibrosed areas occur in lymph spue nuclear or lymphoe mucus and leukocyte The pleura is ve: collections of asbesti are seen within the j ndation of fibrin up leukocytosis. There . eral fibrous area. ' . In the intervening and emphysema., mhi empty. In the lower left h structure being oblitt with' chronic infiamm; purulent exudate in of the overlying tbicl At the apices tlicr numbers of long asbc spaces and in fibrose*, and calcification, emp Sections from the l culous, show the case nomatous. On a baci extensive infiltration ; thelium, maturing in c a bronchus, where the There are considerable area. Within and abo sis than in other porti tion. The histologic d semu, bronchiectasis, bronchial carcinoma. GG 15307 ]"bb"0007298 1 .1? SMITH I wrnz. rrn3,*r. >1Vjj I l'ULMOXAUV ASBESTOSIS i i Ll. 63 itl large mononuclear cells is engorgement of the sinuses with serous material and polymorphonu Polymorphonuclear leuko- clear leukocytes. The histologic diagnosis is asbostosis and acutu arc small groups of large *r large, clear cut vacuoles, rown granular pigment. A lymphadenitis. In the lung there is comparatively heavy, old interlobular fibrosis, along the bronchi and blood vessels. Broad bands of fibrous tissue, ether embedded in the tissue r tissue in cutting, it is difis chronic splenitis, ashes- generally old and hyaline, with considerable hyaline laminated nodule formation, are disposed generally in this area, including some adjacent alveoli. Bronchioles here are irregularly and considerably dilated, and ive for congestion. * the capsule; fibrosis and rlobular framework; patchy there is much deformity of alveoli involved in the fibrosis. In these alveoli are large numbers of asbostosis bodies, generally large, brown, jointed, clubbed, and long dumb-bell shapes, in groups associated with large mononuclear phagocytes. These bodies are also seen embedded in the fibrosed areas, and in some of the bronchioles, while large groups occur in lymph spaces near bronchi. There is only minor small mono nuclear or lymphocyte infiltration of the fibrosed tissue, with some mucus and leukocytes in some bronchioles. The pleura is vei*v thick, composed of old fibrous tissue, and while collections of asbestosis bodies appear in alveoli near the pleura, none ai'e seen within the pleural fibrosed thickening. There is an acute ex udatiou of fibrin uppu the pleura, with some hypex*emia, edema, ant leukocytosis. There is some black granular matei-ial in the same gen eral fibrous area. In the intervening lobules the alveoli are quite defoxmed by pressure and emphysema, many large air sacs being seen. Generally these ar empty. i In the lowor left lobe the fibrosis is very heavy, most of the alveola structure being obliterated, and liei'e there is a marked bronchiectasis with chronic inflammatory infiltration of the walls of the bi-onchi, som purulent exudate in these bronchi, and active pyogenic inflarmnatio of the overlying thickened pleura. At the apices there is a remarkable grade of old fibrosis with- larg *, numbers of long asbestosis bodies in large giant cells in thiek-walle HITS AJf Lt'NQ. X 125 spaces and in fibrosed areas, with hyaline nodule formation, necrosi and calcification, emphysema and bronchiectasis. nuclei of the liver cells are ubstance within. There arc e central venous area. The n, fatty degeneration, portal Sections from the base of the right lung, thought grossly to be tube, culous, show the caseous cavitation and infiltration there to be care nomatous. On a background of heavy fibrosis and bronchiectasis extensive infiltration by masses and coi'ds of stratified squamous ep thclium, maturing in considei*ablo degree. This is shown to come fro ho pleura, with lymphoid eoletal layers, with an internal istologic diagnosis is chronic a bronchus, where there is squamous metaplasia of epithelial linin There are considerable necrosis and purulent leukocytosis of the envi ai*ea. 'Within and about the cai'cinoraa ai'ea there is more active fibr sis than in other portions of the lung, and heavy lymphocytic infiltv re heavy deposits of largo brownish granular substance >sls Mud deposit of asbestosis tiou. The histologic diagnosis is nsbesto-silicosis, with fibrosis, cmpli senxa, bronchiectasis, chronic fibrous and acute iilcurisy; epidemic bronchial carcinoma. in ;nb-bell forms. There r* * 64 KEX3TETII M. LYNCH AND W. ATMAU SMITH SraiarABY This mau had suffered long occupational exposure to dust, some forty-three years all told, about twenty-two in a cotton mill, about twenty-one in an asbestos factory, with resulting fibrosis of extensive grade in the lungs and pleura, the apparent consequences being pul monary circulatory and respiratory disability, with emphysema, bron chiectasis, and cardiac embarrassment. As has been observed by us in other cases of asbestosis, one of which has been previously reported (6), the fibrosis of the lungs here bears the accepted characteristic mark of silicosis, that is, in addition to diffused fibrosis, there occurred the formation of hyaline fibrous nodules. The pulmonary carcinoma appeared to originate from one of the branches of the bronchus to the right lower lobe, where squamous meta plasia of lining epithelium was observed. The duration of the carcinoma cannot be specified. It was appar ently of considerable time but certainly did not antedate fibrosis of tire lung. A conception of its origin by reason of chronic bronchial irrita tion is compatible with the current view of the etiology of such tumors. References 1. Pirchax, A., and Siicl, H.: Cancer of the lung in the miners of Jochymov (Joachimstnl): Report of cases observed in 1023-30, Am. J. Cancer 16: 6S1, 1932. 2. Rostoski, Salpe, and Sciimorl: Die Borgkvankhoit der Err.hergleute in Schnceberg ' . in Sachsen (" Schncebergcr Lttngenkrebs "), Ztschr. f. KrebsEorsch. 23 : 360, 1926. 3. JSiupSON, S. L.: Primary carcinoma of tire lung, Quart. J. Med. 22 : 413, 1929. 4. Schulte, G.j Pneumokguiosen dcr Ruhrbergleule nnd Lungenkaranom, Fortschr. a. d. Geb. d. Roentgenstrahlen 41: 444, 1930. 5. Sacpe, E.: Carcinoma of the lung in arsenic miners: two cases, Arch. f. Gewerbepath.' u. Gewcrbchyg. 1: 5S2,1930. 6. Ltxch, K. 1L, and Smith, W. A.: Pulmonary asliestosis XI, including the report of a pure case, Am. Rev. Tuberc. 23 : 643, 1931. ..... L V "V "-1- . *4' s'J? ft .VO "V S ` ' \s\'S rft? Vli .KC\ \ - ofV % J* LYaMPHOSARC {From the Departmet Lymphosarcoma dition, according to to report the follow! The patient (Chart her admission, Oct. 2,192 in the right side since Apr of breath for six weeks, a< appetite there had been a nothing of significance. The patient was pale r were equal, regular, and n ocular movements were n< were negative. The rancoi The tongue protruded in th `were not enlarged".. The ly; hard. The respiratory exet brownish pigmentation over Ifo other abnormal pulmona what enlarged, bat otherwise The abdomen was grea veins of the thoracic and abd The liver extended 2.5 cm. b firm masswhich Extended me< of the umbilicus and which quadrant. The spleen was nt mass which extended to the le\ movable masses in the abdomi The extremities were slen tion, or pnlpntion. The knee equal and active. Plantar stir The urinary findings wen negative; alhumin, negative, red blood cells or casts. The blood showed: red cel The differential count was: pol; leukocytes, 31 per cent; large m On the day of admission i they were dealing with lymplu performed by Dr. Shipley on C mesentery, extending upward fr of blood-tinged fluid present. GG 15X9 | BB 00Q7300 |