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(tr. U. Current Intelligence received jUL*8l9TO r WHEELER, JR . S'< / 4*4 Angiosarcoma of the Liver in Vinyl Chloride/Polyvinyl Chloride Workers 1977 Update of the NIOSH Register Robert Spirtas, Dr. P.H., and Rose Kaminski, M.5. Hyg. RtCEiVED JUL 2 6 1978 W. C KURYLA In the December 1974 issue of the Journal of Occupational Medicine (16:809), NIOSH presented data on 26 cases of liver angiosarcoma among vinyl chloride workers, 21 of whom worked in the polymerization process. The present update pr(h vides details on 64 cases of angiosarcoma among vinyl chloride polymerization workers reported as of October, 1977. Con tinued surveillance of these workers is encouraged for the pur pose of furthering our knowledge of this disease process in relation to vinyl chloride exposure. 1964-1974.* In the course of their study, CDC identified approxi mately 240 cases (confirmed by a panel of pathologists), of which 75% occurred during the 1964-1974 study period. Some of the information presented in Table 1 is summarized below. The numbers in parentheses represent the medians which were calculated from the data in the previous update.1 (1) The ages at diagnosis ranged from 37 to 71 years with a median of 49 years (44 years)J :'t. stejv'-'il Since the original publication of NIOSH's register of 26 cases of liver angiosarcoma associated with occupational exposure to vinyl chloride or polyvinyl chloride (VC-'PVCI.1 evidence has continued to accumulate which further confirms this association. In the May 1975 issue of fOM.- an additional 12 cases werrepresented. Since that update. 33 more rases have been reported to NIOSH and one case has been disiounted (U.S. Case No. 14) as of October. 1977. This yields a total of 70 cases known to NIOSH. 64 of whom were polymerization workers. Details of the 64 cases among poly merization workers are provided in Table 1. Data on non-poly merization workers is not presented in this update since there has been essentially no change-1 consists of 23 U.S. cases and 41 foreign cases from 11 different countries Diseases Division. Bureau of Epidemiology, CDC, through their nationwide case linding effort for liver angiosarcoma for the years rfuiR itk* illiti'ss I Mini* Sh im ^ l)hll(sNK)SI| Kotvit A Tjii C'Jtanhu P.lfkw.iv nfUli OH Journal of Occupational Medicine/Vol.,20. No. 6/June 1978 A distribution of the cases by date oi diagnosis is presented in Fig 1. Although it is difficult to interpret the aggregation of dif fering sources of data, and while the data for 1977 is incomplete, this figure suggests a gradual increase over time in the reported cases of VC-induced angiosarcoma. sOuring the past 17 years (1961-1977). a total of 23 cases hive been identified in UJ. poly merization workers. Fifty-two percent of these cases had been diagnosed over the past five years. The rise in the number of cases diagnosed in these workers during tie 1970's is probably the reflection of two events: (1) the increased surveillance of VC/PVC workers during this time and (2) the growth of the VC/PVC in dustry after World War B. The 20 to 30 year lag between the growth of the industry after World War and the increase in the number of diagnosed angiosarcomas among VC/PVC workers ob served during the 1970`s roughly coincides with the median latency period (21 years). In regard to some of the observations made from the data in Table 1, it will be interesting to note whether certain trends con tinue. For instance, the age at diagnosis and latency period appear to he increasing. Some possible explanations for these phenomena are (1) the initial cases may have had heavier exposures. (2i ihe ini- *TVk' iihulh til CDCi im> 4fcift W**I` >4*1**4 through jwi'-iinjl i ihiw-b* ulmt wdh Of. Ikfitv fstfc Chnifia Oniwifi. ItBfju * I [nfiwnssik^Y. CDC AiImIi. CtHggii. 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Aim* 77 DOTS?? 10 0307 72 19 02 1947 12 0174 75 29 0* 70 75 70 01-04 76 10 0513 76 1? OOI7 7* 73 0702 76 19 0130 77 a 130077 04 17 7* 74 *0 170*?2 71 Of 10 fS 27 107*75 21 010477 16 103070 _ 71 03 10 7* 31 05 17 77 71 0303 75 13 097R71 70 17 15 3 15 0) 0769 70 04 09 64 12 0774 75 i? *0*7300 15 0070*1 74 030075 17 051001 73 03 16 70 19 050700 70 07 04 74 <M 037700 it him u 1107 75 22 0400 70 1* 01 3*77 21 0107 77 71 170*70 14 0*00 73 K 05 7? 77 70 03 10 ?7 70 0*00 73 11 Of 12 73 *n moCrOKOptillv a*d*m*d 'W *do*t vr*om duo 428 Angiosarcoma of the liver in VC/PVC Workers/Spirtas and Kaminski ucc 041305 Vt One of the values in maintaining this register of cases among vinyl chloride workers is (hat it provides a base from which hy potheses for future research can be generated. However, the ex tremely rare occurrence of liver angiosarcoma lends great impor tance to the need for as complete reporting of the cases as possi ble if we are to develop a better understanding of liver angiosar coma in relation to vinyl -chloride exposure. The occupational health community is asked to report all new or as of yet un reported cases of angiosarcoma among VC/PVC workers to either Dr. Robert Spirtas or Ms. Rose Kaminski. Surveillance Branch/ DSHEFS/NIOSH, 4676 Columbia Parkway, Cincinnati. OH 45226, (513) 684-32B4. In addition to vinyl chloride's association with angiosarcoma of the liver, recent studies have also found vinyl chloride to be asso ciated with excesses in brain cancer and neoplasms of the respira tory and lymphatic systems.1 * * More studies are needed to assess these findings. For an overview of the literature concerning the health effects associated with VC/PVC exposure, the reader is referred to Volume 246 of the Annals of the New York Academy of Sciences.* YEAR OF DIAGNOSIS Fi( 1. -- Number ol cam ol VC/PVC rtUttd anfiesarcomn rupertcd to WOSH by year al diitnow (This rtprtMnli only 63 ol tht 64 cum known to NIOSH lioct io(ormttiM go diifnoirt ii miuint lor one cam.) tul cases were more biologically susceptible, or (3) random fluc tuation. Analysis of the latency period for this disease in vinyl chloride workers should be a fruitful area for future study since multiple ettokigtes do not seem to he a factor in these cases and the exposure periods can be fairly well defined via employment histories.* *trcmi prdwnnury fmdmgi by NtOSH*! Division oi Siamndkal and Sdiaviaal Scwntr uggru that the inltvartion at dnuMwam with Ihr enzymatic detoxAcitmn d ethylene tShnxnide iwsuht m mc-reited carcmngt-mcity Inrtutting angiourcona at dm fcvvv* n libnratwy rats. Thu autNm with to ilunk Of. I. Wttun Lloyd. Dr. Henry Fak and Mr. Richard Waxwriter for the* ronructfvr rntoum. References 1. Llnyd |W: Angiosarcnma of the liver in vinyl chlaride/polyvinyl chloride workers. IOKI (6:809. 1974. 2. Llnyd IW: Angiosarcoma of the liver in vinyl chloride/polyvinyl chlo ride workers. IOM 17:333-334. 1975. 3. Waxweiler Rl, Stringer W. Wagoner IK. et al: Neoplastic risk among workers exposed to vinyl chloride. Ann NY Arad Sri 371:40-48. 1976. 4 Tabershaw IR and Caffey WR: Mortality study of workers in the manu facture of Vinyl chloride and its polymers. /OM 14:509-518. 1974. $. Monton RR, Peters IM. and Minton MN: Proportional mortality among vinyl chloride workers, (anrrf 3:397. 1974. 6. Toxicity oi vinyl chloride-polyvinyl chlarkfc. Ann NY Acad Sci 246, 1975. Angina as a diagnostic Predictor * ` It turns out that a history of typical angina is as good a predictor of ischemic heart pun or coronary disease as any other data we can get! including the exercise electrocardiogram. If you get this typical history your chances of finding significant obstructive coronary disease are 80 or 90%. depending of course, on the "expertise" of your evaluation. If you find atypical features, on the other hand -- something isn't quite right and you're not sure it's really angina -- then the chances are going to fall off to only about 50% that such patients win have obstructive coronary disease. And if you're pretty certain that this is not ischemic pain, then the incidence oi coronary disease falls to about 10 or 20%. So the ability to take a history and identify the typical anginal syndrome is your best way of determining whether the patient is Ukely to have obstructive coronary disease: We're all anxious to use exercise electrocardiography and other studies as supplements, but there's no specific test available that is any better than a good and careful history. -- Frim "BrAidp Cifttet Dugnntri* by f Osteal Humphries n fmwMrory Mrdtea**. tereury. 1971 Journal of Occupational Medicine/Vol. 20, Ho. 6/June 1978 ucc 041306 429