Document p2ZxzzxB0D2jJOwe4ybo4JXQD

{DOCUMENT DESCRIPTION PORK 63 68 69 76 Duplicate in all cards:--> | year as-1961- 00(50060 1 Pile number {Right justify [Numeric only] ^Rhor(s), as Last Name PS (No Punctuation) and coden for journal as JAMA, preceeded by.one blank space 120' T1__________________________________ 40 4160, 61 62'* j--,, c-.---/-------------- T~/?L '/AJA . P. F. Qf/tr S,. b. A TT______ 78 l/o | Sub--Index Code u 12 13 Title of Report; end with space-hyphen-hyphen-space. Pollow with Index Terms, separated from each other with -comma-space. Avoid other punctuation; do not abbreviate. 12 . 61'62 21 Iv fc. m 0 u. S (J ^ ^ o C, t CjrM . l^ C} na^ |^ cTp f_,, | 1 __ f y'* ij i r\ y 1 22 23 K^hUrt.. U PPci [A/'/r'i- 24 Source (Journal, Vol., Number, Pages,Date) (, gy. /1 ce ,-0^ ?. pfi.- /6SC, - /<//, /f 77 61 62.31 32 Brief Summary' 12 10 SUMMARY: 61 62 61 62 63 64 R&S 106344 S. (PP jt-\ 0000060 SQUAMOUS CELL CARCINOMA OF THE BUCCAL MUCOSA ASSOCIATED WITH CHRONIC ORAL POLYVINYL CHLORIDE EXPOSURE i> Report of a Case C'i Charlotte L. Casterune, md,**Peter F. Casterline, md ' AND V . Darrell A. Jaques, md, facs* -- ry-' -V / The following case report describes a 22-year-old healthy man, non-smoker, non- drinker, who developed a squamous cell carcinoma of the buccal mucosa. The appearance of this unusual tumor in an unexpected clinical setting was unexplained until it was discovered that the patient had a lifetime habit of chewing plastic materials containing polyvinyl chloride (PVC). The extent and i chronicity of his intense oral exposure to PVC b believed to be related to his subsequent development of an oral neoplasm. Attention is again focused on PVC as an important environmental toxin and carcinogenic agent. Clarification of the content of PVC in consumer products is urged. Physicians must remain aware of possible environmental carcinogens in patients presenting with unex pected or rare malignancies. Detection of such exposure may well prevent subsequent development of additional unexplained neoplasms. Cancer 39:1686-1688, 1977. The development of a squamous cell car- oped acute aphthous stomatitis with painful ulcers on cinoma of the buccal mucosa in a young the tongue, interdental papillae, buccal mucosa, and adult male, non-drinker, non-smoker, is an esxo-ft palate. The lesions resolved within one week, with :mely rare event. The following case report the exception of a pinhead-sized papule in the right scribes a young man who developed such a cancer in association with a unique lifelong habit of chewing plastic materials. The mate anterior labia! buccal sulcus. This papule grew pro gressively until early December 1975, when it had reached the size of approximately 1 cm and was ex cised by a dentist. The pathology was interpreted as rials he chronically chewed contained polyvinyl an invasive squamous cell carcinoma. He was referred chloride. The extent and chronicity (greater to the Head and Neck Surgery Service at Walter Reed than 14 years) of his intense oral exposure to Army Medical Center, where a wide local resection PVC is felt to be related to h`.s subsequent devel v:,s performed. Tissue margins were reportedly free opment of an oral cancer. of tumor. Since then he has been followed monthly by the Head and Neck Surgery Service. No recurrent Case Report tumor has been noted. The patient denies the use of cigarettes, a pipe, M.B., a 22-year-old white man, was in good health until early September of 1975, at which timehedevel- cigars, chewing tobacco, alcoholic beverages or illegal drugs. He had no prior history of mouth or lip lesions. He currently is a vocalist and audio technician in the Armed Forces Bicentennial Band. From the Departments or AUergy-Clincial Immunology and Head and Neck Surgery, Walter Reed Army Medical Center, Washington, DC. Since the age of eight the patient has been working with electronics equipment, both as a hobby and as a vocation. His jobs have included the rewiring of build * Major, MC, USA, Staff, Department of Allergy and ings, organs, and audio systems. He has developed Clinical Immunology. the habit of chewing plastic-coated wire insulation as ' Major, MC, USA, Fellow, Head and Neck Surgery Serv ice. ' Colonel, MC, USA, Chief, Head and Neck Surgery Serv ice. Address for reprints: Charlotte L. Casterline, MD, OSC Box #191, Walter Reed Army Medical Center, Washington, DC 20012. Appreciation is expressed to Dr. Mary Wolff, Environ mental Science Laboratory, Mt. Sinai School of Medicine, well as other types of plastic materials. He often stores the plastic material in his mouth for as long as six to eight hours. He frequently stores the plastic in either anterior buccal sulcus. Past medical history: He had infectious mon onucleosis in May of 1974 confirmed by a positive heterophile titer. Family history: His maternal grandmother had New York City, NY, for performing the vinyl chloride assay, cancer of the breast. There was no other family his ^^^eised for publication July 7, 1976. tory of cancer. 1686 No. 4 i Buccal Cancer and PVC * Casterline el at. 1687 Physical examination showed a well developed and well nourished male. Scar tissue was present at the site of the prior lesion resection in the right anterior mandibular buccal sulcus. Oral hygiene appeared ex cellent, with no evidence of faulty dentition. His teeth were noted to be grooved secondary to his chronic habit of stripping wire with his teeth. No sclero derma-like skin changes were noted. His fingers and toes appeared normal. No hepatomegaly, spleno megaly or abdominal masses were noted. Neurologic examination was normal. Routine laboratory tests including hematology and chemistry profiles were within normal limits. Gamma glutamyl transferase was normal. Antinuclear an tibody, hepatitis-associated antigen, VDRL, and carcino-embryonic antigen assays were all negative. Im munoglobulin levels (G,A,M,D) and serum complement determinations (C> and C.) were nor mal. Radiographs of the chest, abdomen, hands, feet, and upper gastrointestinal tract were normal. Liverspleen scan showed no organomegaly. Urinalysis and urine cytology were- negative. Delayed skin tests to streptokinasc-streptodornase and monilia were reac tive. Pulmonary function tests showed no'obstructive or restrictive changes. A fat biopsy was done and assayed for vinyl chloride, the results of which were negative. Discussion The incidence of squamous cell carcinoma of the head and neck in the United States is re ported as approximately 5% of all cancers. Squamous cell carcinoma of the buccal mucosa represents only 1% of the squamous cell carci nomas of the head and neck.7 In a recent review of carcinoma of the oral cavity, 478 cases were analyzed. Of these cases, only 14 carcinomas of the buccal mucosa were reported, representing an incidence of 3% of the oral cavity cancers. Ninety-six percent of these oral cancers were associated with heavy smoking and alcohol con sumption. Of the other 4%, nearly all were asso ciated with irritation from faulty dentition. Thus, most cases had some possibly associated carcinogenic influence.1 The case described above is unique not only in the rarity of the cancer described, but in its unexpected appearance in a young healthy man who denied the use of cigarettes, cigar, pipe, chewing tobacco or alcoholic beverages. Fur thermore, his oral hygiene appeared ex ceptionally good. Prolonged and detailed queries as to possible exposure to other oral carcinogens led to the discovery of his unique habit of chewing plastic materials. When the extent and duration (greater than 14 years) of his oral exposure to plastics was elucidated, it began to appear more than coincidental that his neoplasm had arisen in an area of buccal mu cosa in which he frequently stored plastic mate rial for prolonged periods. The known carcino gen polyvinyl chloride is a major constituent of the tubing, wire insulation materials, and ca bles' with which this patient had chronic intense oral exposure. Polyvinyl chloride and its monomer, vinyl chloride, emerged as new occupational carcino gens in January 1974. This followed the in vestigation of several deaths due to angiosar coma of the liver in industrial workers exposed to vinyl chloride. These tumors occurred in workers who had been exposed to vinyl chloride for roughly 20 years.1 Systemic toxicity syn dromes related to vinyl chloride exposure in workers have also been described. Included among these are acroosteolysis, hepatosplenomegaly, pneumoconiosis, Raynaud's phenome non, scleroderma-like skin changes, and contact dermatitis. The manifestations of systemic tox icity vary according to the mode, extent, and duration of exposure.* In a recent mortality study of workers in the manufacture of vinyl chloride and its polymers, Tabershaw and Gafifey found that in humans vinyl chloride may be associated with neoplasia of organ systems other than liver. Interestingly, they found an excess of buccal cavity and pharynx cancers, apparently inversely related to estimated exposure. This finding was possibly a chance occurrence, or related to exposures to other substances. However, the authors postu lated that the mouth and pharynx might be peculiarly susceptible due to the gaseous nature of the chemical. This case report again focuses attention on PVC and VC, linking chronic and intense ex posure to these materials to neoplastic changes in human tissue. Although the occurrence of buccal cancer in the patient described above could have been a chance occurrence, we con sider this unlikely in view of what is known about PVC and its carcinogenic effects.5' Clari fication of the content of this material in wire coverings, insulation, and other consumer prod ucts is needed. Certainly other workers in the electronics field should be made aware of the possible danger associated with chronically placing plastic-coated materials in the oral cav ity. Finally, physicians must remain alert to the detection of patient exposure to occupational carcinogens. Specific interrogation of patients with oral carcinomas as to PVC exposure may reveal similar cases. Detection and prevention of such exposure may well prevent the subsequent development of -additional unexpected neo plasms. R&S 106346 1688 Cancer April 1977 Vot. 39 REFERENCES 1. Braun, P., and Druckman, E.: Vinyl chloride: Can the svorker be protected? N. Engl. J. Med. 294:633-657, 1976. 2. Hirata, R. M., Jaques, D. A., Chambers, R. C., Tuttle, J, R.. and Mahoney, W. D,: Carcinoma of the oral cavity: An analysis of 478 cases. Ann. Surg. 182:98-103, 1975. 3. Keplinger, M. L., Goode, J. W., Cordon, D. E., and Calandra, J, C..: Interim results of exposure of rats, ham sters, and mice to vinyl chloride, Ann. NT Acad. Sci. 246:219-224, 1975. 4. Maltoni, C., and Lefemine, G.: Carcinogenicity bioas says of vinyl chloride: Current results. Ann. NT Acad. Sci. 246:195-218, 1975. 5.. Mancuso, T. F.: Comments for opening or discussion on "Neoplastic Effects." Am. NT Acad. Sci. 246:251-257, 1975. 6. Marsteller, H. J., Lelbach, W. K., Muller, R., ana Ccdigk, P.: Unusual splenomegalic liver disease as evi denced by pcritincoscopy and guided liver biopsy among polyvinyl chloride production workers. Ann. NT Acad. Sci. 246:95-129, 1975. 7. Silverberg, E., and Holleb, A.: Cancer statistics, 1974--worldwide epidemiology. CA 24:2-21, 1974. 8. Tabershaw, I., and Gaffey, \V.: Mortality study of workers in the Manufacture of 'vinyl chloride and its poly mers. J, Occup. Med. 16:509-518, 1974. 9. Veltman, G., Lange, C. E., Juhe, S., Stein, G., and Bachner, U.: Clinical manifestations and course of vinyl chloride disease. Ann. NT Acad. Sci. 246:6-17, 1975. > '* v.'-. j: - {- . R&s 106347 i (pp 0 yjr\ SQUAMOUS CELL CARCINOMA OF THE BUCCAL MUCOSA ASSOCIATED WITH CHRONIC ORAL POLYVINYL CHLORIDE EXPOSURE Report of a Case Charlotte L. Casterline, md,*Peter F. Casterline, md' and Darrell A. Jaques, md, facs* The following case report describes a 22-year-old healthy man, non-smoker, non- drinker, who developed a squamous cell carcinoma of the buccal mucosa. The appearance of this unusual tumor in an unexpected clinical setting was unexplained until it was discovered that the patient had a lifetime habit of chewing plastic materials containing polyvinyl chloride (PVC). The extent and chronicity of his intense oral exposure to PVC is believed to be related to his subsequent development of an oral neoplasm. Attention is again focused on PVC as an important environmental toxin and carcinogenic agent. Clarification of the content of PVC in consumer products is urged. Physicians must remain aware of possible environmental carcinogens in patients presenting with unex pected or rare malignancies. Detection of such exposure may well prevent subsequent development of additional unexplained neoplasms. Cancer 39:1686-1688,1977. rnpt I HE DEVELOPMENT OF A SQUAMOUS CELL CARcinoma of the buccal mucosa in a young adult male, non-drinker, non-smoker, is an ex tremely rare event. The following case report ^Apribcs a young man who developed such a ^Kcer in association with a unique lifelong habit of chewing plastic materials. The mate rials he chronically chewed contained polyvinyl chloride. The extent and chronicity (greater than 14 years) of his intense oral exposure to PVC is felt to be related to his subsequent devel opment of an oral cancer. Case Report M.B., a 22-year-old white man, was in good health until early September of 1975, at which time he dcvel- From the Departments of Allergy-Clincial Immunology and Head and Neck Surgery, Walter Reed Army Medical Center, Washington, DC. ' Major, MC, USA, Staff, Department of Allergy and Clinical Immunology. ' Major, \1C, USA, Fellow, Head and Neck Surgery Service. 1 Colonel, MC, USA, Chief, Head and Neck Surgery Serv ice. Address for reprints: Charlotte L. Casterline, MD, OSC Box #191, Walter Reed Army Medical Center, Washington, DC 20012. Appreciation is expressed to Dr. Mary Wolff, Environmental Science Laboratory, Mt. Sinai School of Medicine, New York City, NY, for performing the vinyl chloride assay. Received for publication July 7, 1976. oped acute aphthous stomatitis with painful ulcers on the tongue, interdental papillae, buccal mucosa, and soft palate. The lesions resolved within one week, with the exception of a pinhead-sized papule in the right anterior labial buccal sulcus. This papule grew pro gressively until early December 1975, when it had reached the size of approximately 1 cm and was ex cised by a demist. The pathology was interpreted as an invasive squamous cell carcinoma. He was referred to the Head and Neck Surgery Service at Walter Reed Army Medical Center, where a wide local resection was performed. Tissue margins were reportedly free of tumor. Since then he has been followed monthly by the Head and Neck Surgery Service. No recurrent tumor has been noted. The patient denies the use of cigarettes, a pipe, cigars, chewing tobacco, alcoholic beverages or illegal drugs. He had no prior history of mouth or lip lesions. He currently is a vocalist and audio technician in the Armed Forces Bicentennial Band, Since the age of eight the patient has been working with electronics equipment, both as a hobby and as a vocation. His jobs have included the rewiring of build ings, organs, and audio systems. He has developed the habit of chewing plastic-coated wire insulation as well as other types of plastic materials. He often stores the plastic material in his mouth for as long as six to eight hours. He frequently stores the plastic in either anterior buccal sulcus. Past medical history: He had infectious mon onucleosis in May of 1974 confirmed by a positive heterophile titer. Family history: His maternal grandmother had cancer of the breast. There was no other family his tory of cancer. 1686 1 R&S 106348 f No. 4 % Buccal Cancer and PVC Casterline el al. 1687 R&S 106349 Physical examination showed a well developed and well nourished male. Scar tissue was present at the site of the prior lesion resection in the right anterior mandibular buccal sulcus. Oral hygiene appeared ex cellent, with no evidence of faulty dentition. His teeth were noted to be grooved secondary to his chronic habit of stripping wire with his teeth. No seteroderma-likc skin changes were noted. His fingers and toes appeared normal. No hepatomegaly, spleno megaly or abdominal masses were noted. Neurologic examination was normal. Routine laboratory tests including hematology and chemistry profiles were within normal limits. Gamma glutamyl transferase was normal. Antinuclear an tibody, hepatitis-associated antigen, VDRL, and carcino-embryonic antigen assays were all negative. Im munoglobulin levels (G,A,M,D) and serum complement determinations (Cs and Ct) were nor mal. Radiographs of the chest, abdomen, hands, feet, and upper gastrointestinal tract were normal. Liverspleen scan showed no organomegaly. Urinalysis and urine cytology were- negative. Delayed skin tests to streptokinase-streptodornasc and monilia were reac tive. Pulmonary function tests showed no'obstructive or restrictive changes. A fat biopsy was done and assayed for vinyl chloride, the results of which were negative. Discussion The incidence of squamous cell carcinoma of the head and neck in the United States is re ported as approximately 5% of all cancers. Squamous cell carcinoma of the buccal mucosa represents only 1% of the squamous cell carci nomas of the head and neck.7 In a recent review of carcinoma of the oral cavity, 478 cases were analyzed. Of these cases, only 14 carcinomas of the buccal mucosa were reported, representing an incidence of 3% of the oral cavity cancers. Ninety-six percent of these oral cancers were associated with heavy smoking and alcohol con sumption. Of the other 4%, nearly all were asso ciated with irritation from faulty dentition. Thus, most cases had some possibly associated carcinogenic influence.1 The case described above is unique not only in the rarity of the cancer described, but in its unexpected appearance in a young healthy man who denied the use of cigarettes, cigar, pipe, chewing tobacco or alcoholic beverages. Fur thermore, his oral hygiene appeared ex ceptionally good. Prolonged and detailed queries as to possible exposure to other oral carcinogens led to the discovery of his unique habit of chewing plastic materials. When the extent and duration (greater than 14 years) of his oral exposure to plastics was elucidated, it began to appear more than coincidental that his neoplasm had arisen in an area of buccal mu cosa in which he frequently stored plastic mate rial for prolonged periods. The known carcino gen polyvinyl chloride is a major constituent of the tubing, wire insulation materials, and ca bles* with which this patient had chronic intense oral exposure. Polyvinyl chloride and its monomer, vinyl chloride, emerged as new occupational carcino gens in January 1974. This followed the in vestigation of several deaths due to angiosar coma of the liver in industrial workers exposed to vinyl chloride. These tumors occurred in workers who had been exposed to vinyl chloride for roughly 20 years.1 Systemic toxicity syn dromes related to vinyl chloride exposure in workers have also been described. Included among these are acroosteolysis, hepatosplenomegaly, pneumoconiosis, Raynaud's phenome non, scleroderma-like skin changes, and contact dermatitis. The manifestations of systemic tox icity vary according to the mode, extent, and duration of exposure.* In a recent mortality study of workers in the manufacture of vinyl chloride and its polymers, Tabershaw and Gaffey found that in humans vinyl chloride may be associated with neoplasia of organ systems other than liver. Interestingly, they found an excess of buccal cavity and pharynx cancers, apparently inversely related to estimated exposure. This finding was possibly a chance occurrence, or related to exposures to other substances. However, the authors postu lated that the mouth and pharynx might be peculiarly susceptible due to the gaseous nature of the chemical.* This case report again focuses attention on PVC and VC, linking chronic and intense ex posure to these materials to neoplastic changes in human tissue. Although the occurrence of buccal cancer in the patient described above could have been a chance occurrence, we con sider this unlikely in view of what is known about PVC and its carcinogenic effects.'-`Clari fication of the content of this material in wire coverings, insulation, and other consumer prod ucts is needed. Certainly other workers in the electronics field should be made aware of the possible danger associated with chronically placing plastic-coated materials in the oral cav ity. Finally, physicians must remain alert to the detection of patient exposure to occupational carcinogens. Specific interrogation of patients with oral carcinomas as to PVC exposure may reveal similar cases. Detection and prevention of such exposure may well prevent the subsequent development of additional unexpected neo plasms.  t 1688 Cancer April 1977' Vol. 39 REFERENCES 1. Braun, P., and Druckman, E.: Vinyl chloride: Can the v/orkcr be protected? N. Engl. J. Med. 294:653-657, 1976. 2. Hirata, R, M., Jaques, D. A., Chambers, R. C., Tuttle, J. R., and Mahoney, VV. D.; Carcinoma of the oral cavity: An analysis of 478 cases. Ann. Surg. 182:98-103, 1975. 3. Kepiinger, M. L., Goode, J. W., Gordon, D. E., and Calandra, J. C.: Interim results of exposure of rats, ham sters, and mice to vinyl chloride, dun. AT Acad. Sci. 246:219-224, 1975. 4. Maltoni, C., and Lefemine, G.: Carcinogenicity bioas says of vinyl chloride: Current results. Ann. NT Acad. Sci. 246:195-218, 1975. 5. Mancuso, T. F.: Comments for opening of discussion on "Neoplastic Effects." Ann. NT Acad. Sci. 246:251-257, 1975. 6. Marsteller, H. J,, Lclbach, VV. K., Muller, R., ana Gcdigk, P.: Unusual splenomegalic liver disease as evi denced by peritineoscopy and guided liver biopsy among polyvinyl chloride production workers. Ann. NT Acad. Sci. 246:95-129, 1975. 7. Silverberg, E., and Holleb, A.: Cancer statistics, 1974--worldwide epidemiology. CA 24:2-21, 1974. 8. Tabershaw, 1., and Gaffey, W.: Mortality study of workers in the Manufacture of vinyl chloride and its poly mers. J. Occufi. Med. 16:509-518, 1974. 9. Veltman, G., Lange, C. E., Juhe, 5., Stein, G., and . Bachner, U.: Clinical manifestations and course of vinyl chloride disease. Ann. NT Acad. Sci. 246:6-17, 1975. ) 4 > 33 03 o 07 W Ul o :e-i- Air .. , ('ueiAX'is . -r-~i i-i . - *: ' * f j/". i,1- - *r V 'tv- J..f A