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Pleura! mesothelioma in a cigarette filter factory worker by Michael Huncharek, MD1 HUNCHAREK M. Pleural mesothelioma in a cigarette filter factory worker. Scand J Work Environ Health 1994:20:146--7. The incidence of pleural mesothelioma is increasing. Over the past two decades many new occupational and nonoccupationai risk groups have been identified. This paper reports a case of pleural mesothelioma in an office worker employed in a cigarette filter factory. Both secondary occupational and domestic asbestos exposure may have occurred. Only one prior report describes the potential asbestos health risks of this occupational group. Key terms -- asbestos, crocidolite, mesothelioma. | \ i ! ! | Pleural mesothelioma is a relatively uncommon tu mor. although its incidence is increasing (1,2). The etiologic link between asbestos and mesothelioma is well established (3. 4), many new occupational and nonoccupationai risk groups having been identified over the last decade (5). In 1989, Talcott et al (6) reported the mortality and morbidity experience of a cohort of cigarette filter workers (33 men) exposed to crocidolite asbestos (6). A marked excess in mor tality and morbidity from asbestos-related diseases was described, including lung cancer, mesothelioma, and asbestosis. This communication outlines a case of pleural mesothelioma which occurred in an office worker employed in the same cigarette manufactur ing plant as described by Talcott et al in 1989. This patient was not. at any time, involved in the manu facturing process and had no other known source of asbestos exposure, although domestic exposure may have occurred. markedly diminished over the entire left hemithorax. 1 The remainder of her examination w as unremarkable, j She reported no significant past medical history. ; A thoracentesis was performed w hich was nondi- : agnostic. The results of a needle biopsy were suspi cious for mesothelioma and on the second hospital day a bronchoscopy and thoracotomy were per- * formed. No endobronchial tumor was noted although j the left basilar segmental bronchus was occluded by I extrinsic compression. A partial pleurectomy and decortication of the left lower lobe was carried out. , Pathological examination showed malignant mes othelioma of the epithelial subtype with positive staining for cytokeratins. The tumor was carcinoem- * bryonic antigen (CEA) and LUE-M1 negative. Ex amination by electron microscopy revealed large. Case report The patient was a 53-year-old white female with a 90 pack-year smoking history who was well until four months prior to presentation. At that time she developed left-sided pleuritic chest pain initially treated with nonsteroidal antiinflammatory medica tion with complete resolution of her symptoms. Thereafter, the patient noted a gradual onset of dys pnea on exertion without chest pain or other symp toms. A chest radiograph (figure 1) showed a large left-sided pleural effusion and extensive pleural dis ease. A physical examination showed prominent veins on the left neck and overlying the anterior area of the left part of her chest. Breathing sounds were > Department of Radiation Oncology. Massachusetts Gen eral Hospital, Harvard Medical School, Boston, Mas sachusetts. United States. Reprint requests to: Dr M Huncharek, Department of Ra diation Oncology, Massachusetts General Hospital, Harvard Figure 1. Chest radiograph showing pleura! mass in the left i ova! neoplastic cells, focally raised into microvilli. Some of the cells had microfilaments and tonofibrils. The patient had an uneventful postoperative course and was discharged in one week in good condition. She died at home two months after the surgery, prior to beginning chemotherapy. A complete occupational history was obtained prior to her death. Upon graduation from high school in 1954 she was employed as a payroll clerk for a company which manufactured cigarette filters. The primary components of the filter were asbestos (crocidolite), cotton, and acetate fibers (6). During her senior year in high school, the patient had been em ployed by this company as a payroll clerk on a part time basis. Although she had no direct contact with the cigarette filter manufacturing process, she made daily trips to the mill to pick up the workers' time sheets. She was also directly involved in distribut ing pay checks to the company's employees. At the time of her marriage, she stopped working until 1970. She then began work as a clerk in a mu nicipal department and held a series of clerical jobs until her diagnosis of mesothelioma in 1989. No oc cupational exposures were noted during the period 1970--|989. The patient's husband had worked in the same cig arette filter company. He reported working for sev en months in the filter manufacturing plant where acetate, cotton, and crocidolite asbestos were blend ed. The work conditions were described as extremely dusty. At the end of his workshift, he stated that he .. looked like a huge teddy bear... You were cov ered with dust and the fibers of all three components, the acetate, the cotton and the asbestos." These de scriptions were corroborated by air sampling con ducted at several production locations in the factory on 27 October 1952 (6). As mentioned by Talcott et al, these measurements showed an airborne concen tration of 80 particles of asbestos dust per milliliter of air. The patient's husband had no other occupa tional exposure to asbestos and died of asbestosis in 1982. example, insulators, pipe mmi, w>Um.,.v.. _____ ers, brake mechanics, and railraod workers, have been shown to experience a high incidence of this tumor. In addition, household contacts of asbestos industry workers have been described as being at risk, and this phenomenon demonstrates that ''sec ondary" or "bystander" exposure to asbestos may represent a serious health hazard (7). In 1989, Talcott et al (6) reported on the occur rence of asbestos-associated diseases in a cohort of workers employed in the same factory as the patient in this case report. The 33 men described by Talcott and his co-workers were ail involved in the manu facturing process itself with exposure to crocidolite asbestos. Industrial hygiene surveys conducted at the plant in the 1950s revealed a very high airborne as bestos concentration (ie, 80 particles per milliliter of air). Overall mortality was increased in this group, 15 of 28 deaths being due to cancer as compared with the 8.3 expected. Eight died from lung cancer, five from mesothelioma, and two from other types of cancer. The patient described in the present report had three potential sources of asbestos exposure, name ly, (i) exposure during the workday via trips through the manufacturing plant to pick up payroll material, (ii) secondary exposure from contaminated workers entering the payroll office, which was her primary work area, and (iii) domestic exposure from her hus band's workclothcs. It is important to note that the patient's husband died from asbestosis secondary to heavy asbestos exposure at the same manufacturing plant. This case report presents a case of pleural mes othelioma associated with unusual occupational and nonoccupational exposure to asbestos. Such expo sures are often unrecognized and therefore have med ical, legal, and public health implications. Physicians and public health professionals need to be aware of unusual sources of asbestos exposure in order to in stitute appropriate management and preventive meas ures. References Discussion Hie incidence of pleural mesothelioma has risen over the last two decades. Data from the National Can cer Institute's program of population-based registries, called SEER (surveillance epidemiological and end results), show that the annual age-adjusted incidence for the years 1973 to 1978 versus 1979 to 1980 in creased by almost 10% per year (among men) (1). More recent data from SEER shows that the inci dence rate among white men for the period 1973-- 1984 increased from 0.7 per 100 000 persons to 1.8 per 100 000 persons (1). The etiologic link between asbestos and mesothe lioma is well known. Disease risk is no longer con fined to workers in the asbestos industry. Occupa tional groups using various asbestos products, for 1. Ries LAG, Hankey BF, Miller BA. et al. Cancer sta tistics review 1973--1988. Bethesda. MD: National Cancer Institute, 1991. (NIH pub no 91-2789.) 2. Churg A. Malignant mesothelioma in British Colum bia in 1982. Cancer 1982;55:672-4. 3. Newhouse M. Epidemiology of asbestos related tumors. Semin Oncol 1981;8:250-7. 4. Huncharek M. The epidemioldogy of pleural mesothe lioma: current concepts and controversies. Cancer In vest 1989:7:93--9. 5. Huncharek M. Changing risk groups for malignant me sothelioma. Cancer 1992:69:2704--11. 6. Talcott JA. Thurber WA. Kantor AF. et al. Asbestos associated diseases in a cohort of cigarette filter work ers. N Engl J Med 1989;321:1220-3. 7. Anderson HA. Lilis R. Daum SM, et al. Household con tact asbestos neoplastic risk. Ann NY Acad Sci 1976;271:311-23. Received for publication: 28 September 1993