Document v14QZ2XRqVYnOV537Z8x82Bm9

FILE NAME State of the Art Literature SAL DATE 1935 DOC SAL023 DOCUMENT DESCRIPTION Journal Article - Pulmonary Asbestosis - Carcinoma of Lung in Asbestos * 1935 1935 1935 1935 PULMONARY ASBESTOSIS III CARCINOMA OF LUNG IN SILICOSIS KEN ETH . KENNETH M. LYNCH M.D. AND W. ATMAR SMITII M.D. From the Departments Departments of Lathology and Medicine Medical College of the State of South Carolina ; Primary carcinoma of the lung has attained a position of major interest in malignant neoplastic disease through at least a more common recognition if not more frequent occurrence within recent Likewise asbestosis has assumed a rank of years considerable importance in industrial medicine Workers in the mines of the Erz Mountains on both the Bohemian and the Saxon sides have suffered henvily for some centuries from monary disease now recognized as carcinoma and well known as Schnpeuel-- berg and J^chymovJoachimstulJoachimstul lung cancer Pirchan and Sikl 1 in report upon a series of these state ntohattitnchleinreed wtoeraettoanclhy moderate degrees of anthracosis ancdastehsey are any particular importance to the degree of phen- monoconiosis as a cause of the cancer but consider that the inny be somewhat different with regard to the quality of thequfeosrteiiognn substance deposited in the lung Chemical analysis in one of their cases revealed only calcium magnesium alumiuum silicic acid ch^<o rides and phosphates no trace of arsenic bismuth cobalt nickel or ruardainuimumemwaansatfioonunandd They lay suspicion as others have done upon the Schneeberg and J^ucphoynmaorvsmeinniecsboth factors being encountered in Rostoski Saupe and Schinorl 2 found severe anthracosis in Schneeberg miners the subjects of lung cancer and are inclined at- tribute the causation of the cancer to the anthracosis while Simpson 3 states that pulmonary cancer is a rare complication of silicosis in South African miners Schulte 4 has reported lung cancer in puen monoconiosis among coal miners and Sanpe ) has recorded two cases in arsenic miners There appears to be no previous report of its on 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 ease of pulmonary asbestosis with associated carcinoma of the lung is reported . CASE REPORT A came pital white fifty white man seven years of age at the time time his of his death first first under observation at the Shirras Dispensary of the Roper Bes on Jan. 10 1934 at which time he appeared very old weak anh 50 2 . Amaciated His tommeh righ Apratio Apratio History Prio 3. time was last ; 1. had noticed so best except for th trom work ou ter 1 three lower ins occurred i days Except fo tems until Nov. 7 lug right show The pain occurri 1 seemed to be n site weak and s ork and seek n alical care he aggravated and Coped On fai and mixed with The family hi Occupational Occupational curred when a cotton mill ors and windo | not consider rk as a weave ful a weavei hospital admi aled he did od > ning in 1913 the fact that w : out 1923 hui y inefficient er the heatin ling of dusty from the fore the plant five or six m of dry wee to work ov This man the two years rs which may may lition to the corpse Thro mplain of pe a cots | Oe ng PE By Bay eT w ~~ eT wee wr pening 0 ee : mn ~ > ~ ~ . *. ~ : IN . te of : ajor in URIINON years ance in ' hemian om pul Selince 9 state hey are pneu- (recrtecitioonn chlu vir chlu ekel or e upon ered in sis in 1 to at- impson rosis in i pneti- 10 cases its ocord of as their is with first h first Hos k and ee PULMONARY ASBESTOSIS 57 maciated His chief complaints were pains in the right side of the stoomuch right side of the back and shoulder and shortness of breath History Prior to 1931 the patient's health was good and practically ... time was lost from work as result of illness although for five years 4. had noticed some shortness of breath He had had influenza in 1918 tat except for that had always been well In 1931 he lost three days Hem work on account of sharp pains in his back extending down over the three lower ribs Nine months 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 toms until Nov. 7 1933 when there were renewed attacks of pain sympinvolv- ing the right shoulder axilla and the three lower ribs on the same side The pain occurred about every hour and lasted about thirty minutes It seemed to be more severe during 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 cought productive of wiry white mucoid sputum de- veloped On Jan. 8 during a spell of coughing he expectorated fresh blood mixed with mucoid material , The family history was not significant Occupational History The first exposure to a dusty atmosphere vecurred when the patient was about sixteen when he began to work in cotton mill as a weaver He first worked in a place with open dours and windows and later a humidifying system was installed he iii not consider the atmosphere excessively dust laden He continued work as a weaver in various cotton mills until 1913 when he obtained a job a weaver at an asbestos factory which he held until just prior to hospital admission During times when his work there was sus- pened he did odd jobs with apparently no occupational hazards Berinning 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 be considered very inefficient though 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 outside the plant entered the room in which the patient worked The last five or six months of his employment he was at wet work instead of dry weaving reducing the exposure to dust He was accnstetned to work overtime since he was paid by the yard This man then worked as a cotton mill weaver for twenty years and as an asbestos mill weaver for soampeprtowxiemanttelyy years which may account for certain features of silicosis in the lungs naddition to those of asbestosis Course Throughout his stay in the hospital the patient continned complain of persistent pain along the right costal border and right eee -~ (~ ~ 58 , KENNETH M. LYNCH LYNCH AND ATMAR SMETIC side 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 strength For the first three weeks after admission there was an irregular afternoon elevation of temperature In the latter works of the illness fever of remittent type was constantly present 99 101 rising on the day of death to 10. The pulse rate ranged between 90 and 100. The respiratory rate was constantly above normal and on the slightest exertion there was dyspnea Examination In general appearance the patient looked much older than seven He appeared exhausted and was extremely weak and dem presente previously ne ray exa who reported a generalized generalized generalized There is gem by plenrat il areas throng Impress right base some irritan r a : oe . 5 z 4 ry ; - rv) * g . - Pa a . > 4 ne on * . oC ee c . of : wi = Fig 1. Ro NTGENOGRAM Showing PuLMONARY ASBESTO AND CARCINOMA OP LOWER RIGht Lobe emaciated The finger nails and toe nails were clubbed and somewhat cyanotic The bony thorax was of the emphysematous type Expansion was equal but poor Duliness was present over the bases of both lungs being more marked on the right The upper levels were resonant Breath sounds were suppressed over the right base Rules 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 increased by cough There were numerous coarse dry squeaking sounds over the upper lobes as well The heart was normal in size and position the sounds were good There were inurmurs The pulmonie second sound was accentuated The systolic blood pressure was 100 diastolic 60. The superficial ves- sels were thickened and tortuous The abdomen museles bones joints extremities and nervous sys The tu No tuberel tuberel Asbestosis pus Tes mal Blo cent Dar motissimielmotiisimeli Dare l neutrophi The as * ^flnsion phenmonpheinmoni Autop Autop begical begical begical ne Penta nes ) e quantity wre pe rated For af BONY s fever of the day of The res st exertion auch older weak and tem presented no abnormalities except for the clubbing of the fingers previously noted : ray examination of the chest was made by Dr. Hillyer Rudisill who reported as follows " First examination Jan. 12 1934 There is a generalized fibrosis throughout hoth lungs particularly in the bases There is generalized increased density in the right base probably caused by pleural thickening In addition I believe there are bronchiectatic 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 ae m em 8 + K - so CINOMA Or Ae oea somewhat usion was lungs be- resonant f all varie- the chest y were in neaking vere good centuated rficial ves- rvous sys- FIG 2. ASHESTO silicosis with Carcinoma or Lower LobE The tuberculin Mantoux and Wassermann tests were negative No 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 normal 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 S6 Feb. 20 1934 hemoglobin 72 per cent Dare leukocytes 13,250 small lymphocyte1s8 large mononuclears 4 neutrophils 76 cosinophils 2 The admission diagnosis was pulmonary fibrosis and pleurisy with effusion The final diagnosis was asbestosis and chronic indurative | pneumonia . Autopsy B.G. No. 20514-31-58 20514-31-58 March 17 1931 Summary of path ological diagnoses Fibrosis of lungs pulmonary asbestosis epider- KENNETH M. LYNCH LYNCH AND ATMAR SMITH moid carcinoma of right lung bronchiectasis purulent bronchitis aente pleurisy chronic myocarditis The body is extremely wasted as to adipose tissue and musenlature all muscles including the interosseous are quite shrunken The distal phalanges of the fingers and toes are broad and rounded is quite prominent anteriorly . The chest The right lung is densely adherent over its whole surface but par ticularly over the lower lobe and at the base 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 fourths con- Fig oo 2m - Ce ee ee ae te og ew -#o-3 2 ee oe aa 48. 88 VL ome OE + a et g Oe oS xy, - ae $S, Fe, . ee wp * SA ita YAN gees Sof. 4 at. : ad 7) > Aan = re a ee zoe fa * whos ao , rS v ww eet . % . . : fs 2 % IT ND * 180 . 7 y. 7k < fot 0 be eon 3 Jee aed ba . f 3. Silicotie Hyaline and . we arrears os frase ov OW ST Se j ? ee ote q - te) ose ; he ys hee ee vm oe Se a . . ey . ae) aa Sl omet ah i er i Stearn 7 . . vee os eqect a Comes Ns 4 NN re ee NES Ar: Sees yeMe oom , eee ete 8 * Bh yy ~4 ae oa ~ a wewe ara :, Ne? seo o + eS . we es ty, o* aes 16 ce : te a8, yer f eee . oo 74 - ere 2 * ah, \ h, os , eos fo a t- raz . a i . : vous Tan! = oe , soo & - oe mm *. 7 Swe . ae A . of ae | ta Pe? an 4 ae a *, * e ays te ^' . a ae .* ! a ae SSa ws Nace 4 yt . wet a e Ge mS o ras Lt &- oy 2 ee? oh ce oe . htal . wen o%f Coe es _ +72) ty .-e"N4 PATOL ote Se a7 On L%,6 on ar e hoe . e a ah aywes nae! <a rn . o Ff voce mes? brane ; ee . bo . s 4 m0 4, ale Calcareous Nodule in Luxo witII ASBESTOSIS BODIES X 210 tains about 300 e.c. of turbid fluid and there are 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 ealcareous quality over the base That of \ the left lung is likewise thickened but over the free portion it is rough congested and furred with small modules in the surface The apex of the left lung is composed of a globular mass of light balloon emphysematous bullae with intervening fibrous trabeculae and apically there is a group of small caseous and calcareous hard nodules The midportion of this lung is light spongy dry and of a mottled dark slaty bluish color Beginning at the apposition of the interlobar pleura the lower part of the lung is densely tough with gross fibrous trabeculation fusing with the thickened pleura and the base honeycombed by rounded cavities about the size of bird shot The rit anal the laur is of bower as d bris ru to the spir and the sm less in porking The ly moderatel The c dematon The he ade and Other step ar ts Patine Patine Treulosis Treulosis Te chice Macrus Macrus ..har . t oli Itheny A | and auditis ae en ee er . -- og nme. oe bronchitis and musculature uken The distal nded The chest surface but par- e diaphragm and at the apex and he base and din fourths con- mewn tw tee Ot Ao + To ure _ 2 teal ntendameemaiion PULMONARY ASBESTOSIS . 61 The right lung has a similar group of halloon bullae at the apex and in the midportion is similar to its fellow The lower third of lung is of nodular hard solidified consistence the Occupying the inner lower aspect at the spine is a honeycombed cavity containing caseous d^'brisruptured in removing the hung because of its dense adherence quite to the spine The inner aspect of the envity is quite rough nodular and the surrounding substance lumpy and caseons This merges more or less into heavy trabeculated fibrous induration and small cavity pocking as in the opposite lung The lymph nodes at the root of the lungs are not conspicuous a few few moderately enlarged black nudes being found { " ^ sbestoSIS tachments here and is of car- base That of ion it is rough face . mass of light us trabeculae alcareous hard dry and of a _ apposition of dy tough with tra and at the as ird shot e on pt) a s don ' ae as a D es a if "4a ied eR r) . mi ; Pto 4. rf 2 . Po. * el , og Py ae Cairne cate wore eG le ee ord ha CHROxic Bronchitis and EroscHIECTASIS Asbestosis Bodies in Bronchiole ^ 130 edeTmhaetouesntire hilar and mediastinal tissue is quite fibrous and The heart is not enlarged but is of rather small size the muscle pale and flabby the right cavity rioderately 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 Microscopic 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 histologie diagnosis is chronic carditis myo- of oe 62 KENNETH M. LYNCH W ATMAR SMITH In the spleen young fibrous elements and large mononnelear cells increase the thickness of the sinus walls Polymorphonuclear leuko- cytes are conspicuous * Here and there are small groups of large foam cells the cytoplasm full of rather large clear ent vaenoles In these and other mononuclear cells is brown granular pigment A shaped asbestosis body is seen whether embedded in the tissue or merely upon it from transfer from other tissue in cutting it is difficult to say The histological diagnosis is chronic splenitis asbestosis ? The kidney 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 gee ge os CREO R SE Bard ESTE a . &; . . a ua. Pa os yor re ove. er) : &:~~ % . ew a we ohh *s Fig . ae . fad es. . a ens fa 2? e7teen Me oy 4 . 36 af 20h; Lae 8 . ." fi aren Gers a; t - ie 3 4 ast, peel oe OS OES \ more} ak ake z , . we weal aes a - ceeaened 2 te wt. OY . me an iti a SS or . Oo uw we .o . 7 / wae. e % fet vege NG 7 \. tet . Hyar'y a .$ Fan ~e ant. 5. Eridernoid Carcinoma of BRONCHUS AND Lung ^ 125 fatty vacuolization of liver cells Many nuclei of the liver cells are large and cavitated 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 collections 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 the pulp with moderate associated fibrosis and deposit of asbestosis bodies generally of shorter eluhled rod and dumb forms There in otis clear lympl In along Gener form alveol there alveo jointe large in the eseretaee mucle maenmaen T collec are si mulati leuko vral 1 Iv and c empt In struc with - purn of the A nunl Sprek Sprek undi ( Ne culou 711283330 extenexten thelit bro Ther AVeery, tion Sot broth 5 - Perey . = na on wore: C~ emte Hit ar cells uclear leuky ups of large rut vacuoles pigment A in the tissue ting it is dif enitis asbes- tion fibrosis and work patchy AW ad: oat ga ae Lark "4 weekfal JSS tereyset ete bet ee *t 4. t es UN. Kk etm ae Om e ' ne sf? .s i nS PA) ae be ye pA b eaek me e wt Le liver cells are n There are us area The eration portal t lymphoid col- th an internal usis is chronie osits of large ular subsinnce of asbestosis forms There f PULMONARY ASHESTOSIS ASHESTOSIS 63 is engorgement of the siumses with serous material and polymorphonnelear leukocytes The histologie diagnosis is asbestosis and acute lymphadenitis In the lung there is comparatively heavy old interlobular fibrosis along the bronchi and blood vessels Broad bands of fibrous tissue generally old and hyaline with considerable hyaline laminated uodule formation are disposed generally in this area including some adjacent alveoli Bronchioles here are irregularly and considerably dilated and there is much deformity of alveoli involved in the fibrosis In these veoli are large numbers of asbestosis bodies generally large brown jointed clubbed and long dumb 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 uceur in lymph spaces near bronchi There is only minor small mononuclear or lymphocyte infiltration of the fibrosed tissue with some mucus and leukocytes in some bronchioles The pleura is very thick composed of old fibrous tissue and while collections of asbestosis bodies appear in alveoli near the pleura none ure seen within the pleural fibrosed thickening There is an acute exudation of fibrin upon the pleura with some hyperemia edema and leukocytosis There is some black granular material in the same gen- eral fibrous area In the intervening lobules the alveoli are quite deformed by pressure and emphysema many large air sacs being seen Generally these are empty in the lower left lobe the fibrosis is very heavy heavy most of the alveolar structure being obliterated and here there is a marked bronchiectasis with chronic inflammatory infiltration of the walls of the bronchi some purulent exudate in these bronchi and active pyogenic inflammation of the overlying thickened pleura At the apices there is a remarkable grade of old fibrosis with large numbers of long asbestosis bodies in large giant cells in walled spaces and in fibrosed areas with hyaline nodule formation necrosis and calcification emphysema and bronchiectasis Sections from the base of the right lung thought grossly to be tuberculous show the caseous cavitation and infiltration there to be carcinomatous On a background of heavy fibrosis and bronchiectasis is extensive infiltration by masses and cords of stratified squamous epi- thelium maturing in considerable degree This is shown to come from a bronchus where there is squamous metaplasia of epithelial lining There are considerable necrosis and purulent leukocytosis of the cavity area Within and about the carcinoma area there is more active fibro sis than in other portions of the lung and heavy lymphocytic infiltration The histologie diagnosis is siliensis with fibrosis emphysema bronchiectasis chronic fibrous and acute pleurisy epidermoid bronchial carcinoma tt | naan ate 04 KENNETH LYNCH AND ATMAR SMITH SUMMARY This man had suffered long occupational exposure to dust some three years all told about twenty in cotton mill about twenty in an asbestos factory with resulting fibrosis of extensive grade in the lungs and plenta the apparent consequences being pul monary circulatory and respiratory disability with emphysema bronchiectasis 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 benrs 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 plasia of lining epithelium was observed squamous meta- The duration of the carcinoma cannot be specified It was ently of considerable time but certainly did not antedate apparfibrosis of lung A conception of its origin by reason of chronic bronchial the tion is compatible with the current view of the irrita- etiology of such tumors REFERENCES 1. PIRCHAN A. AND SIKL .: Cancer of the lung in the miners of chim Report of cases observed in J^chymov Joa 2. Rostuski Saupe and Schhonz 1929-30 Am J. Cancer 16 651 1932 in Sachsen Die Bergkrankheit der Erzbergleute in Schneehers Schneeberger Lungenkrebs 3. Stupsox S. .: Ztseir f Kreinsforse 25 500 1829 Primary carcinoma of the lung Quart J. Med 22 413 1929 4. SCHULTE .: Pneumekoniesen der Ruhrbergleute und Lungenkarzinom Fortschr d Geb. d Roentgenstrahlen 41 441 1930 a 5. SAUPE .: Carcinoma of the lung in arsenie miners two Arch f Gewerbehyg 1 552 1930 cases Gewerbepath 6. LYNCH M. AND SMITH W. .: Pulmonary asbestosis II including the of a pure ense Am Rev. Tuberc 23 643 1931 report LYMP From Lymi lition a In report The 1 Iwe admiss in the righ * 4 herath lite th nothing nothing of The P were rijika udar no sere Het Tha Tha t write the e ham The brownish brownish No other : what enlar The a veins of fl The liver : fimm inass f the um qendrant mass whici movable r The tin ur " ptalptal and| This 11 restativet tod hhwui The b T'dition T'dition Thowextes Thowextes Thowextes On il for were performa performa * sentury 1. Ikumist