Document yZRNXQ511m296e9835QNzKKE

ARCHIVES OF PATHOLOGY VOLUME 72 July ntKiu.'OJi DK.rK.Mun?, 1961 Th-s George Washington University Medicai Library ` 1332 H Street, N. W. . Washington 5t D. AA1K1UCA.N MEDICAL ASSOCIATION PiiMirution  r* >* 234 W;A2J/avw*r w.sv? I_ Pulmonary I Asbestosis M. TEUSCH1, M.D. AND AjJOi'iait'd `TilIt Primary Car cinoma of the Lung, Bronchial Adenomas, and Adenocarcinoma of the Stomach A. I. XUSENSTONE, SLD. CHICAGO Tlie stmuH;mcxi.*> *x.vum*m-o of nsixssiosis :md carcinoma of ihc lung ha> been retried frequently in the literature ami has assumed considerable im|**rtance in industrial medi cine.7 At the |irwnt time most observers Ix-lieve that ihere i a statistically sigttificaiU increase of pulmmiarv maiignnncv among :i5iKrsts worker**-. As far n> we can deter mine, however, the coexistence of aslicstosis with bronchial adenomas ami bronchial car cinoma has not Item established. The as sociation of asbest ***> with gastrointestinal malignant tumor- ha** ?k*v briellv referreil to in the literature. The pur^xasc-oC dvw -pay-cv is 'o present a case of asbestosis not oniv asstxiated with a ftmamous-ceU carcinoma of vhr* lung. but also with 2 bronchial adenomas and an adenocarcinoma 'i the stomach. Asbestos belongs to the pyroxene or horn blende group of minerals and is classed with svenite and granite; it is a silicate occurring :n minerals in combination with iron, copper, calcium, or magnesium.3*:s Various types oi asbestos differ tu chemical constitution and physical chan;cteristic.s. h is quarried or mined in various parts of tile world--Italy and the Mediterranean, Smith Africa, Rho desia. and Canada. In its natural state it appears as strands of long silky fibers which Submitted ior pitiilicnuou Sept. 6, I960. Tliis work was *upjwncd m part by the Eugene A. Friedman Memorial [*uttd. Prom the Dcwruncnt of Pathology, Michael I\et<e llcxpiinl ami Medical Center. are highly resistant to heat, strong ari$*. - ami alkalis. These masses are usually bnii t> into short lengths which are in i` crushed into a line dust. They ate bet either mixed with various substances* W hardening or used as an inert diluent and1* lilling of a heat-resistant diameter, Mice ct>]hc dark-ground illumination of the Iwstos fiber gives the impression of a brittle, metallic wire broken off at van* angles ami lengths, which is highly refracts *J*he asbestos fil>cr cotnjKJScs the central aide of an asbestos Ixxlv upon which cniliid* aggregates of bhxxl proteins and iron si' have been adsorbed and molded by cuttw. in the bronchi and alveoli. ' Report of Case * Only pertinent clinical, gross and microti changes will txr mentioned." A 65-year-old Xrt with the occupation of "piaster mixer" ottmrf Michael Reese Hospital on Dec 12. 1959. ifl the ciiief complaints of a progressively ibir?r abdominal na-n associated with black uo^ hencuemesis, anorexia, )o*-< of weight, and a jr*tnai onset of exertional dyspnea, jaundice, M pruritus. Symptoms first -.ipiared 3 montin V* fore admission at which time he stopped worfex' He hatl worked as a plaster mixer in a company tor approximately 12 years prior to im Itospital admission. In his work he mi.srtl ^ dry jowdered materials used in making the rao* The material was known to contain a cma* amount of asbestos :uul it was known w f<v considerable iltist in the air. * We .ire grateful to Or. Lawrence Perlman i/m the u-: of the clinical history. 21A P* J - Pleural surf tdiO^is, rsuinnuitiot and jaunt *eiyht lo Vkl J*rs*ire WSL rrspiratiuu f ttrull). His < avntal to jrfn 2 mum was sea bw was felt TV* *** did tux pull: Xtow \ f*y r.samtuai 2 mith* prior prepyloric a dM, to our McnvayiiMliu WUJ wmr ptl was 09 !Ori Tlirre ***a? Uit tu giver t--Kts !ii**>pitai c tixravrtiims at --< *w^*TliiK* ( Oeme rwl iLv tit Itospit U the jeitit jauinlicciL ' ^ mm bAttrrs aiul toe Wr> <bii not coll, hlline the *irii 1,1*0 n. jtul jsmet:-. 11 * tlin L tleil ;smi m rrrtjjjj arais The iunys. on 4 r*hiLir areas v !* J lt 5 c `IllllSil j.-^ - ?#^ *\ T?- _ v5kv-v4 r5. 1.--Plniml surface <i Imig. slKiwing thickinal fibrosis. rv .~g. %--Cut surface nf lung -bowing severe Illinois, bronchiectasis. and multiple tumors. ftywral examination revealed a chronically ill. ^siinted, and jnuudio-d nude. C'it|ii;uiiimt oi ^^rraliie weight los- and *\crtimial dyspnea. E Uuui pressure was '<0/70 mm. lit;. pulse rate 2^,'san. respiration 2X/min. and tent]>eHUurc feeiaJly. His chest and hunt* were essenmortal to percussion ami auscultation. A -air 2 systolic murmur was* heard at the apex. <m Jlumen was scaphoid, and a lumi, slightly mass was felt in the epigastric region, suss <iii not pulsate ami imscd with respiru- ;jfci ** .\-ray examination t the '.rax "intestinal net 2 months prior to adint-->ii;ti It'-iiPM-d an *<?wiive prepyloric Ioumi. ilmtitvcr, no x-ray * if chest, to our knowledge. itad ever Wen - Henociobin was 11.4 gm. and hematocrit \ the urine pH was 0.0 and the 'ferine unv* e 1015. There was a large autumn ot al`wauiru but no glycosuria or aretonuria. l>satC his hospital course, the patient >a;0 man*i intravenous and oral ihtids, trano usiotis. W m^vrtdine (Demerol) lor j^dn. lie died on W ami day of hospitalisation. totopsy the patient was -cvcrciy emaciated ^drrply jatmdictiL There ;n extreme dubbing 4 4r finerrs and toes. On *>jieimtg the thorax ^ lasts did not collapse Imt remaitu.il intlatcd, w^ftrir filling the picnrtd cavities The right r^cthed 1,150 srm. and the left I.Otxi -.mi. Iloth and parietal leaves *.f tin- pleura were wildly thickened and gray (Fig. I ). The visceral * certain areas was covered with a dhrinotv* The lungs on pnhaiiti di-clo^d :i ntttn- "lular areas which were lint: and nteas- (n*n 2 to 5 on. in greatest dimension. ttctwevn* the nodules the lung was air-containing r s-vmcd edematous or diffusely fihrotic. The lungs cut with increased resistance, in general apt>careti ibirkcr than normal. ami were the scat oi severe amhrneosis. On wetton the nodules were obviously tumor and were gray. sott. and more pronounced in the left lung. 'Hie largest measured 5 mi. in greatest dimension ami was locntetl snitpienraily in the lett upper lol*. They varied in color anil consistency. Some were slate gray ami vers* firm with minute `oci oi `-ecming uiuhmco*bs. The lartrvr one* were more gray or pink, presenting a finely granular or somewhat veivetv cut surface. It the region of tlte upper !<4h~s <-mie of die tuxinies were m close approxi mation to diluted lirimchi. Large foci of emphywtna were noted in ixilate*i regions Tnlntlar Lrnnchiectasis was found in l>oiis upper and loth lower Uilies (Fie. 5) There wn an abundant amount of giary. rather thick liiptid covering the -urtaces made by cutting. A similar iuaicri.il was also notiil in the lumen of the tracheobronchial tree. The hilar lytniih im*1v? were markedly en larged bm rather xu and grayish-ml. Rnnttovn micTosO>pic sevtions uf the king tliscknwtl :irchiicctunl oiditcrtitiou l>v exu-nsivg. tlilVusc. acute ami chronic inllntnnuuorv jirocesso. The acute lesions consisted ui etisMun anti tnci ot imn-fwonc hronciiopneumotiia with minute tmilttjde aicesss'<. Tlte chrome le>ions were clwnicterizetl Iv va-t areas of inierstitial hhfosts f1Kp (Jf ur- ,^:mi/int: -mri organized. Ir. nciit>|uieunumia. a iff ui. *. * T: ;: M rr<t .C| i-i p r. Sa l-, iV 226 ARaUl'ES OF PATHOLXf K nto.w-u?: J: Fig. 2. -- Alveola* < lung with nucTt>ifci ^^5histiocytes and asl 5S>.iMjdies. Hematoxylin at eusht preparation; diiceti Il^c from s* xw. r* ; -Ashehvwl ar tyJJn r lun; rn *-*. X nt( -i VoT Li ^ **.&* ^ * - 'Hicrc was aUi marked perivascular ami peribronchial fibrosis. Between such areas, foci ii vmphy-emn were noted which were more pr<-uunced in the suhpleurnl areas. Within areas.of interstitial fibrosis but some times ali-* in regions of organized broncho pneumonia. typical asbestos bodies, to lx describoI 1k-!i.w. were notetl. Adjacent to these Unlii-s. ]..reign-body giant cells were present, as well as many lymphocytes and histiocytic cells. Asbestos bodies were d* notetl within alveoli (lug. 3) either as ir dividual Ixxlies or arranged in small groc* W.mi ,t( the; C***1^'. *,on: They were often found itnlaedtled in a dev blue connective-tissue stroma which was prl JL"* .`**^ra*4**c P'S between the alveoli and often also rqiiarf aiveolt (Fig. 41. Tn a mimixrr of fields macrophages pr* dominated. Often the lumens of alveoli & hronchmles were crowded with these cti M^ttntK leated Ivutphoc ^ in abun * la i uumlie: V#u* ^ err en r. -v: ;{ . ^ i-le. -- Imer-ainal tibrous n*ic and Irtlii-- 1 Ictnaiuxyim mid evsin ]r paraiion; rchicctl H'r from mac. X 170. &!%.. M?- nX*d.vd1 v . > {i{.' ; -*'1i ' ** V <V . , i fcf : %'V KUtONARY ASRRST0S1S 237 17331 Tic 3.--'Asbesto* body. Z*m typiraJ architecture. Srcumxyiin and Pennon; reduced 11 r.i Sw ra*. X 1.200. - ff* -BC* * w JH:*. i; j/* i*r"fJ .il 'V- \ ef fM of these contained brown pigment pinnies, some of which gave : jmsitive Pnndnu blue reaction. Many also contained ethracotic pigment. Aside from granulomas, nsltimideated giant ceil* of the forcign-ljodv *?''' lymphocytes. ami plasma ceils wore f.nil in abundance in mnnv fields. !n i number of -c^tion^ <ut>j>okcn granti*tms were encountered. T1h-v consisted of central areas of fibrinoid neurosis with a few giant cells and many lymphocytes and his* tioevtes at the periphery. Asbestos bodies-- either intact or api>enring as broken-up rods which gave a positive Prussiatt bine reaction were found cither loose within the fi brinoid necrosis or within giant ceils. The asbestos bodies were Segmented bod ies. straight or ciub-iikc in shaoe. and k .mn. T'-** .7:5k .4*. j c. tr-' T J:-. -** v: ` 'f t - t. ' ' rr`i ` Me. 0.--AieSto.s bod ies, positive Prussian blue reaction. Reduced 11% front rmj. X <X>0. o..l. 238 ARCWVES OF PATHOISO 5? tVLStONAt averaged in length. They were charac teristically segmented with bulbous ends ami ycllim nr uranic in sections stained with beinaioxylm :uul eo*in (Kig, 5). They stained dark hlu in sections >t:rmed for the presence of iron with potassium ferric cvaniiif rtml hvilnvhinric acii) t 1 'russinn blue reaction, big. '>. A-* Mated. these bodies were fniiud either imiicddcd in fii)rous enn- nccti\e tis-ne nr in the midst of small gramt- Fit;. 7.--Lung: motts-edl arcutona 1 u.'lie.'iOi Ixkiiei. Hr tuxyJin ami eosin fj onion; reduced ll in mac. X 2^5. lomas, sometimes engulfed in foreign-bcr' giant cells. and occnsiunaUy also alveoli. * The small bronchi were dilated, and pe? bronchia) fibrosis was outstanding. A aicrir of smaller bronchi showed focal aroj&fibrosis of their muscular coat, combinedrf an infiltration of lymphocytes and nhsaj^cells. Many blood vessels disclosed a o -iderabte degree of ]>erivascuiar fibrosis ri wyic deg *jojnK>us*cc Issn extendiat. Section? v IV Mjftcr jk >r wall of 5 bronchial mi father wcll-db aany atvpiea. to ter hyperc; iwroonding ti tt were :ds< cfuractcrisl ics carcinoma. Xi jrfr^nt within free and in gu i HUer node, tumor The tumor pre trmne alveolar hi*r fillers e of tumu frijtjvplv large 7V nuclei wer i^htly oval, a tcurcs were ; ere 4itv smuur: rnr nor was tto formation of X --l.imw filial :lvi><i>a I i \ ini ami .i~ut Ircj.:,r-- Hon: if ' inm m;<e. > 'Tn W\<Th:?. @*i:gS e^r S __ / A1 mring degrees of intimal fibrosis. Focal the cells somewhat resembled those compos- tpumous-ceil metaplasia of bronchial[cpithc- _ mg a carcinoid tumor, argcntafifine granules hsn extending into alveolar ducts was com* could not be identified (Fig. S). Occasional DU. aslxr>tos bodies were noted. Sections which were taken from uiie of There was also present a third tumor in 6e softer nodules of the lung adjacent to the lung. This tumor consisted of small or ir wall of the brunchu> anti replacing the larger glandular structures composed of low VijnchiaJ mucosa disclwcd large loci of culxfidal cells which varied considerably in ndicf well-differentiated vjuanious cells with dac, >hnpc, and staining qualities and showed tuny atypical mitotic figures and small and a number of mitotic figures. These tumor iugrr hyperchromatic miclci infiltrating the structures were identical with those found r:ounding tissues. btnail foci of kerntiniza- in the stomach and obviously represented ti were also noted. These fields hatl the metastases from the primary adenocarcinoma (iancteristics of a primary squamous-cell uf the stomach described below. camnoma. Numerous aslxjstos bodied were The liver weighed 2.S60 gm. and contained f-r*.nt within the tumor mass Ix>th lying a number of irregular tumor nodules, the fire and in giant cells i l`ig. 7). largest one measuring 15X15 cm. Gross C'ther nodules n microscopic studies ly these nodules had the characteristic wSwni tumor of an entirely different t\qx.\ apftenrance of carcinoma metastases. Micro TV tumor presented a more or less chamc- scopically they consistetl of adenocarcinom- sri<tic alveolar pattern, stninds of connective atous structures similar to those found in t"ue fibers enclosing smaller or larger the stomach. puups of tumor cells. `I*he tumor cells were The stomach was distended and contained rdativriy large with an indistinct cytoplasm. a large amount of dark-brown, thick liquid TV nuclei were relatively small, round or Huid. Just proximallv to the pylorus there dsghtlv oval, and hyperchromatic. Mitotic was a large fungating tumor occupying inures were not encountered. Nowhere almost the entire circumference of the rre any squamous cells encountered >u the >tnmaeh. The. tumor was ulcerated. On sr>r nor was there any tendency towards -cCliou it extended throughout the mucosa, v.t;.nation of glandular structures. W hile muscular coats, and into the serosal surfaces. . ;l "'Vj'T. i- M. -V 1 a- s- ?*n a-x t w - a ; I a ^i Zttiithi^Ruienstme hie. 9.-- Stomach: pri mary :iliMi<arcim>ma. Hematoxylin an<{ cosin jiri^nnukm; miui-iil 11% irom may. X 70. .1* 121 b'J* 2*0 ARCHIVES OF PATHOLOQ KUiONARY AS2EST01 jrcfiferalion of the fibrot ^ribronchial and pertalvi fibrosis gradually en Wubliieration of the puhn epical whorled formatio: Fw. 10 -- Hiv'hlv rifreveille* cnvmsU-* unhm to>nach carcim*nii a> s^eii uixit'T jx^hiriziiju mi- cro-<0|e. Hi*Tiiat.xyliii eoisis, however, is not snerous foci of Ivmphc ^t to fibroblasts. Krnphy ~-zx} numerous. In general ^3 to 7 years between the and xn prejuaruttnii; reduced \\r, from nwa. X. % sgh concentrations of as Jf et of clinical asbestos: *rral reportetl by Merew Aile longer intervals a ft*suaily symptoms do m m fcgc part of the respi: heat reduced by fibrosis, mnptotns once licgin an *0 becomes apparent, Along the los-vr curvature a mimlicr ot Ivmph nodes were replaced by tumor. Micro-cnpicallv the minor consisted of atypical glandular <;rucuvrv>. l'hc absence of base ment membrane?, market! variety in size, Jiape. and staining quality of the tumor cells, and large number* of atypical mitotic fig ure*. were characteristic of adenocarcinoma i Fig. 9). In Itematoxylin-and-eosin-staincd sections, mimtte brown pigment granules . were aew throughout the tumor as well as small grouj* ot asbestos bodies in the mu spill progressive course concentration of less than 5.000.0CG paiw ^ ixasc docs not progres !>er cubic foot of air. The pathologic j** : inr after exposure to a esses resulting from the iufiaJatton of k ^ tifumgh the fibrosis cat bestos panicles are not lielieved to be dart if, ii exfjosure persists their chemical nature but rather to the sr & am*c scar. chnnical irritation of fibers lodged ia 6 In minor and mediu respiratory tree. The inhaled panicles at iiinagr in aslx.*stosi$. the: in general, too large to pass beyond i* y recognizable influc: respiratory bronchioles. They may rwais* S2*r. Characteristically, the respiratory tree and initiate 2 forri^ iim ts usually the c body reaction which eventually lads * aelt circumstances, the fibrosis.3 The pathologic sequence of eras cosa and on the serosal surface of the stomach. F<>me of the^e granules gave a ]Misitive I'nis-ian him* reaction and under die polarizing microscope were highly re tractile r'Fig. Id). In addition, a few bodies ciosclv rvsonblmg broien-np asbestos luxilcs were found Ivmg loo-clv nrit onlv in the imioici of tlie Momach but also m the serosal areas. can l'x cons'idered as occurring in 3 f 1 ) desquamation and exudation; (Z\ iff ^ nation nf asiieslus ladies. ami (3) non** 4 and scarring. In the first stage, the asbe * fibers traumatize rhe cpititciiai ceils ime? tiic smaller bronchioles, ami the constaar ritntion anti friction causes the cciU desquamate. Macrophages aggregate in s effort to phagocytizc the fibers. There a* until disclosed c jd advanced form Is asbc ease ami the o!c factor It is not known u j-***riiied in this pane: gtiiticam progressive p nhrativc of the nau ?sw4*c. 'ince no chest : U*r However, it is < d approximateiv 1 . Comment gradual change from the asbestos fiber* known to contai A.-ljvstosi* "]> retain led as an oectipational liseaiw caused by inhalation of :us!jcsios the asbestos Ixxiy formation.3,12 This is dr )> the definition of a protein matrix, laitiing Iron, over the filers along its cucr jhhoogh the concen mu'! presume it was fiber* which lead* to a progressive fibro>is atul warring within the lungs.,H It hn.s lx*en detnirf*<rated by Hardner1 and again be Vorwald l= that the disease will not t*ccur with filler* 5e>* than 21V in length or in a which prtilinbiy serves to reduce the irritant* mechanism of the fillers. Foreign-body jne 7 tdomas and insists of phagocytic cells 2*%a)*o encountered. Hie third and most sipG icant tissue rcs^xmse is the production *r f. in 7uR-at.iry asiicstosis. I: `''it I^VU the factorv : * r?nflm-oJ may not >t* *4icnitration of as! **S hn It tlie patien 1 best x-ravs wc v .isbustosjs ition of the fibruti* tissue al/out the Only after the autopsy findings were the ichinl ami perialveolar area*. A dif-__.cmployers_mntie.awarc of the situation, and rosis gradually en*uc* which results x-rays of all employees were suggested. The .nition of the pulmonary luitern. The jiatient had dubbing of. the fingers ami toe* whorlcd formation characteristic of ami exertional dyspnea, the duration of , however, i> not present. There are which is not dear. The histological features j< foei of lymphocytic cell- in addi- of the lungs were typical of the disease. ihryblasts. Kmphysematous area? arc There was a rapid downhill course due to nerous. In general ilu-re i> a delay of dissemination of carcinoma of the stomach ,-ears between the initial ex insure tu with severe involvement of the liver and acentrntiou* of aslvstos dust ami the obstructive jaundice. The terminal event was I clinical nsl>c*tosis. The average in- extensive continent bronchopneumonia. Since eported by Merewether is 11 year>.,M the jmiiem was in the hospital only 3 days on^er intervals are not uncommon. ami had had no previous hospitalization, .symptoms do not apjvar Ik* fore a clinical and lalxjmtory data were meager. art of the respiratory reserve has An important point to be stressed was that juced bv fibrosis. However, when the the occupational history of the patient was .715 once Iicgin and significant dy*p- not contained in tlx* clinical history. Vet the romes apparent, there is usually a actual facts revealed that the diagnosis, -'^Tessive course of the disease. Hie though adminedtfv difficult because of the is not progress beyond a limited complicating carcinoma of the stomach with y xpositre to aslvsttw dust ceases, pulmonary metastases, could only have l>een h uc fibrosis caused as a result of thought of with ihc occupation of the patient tposurc persists and develop* into carefully noted and investigated. scar. A 1f ? saline susj>onsion of a sample of ainor and medium grades of lunt; the material used by the patient in his work in asbestosis. there is little to indicate was injected into the trachea of rats. These cognizable inllitence of the a>lx*>(os rats were killed after one week. Tvpicai Ihamcteriticnl1v. some unrelated am fwreign-lxjdy granulomas were seen in the is usuallv die crux* of death. In lungs with thin, long, retractile fiber?, which ireumstanees. the a>i**s(osi> is undi had the appearance of asbestos fibers. P.e- d until disclosed at necropsy. Only in enuse of the short time interval asbestos r.nced focrn is asU-stosis a conspicuous Unites hail a* vet not formed. nd the sole factor in tin* fatality. *I*he interest it? thi> case lies, of course, s not known whether the patient in the as*ociaicd finding* of the bronchogenic ted in this paper demonstrated any xjuamoos-ceil carcinoma, the bronchial adc- am progressive pnlmonarv symptoms noiuas, and the aden<x'nrcinotii:j of the ive of the natural vour-c of tfie stomach. In the literature there is a difference since no chest x-rav had ever liven of opinion as to nslxrstos living the cause of However, it is obvious that ho laid lung cancer. Some authors Itciiovc that per i approximately Id years in an nrmos- tinent rases " arc loo few in number to be known to contain nsU**to* particles, of significance: others, especially Yunvaid :hough the concentration is not known. and Karr,M staled that inhaled dusts--except resume it was MUhcient to produce those containing recognized carcinogenic sub tsbestosis. H i* im^iortam to note stance* such as tar and radium--cannot in vci. ae factory at which the patient general lie considered as ctiologic factors in nployed may not have !cen aware of the development of primary pnlmonarv car ncentration of nslxtsius in the material cinoma. 1 Imvever, considering the incidence which the patient worked, and thus of carcinoma among the rases with nsiicMosis e chest x-rays were not insisted upon. i an average of l.i.S'y in 5 analyses recorded ii--i?ttbmsione 77'* m_ tf USSi J pllf:J 242 ARCHIVES OF PATHOUd^gg. tTUtPSAM m the literature) and comparing this in were also found. As for as could be dr***^^; Inti no cidence with that of bronchogenic car- mined there are no data indicating xar cin/flja of tin* gmcral population, the former Intiotiship lietwcen pulmonary adenoma* td i.s much higher, liloyuc8 reported an inci aslx-stosis in man. However, Lynch a* dence of ot primary carcinoma of the conducted experiments on ACFi micr W lung in silico-is and 6.7'c in other forms of exj>osing them fur various lengths of e* pncumtx'oniosU. to dust containing asbestos Soar. They A* It i> UMtallv agreed that among the general unstrated that in the 127 animals population bronchogenic carcinoma is much were "dusted.'* 46fe had developed prissy rarer in the female than in the male (4.4 lung adenomas: in 222 control animals a* males t 1 female*). Ochsner11 stated that had developed pulmonary aricna* from statistical studies the highest incidence There were no histological or cytowfo of pulmonary carcinoma in the female was differences in tiie tumor in the controls W 10.3fr. Among nslx??Tos workers, however, "dusted" animals. Also, there was nn i.^ . the incidence of pulmonary carcinoma in the deuce of malignancy found in any of fir female \va- 2\,r c as quoted by Merewether 10 lungs. Tliese authors have been unalJr a and 41.2'/ as quoted by GlovneA These demonstrate carcinogenicity of the figure' nutv Ik- even more significant if one mider the conditions of exj*riment, bu: S realizes. as rilm-iic" remarked in his series, increased incidence of !tmg tumor in " there are in general more female workers vd** animals was regarded as a possibles ( n the asix'*to* industry than male workers. ccntuniiou of an existing' tendency to dewrf The average time interval between the lung tumor. initial exj*ure to the asliestos dust ami the It is, of course, possible that these pi development of bronchogenic carcinoma is tnonary adenomas in our case were inridta 16-18 years. 'Also, a short but intensive ex findings. However, because experiment posure to aslxsto* dust may muse pul just quoted are suggestive of a re!atirit Jpr" monary carcinoma long after the exposure between pulmonary adenomas and pulnv** ha* ceased. ( hie of filoync's patients, a fe aslx-stosis and because such pulmonary jA s*,, male. why was exjxasod only 10 months diet! emomns per sc are rather rare, we are.raa* 15 years later with a squamous-cell carcinoma inclincrl to believe that they also are rrbs^ of the hmg. As to the site of carcinoma, it to asbestosis. It would thus seem impnra* 4*5^* has l>evn noted that in four-fifths of the in future cases of asbestosis, even a/trra^^* patient? in whom primary site i< indicated, primary lung carcinoma lias been view* ^?v die origin >(' tiie neoplasm wa< in die lower strnted, to search the lungs by mean* llohlig and Jacob 1 fotmrl carcinoma multiple sections to see whether or not nrjfc in the upix-r loin* in only one-third of their pic other tumors mnv not lx encottnirvi cases. Thi* i in coiunist to the location of This seems particularly important since <r *|>* a broncSngvnic careinoma in the general aniination of an organ is usually consblmrf gu'. jtopulaiiou wliere carcinoma seems to be completed after once a major lesion i'i mure frequent in the upjier lolxr.5 As to tile as a primary carcinoma is encountered Jfy type of carcinoma of tlic lung associated The main disease which the patient W ^ with aslx*Mo*ii. -qunmotis-ccil carcinoma ami for which he was admitted to thehoq* " '' outntmilxTs other tyjies. In our case the car tal was a primary adenocarcinoma of ^ cinoma was small, recognized onlv micro stomach which had caused pyloric obstrar svopically ** that tiie site of origin could not lion. A check of the available literature 4 yy !x* detected. However, the adenomas in our doM.nl one report of 8 cases where puimnm- 5s case were subpleuniilv located and were in asbestosi* was associated with carcinoma <t i-ih the npjxT and lower lobes. the lung ami neoplasm* at other sites.* Md 1 besides the bronchogenic squamous-cell tiple sections of the carcinoma diwl>*W carcinoma, multiple pulmonary adenoma* numerous highly refraciile dots and sha? . ......... _ ?Sr*> VUtONARY AS3ZST0SIS 243 rods, but no typical asbestos fibers were mcountered and ernumiv no asbestos bodicsr However, jecrions >ji the ntliacem mucosa \ai also of the serosd >nmcc ot the >\om*h showed the occasional presence of not eoiv ab$e5to< fibers lut aKo asbestos Itodies fcich gave a positi\c rrusHan*bJu< reaction. TV pertinent question i<. of course, whether cr not ihe gastric carcinoma was related to far pulmonary aslx->i'*-i nr not. Since asV*tn* bodies can U* demonstrated in the pvstmi. it seems r.*a>oualjIe to assume that tfry are also swallowed ami may Uxlge in the stomach as was demonstrated in this ar. Titus its role a carcinogen in its fntnc with the ga-trie mucosa ntucit ! brae hi mind, llowcvrr. ttice true :n*le>tus llics could not U- demuti.-tmied in the emor ot the stomach, it would >eem that b stomach carcinoma in this case was an ^dental finding. Otto Saphir, M.D., Department of Pathology, -Michael Jicesc. 1 lo^pital aivi .Medical Center, 29th St. ami Kllis Ave., Chicago 16. 111. REFERENCES 1. Bohlig, ]l,, and Jacob. 0.: Neue Gesichtpunkte ulr den Lungcnkrcbi der Asbestnrbeiter, 1 Outsell. Med Wschr. SI :2J1-2J3, 1954. 2. Gimivet, M,: Asbestose ct cancer bronchique, Prcsse Med. 66:008-910, 1958. 3. Cooke, W. E,: Asbestos Dti<t and the Curious Bodies Found in Pulmonary A*fw"ito*ts. Brit. Med. }. 2:575*581, 1929. ' 4. Gardner, I~ U.: Etioloey of Pneumoconiosis, T. .OLA. 111:1925*1936, 193S. 5. Gardner, L. W., and Cummins-. D. E.: Stud io** <> lixix-rimenial Pncinnocuni">i- VI. Inhala tion o{ A-l^roo* 1 hist: U- r.fTect Vpon Primary Tul<rcniou Injection, J. Industr. Hyp. 13:65-81, 1<U1. * 6. Gloyift, S. R.: Pncumocoitiu-is: A Histo logic Survey of Necropsy Material in 1.205 Cases, 1-n.rtt 1 :S10-8U. 1V51. Summary An cideriv plaster mixer in a casting comptflr where he worked wirii drv {>owdered kutrials used in making ca>ts ant! which esuined asbestos wa? admitted l<ecause of wdderablc weight !<** and exertional ilvspatx At the hospita'. x*ray examination iviosed an obstructive prepyloric lesion. At autopsy, chronic pulmonary asbestosi's proem in adtiith'U to a primary hron- rb^mic snuarnous-cJl carcinoma ami mul5.^ puimonarv adenomas. Hiere wa- also a lnnury adenocarcinoma of the stomach hich leal produced ineta>wses to the lungs. TV relationship of chrome asbesto!*ts to ^knmtary carcinomas and to pulmonary vimomas is discussed. While asbestos Ixodics *err also found in the stomach ami brokenA*cn asbestos fibers within the gastric car* raoma itself, it was not considered likely Hit there was anv relatiomdiip Ixrlwecn the *ic caronoma and puimonarv asbcsiosis. 7. IsM'ilinrhcr, K. T.; Klans. II,, and Hardy, U. I.: Asbestofis and Eronchocmic Carcinoma, Amur. .1. Med 15:721-732, 1953. 3. IJndskou. G. F., and Bloomer. \V. D.: Bronchogenic Carcinoma. Cancer 1 :2.U-2J7, 1943. Lvnrh, K. M.; Mclver, F. A- and Cain, .1. K.: Pulmonary Tumors in Mice r.:q**od to Asbestos Dum, A.M.A. Arch. Industr. Ihahlt 15: 207-214, 1957. 10. Mercwciltcr, 1L R. A.: A Memorandum on Asbcsti**i<, Tubercle 35:109, 1^33; 15:152. 1934. 11. Orhsncr. A.; DeCamp. P. T.: DcSakey, M. M, and Ray. C Eronchoecntc Carcinoma, .I.A..UA. 14S:69l-697, 1952. " 1Z Stewnrt, M. J., and HadJow. A. C.: Dem onstration of the Peculiar Bodies oi Pulmonary .\>bcsto?i3 (Asbestos Bodies) in Maieml Ob tained 1\* Lung Puneture and in the sputum, J. Patio Bticu 32:172. 1929. ' 13. Vortvajd. A. T.; Durkan, 7. M,, attd Pratt, D. C: Exiierinumtal Studies on A#U-siosis, AAl-V Arch. Industr. Hvg. 3 1951. 14. VonvaUl, A. .1^ and Karr. J, \V.: Pneuami Pnlmon:ir>* Carcniuma. Amer. .1. Path. 14:49-58, 1938. fivomstrmr /2A