Document yk3G8K2pVe8eqKzBeQzmY4o26

FILE NAME: Talc (TALC) DATE: 2019 June DOC#: TALC186 DOCUMENT DESCRIPTION: Medical Journal Letter to the Editor Malignant Mesothelioma and Its Nonasbestos Causes Localized Renal Masses: Comment on Recent American Urological Association Guideline To the Editor.--Localized renal masses are increasingly being detected as incidental findings during imaging studies and the clinician must decide to excise, ablate, follow, or perform limited tissue sampling for diagnosis. A guideline on management of local ized renal masses was published in 2009 by the American Urological Association (AUA).1 In 2014, the AUA assembled a group of experts to update the guideline, focusing primar ily on evaluating and managing clin ically localized masses in adults suspicious for renal cell carcinoma.2 The expert panel that updated the guideline included members of the AUA and representatives from the College of American Pathologists (CAP), the Society of Urologic Oncol ogy, the American College of Radiol ogy, the American Society of Nephrology, the Endourological Soci ety, and the Society of Interventional Radiology.2 In March 2017, the AUA requested the CAP's formal endorsement of the updated guideline. The CAP appoint ed a small group of pathologists (the Endorsement Review Panel) to review the AUA recommendations and pro vide their opinion to the CAP Council on Scientific Affairs and Board of Governors. After review and discus sion, the CAP endorsed the AUA guideline with one comment concern ing the method of solid renal mass sampling. Item 13 in the guideline states that for patients with solid renal masses who elect renal mass biopsy, ``multiple core biopsies are preferred over fine-needle aspiration'' (FNA) [italics added].2 We originally submit ted our endorsement comment to the AUA Practice Guidelines Committee and to the Journal o f Urology, but the 1-year limit on letters related to published articles had lapsed by the time of submission. Renal mass sampling is usually performed percutaneously under com puted tomography or ultrasound guid ance, by core biopsy and/or FNA biopsy. In reference to the accuracy of FNA, the only study cited in the AUA guideline is one by Patel et al,3 which reported a sensitivity of 62.5%. Arch Pathol Lab Med-- Vol 143, June 2019 Letters to the Editor Several recent studies on FNA of kidney masses have been published that show the diagnostic performance to be far superior to that found in the AUA guideline, albeit generally some what inferior to core needle biopsies.4-7 For example, in the systematic review and meta-analysis of diagnos tic accuracy of percutaneous renal tumor biopsy performed by Marconi et al,4 the sensitivity and specificity of diagnostic core biopsies were 99.1% and 99.7%, compared with 93.2% and 89.8%, respectively, for FNA. Core needle biopsy and FNA are ideally performed together because the 2 methods are complementary; occa sionally only the FNA will be diag nostic, whereas the core biopsy is nondiagnostic.8 Diagnostic yield for FNAs of the kidney is operator de pendent, and the yield may be low if the radiologist is not adept at per forming FNA. Some pathologists per form touch imprints from core biopsies, which confirms the adequacy of diagnostic material in biopsies.9 The recommendation preferring core biopsies over FNA was rated as a moderate recommendation with low strength of evidence (grade C). In the AUA nomenclature, this means that better evidence is likely to change the estimate of its effect; such recommen dations are not considered practice standards. The AUA guideline ac knowledged the limitation of its as sessment of FNA based on inclusion criteria of the systematic review.2 Many pathology practices analyze both kidney FNA and core biopsy; therefore, we recommend, based on the updated evidence, that core biopsy and/or FNA be performed at the discretion of the radiologist and pa thologist. Lisa A. Fatheree, BS, SCT(ASCP)1; Patrick L. Fitzgibbons, MD2; Priya Rao, MD3; Nicole E. Thomas, MPH, CT(ASCP)CM1; Ming Zhou, MD, PhD4; Rosemary Tambouret, MD5 1 Pathology and Laboratory Quality Center for Evidence-Based Guidelines, College of American Pathologists, Northfield, Illinois; 2 Department of Pathology, St Jude Medical Center, Fullerton, California; 3 Department of Pathology, UT MD Anderson Cancer Center, Houston, Texas; 4 Department of Pathology, University of Texas South western Medical Center, Dallas; 5 De partment of Pathology, Massachusetts General Hospital, Boston 1. Campbell SC, Novick AC, Belldegrun A, et al. Guideline for the management of the clinical T1 renal mass. J Urol. 2009;182(4):1271-1279. 2. Campbell S, Uzzo RG, Allaf ME, et al. Renal mass and localized renal cancer: AUA guideline. J Urol. 2017;198(3):520-529. 3. Patel HD, Johnson MH, Pierorazio PM, et al. Diagnostic accuracy and risks of biopsy in the diagnosis of a renal mass suspicious for localized renal cell carcinoma: systematic review of the literature. J Urol. 2016;195(5):1340-1347. 4. Marconi L, Dabestani S, Lam TB, et al. Systematic review and meta-analysis of diagnostic accuracy of percutaneous renal tumour biopsy. Eur Urol. 2016;69(4):660-673. 5. Yang CS, Choi E, Idrees MT, et al. Percutaneous biopsy of the renal mass: FNA or core needle biopsy? Cancer Cytopathol. 2017;125(6):407^ 15. 6. Cate F, Kapp ME, Arnold SA, et al. Core needle biopsy and find needle aspiration alone or in combination: diagnostic accuracy and impact on management of renal masses. J Urol. 2017;197(6): 1396-1402. 7. Renshaw AA, Cibas ES. Kidney and adrenal gland. In: Cibas ES, Ducatman BS, eds. Cytology: Diagnostic Principles an d Clinical Correlates. 4th ed. Philadelphia, PA: Saunders/Elsevier; 2014:423-452. 8. Chen AL, Brown PA, Sweeney BJ, et al. Smears are important for adequate cytologic diagnosis of kidney lesions. J Am S oc Cytopathol. 2017;6(4): 162-164. 9. Hahn PF, Eisenberg PJ, Pitman MB, Gazelle GS, Mueller PR. Cytopathologic touch preparations (imprints) from core needle biopsies: accuracy compared with that of fine-needle aspirates. AJR Am J Roentgenol. 1995;165(5):1277-1279. Accepted for publication February 14, 2019. The authors have no relevant financial interest in the products or companies described in this article. doi: 10.5858/arpa.2019-0023-LE Malignant Mesothelioma and Its Nonasbestos Causes To the Editor.--Attanoos and colleagues1 reviewed the literature con cerning nonasbestos causes for malignant mesothelioma. They con cluded that most mesotheliomas not clearly attributable to asbestos expo sure are spontaneous. Their review did not consider a common occult form of asbestos exposure arising from the use of talcum powders. In 1976, Rohl et al2 analyzed consumer talcums and re ported that 10 of the 20 products (50%) analyzed contained tremolite and anthophyllite. Blount3 reported asbestiform tremolite contamination of the ore used in a popular baby powder. Gordon et al4 found asbesti- Letters to the Editor 659 Letters to the Editor form tremolite and anthophyllite in a popular body powder, and Anderson et al5 found anthophyllite fibers in the same brand. Statista6 (Hamburg, Germany), a market research company, reported that some 100 million Americans used body and baby powders in the years 2011 to 2017. It is possible to draw inferences about the prevalence of exposures to talcum powders in sub jects with mesothelioma by querying the database of lung asbestos fiberburden measurements compiled by Victor Roggli, MD (Duke University Medical Center, Durham, North Car olina). Fiber-burden measurements were made on 566 subjects (female, n = 75; 13%) with pleural mesothelioma. Talc fibers were detected in 332 of 491 (68%) of the men and 62 of 75 (83%) of the women. The detection of tremolite was significantly associated with the presence of talc (P < .001) as was the detection of anthophyllite (P = .002). The presence of talc and asso ciated amphiboles was more common in women than it was in men (odds ratio, 3.24; 95% CI, 1.65-6.35). This would be expected if women were more likely to be users of baby and body powders than men were. Lung burdens of talc and its amphi bole contaminants are markers of exposure to talc-containing dusts. In addition to talc exposures from talcum powders, there has been occupational and hobby exposure to industrial talc in the United States, but the number of persons with exposures to industrial talc is small compared with the 100 million users of baby and body pow ders. I conclude that: 1. The use of body and baby powders is common in the United States. Consumer surveys found that about one-third of the population used those powders between 2011 and 2017; 2. Measurements of retail talc prod ucts have found amphibole asbestos contamination of those products; 3. A large series of measurements of asbestos fiber burdens in patients with pleural mesothelioma has found the presence of talc to be common, exceeding 65% among both men and women; 4. Women were more than twice as likely as men were to have talc in their tissues, compatible with the hypothesis that women were more likely to be users of baby and body powders. Without accounting for amphibole asbestos exposures aris ing from the use of baby and body powders, it is not possible to conclude, as Attanoos and col leagues have done, that ''In North America few mesotheliomas in women at any site are attributable to asbestos exposure.''1(p753) It is my opinion that, without ac counting for those occult asbestos exposures, it is inappropriate to con clude that ''most mesotheliomas not clearly attributable to asbestos exposure are spontaneous (idiopathic).''1(p753) Murray M. Finkelstein, PhD, MD University of Toronto, Family and Community Medicine, Toronto, On tario, Canada 1. Attanoos RL, Churg A, Galateau-Salle F, Gibbs AR, Roggli V L. Malignant mesothelioma and its non-asbestos causes. Arch Pathol Lab M ed. 2018; 142(6):753-760. doi: 10.5858/arpa.2017-0365-RA. 2. Rohl AN, Langer AM, Selikoff IJ, et al. Consumer talcums and powders: mineral and chemical characterization. J Toxicol Environ Health. 1976;2(2):255-284. 3. Blount AM. Amphibole content of cosmetic and pharmaceutical talcs. Environ Health Perspect. 1991;94:225-230. 4. Gordon RE, Fitzgerald S, M illetteJ. Asbestos in commercial cosmetic talcum powder as a cause of mesothelioma in women [published correction appears in Int J O ccup Environ Health. 2015; 21(4):347-348]. Int J O ccup Environ Health. 2014; 20(4):318-232. 5. Anderson EL, Sheehan PJ, Kalmes RM, Griffin JR. Assessment of health risk from historical use of cosmetic talcum powder. Risk Anal. 2017;37(5): 918-929. 6. Statista. U.S. population: most used brands of body and baby powder from 2011 to 2017. https:// www.statista.com/statistics/285799/brands-of-bodyand-baby-powder-in-the-us-trend/. Accessed July 16, 2018 Accepted for publication July 16, 2018. The author has served as a consultant toplaintiff's lawyers in asbestos and talc litigation. doi: 10.5858/arpa.2018-0145-LE Overdiagnosis of Thyroid Cancer: The Children in Fukushima Are in Danger To the Editor.--I am writing this letter because I was inspired by the editorial by Vicki J. Schnadig, MD.1 The children in Fukushima, Japan are in danger. In the thyroid screening program of the Fukushima Health 660 Arch Pathol Lab Med-- Vol 143, June 2019 Management Survey (FHMS), more than 200 children have received a diagnosis of thyroid cancer by ultra sonography (US) and fine-needle as piration cytology, and most of them have already undergone surgery.2 The number is still increasing because there has been no change in the screening program since 2011. We must reconsider the natural history of thyroid cancer. There are 2 major theories about thyroid carcinogenesis: fetal cell carcinogenesis and early-onset multistep carcinogenesis.3 It should be noted that in both theories, early detection of thyroid cancer in children can be harmful because of either overdiagnosis or diagnosis too early. Only a limited number of residents of Fukushima realize the risk of overdiagnosis in thyroid US screening because Fukushima Prefecture pro vides little information on possible negative effects of this program. Fur thermore, the US examination is performed as one of the school programs.4 Thus, even though the local government insists that the participa tion of residents is voluntary, most of the children and their parents regard it as mandatory. In fact, the rate of participation by schoolchildren is more than 90%. Only a few Japanese experts have reported on the possible harm caused by the FHMS, and there has been no recommendation to stop thyroid screening from related academic societies.5 This might be due to the following 2 reasons: First, the FHMS, which was planned by chief Japanese experts, was started as a large national project with a budget of up to $1 billion. Currently, there is an awkward atmosphere, with Japanese experts not willing to talk about the harm caused by this project. Second, as also hap pened in the case of Korea, numerous experts still do not understand the concept of overdiagnosis. They can see no harm in the early detection and treatment of cancer. Some say, ''This should not be called overdiagnosis, since the FHMS helps to reduce the anxiety of residents.'' Others say, ''The harm caused by US thyroid screening in Fukushima is very limited, since the procedures are carried out with care.'' Overdiagnosis of thyroid cancer in Fukushima has occurred in the youn ger generation. The harm is more serious than that which occurred in Korea. The children who receive a diagnosis of thyroid cancer are regard- Letters to the Editor