Document yrBX1NjJ591Y13eXVgOKo9pb2

4 'JOTE'. itT'b "' S, < r j I-# ^ PULMONARY ASBESTOSIS AND CARCINOMA Report of a Case with Necropsy Findings1 DAN S. EGBERT and ARTHUR J. GEIGER Although there is a steadily growing recognition of pulmonary asU-losis as a disease entity and industrial hazard, the number of reported ci-os is still small. In a recent review by Egbert (1), in which 28 fatal c.i'ts were collected, pulmonary tuberculosis was found to be a common^ , ..triplicating disease. Tlje following report was deemed especially^' foresting since it is apparently me nrst to describejprimary carcinoma J ct'TruTlung as an associated condition. i Case Report //: lory: J. V., a 41-year-old Hungarian factory-hand, was admitted to the Tuberculosis Ward of the New Haven Hospital, May 11, 1934, complaining of iong-standing breathlessness and cough, and a recent disabling pain in the back. * The patient's mother had died at the age of 33 with a protracted "cold in,, the chest"; his father had met death by accident. Two siblings, as well as the patient's wife and two children, were well. No family history of tuberculo sis or of carcinoma was obtainable. The patient had immigrated in 1911, when he was 18 years old. Five years hic-r he secured employment as a weaver in an asbestos factory, and he con tinued at this occupation uninterruptedly for IS years. lie had considered his general health good until 1925, when he suffered a febrile illness of sudden onset and associated with pain in the left chest; the diagnosis had been "pneumonia." Although the acute illness subsided within a week, the patient was left with distressing dyspnoea on exertion and a moderately productive cough which prevented his returning to work for five months. X-ray examination of the lungs at this time was reported to have revealed nothing abnormal, and the ; client resumed his occupation. His symptoms, however, persisted unabated fi-r the next seven years. At the end of this tinurwhich was two years before t!ie present hospitalization, alterations at the asbestos factory led to a great redaction in the amount of atmospheric dust to which the patient was daily exposed ami bis respiratory symptoms disappeared almost completely. During the eight months preceding his hospital admission the patient dc- From the Dcpartno.-nt ot Pathology and the Dipp.r'rr.ent of Tr.lt.Tral Medicine, Vale easily School of Mu-dirine, New Haven, Connecticut. pior'l IMFNT WAS NOT A RECORD OF - "isssss;rrs FILES AND CANNOT BE AUTHENTICATE* BY PPG INDUSTRIES, INC. CC 15219  1* t - ( V note THIS oowwito ./vv* /'.,*' ;i '. i' Ik i SLuO 144 DAN . EGBERT AND ARTHUR J. GUI "EE. veloped an insidious, gradually increasing pain of aching character throughout the bad;. Although the removal of five allegedly bad teeth and the applica tion of heliotherapy to the back were followed by temporary amelioration of the pain, its recurrence with gradually increasing severity soon resulted in the patient's complete ir.capadty for work. During the month before admission the dyspnoea, cough and expectoration had returned along with pain of pleural character in the left a villa. The sputum was described as white and heavy, but not foul. The patient had lost 40 lbs. in the last several months. Physical examination: A lean male of sallow complexion with anxious, care worn expression. He looked chronically ill and his loose skin suggested that weight loss had been considerable. The patient's movements in bc-d were cautious and deliberate, apparently to avoid pain. The respirations were regular, 30 per minute, and notably shallow. The lips were cyanotic. A frequent, loose cough "raised" thick, yellowish and blood-streaked sputum in abundance. Dirty teeth, a lightly coated tongue, and injected tonsils were observed incidentally. The chest, with barely per ceptible respiratory movements, was definitely asymmetrical, with tjie left, side fatter and less mobile than the right. No measurable diaphragmatic excursion could be-demonstrated. *Eoth sides of the chest were dull over the . lower lobes, and numerous crepitant and medium moist rales were scattered from scapular angles to bases. The heart did not appear displaced or enlarged and, except for tachycardia of 110 beats per minute, no abnormal signs were noted. A arm, subcutaneous nodule, about 1 cm. in diameter, was found in the left Hank. Movement and manipulation of the lower spine and flexion `of the thighs caused agonizing pain in the back with radiation down the thighs. The extremities were remarkable only for .moderate dubbing of the fingers with double curvature of the nails, and the nail-beds were cyanotic. The rands, though calloused, presented no "asbestos corns." Laboratory studies: The red blood cell count was 5,400.000, with 92 per cent haemcglobln: the leucocytes, 13,550, of which 9 per'ccnt were p;*I> m.orphonuclears. No tubercle bacilli were ;Vmd in any of the 6 s; .einens of sputum examined. The urine was normal, and Kahn test of the blood negative. Be cause of extensive bone disease seen by X-ray} chemical examination of the blood was incidentally carried out, with the following results: The serum's calcium content was -27 m.gm. per cent, and the phosphorus 4.05 mgm. per cent, with a total protein level of 6.14 per cent, of which 3.19 per cent and 2.45 per cent were made up of albumen and globulin r^pwctively. The icteric index was 4. gg i.c,;:o 1 SB 0007211 j I't/LM'-NAI'Y i * i- > \i'< rr-.-.MA 1-J5 tinal and cardiac shadows were normal in character and position, hut the hilar shadows on both sides were increased in size and density. The bronchovascular markings throughout both lung-fields were obscured by a coarse, rather dense, nodular infiltration, which roughly followed the course of the linear mark ings and was symmetrically distributed throughout both entire lung-fields. In the left lower lobe was an associated haziness, with a poorly defined area of complete opacity between the left heart border and lateral chest-wall. The latter change suggested partial atelectasis or a pneumonic process in the left lower lobe. In view of the additional discovery of widespread destructive bone lesions of the pelvis and lumbar spine, which were characteristic of metastatic carcinoma, the pulmonary findings were summarized as pneumonoconiosis and additional infiltration of the left lower lobe due probably to a malignant bron chogenic tumor. Course: Throughout the ten days of hospitalization there was fever ranging continuously between 100 and 103F., with the heart rate varying between 100 ami 130. The patient complained repeatedly of distressing pains in the back and thighs, and analgesics had to be administered liberally. A steady and profuse perspiration sometimes required several changes of clothing daily. After a few days, patchy signs of pulmonary consolidation and pleurisy ap peared over the'lower lobe of the left lung; with this, the cyanosis grew deeper and the dyspnoea became so extreme that the patient found it difficult to take his meals. A loose cough produced bloody sputum in moderate amounts. On the last day, after a series of particularly violent coughing spells, the patient's pulse suddenly weakened, the skin grew clammy, and he complained of a >niothcring sensation in his chest. In spite of stimulating measures, including adrenalin and' cafTein'hypodermically, death ensued within a few minutes of the onset of collapse. V- < ro/>sy: The report of the necropsy findings will be limited to the pertinent changes in the lungs. Both pleural cavities were completely obliterated bv i -'m fibrous adhesions. The lungs, after removal from the body, retained al.T-.-ii the shape which they had while in siln. With the parietal pleura and t Tt <>f the adherent diaphragm attached, the right lung weighed 1,179 and the ! ft 1.12S gm. They were both fairly noncrepitant and of a rubbery firmness 'hich rendered sectioning unusually easy. The grayish-red surfaces, which re mottled with large amounts of black pigment, revealed a large, solid tumor t^'t' periphery of the lower lobe of the left lung (figure 1). The mass meas! 'I M'provimately 5x5x4 cm., its edges were well demarcated, and it was -t .urav witfi monied zones of black pigmentation. A few tumor nodules, 1 BB 0007212 | NOTE: THIS DOCUMENT DID NOT COME i T ' $ 146 lr\ S. LMJJ.RT \Sl> \KIHt K 1. GKICEK aLoul 1 cm. in diameter, were scattered through the remainder of the lungs and had a mucinous appearance on section. At the hilum of the left Log was a large, firm lymph node measuring 2 x 1.5 x I cm., which revealed about half Fig. ]. rulmeiiary asbestosis \\ ith bronchogenic Cdrcinuma: B, pi unary fill in main bronchus of lift lower lobe. rholtmicrcigraph of this region is shewn in figure 2. its substance to be occupied by tumor metastasis. A lymph node of similar dimensions was present at the hilum of the right lung.but it contained no tumor. Cartful t.vaminations'of the bronchi revealed the primary site of the tumor to | BB 0007213 1 148 M i ash \i;'ii:n: J, (.l'.U.CR be in a large brar.th <:' the main bronchus of the left lower lobe (see II, figure 1), Al this point the r-.uccs.nl suii'ace was roughened and finely nodular; the bron- chial wall was thickened ami infiltrated by firm, grayish tumor tissue. The bronchus itself led directly into the large tumor mass described in the left lower lobe. Miscroscopic examination of fresh fluid scraped from the cut lung surfaces (CD showed large numbers of typical asbestosis bodies. Histological sections confirmed the primary site of the tumor in the bronchus ^ , of the lower lobe of the left lung (figure 2). Here in the submucosa and in a considerable zone of the peribronchial tissue were groups of carcinoma cells arranged in well-formed acinous structures which varied greatly in size and ' shape (figure 3). The neoplastic cells lining the acini were one to several layers in thickness. They were almost all hyperchromatic, varied consider- f. ably in size and shape, and exhibited very few mitotic figures. The arrange- - ment and appearance of these cells were quite similar to those of submucosal . bronchial glands. There was a tendency for the nuclei to be located at the base of the cells similar to their position in normal submucosal glands. Many of the carcinomatous acini were filled with a pale, gray-staining mucinous material, and in some of the preparations of the bronchus apparently normal submucosal glands could be seen merging with carcinomatous growth. -J' Asbestosis bodies were scattered throughout the pulmonary parenchyma, in alveoli for the most part and also extending through the carcinomatous zones ), O& (figure 4). The color of these bodies was yellowish-brown to brownish-black. They had varying shapes, but {ended to be in the form of nodular rods with enlarged rounded heads. In, many of the*bodies a'central somewhat .paler and translucent core apparently represented the original asbestos fibre (figure 5). These asbestosis bodies did not give a positive iron reaction. Tn many, in stances they were enclosed in the cytoplasm of the macrophages, which were very numerous in the alveoli. Many of the macrophages were mullinudeated and extremely large. There was some diffuse, fibrous thickening of the alveolar walls, and the regions around the bronchi and bronchioles contained a large amount of fibrous tissue. The pleura in all the preparations was thickened, dense and hyalinized. Tumor metastases. besides those in the lungs and tracheobronchial lymph nodes, were also present in the aortic lymph nodes, the right adrenal gland, the left external oblique abdominal muscle, and in the bony pelvis, \ertebrac end skull. DISCUSSION Pulmonary asbestosis. a form of pneumonoconiosis which is growing in medical and industrial importance, has been fully discussed in a GG I5PP1 NOTE: THIS DOCUMENT NOT COME FROM PPG F PULITONAT.Y ASBESTOSIS AND CAhCiUOlLK U9 rtcc-nt review by Gloyne (2). Clinically, the condition is characterized cr.icily by dyspnoea, by the appearance of a fine, diffuse fibrosis, and by aibestosis bodies demonstrable in the sputum. A review of the fatal cases reported in the literature up to 1932 (1) indicates that the condi tion comes on slowly and requires an average of 9 years of exposure to the dust before the onset of symptoms. The total time of exposure in uncomplicated cases with fatal terminations was found to average ]G vc-ars. Pathologically, the pulmonary fibrosis is diffuse and is most marked around bronchioles and bronchi. This is in distinction to the fibrosis of silicosis, which consists of discrete, dense, hyalinized connec tive-tissue nodules around and in the pulmonary lymphoid tissue. Asbestosis bodies are always demonstrable in the microscopic sections. The association between the pulmonary asbestosis and carcinoma in this case is unique and the possible interrelationship of the two processes offers interesting speculation. Gloyne (2) mentions one case of pul monary asbestosis with carcinoma of the pleura and adds, "There is ro evidence at the moment that this is in any way related to the as- bfstosis." Otherwise, no mention of any such associated pulmonary r-.aligrant.tumor has been found in the literature. The relationship between exposure to irritating dusts.and malignancy of the lung has atpused a great deal of comment, especially since variQus statistics would tend to show that the incidence of pulmonary cancer is increasing. Recently, Hruby and Sweany (3) have analyzed the incidence oT cancer of the lung and they conclude that not only has there been an approximately tenfold increase in the number of cases coming to autopsy within the last forty years, but that a twofold increase has occurred in the last ten years alone. Reports of other forms of pneumonoconiosis in which carcinoma of the lung has occurred are fairly numerous. It' is not uncommon in silicosis (4). The incidence (10 per cent) of carcinoma of the lung found a*, autopsy among the cobalt miners in Schnccberg is well known (S). Tj-.a; the irritating effects of the inhaled asbestos-particles, mav in ' jh:cu=f have been a s'cr/ffcant factor concerned in ,,thedeye'opment,of r-j--.an- lung cancer seems_sui5dgntl^-phiu5ible to be_ worthy -of - -r.s:crr:;`.ion. ' SUiniAHY * . The clinical_and anatomi cal findings arejpreson t <:-d in ajiasc_of < -m.onary asbestosis with an associated primary carcinoma of the lung. I \o 4 BB 000721 f^T^i^sppQ p(LE| ISO l)AN S. EGBERT AND ARTHUR J. GEIGER 2. The associated incidence and possible aetiological relationship; pneumonoconiosis to carcinoma of the lung are discussed. REFERENCES (1) Ecbest, D. S.; Pulmonary asbestosis: report of a case with necropsy finding, A- Rev. Tuberc., 1935. urn, 25. (2) Gloynt, S. R.: Morbid anatomy and histology of asbestosis. Tubercle, July, Aupa; | September, 1933, xiv, 445; 493; 550. (3) Hpcey, A. J., a.nd SweanY, H. C.: Primary carcinoma of lung with special referti:* *. incidence, early diagnosis and treatment. Arch. Inb Med., 1933, lu, 497.., (4) Klotz, 0., and SihpsON, W-: Silicosis and carcinoma of lung, Libman Anniv, Vok, !' . ii, 6S5. (5) Obeentjopjxh, S.: Das Lungenkarzinora, MOncben. med. Wchnschr., 1933, ka, I_BB 000721 7~J '"V /_ / !' j