Document zoRKQ28yMjMadM2eMX441Z7O3

4f* .gL: One of ..e of cur* imVctious :;*t)Locc<* i tamilic-' i t HI iru Case Reports ASBESTOSIS ASSOCIATED WITH BRONCHOGENIC CARCINOMA oOCA^\ EDS".ROGER STOLL, M.D. Tu\c. RICHARD BASS, AMO F ALFRED A. ANGRRIISSTT,, M.D. MQT JAMAICA, H* Y. HQLLEB and Angrist1 in 1942 reported two cases of bronchogenic carcinoma in association with pulmonary asbestosis. The first case of carcinoma of the lung in association with pulmonary asbestosis was reported in 1935 by Lynch and r- r-- Smith.1 In that year Gloyne reported two cases and in 1936 another.3 Egbert and Geiger * reported one case in 1936. Nordmann * presented two cases in 1938. One year later Lynch and Smith * added another. Of these, six were of squamous cell carcinoma, one of squamous-cell carcinoma with glandular features, two of. oat-cell carcinoma, one of glandular carcinoma, and another of squamous-cell non- keratinizing carcinoma. The age of the patients ranged from 35 to 71 years, and the duration of exposure, from 19 months to 25 years. All but two had metastases. Freedom from exposure before death varied front four months to 15 years. We have found four additional cases not mentioned in the report by Holleh and Angrist1 Two cases reported by Koelsch' in 1940 were in an oral communication, and no -details are kncwnr-Two-more cases were reported by Linzbach and Wedler1 in 1941, one of which was of a squamous-cell carcinoma in a man 61 years old, exposed for at least three years' to asbestos; of the other, no. details were known. In 1941 also Desvneules9 added two more cases to the literature, one of a man 57 years old in whom alveolar-cell carcinoma was found and who had been, exposed *8 From the Departments of Pathology and Medicine (Dr. James R. ReuEng. Director), Queens General Hospital. 1. Holleb, H, and Angrist, A.: Bronchiogenic Carcinoma in Association with Pulmonary Asbestosis: Report of 2 Cases, Am. J. Path. 18:123-155. 1942. :c. 2. Lynch, K. M., and Smith. \V. A.: Pulmonary Asbestosis: III. Carcinoma of Lung in Asbesto-Silicosis, Am. J. Cancer 24:56-64, 1935. 3. Gloyne, S. R.: Two Cases of Squamous Carcinoma of the Lung Occarrmg in Asbestosis, Tubercle 17:5-10, 1935; Case of Oat Cell Carcinoma of Lung Occurring in Asbeetnsis, ibid. 18:100-101, 1936. 4. Egbert. D. S, and Geiger. A. J.: Pulmonary Asbestosis and Gtccnoma: Report of a Case with Necropsy Findings. Am. Rev. Tuberc. 34:143-150, 1936. 5. Nordmann, M.: Der Beruiskrebs der Asbestarbeiter, Ztschr. Kotbsiorseb. 47:28S-302, 1938. . / 6- Lynch, K. M., and Smith, \V. A.: Pulmonary Asbestosis: V. A Report of Bronchial Carcinoma and Epithelial Metaplasia, Am. J. Cancer 36:567-373, 1939. 7. Koelsch: Lungenkrebs und Eeruf, abstracted in Zcntralbl. Gewerbrfivg. 7:32-33, 1940, 8. Linzbach, A, J.. and Wedler, H, W.: Beitrag zutn Benifskrebs der Asbestarbeiter, Arch. path. Anat. 307:337-109, 1941. 9, Desmeules, R.; Rousseau. L.: Giroux, M,, and Sirois, A.: Amiantose et cancers pulmonaires, Laval med. 6:97-108, 1941. ___ 831 | BB 0007301 | THIS DOCUMENT WAS NOT A RECORD OF PPG INDUSTRIES* INC. DID NOT COME FROM IT'S FILES AND CANNOT BE AUTHENTICATED BY PPG INDUSTRIES,. INC. GG 15310 832 A. M. A. ARCHIVES OF INTERNAL MEDICINE to asbestos for 25 years. The other- was of a man of 50 with squamous-cell carcinoma who liad been exposed for 22 years. Both had metastases to the pleura. Since 1941, a number *of similar cases has been reported. In 1942 Homburgcr10 reported three cases in men 45, 43, and 49 years of age. In two, squamous-cell carcinoma was found; in the other, an anaplastic carcinoma. One had been exposed to asbestos for five years, another for 20 years. The duration of exposure in the third was not known. All three had metastases. In Homburger's laboratory from 191S to 1938, in 4,137 autopsies, asbestosis was diagnosed in eight cases. Pulmonary carcinoma was found in four of these. Wedler11 in 1943 collected 92 postmortem reports of cases of asbestosis from different parts of the world and found an incidence of 16% with associated pulmonary carcinoma. In 1947 Merewether112011r3e1viewed the accumulated data over a period of 22 years (1924 to 1946) in the "Annual Report of Chief Inspector of Factories in C/3 -Lj England." In 235 cases asbestosis was found, and in 31 of these pulmonary card- f ~-- noma was also present, an intidence of 13.2%. The inddence of pulmonary 1 cardnoma in the general adult population was 1.0%. Lynch and Cannon in 1948,11 reported that among 40 cases of asbestosis over -- a period of 18 years in their postmortem series a total of 3 cases of carcinoma of ~~v; , the lung was encountered, an incidence of 7.5%. Each of these three cases showed C./ - medium to advanced grades of asbestosis. dT dj. Wyers in 194914 reported on a series of 115 cases of asbestosis. Pulmonary cardnoma was present in 17, an incidence of 14.8%. Squamous cardnoma was present in nine cases, oat-cell cardnoma in jive, and columnar-cell carcinoma in one. -v* x-- 7*"" REPORT OF CASE I1' j D. L., a white man 40 years old, Was admitted to Queens General Hospital complaining of cough, fever, and weakness of two weeks' duration. For four to five mouths prior admission he felt weak and slightly anorectic, with a weight loss of about 10 lb. (4.5 kg.).-- Two weeks prior to admission his weakness became more marked, and he began having a dry persistent cough which was nonbloody. He visited his local physician at that time fnd was found to be febrile. A roentgenogram was taken, and he was told he had viral, pneumonia. He . was treated with penicillin, sulfonamides, chloramphenicol (chloromycetin*), and aureomycin without a fall in temperature, and with persistence of the cough. His local physician then advised hospitalization. There was no history of previous illness. From 1925 to 1940 he had worked as a plumber but did not use asbestos in his work. In 1940 he obtained a job with the Works Progress Administration as a pipe coverer in which he worked with asbestos exclusively for one and a half years. For the next four and a half years he continued to work as a pipe coverer in a shipyard, where he again used asbestos only. During this time he was told to wear a mask while working but neglected to do so and complained that the smell always made him sick. o o 10. Homburger, F.: Co-Incidence of Primary Carcinoma of Lungs and Pulmonary Asbesto sis: Analysis of Literature and Report of 3 Cases, Am. J. Path. 19:797-807, 1943. 11. Wedler, H. W.: Asbestose unrt Lungenkrebs, Deutsche med. Wchnschr. 69:575, 1943: abstracted. Bull, Hyg. 19:363, 1944. 12. Merewether. E. R. A.: Annual Report of the Chief Inspector of Factories, London, His Majesty's Stationery Office, 1947, 13. Lynch, K. M, and Cannon, W. M.: Asbestosis: VI. Analysis of 40 Necropsied Cases. Dis. Chest 14:874-880, 1948. 14. Wyers. H.: Asbestosis, Post-Grad. M. J. 25:631-638, 1949. I --.'i-'-'y.-1r.i,, tijaZjjT ^1iaAkililiW>M ,,ir, :ia :--.:ry.-r .rianis-cell IT i'XJXSCtl -: in the ;*try from 'monary '-is tpmt rt>l oi 22 .stories in :.;ry carcirnlmonary -'.O'is over. : cin>*ma oi . -t < showed :'ulnionary niima was - i mplainiiv-t it* l>riiir to t-1.5 kg.).' nvitig a dry "'a- and was rv.otlia. He : aureomycin 'ysician then iv. lib work, e coverer in ; ext four and `l'fd asbestos "id to do so "iry Ashesto- 0:575, 1943: 'ies, London, r. ipsied Cases. STOLL ET AL.--ASBEST0SIS-BR0NCII0GEN1C CARCINOMA 833 Physical examination revealed a well-developed, well-nourished, moderately ill white man lying in bed and coughing: Examination of his' chest disclosed a slightly diminished percussion note with depressed breath sounds and occasional expiratory wheezes at the base of the right lung. There were no unusual findings in the heart, abdomen, extremities, or venous system. Laboratory Data.--The temperature wras 102.4; the pulse rate, 104 per minute, and the blood pressure, 120/76. The urine was normal. The hemoglobin concentration was 15.5 gm per ICO cc. and the white blood cell count 10,000 per cubic millimeter, of which 75% were polymorphonuclear cells. The Wassermann reaction was negative, and blood chemical values were within the normal range. Examination of the bone marrow revealed clumps of malignant cells. An electrocardiogram was normal. A chest roentgenogram taken shortly after admission showed generalized, large discrete oval shadows of increased density throughout both lung fields indicative of pulmonary metastases. A bone survey revealed multiple osteolytic lesions in the cranial vault in the frontal and parietal regions. The long bones and pelvis showed no lesions. The appearance on retrograde urography and on a gastrointestinal series was normal. Proctoscopy revealed no abnormal findings. - Throughout the patient's hospital stay the temperature continued to range from 101 to 104 F. On the ninth hospital day he complained of numbness of the right arm, with definite weakness or the right peripheral facial nerve. There were no definite motor changes in the extremities. A spinal tap performed at this time revealed crystal-dear fluid under no increased pressure: The cell count was 0; sugar measured 72 mg. proteins, 28 mg., and chlorides, 115 mg, per 100 cc. On the 28th hospital day the patient displayed Babinsld's sign with hyperreflexia on the right side. On the 31st hospital day a course of treatment with nitrogen mustard (methyl-6r or tris[2-chloroethyl] amine hydrochloride) was started and given for three days without improvement. His condition went gradually downhill, and he .died on the 54th hospital day. The final clinical diagnosis was metastatic carcinoma to lung and bone, primary site unknown. Postmortem Observations.--There were no adhesions or fluid in either pleural space. The pleural surface of the lung was studded with nodules varying to 2 cm. in diameter. These were yellow, slightly .raisecU and.idughly rounded in outline. The cut surface of the lung showed these nodules to be scattered throughout both lungs and varying to 4 cm. in diameter. `The right lower bronchus opened into a cavity about 2 cm. in diameter which was filled with necrotic material. The right upper bronchial site of tumor tissue was not discovered. Interstitial fibrosis was present throughout the lung, with areas of chronic pneumonitis. In addition, there was an area in the upper part of the middle lobe of the right lung which was dark red and noncrepitant, measuring about 2 cm. in diameter. This resembled infarct in the gross, but on microscopic section it was seen to be atelectasis and pneumonitis. At the upper pole of the right kidney, a nodule measuring 2 cm. in diameter was noted. This was raised, rounded, firm, and yellow. A similar nodule was observed in the lower pole of the left kidney. Several swollen nodules were seen scattered through the remainder of both kidneys. In each frontal lobe of the brain was seen an oval-shaped area, 2 cm. in diameter, containing small hemorrhages, which was slightly paler than the surrounding tissue. These areas were surrounded by a small area of softening. In the liver occasional small, white, discrete nodules were noted. The largest of these measured 0.5 cm. in diameter. The other organs appeared normal. Microscopic Study.--The neoplasm was composed of loosely arranged cells, irregular in shape, varying in size, and staining quite markedly. Many mitoses were seen. There was no regular arrangement of these cells into any pattern. These cells were mingled in an unusual manner with plasma cells, lymphocytes, and fibroblasts, and many giant multinuclear cells were noted. Large areas of necrosis were seen throughout the lung. . Typical club-shaped brown asbestos bodies were seen throughout the lung in the tumor and outside the tumor areas. Metastases observed in the kidneys, brain, and liver showed a similar histological appearance, including extensive areas of necrosis. NOTE: THIS DOCUMENT DID NOTCOMEFROMPPGFILES Mi CC 15312 834 A. it. A. ARCHIVES OF INTERNAL MEDICINE Chemical examination yielded 80 mg. of silicon dioxide per 100 gm. of tissue. The final diagnoses were (1) anaplastic carcinoma of the lung with possibility of multicentric origin, with metastases to kidney, brain, and liver, and (2) pulmonary asbestosis. C01I itENT The diagnosis of pulmonary asbestosis is based primarily on a history of a long exposure to asbestos dust. The most consistent complaint is dyspnea. Other symp toms are a chronic cough, weight loss, fatigue, and occasionally chest pain. Exami nation of sputum may disclose asbestos bodies. A roentgenogram may reveal little or show a haziness only. In regard to the mechanism of the malignant change in asbestosis, it is question able whether the silicate in asbestos itself is directly carcinogenic or whether the silicate causes bronchiectasis with metaplasia due to irritation of the bronchial epithelium, thus leading to carcinoma. The former mechanism seems significant, since this high an incidence of carcinoma does not occur in. other forms of silicosis, though they do tend to produce an equivalent degree of bronchitis and bronchiectasis. CONCLUSION'S A case of bronchogenic carcinoma in association with pulmonaiy asbestosis is presented. The importance of this association of carcinoma in cases of asbestosis is indicated from the review of the literature presented. This- association emphasizes the hazards of industrial exposure, the compensa bility of the cancerous process as well as the asbestosis, and the need of careful preventive measures, j__ * GG 15313 0007304"