Document zod2YEDqnZ9vKaxzb5ZLq8pdg

R&s 104473 Angiosarcoma of the Liver Following Vinyl Chloride Exposure J. Bradford Block. MO Nwnll|. jndouieMM of fho llvor has bean found In six worker* **paaad Is vinyl chlorido. This ralationship has navar boon rocognizod. UMM 229:93-54. 1S74) . of a peripancreatie node. Infiammatinn, consistent with cholangitis in the ascend ing duct, was observed. Tlx patient dil . on Dae 19. Diagnosis at autopsy was angioaraama of the liver. THE B. F. Goodrich plant in Lnuisvfttt> Ky, has recently, voluntarily and admirably, released tha intorma- ths that several of thair employee* Jknid to vinyl chlonda have died of ^HTfioearcoraa. This has boon a unique situation. Gas l-flv patient, a *4-year old man sdm had worked in the vinyl chloride araa for IS peers. was tm admitted ox hoepital aa Aug 67. with an enlarged Cpieea aad liver, Boentgenngraphy of the Uppar gaeuvinteetiaal tract, angiography, sad a bone marrow biopey were per formed. On Aug 23, he n* transferred to aaethm hospital for surgery. The diagseem at that time was carcinoma of the liver. The patient had a svmpaUxetomv on 3, sad a vagotomy with pyloroplasty ea Sept 9l On Ovt 2, he underwent splenec tomy, aspiration f a liver "hematoma," and a wedge iHNtse of a liver tumor, which waa diagnosed as angiosarcoma. Chemotherapy by intra-arterial infusion begin on Oct 3. and was repeated on Nov r, and Dec 12. The patient died on Jan 7. 1966, and diagnosis uf angiosarcoma of the liver waa confirmed at autopsy. Cam I-A 3*-y;r-old male worker, who bad worked with vinyl chloride for 16 brmOeOpleerun*** jf Conviliirq Group. LaCar frsonloo Set- hone <sa-vtv to i22s Cap-tsi Piers Tower, rienerert, nr sitaji (Or ewes) yenrs. was first admitted to the hospital on Jan &, 1970. He complained of general weakness and had a history of tarry stool*. The working diagnosis was bleeding gas tric ulcer. He responded well to conservelive treatment and was released. He waa readmitted in Marrn 1970. At exploratory laparotomy on March 5, a diagnosis of canear of the liver waa made. The patient died Sept ST, 197L Gross and microscopic exam inations at autopsy confirmed the diag nosis of angiosarcoma of the Hvr. Case A--Ibis male worker. SO yearn of age. waa first admitted to the hospital in 1964; he had worked in the vinyl chloride area for 17 years. The diagnosia at that time was a bleeding gastric ulcer. He re sponded well to conservative treatment aad was released. He was again hospi talized on May 10. 1963, with the same diagnosis. AL surgery. so ulcer was found. A portal shunt was performed, and an open liver biopsy specimen was taken. A diagnosis of toxic hepatitis resulting from "densicJi" was made. >iaill>Udder sur gery was performed Oct 19. 1970. The pa tient died on March 3. tT;{. At autopsy, a diagnosis of angiosarcoma of the liver was made on the basis of gross and microscopic evidence. Caw A--Another male worker, in the same plant for is years, waa first admitted to the hospital on Juiy 13. 1973. when he was 3s years of age. Uf had hepatosplenfimv^-.ily of unknown causation On Aug an exploratory Innurniomy was performed. Multiple biopsy .-pccimena of the liver were taken as well as a specimen Cam A--The patient, n 32-year-old man, had worked in the vinyl chloride area for almost 2D yean. He was first admitted U> the hospital in January 1961 The diagnosis on admission waa cholecystitis. He had had vague pain in the right upper <iuadrant for some tune, but no other complaint!. At surgery, a mass was discovered in the dome of the liver. It was thought to be a hematoma and an attempt was mad* to drain it Further investigation showed me tastasis to both lungs. The ease was complicated by intrapleural hemorrhage. Death on April 4. 1964. was attributed to cardiac tamponade. At autopsy, diagnosis of angiosarcoma of the liver with wide spread metastasis was mud*. Both lungs, ss well as the heart and bowel, ware in volved. Microscopic examination of liver tissue from outside the area of the tumor showed "minimal hepatitis." fra* 6--The patient, n 47-year-old man. was hospitalized in February 1974. He complained of vague pain in the right up per quadrant. Examination in the company laboratory showed an elevated level of lac tic dehydrogenase- type 4 On admission to the hospital, concentrations of lactic Jrhy. drngenase and serum alkaline pko-mtaie were elevated. Chest roentgenogram and lung scan were normal. Kevults of the Iv.er scan were questionable. On the best* of the man's work history, it was derided to per form an open biopsy of the liver. The liver was large and widely involved with n>-pla-m, the mam mass bring in the dome of the liver. The tumor appeared to ( -nfined to the liver itaelf. Microscopic exami nation of the hiop.y specimen* d--m<mitraied angiosarcoma of the liver. The JAMA. July 1. 1974 e Vol 229. No 1 Lhmr Angiosarcoma-Bloc* 63 patient ha* worked in the vinyl ehinnde am fr IS years. The 4iati<mta <>( of the lt*f *i' n.nhrm| >n j!I m nw by |u*- thnlnguU at the Nath.rui Institute* of IMtll The psUmWi'i' .n-o r**|->neii that (nBff4ni Oiwnl "an ^nu u*l type of cir- rhnsraThey had no fn-tt.. r rumimni * nyt U> ay that tin- cirri!.i was dwV MUl| nK of til* akuhoiir tvpr Cammant Primary carcinoma of the liver (sometimes called kupiTer roll sarruma. homangioendotmlionia, angio sarcoma, angiomnii>i nu*cmiy- moma. or hemangioblastoma) is uacummon in this country. and pri mary carcinoma of mesodermal origin extremely rare. To date, of these tumors in adults have lm.ii reported in tha world literature (this figure does aot include cases in children or ThorMnst caaesl.' None of the tu mors was in any way linked to vinyl chloride exposure. Pour of the patients described here had some nonalconolic form of cir rhosis of the liver. It is possible that preexisting cirrhosis due to other enuaas msy play a ride in the genesis of vinyl chloride-associated angiosar- About two thirds of all carcinomas of the liver have a clinical onset char acterised by indefinite abdominal symptoms that are usually attributed to gastric disturbances.- In the six cases we have reported, three of the neoplasms that had resulted from vi nyl chloride exposure were at first diagnosed as gastric ulcers. The liver was enlarged in all six. In vinyl chloride workers, the se rum alkaline phosphatase determina tion appears to be more sensitive than other serological tests. Levels of serum glutamic oxaloacetic transami nase are also elevated in a high per- centag of putientx, hut this does not occur until late in tne course of their disease.' A test for u>c presence of al* phafetoprutein in patients with pri mary liver carcinoma, as demon strated by Tatarinov,* may be used as a diagnostic prm-edurv, hut the value of this tst in serening vinyl chloride worker* has not lawn established. Photoacanning with iodine 131, rose bengal, and gold Au lift* may be use ful in identification of the tumor. Percutaneous needle biopsy has been successful in identifying liver carci noma in aliout one third of the cases. The vascular nature of this tumor, however, increases the possibility of exsanguinating hemorrhage, and these p-ucvdurcs are contraindicated when angiosarcoma is suspected. In adults, carcinoma of the liver, if untreated, is umfurmly fatal within six months. The use </ chemotherapeutic agents is of palliative value only. Carcinoma of the liver can lie cured only by sur gical excision and this is possible only when the lesion is well localized.* In one senes' of 11$ cases, however, only 27% of all carcinomas were resectable. Radiation therapy may alleviate symptoms but does not prolong sur vival A dose of less than 2,000 rods is not effective; larger doses arc only palliative.* From the standpoint of preventive medicine and occupational health, there are at least two basic hypothe ses that must oe explored: (1) The development of angiosarcoma of the liver is the result of iow-leve! expo sure to vinyl chloride over a period of years. 12) The tumor is the result of a higit-levei exposure many years pre viously. The fact that all of these men were veteran employees with at least 12 yean* potential exposure would seem to favor the first hvputhi-is. In each rase, however, then: v:i also the pos sibility of a high-level exposure dur ing the early work history. All of these men were at one time "pot cleaners." They were required to en ter large tanks approximately 10 feet high and *> fee* in diameter with only a 2-foot oval ofn-ning in the top in or der to chin the residue of the chemical reaction from the sides of the tank. The potential lor ex|m*ure to high levels of vinyl chloride while a man was rieanmg these tahks was panic-. uiarly great during tlx- early years of this om-mtion. since the residue often contained lun-k-ts of trapped gases that were literally released in the deancrV lace when they were rup tured by his chipping operation. New cleaning t<x-nm>]ues. as well as the de velopment of new industrial hygiene control that include* the use of res pirators. have considerably reduced exposure. 1 AOm YO. HuuoAii. H-lwlll Mat.cnaat woiv tumor, of Utrt So .-.o l.i4TrM, WTA X BvfOUS t* Primary rsmnsms of (hr livsT. a uttwiv m mmlHW. r.inu a. miaifnlilMn, pa* Xhohmy. iim tiuHiii,, LuiuMt. Ilk Leins 4 C<rai|Hm Lid l-o 3 Nrhut US. glrvaim- Kb. Ho-- CD Chae sl syetk of pnmarv wniMmi nl us ii.sr Coro- !' lino 4 Tsinim V Inmn* f rmsryu.pmkr- pMin is iis to nl *f patr-nfa > pn- msrr lnr turns** 'if* IM I'os IVWetl, 1MM .V Ariel IM AS e1 for l-lrnr.ninf trvsfsesl f liver oior Ov nui.m:.-<i i-tmtir (tmss wassinc >"- l.y-.ru. -|.XT-rt ISA*. A FImsim L J*. t'n-i-r JN HrisUr re-- IM for snoMiit easier. AM J 4-r* HiLJl- aST. 1967. T. B-bvmmn AA. *t si. Pcmrv maltgaam Wan f the hvrr i -i-- gT T-ll. 1*71 1 Philip- K. Musuni K I'rtirare ei'i--in of thr liver Kmlu f rsilmUuS therapy tinnr tarta-TJu. imu. R&S 104474 M JAMA. July 1. 197* Vo! 229. N 1 Uear Angioxircome--8>oca