Br J Ind Med: first published as 10.1136/oem.48.5.338 on 1 May 1991. Downloaded from http://oem.bmj.com/ on December 23, 2019 at India:BMJ-PG Sponsored.

338 British Journal of Industrial Medicine 1991;48:338-341

Asbestosis, laryngeal carcinoma, and malignant

peritoneal mesothelioma in an insulation worker
Alf Fischbein, Jiin-Chyuan J Luo, Glen R Pinkston

Abstract peritoneal mesothelioma. A brief review of multiple

Asbestos associated diseases consist of both primary cancers occurring among asbestos exposed
benign and malignant conditions. A rare con- populations is also presented.
stellation of asbestosis, laryngeal carcinoma,
and malignant peritoneal mesothelioma oc- Case report
curring in a patient with long term occu- CLINICOPATHOLOGICAL SUMMARY
pational exposure to airborne asbestos fibres is The patient was a man born in 1921. His medical
presented. The observation illustrates the history was non-contributory except for two episodes
powerful disease-causing potential of occu- of atrial flutter in 1973 and in 1975. In July 1982 the
pational exposure to asbestos. A brief discus- patient developed hoarseness. His voice returned to
sion of multiple primary neoplasms associated normal, but during the summer of 1983 it became
with exposure to asbestos is also presented. worse again, with hoarseness and phonasthenia. A
weight loss of around 15 pounds occurred during the

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summer months of 1983. He was admitted to hospital
Asbestos associated diseases continue to pose a major for evaluation in August 1983. Laryngoscopy showed
public health problem in the United States.' They an exophytic lesion along the right vocal cord, which
include both benign disorders, such as asbestosis and had well preserved motion. Biopsy was performed
asbestos related pleural abnormalities, and malignant and histopathological analysis showed infiltrating
conditions. The malignant group of disorders is well differentiated squamous cell carcinoma of the
represented primarily by lung cancer and malignant right vocal cord.
pleural or peritoneal mesothelioma. Epidemiological In December 1983 the patient noticed distention of
investigations have suggested that other neoplasms the abdomen. Evaluation with upper gastrointestinal
may also be associated with a history of exposure to series was essentially unremarkable. A computed
airborne asbestos fibres. These include certain gas- tomography scan of the pancreas and a liver scan
trointestinal neoplasms as well as cancer of the were also within normal limits. Cholecystography
larynx.2 The increased risk of developing lung cancer and an intravenous pyelogram were also normal.
among people exposed to asbestos is widely con- Paracentesis fluid cytology was not diagnostic of
sidered to be a synergistic effect between cigarette malignancy. Exploratory laparotomy showed con-
smoking and exposure.3 In this context, multiple siderable ascites and generalised intra-abdominal
aetiological factors, such as cigarette smoking, alco- tumour spread. The omentum was largely replaced
hol intake, and exposure to asbestos have also been by tumour and innumerable tumour nodules of
suggested for cancer of the larynx.4 varying size were implanted on the peritoneal sur-
We report on a patient with pulmonary asbestosis faces. Histopathological examination of an omental
who developed cancer of the larynx followed three biopsy showed diffuse peritoneal mesothelioma
months later by the clinical onset of malignant exhibiting a tubulopapillary growth pattern charac-
terised by fibrous stromal cores covered by polygonal
to columnar mesothelial cells exhibiting moderate
nuclear pleomorphism. In January 1984, ascites
Division of Environmental and Occupational recurred and an additional tap of four litres was done.
Medicine, Department of Community Medicine, the The patient experienced a rapidly progressive clini-
Mount Sinai School of Medicine of the City Univer-
sity of New York, New York, New York 10029, USA cal course and died in May 1984.
A Fischbein, J-C J Luo Post mortem examination disclosed residual,
Department of Pathology, Halifax Hospital Medical locally infiltrating squamous carcinoma in the right
Center, Daytona Beach, Florida, USA (present vocal cord. The lungs were encased by partially
affiliation: Jackson Hospital and Clinic, Mont- confluent, focally calcified pleural plaques,
gomery, Alabama 36106, USA).
G R Pinkston predominantly embodying the visceral and parietal
surface of the lower lobes and hemidiaphragms.
 Br J Ind Med: first published as 10.1136/oem.48.5.338 on 1 May 1991. Downloaded from http://oem.bmj.com/ on December 23, 2019 at India:BMJ-PG Sponsored.
Asbestosis, laryngeal carcinoma, and malignant peritoneal mesothelioma in an insulation worker 339

Considerable interstitial fibrosis, emphysematous mills, powerhouses, and various other industrial
changes, and severe necrotising bronchopneumonia facilities. Thus he had a history of potential for
were present bilaterally. The abdominal cavity appreciable exposure to airborne materials contain-
exhibited diffuse peritoneal mesothelioma with ing asbestos during several years.
replacement of the omentum and extensive perito- The patient smoked 30 cigarettes a day between
neal studding of the spleen, gastrointestinal tract, 1936 and 1967. He smoked cigars between 1967 and
pancreas, liver, diaphragm, and abdominal walls. 1981 and chewed tobacco for most of his adult life.
Asbestos bodies were identified in both lungs, but He drank some six cans of beer a day for several years.
were not seen in either tumour. No evidence of
metastatic carcinoma was found. Mesothelioma was Discussion
not identified in the thoracic cavity. The reported case shows the potential for the
Review of a series of chest radiographs taken development of multiple diseases after occupational
between December 1980 and August 1983 showed exposure to airborne asbestos fibres. The patient
extensive parenchymal scarring graded as s/t 2/3 manifested pulmonary asbestosis, laryngeal cancer,
according to the International Labour Office Inter- and peritoneal mesothelioma. The last disorder
national Classification of Radiographs of Pneumo- became clinically evident three months after the
conioses.5 Pleural abnormalities consisted of bilateral diagnosis of the first malignancy. Both malignant
thickening of the lateral costal pleura graded as b3 on diseases developed, characteristically, some 40 years
the right side and as b2 on the left side with after the onset of employment in the asbestos related
calcifications in the thickened pleura and on the trade.
domes of the hemidiaphragms (figure). The potential health consequences after occupa-
tional exposure to asbestos have been studied in
OCCUPATIONAL HISTORY detail in clinical and epidemiological investigations
The patient had worked as an insulator between 1942 as mentioned above.'13

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and 1973. During these years he had routinely Multiple primary malignant neoplasms in general
handled insulation materials containing asbestos. He were described in case reports by Billroth and von
applied thermal insulation to pipes and pressure Winiwarter.6 They reported patients with both
vessels and removed old thermal insulation cutaneous and gastrointestinal malignancies, which
materials. He was employed in shipyards, paper- were independent of each other. Warren and Gates
found 1259 patients from published reports, who had
reasonably well documented multiple primary
malignancies. These workers also suggested diagnos-
tic criteria for multiple primary neoplasms-namely,
that each of the tumours must present a definite
picture of malignancy, that each lesion must be
distinct, and that the probability that one is a
metastatic lesion from the other must be excluded.7
Classification systems for multiple primary neo-
plasms in terms of site and tissue of origin have also
been established.8 Various aetiological factors in-
cluding environmental, endocrine, and genetic risk
factors have been suggested for multiple primary
cancers and related to specific organ systems.9
In 1961, Telischi and Rubenstone reported a case
of pulmonary asbestosis with squamous cell carci-
noma of the lung, bronchial adenoma, and adeno-
carcinoma of the stomach."0 This is, to our
knowledge, the first reported case of multiple
primary cancers in an asbestos exposed patient.
Subsequently, Dohner. et al reported five asbestos
exposed patients with multiple primary tumours.
Two patients had lung carcinoma and colon carcin-
oma and three others had two distinct pulmonary
carcinomas." Selikoff et al reported the presence of
multiple cancers in 48 (2%) of 2271 deaths among
Chest radiograph of patient with laryngeal cancer and insulators.3 The simultaneous occurrence of perito-
peritoneal mesothelioma showing interstitial lung disease neal mesothelioma and laryngeal cancer as separate
(asbestosis), pleural thickening, and calcifications. entities was not reported in this large scale popula-
 Br J Ind Med: first published as 10.1136/oem.48.5.338 on 1 May 1991. Downloaded from http://oem.bmj.com/ on December 23, 2019 at India:BMJ-PG Sponsored.
340 Fischbein, Luo, Pinkston

tion study, and we have been unable to document a studies, great variations in risk assessment exist
previously reported case. between different investigations.
With regard to aetiological considerations for the We had little reason, in the present case, to
development of these disorders in this particular question the association between the malignant
patient the following considerations are presented. mesothelioma and the history of occupational ex-
Although mesothelioma was clarified as a clinico- posure to asbestos, particularly in the presence of
pathological entity in 193112 and "endothelioma of severe asbestosis. Regarding the laryngeal cancer, we
the pleura" was reported in asbestos workers in suggest that tobacco smoking, alcohol consumption,
1947,13 it was in 1960 that Wagner et al reported cases and asbestos exposure were all likely contributory
with malignant mesothelioma on a population basis factors.
related to occupational and environmental exposure Our patient developed pulmonary asbestosis,
to asbestos.'4 Several epidemiological studies have laryngeal cancer, and malignant peritoneal meso-
subsequently established a strong association be- thelioma after considerable exposure to airborne dust
tween mesothelioma and exposure to asbestos. A containing asbestos over three decades. The con-
long period of latency, usually 30 or 40 years, stellation of all three diseases in one person appears to
between initial exposure to asbestos and the develop- be very uncommon. Although the observation in one
ment of mesothelioma is characteristically noted. case can be a random event, we believe that the
Mesothelioma has a high malignant potential, and asbestos related epidemiological features of these
local invasion and metastases are common sequelae. diseases permit us to suggest this case report as an
The survival time after diagnosis usually does not illustration of the powerful disease-causing potential
exceed one year.'5 of occupational exposure to asbestos.
Association between exposure to asbestos and
laryngeal cancer has been reported.'"'8 Doll and Peto Requests for reprints to: Alf Fischbein, MD, Div-
also reviewed some case-control and cohort studies of' ision of Environmental and Occupational Medicine,

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laryngeal cancer risk in asbestos workers. In case- Department of Community Medicine, Mount Sinai
control studies, the relative risk has been reported to School of Medicine of the City University of New
be between 0-8 and 14-5, whereas in cohort studies York, One Gustave L Levy Place, New York, New
the relative risk ranged between 0 6 and 2-7. Based on York 10029, USA.
the evidence in their review, the authors concluded
that asbestos should be regarded as one of the causes
of laryngeal cancer.'9 Tobacco and alcohol are con- 1 Mossman BT, Gee JB. Asbestos-related diseases. New Engl J
Med 1989;320:1721-30.
sidered to be important aetiological factors in the 2 Selikoff IJ, Hammond EC, Seidman H. Mortality experience of
development of laryngeal cancer.4 insulation workers in the United States and Canada, 1943-
Chan and Gee conducted a critical analysis of the 1976. Ann N Y Acad Sci 1979;330:91-116.
3 SelikoffIJ, Hammond EC, Churg J. Asbestos exposure, smoking
available epidemiological investigations on the causal and neoplasia. Journal of the American Medical Association
relation between exposure to asbestos and laryngeal 1968;204:106-12.
4 Burch D, Howe GR, Miller AB, Semenciw R. Tobacco, alcohol,
cancer. They reviewed nine case-control studies and asbestos, and nickel in the etiology of cancer of the larynx: a
12 cohort studies and concluded that the available case-control study. J Natl Cancer Inst 1981;67:1219-24.
5 International Labour Office. Guidelines for the use of ILO
epidemiological evidence did not support a causal International Classification of Radiographs of Pneumoconioses.
association between exposure to asbestos and laryn- Geneva: ILO Office, 1980. (Occupational Safety and Health
geal cancer because significant associations did not Series No 22.)
6 Billroth CAT, von Winiwarter A. Die allgemeine chirurgische
remain after adjusting for smoking and alcohol Pathologie und Therapie. 14th ed. Berlin: George Reimer,
consumption. 20 7
1989:908.
Warren S, Gates 0. Multiple primary malignant tumors: a
In a recent study of laryngeal cancer in Denmark survey of the literature and statistical study. American Journal
based on register linkage data, smoking and alcohol of Cancer 1931;15:2001-12.
8 Moertel CG. Multiple primary malignant neoplasms: historical
habits did not fully explain the variation in risk. The perspectives. Cancer 1977;40:1786-92.
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10 Telischi M, Rubenstone AI. Pulmonary asbestosis associated
considered.2' An analysis by Smith et al of data from with primary carcinoma of the lung, bronchial adenomas, and
published cohorts or subcohorts of sufficient size adenocarcinoma of the stomach. Archives of Pathology 1961;
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thelioma and asbestos exposure in the Western Cape Province.
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20 Chan CK, Gee BL. Asbestos exposure and laryngeal cancer: an Accepted 1 October 1990

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