6
la Medicina del Lavoro ~\Ied Lav 2005; 96,4: 354-359 ", .. Peculiar features of mesothelioma occurrence as related to exposure patterns and circumstances in the Lombardy Region,Italy ANGELA CECILIA PES:-\TORl, C-\ROLINA NIENSI Departmem of Occuparional Health, U niversity of j\Iilan, Italy KEYWORDS lVIesothelioma, National Registries SUìVlìVIARY Baekground: The ''Lombardy ivJesothelioma Registl/' started its acti·vity in 2000 in accordance with ltalian law DL 277/91. Objectives and methods: The Registry collects ali new incident cases of NJalignant Nlesothelioma (iV]NJ) of pleura, peritoneum, pericardium and ·vaginal tunic of testis occurring in residents in the Lombardy Re- gion (Northern ltaly). For each "possible case" reported to the Registry by Lombardy hospitals, diagnosis is ascer- tained according to ISPESL Guidelines. For confirmed eases, a standardized questionnaire is administered to the subject or next-of-kin, to verifY sourees of lifetime asbestos exposure. Descriptive results are given jòr cases collected in 2000-2001. Age standardized incidence rates jòr the year 2000 ·were ca!culated jòr males and ftmales. Results: After revision of clinical records, diagnosis was judged as "certain" ND1;J in 307 (60%) subjects, probable in 63 (12%) and possible in 33 (6%) subjeets. 21 were peritoneal mesothelioma. Standardized ratesjòr pleural mesothe- lioma were respective/y 3.7 and 1.4 per 100,000 jòr males and ftmales. Occupational asbestos exposure was ascer- tained jòr 71% of male cases and 26% of ftmales. Exposure was unknown in 11 % and 27% of males and ftmales respective/y. The main relevant exposures ·were in building trades, metal manulacturing, machine production and maintenance; an unexpected/y high proportion 01 ftmale cases was engaged in non-asbestos textile factories. Con- clusions: The high proportion of cases ·with unknown exposure underlines the need to explore new tools and sources to ascertain asbestos exposure. An ad hoe sur·vey in textile industries showed exposure to asbestos to be wide/y spread in this industry. RIASSUNTO <<Aspettipeculiari dell'incidenza di mesotelioma in Lombardia correlati a modalità e circostanze di esposizione", In applicazione del DL 277/91 è stato istituito il Registro Lombardo dei NJesoteliomi che a partire dall'anno 2000 raccoglie tutti i casi incidenti di mesotelioma maligno della pleura, del perito neo, e della tunica vaginale del testicolo insorti tra i residenti della regione Lombardia. Per ciascun caso segnalato al registro dagli ospedali lombardi, viene raccolta tutta la documentazione clinica necessaria a una riverifica della diagnosi sulla base di criteri standardiz- zati stabiliti dalle linee guida ISPESL. Per i casi conftrmati l'accertamento delle possibili jònti di esposizione ad amianto viene effettuato tramite intervista al soggetto o a parenti/colleghi di lavoro. Vengono presentati alcuni ri- sultati relativi ai casi raccolti negli anni 2000-2001. Dopo la revisione della documentazione clinica 307 (60% Corrispondenza: Angela Cecilia Pesa tori, Departmem of Occuparional Health, Universif)' of Milan, Italy, Clinica del Lavoro "L. Devoto", Via San Barnaba 8, 20122 .Milano - Te!. 02-50320120 - Fa." 02-50320126 - E-mail [email protected]

Peculiar features of mesothelioma occurrence as related to ... · Peculiar features of mesothelioma occurrence as related ... tained according to ISPESL ... raccolta tutta la documentazione

  • Upload
    tranthu

  • View
    227

  • Download
    0

Embed Size (px)

Citation preview

Page 1: Peculiar features of mesothelioma occurrence as related to ... · Peculiar features of mesothelioma occurrence as related ... tained according to ISPESL ... raccolta tutta la documentazione

la Medicina del Lavoro ~\Ied Lav 2005; 96,4: 354-359

",

..

Peculiar features of mesothelioma occurrence as related

to exposure patterns and circumstances in the Lombardy

Region,Italy

ANGELA CECILIA PES:-\TORl, C-\ROLINA NIENSI

Departmem of Occuparional Health, University of j\Iilan, Italy

KEYWORDS

lVIesothelioma, National Registries

SUìVlìVIARY

Baekground: The ''Lombardy ivJesothelioma Registl/' started its acti·vity in 2000 in accordance with ltalian law

DL 277/91. Objectives and methods: The Registry collects ali new incident cases of NJalignant Nlesothelioma

(iV]NJ) of pleura, peritoneum, pericardium and ·vaginal tunic of testis occurring in residents in the Lombardy Re­

gion (Northern ltaly). For each "possible case" reported to the Registry by Lombardy hospitals, diagnosis is ascer­

tained according to ISPESL Guidelines. For confirmed eases, a standardized questionnaire is administered to the

subject or next-of-kin, to verifY sourees of lifetime asbestos exposure. Descriptive results are given jòr cases collected

in 2000-2001. Age standardized incidence rates jòr the year 2000 ·were ca!culated jòr males and ftmales. Results:After revision of clinical records, diagnosis was judged as "certain" ND1;J in 307 (60%) subjects, probable in 63(12%) and possible in 33 (6%) subjeets. 21 were peritoneal mesothelioma. Standardized ratesjòr pleural mesothe­

lioma were respective/y 3.7 and 1.4 per 100,000 jòr males and ftmales. Occupational asbestos exposure was ascer­

tained jòr 71% of male cases and 26% of ftmales. Exposure was unknown in 11 % and 27% of males and ftmales

respective/y. The main relevant exposures ·were in building trades, metal manulacturing, machine production and

maintenance; an unexpected/y high proportion 01ftmale cases was engaged in non-asbestos textile factories. Con­clusions: The high proportion of cases ·with unknown exposure underlines the need to explore new tools and sources

to ascertain asbestos exposure. An ad hoe sur·vey in textile industries showed exposure to asbestos to be wide/y spread

in this industry.

RIASSUNTO

<<Aspettipeculiari dell'incidenza di mesotelioma in Lombardia correlati a modalità e circostanze di esposizione",

In applicazione del DL 277/91 è stato istituito il Registro Lombardo dei NJesoteliomi che a partire dall'anno 2000raccoglie tutti i casi incidenti di mesotelioma maligno della pleura, del perito neo, e della tunica vaginale del testicolo

insorti tra i residenti della regione Lombardia. Per ciascun caso segnalato al registro dagli ospedali lombardi, viene

raccolta tutta la documentazione clinica necessaria a una riverifica della diagnosi sulla base di criteri standardiz­

zati stabiliti dalle linee guida ISPESL. Per i casi conftrmati l'accertamento delle possibili jònti di esposizione ad

amianto viene effettuato tramite intervista al soggetto o a parenti/colleghi di lavoro. Vengono presentati alcuni ri­

sultati relativi ai casi raccolti negli anni 2000-2001. Dopo la revisione della documentazione clinica 307 (60%

Corrispondenza: Angela Cecilia Pesa tori, Departmem of Occuparional Health, Universif)' of Milan, Italy, Clinica del Lavoro

"L. Devoto", Via San Barnaba 8, 20122 .Milano - Te!. 02-50320120 - Fa." 02-50320126 - E-mail [email protected]

Page 2: Peculiar features of mesothelioma occurrence as related to ... · Peculiar features of mesothelioma occurrence as related ... tained according to ISPESL ... raccolta tutta la documentazione

MESOTHELIOì\Lo\ Aì\'O ASBESTOS EXPOSURE lì\' LOMBARDY 355

della casistica totale) sono i casi di mesotelioma maligno certo, 63 (12%) probabili e 33 (6%) possibili mesoteliomi.

21 erano mesoteliomi peritoneali. I tassi standardizzati per età nell'anno 2000 erano 3,7 e 1,4per 100.000 resi­

denti rispettivamente per i maschi e lefemmine. L'esposizione occupazionale ad asbesto è stata accertata per il 71 %

dei casi tm i maschi e i126% nelle femmine, mentre è risultata ignota nel 11% e 27% rispettivamente. I principali

settori lavomtivi coinvolti sono l'edilizia, la metallurgia e la metalmeccanica; una ele·vata e inaspettata proporzio­

ne di casi è stata osservata in donne la·vomtrici nella industria tessile non-amianto. È stata compiuta una indagine

ad hoc in tale settore che ha permesso di identificare diverse fonti di esposizione ad amianto nel settore tessile. L'alta

p7'oporzione di casi con esposizione tuttora ignota e·videnzia la necessità di tro·vare nuo·vi strumenti efonti per l'ac­

certamento delle esposizioni di interesse.

The "Lombardy Mesothelioma Registry" was

established in January 2000 and comprises the Re­

gional Operational Cemre of the ltalian National

Registry. The Registry collects all new incidem

cases ofMalignam Mesothelioma (MM), with fìrst

diagnosis after J anuar)' 2000, occurring in residems

of the Lombard)' Region.

MESOTHELIOMA REGISTRY PROCEDURES

The main departments of each Lombardy hospi­

tal report mesothelioma cases to the RegistI}' di­

rectl)' or through local sciemific institutions which

have already implememed collection of cases in the

past, for example, in the provinces of Brescia, Berg­amo, Cremona and l\1amo\'a. For each case, all

available clinical records are collected and reviewed,

including radiological examinations, histology re­

pom, and disease history, so that a panel composed

of pneumologists, oncologists, and pathologists ma)'

revise the diagnoses. According to standardized cri­

teria set up by the national registI}' (2), diagnoses

are categorized as certain, probable or possible,

based on the availability of histology, immuno-his­

tochemistry assays, and radiological examinations.

Evaluation of asbestos exposure is based on infor­

mation collected through a standardized question­

naire administered by trained interviewers to the

subject or next-of-kin. The information collected is

then discussed with an industri al hygienist, occupa­

tional health physicians, and an occupational epi­

demiologist to evaluate asbestos exposure in the

workplace and in environmental senings.

Case ascertainmem completeness is \'crified us­

ing other sources. Hospiral discharge records and

death certificates coded as 163 according to theICD (Imernational Classification of Diseases) are

obtained from the Lombardy regio n along with the

list of cases compensated by the National Insur­

ance Institute. A link is made with the Registry'sdatabase to idemifv undetected cases for which a

search for clinical documemation is then imple­

memed, and the usual procedures are followed to

conflrm diagnosis and ascertain exposure.

CASE DESCRIPTION A..i"iDDISCUSSION

Case completeness was verified for the years

2000- 2001 following the procedures describedabove. Abour 3000 records were extracted from the

regional database, corresponding to 625 subjects

with a discharge diagnosis of possible pleural tu­mour. After the collection and revision of clinical

records, it was clear that 106 cases had already been

identified b)' the Registr)', another 106 were non­

cases, 93 were prevalem cases. The number of cases

confirmed but not reported to the Registry was

134, equall)' distributed over the two years; these

have been included in the Registry database.

Our of 512 possible cases reviewed by the Reg­

istr;' in the first two years of activity (2000-2001),307 (60%) were judged as "certain" MM, 63 (12%)were probable MIVl, and 33 (5.8%) possible MM;

whereas the diagnosis \Vas not confirmed in 109subjects (21%). As expected, most of the cases

(94%) were pleural mesothelioma; only 21 were

peritoneal cases. Descriptive results are given for

certain and probable cases onl)'.

Histological diagnosis \Vas available for 93% of

the cases (361). The most frequent histological

Page 3: Peculiar features of mesothelioma occurrence as related to ... · Peculiar features of mesothelioma occurrence as related ... tained according to ISPESL ... raccolta tutta la documentazione

356

,l! ~"

"

,.

types were epithelial (216 cases), followed bybiphasic (66 cases) and tìbrous mesothelioma (32cases); a small proportion of cases (30) \Vas detìnedas mesothelioma not otherwise specitìed.

67% of the cases were interviewed directly, in29% of the cases the interview was administered to

relatives. No interview was available for 13 subjects(4%).

Case distribution by age and gender (figure 1)showed a higher proportion of cases among maleswith a 2:1 male/female ratio. Founeen cases oc­

curred in relatively young subjects, less than 45years old. This group of young cases was mainlycharacterized by environmental exposure to as­bestos at a young age (almost half the cases) or un­known exposure. Three cases lived in the Broniarea, weli known for being poliuted by a local as­bestos-cement factory. Only 1 subject had occupa­tional exposure as a plumber.

Age standardized incidence rates were calculatedusing the Italian population in 1991 as Standardand applying the direct method. Results are pre­sented for the year 2000 in which data coliectionand interviews were completed. In figure 2 stan­dardized rates for pleural mesothelioma includingalI diagnoses (certain, probable and possible) are

100 --:

90 -:

80 ­

70 ­

60 -­

50 ­

40 ­

30 -

20

10

O

reponed separately for males and females and com­pared with the 1997 National Registry rates (4).The Lombardy rate for males was 3.7 per 100.000inhabitants and 1,4 for females. Both were some­

what higher than the national rates reflecting mor­tality data patterns (3). Rates by province did notdepan significantly from the regional rates. Mostof them were based on a very small number of cas­es and prevented any further detailed analysis ac­cording to occupational sectors located in the area.

The evaluation of asbestos exposure derivedfrom information coliected through the standard­ized questionnaire produced different results formales and females.

For males, the major source of exposure was re­lated to occupational activities (71%), 3% had envi­ronmental exposure, and for 11% of the cases, ex­posure was unknown, meaning that, based on theavailable information and current knowledge, wecannot exclude asbestos exposure.

The picture for females was quite different: only26% had occupational exposures, and a similar pro­portion (27%) of cases had unknown exposure. Inaddition, the proponion of cases that had not beenexposed (20%) was higher than in males. About10% had environmental exposure.

98

a Mi~F

35-44 45-54 55-64 65-74 75+

Figure 1 - Case distribution by age and gender (certain and probable cases, 2000-2001)

-

Page 4: Peculiar features of mesothelioma occurrence as related to ... · Peculiar features of mesothelioma occurrence as related ... tained according to ISPESL ... raccolta tutta la documentazione

~---------------MESOTHEUO:-'L\ A:\'D .-\SBESTOS EXPOSURE I?\ LO:-'1BARDY

4.5 I

::L_~-::t=-~--~:n=~~2.5 r-------------------------2.0 _! ------------

4.5

4.0

3.5 ------------------

3.0 -!c------2.5 -------------------------

2.0

357

1.5

1.0

I•l 1.5

1.0 ----!-0.5 --------------

0.0 -,.----------------

0.5

0.0M

Lombardy,2000

F M

Italy,1997

F

Figure 2 - Age Srandardized Incidence Rares (per 100,000 inhabiranrs) b:' gender. Pleural mesothelioma (certain, probable,possible). Srandard popularion: Ital:'1991

As can be dearly seen there was a high propor­tion of cases both in males and females with un­

known exposure, for which current tools of infor­mation collection do not seem sensitive enough toreveal possible unusual exposures. A national re­search programme has been recently implemenredto improve exposure ascertainmenr, also expIoringtools and sources other than inrerviews. An exam-

pIe of the importance of this approach wili be giv­en Iater on based on the experience in our registry.

As regards cases with environmental exposure(11 females and 8 males), almost half of them were

subjects living dose to an asbestos-cement plantIocated in Broni in Pavia province. Another 9 caseswere exposed to asbestos through different sourcesin the house where they Iived most of their Iives

50%

45% -

40%

35% .

= Female l!! Male

I]. ~n .=-~. __~_Building & Metal & Steel

Constnuction

Metal·

Mechanical

Textiles Transport Other

equipment manufacturesmanufacture

Rubber ano

plastlc

Others

Figure 3 - Case disrriburion by occuparional sector and gender

Page 5: Peculiar features of mesothelioma occurrence as related to ... · Peculiar features of mesothelioma occurrence as related ... tained according to ISPESL ... raccolta tutta la documentazione

358

ii

~

i 30 ii ~ Female.. t:ii.,

I

!i

l [SI Male

Il!·;

25li 1:li

I 20I 15

10 J5 I

0-,

1920-1929

1930-1939 1940-1949

PES...••TORI ...••:\D \[E:\5]

1950-1959 1960-1969 1970-1979 1980-1984

Figure 4 - Case distribution by period of fìrst exposme and gender in occupational settings

Clinical

The distribution of cases by period of first expo­sures in occupationa1 settings (figure 4) was similarfor both genders with the possib1e exception of theearlier period from 1930-39 in which the propor­tion of females was higher than males. The median1atency did not differ and was 48 years for ma1esand 45 for females.

In tab1e 1 a synthetic description of peritonealcases with occupational exposures (15 out of 21) isreported. AH occupationa1 settings involved are

Plemal plaques, and positive BAL

Asbestosis

Asbestosis and plemal plaques

Asbesrosis

AsbestosisRecycling jute sacks

~Ianufacturing of packing and asbesros ropes

Packer in dothing industry, working area dose ro iron repair shop

~Ianufacture of asbesros cupels

Bricklayer, "Eternit" roofìng

Tester of asbesros-cement slabs, pipes and other

.l'vIanufacture of asbesros-cement panels and pipes

Tale and asbestos mining in ValmalencoResin manufacture. Insulation workers

.i\tlanufacturing of packing and asbestos ropesRailwav worker

vVeaving and iron maintenance

.i\tlaintenance of railway cars, brakes, dutches and packing

Use of asbesros cardboards and blankets as insulation in the

manufacture of resisrors

l'vlanufacture of asbesros-cement industrial products

Jobs

Table 1 - Peritoneal caseswith acwpational expasures

and 1 case was a fema1e who was a student and

then a teacher in a schoo1 where asbestos was pre­sent in the insu1ation.

Ana1ysis by occupationa1 sector showed againdifferent pictures for males and females (figure 3).Among males the highest proportion of cases wereseen in the bui1ding and construction industry, fo1­10wed by metal and steel industry and mechanicalindustry. Among fema1es the highest pro portio nwas detected in the non-asbestos textile industry.

GenderAge

F

68

F

54

F

46

Wl

63

Wl

66

Wl

62

Wl

68

Wl

68

Wl

73

Wl

62

Wl

73

Wl

76

ii

Wl69

'iWl

73

·Ii

j,

Wl79li!

Il:il!'rl';'J

I

I;I

Page 6: Peculiar features of mesothelioma occurrence as related to ... · Peculiar features of mesothelioma occurrence as related ... tained according to ISPESL ... raccolta tutta la documentazione

MESOTHELIO:\L-\A:\D ASBESTOSL'(POSURE1:\ LOfvIBARDY 359

characterized by high exposure levels, documentedalso by the presence of asbestosis and pleuralplaques in some of these cases. Far another 6 caseswe were unable to identify the possible sources ofasbestos exposure.

In the revision of cases collected in our registf)',we were struck by the fact that another 18 casesoccurred among non-asbestos textile workers, andwe were unable to identin' known sources of as­

bestos exposure. These subjects had various jobs inthe textile manufacturing process, such as spinning,weaving, and fìnishing. In view of this high preva­lence of cases in the textile industf)', the RegistI}'began a thorough research, contacting technicians,local experts, and maintenance personnel (1). Inaddition, direct inspections were carried out in nu­merous workplaces where working conditions weresimilar to the pasto Inspections showed that untilthe Seventies, large amounts of asbestos had beenregularly applied to factory ceilings and walls toavoid steam condensation and to dampen noise.Both chrysotile and crocidolite were applied. Inaddition, the braking systems of most of the ma­chines had asbestos gaskets, and on severalloomswhere some brakes operated continuously in arderto keep the warp in constant tension, dispersion of

fìbres into the environment was the result. Anotherreason that facilitated contamination was that as­

bestos fìbres were not tightly bound to the matrixand the breaks were not encapsulated.

Based on this information we believe that as­

bestos exposure must be recognized as a risk factorin the textile industI}', and mesothelioma cases oc­curring in this occupational sening must be consid­ered occupationa1ly exposed.

REFERENCES

1. CHIA.PPINO G, MEri SI C, RIBOLDI L, RIVOLTA G: Il ri­

schio amiamo nel settore tessile: indicazioni dal Registroìvlesoteliomi Lombardia e definitiva conferma. Med Lav

2003; 94: 521-530

2. ISPESL: Linee guida pa la rilevazione e la definizione dei

casi di mesotelioma maligno e la trasmissione delle injòrma­

zioni all1SPESL da parte dei Centri Operativi Regionali.Seconda edizione. Roma: ISPESL, 2003

3. ìvL-\STRA:\TOl\"IOM, BELLI S, BlriZA.Al A, et al: La mor­

talità per tumore maligno della pleura nei comuni italiani

(1988-1997). Rapporti Istisan 02/12. Roma: Istituto Su­

periore di sanità 20024. NESTI M, IvhRIriACCIO A, CHELLIl\"I E, RECIOriAL OP­

ER.-\TIOl\"ALCEl\"TERS: Ivlalignam mesothelioma in Ital)',

1997. AmJ Ind Ivled 2004; 45: 55-62