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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]
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
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)
-
~---------------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
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
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