Mesothelioma
Classification & external resourcesICD-10C45ICD-9163ICD-O:9050-9055OMIM156240DiseasesDB8074MedlinePlus000115eMedicinemed/1457
Mesothelioma is a form of cancer that is almost always caused by previous exposure to asbestos.In this disease, malignant cells develop in the mesothelium, a protective lining that covers most of the body’s internal organs. Its most common site is the pleura (outer lining of the lungs and chest cavity), but it may also occur in the peritoneum (the lining of the abdominal cavity) or the pericardium (a sac that surrounds the heart).
Most people who develop mesothelioma have worked on jobs where theyinhaled asbestos particles, or have been exposed to asbestos dust andfibre in other ways, such as by washing the clothes of a family memberwho worked with asbestos, or by home renovation using asbestos cementproducts. Unlike lung cancer, there is no association betweenmesothelioma and smoking.
Signs and symptoms
Symptoms of mesothelioma may not appear until 20 to 50 years afterexposure to asbestos. Shortness of breath, cough, and pain in the chestdue to an accumulation of fluid in the pleural space are often symptomsof pleural mesothelioma.
Symptoms of peritoneal mesothelioma include weight loss and cachexia, abdominal swelling and pain due to ascites(a buildup of fluid in the abdominal cavity). Other symptoms ofperitoneal mesothelioma may include bowel obstruction, blood clottingabnormalities, anemia, and fever.If the cancer has spread beyond the mesothelium to other parts of thebody, symptoms may include pain, trouble swallowing, or swelling of theneck or face.
These symptoms may be caused by mesothelioma or by other, less serious conditions.
Mesothelioma that affects the pleura can cause these signs and symptoms:chest wall painpleural effusion, or fluid surrounding the lungshortness of breathfatigue or anemiawheezing, hoarseness, or coughblood in the sputum (fluid) coughed up
In severe cases, the person may have many tumor masses. The individual may develop a pneumothorax, or collapse of the lung. The disease may metastasize, or spread, to other parts of the body.
Tumors that affect the abdominal cavity often do not cause symptoms until they are at a late stage. Symptoms include:abdominal painascites, or an abnormal buildup of fluid in the abdomena mass in the abdomenproblems with bowel functionweight loss
In severe cases of the disease, the following signs and symptoms may be present:blood clots in the veins, which may cause thrombophlebitisdisseminated intravascular coagulation, a disorder causing severe bleeding in many body organsjaundice, or yellowing of the eyes and skinlow blood sugar levelpleural effusionpulmonary emboli, or blood clots in the arteries of the lungssevere ascites
A mesothelioma does not usually spread to the bone, brain, oradrenal glands. Pleural tumors are usually found only on one side ofthe lungs.
Diagnosis
Diagnosing mesothelioma is often difficult, because the symptoms aresimilar to those of a number of other conditions. Diagnosis begins witha review of the patient’s medical history. A history of exposure toasbestos may increase clinical suspicion for mesothelioma. A physicalexamination is performed, followed by chest X-ray and often lung function tests. The X-ray may reveal pleural thickening commonly seen after asbestos exposure and increases suspicion of mesothelioma. A CT (or CAT) scan or an MRI is usually performed. If a large amount of fluid is present, abnormal cells may be detected by cytology if this fluid is aspirated with a syringe. For pleural fluid this is done by a pleural tap or chest drain, in ascites with an paracentesis or ascitic drain and in a pericardial effusion with pericardiocentesis.While absence of malignant cells on cytology does not completelyexclude mesothelioma, it makes it much more unlikely, especially if analternative diagnosis can be made (e.g. tuberculosis, heart failure).
If cytology is positive or a plaque is regarded as suspicious, a biopsy is needed to confirm a diagnosis of mesothelioma. A doctor removes a sample of tissue for examination under a microscope by a pathologist.A biopsy may be done in different ways, depending on where the abnormalarea is located. If the cancer is in the chest, the doctor may performa thoracoscopy.In this procedure, the doctor makes a small cut through the chest walland puts a thin, lighted tube called a thoracoscope into the chestbetween two ribs. Thoracoscopy allows the doctor to look inside thechest and obtain tissue samples.
If the cancer is in the abdomen, the doctor may perform a laparoscopy.To obtain tissue for examination, the doctor makes a small opening inthe abdomen and inserts a special instrument into the abdominal cavity.If these procedures do not yield enough tissue, more extensivediagnostic surgery may be necessary.
Screening
There is no universally agreed protocol for screening people whohave been exposed to asbestos. However some research indicates that theserum osteopontinlevel might be useful in screening asbestos-exposed people formesothelioma. The level of soluble mesothelin-related protein iselevated in the serum of about 75% of patients at diagnosis and it hasbeen suggested that it may be useful for screening.
Staging
Mesothelioma is described as localized if the cancer is found onlyon the membrane surface where it originated. It is classified asadvanced if it has spread beyond the original membrane surface to otherparts of the body, such as the lymph nodes, lungs, chest wall, orabdominal organs.
Pathophysiology
The mesothelium consists of a single layer of flattened to cuboidal cells forming the epithelial lining of the serous cavities of the body including the peritoneal, pericardial and pleuralcavities. Deposition of asbestos fibres in the parenchyma of the lungmay result in the penetration of the visceral pleura from where thefibre can then be carried to the pleural surface, thus leading to thedevelopment of malignant mesothelial plaques. The processes leading tothe development of peritoneal mesothelioma remain unresolved, althoughit has been proposed that asbestos fibres from the lung are transportedto the abdomen and associated organs via the lymphatic system. Additionally, asbestos fibres may be deposited in the gut after ingestion of sputum contaminated with asbestos fibres.
Pleural contamination with asbestos or other mineral fibres has beenshown to cause cancer. Long thin asbestos fibers (blue asbestos, amphibole fibers) are more potent carcinogens than "feathery fibers" (chrysotile or white asbestos fibers).However, there is now evidence that smaller particles may be more dangerous than the larger fibers.They remain suspended in the air where they can be inhaled, and maypenetrate more easily and deeper into the lungs. "We probably will findout a lot more about the health aspects of asbestos from [the WorldTrade Center attack], unfortunately," said Dr. Alan Fein, chief ofpulmonary and critical-care medicine at North Shore-Long Island JewishHealth System. Dr. Fein has treated several patients for "World TradeCenter syndrome" or respiratory ailments from brief exposures of only aday or two near the collapsed buildings.
Mesothelioma development in rats has been demonstrated followingintra-pleural inoculation of phosphorylated chrysotile fibres. It hasbeen suggested that in humans, transport of fibres to the pleura iscritical to the pathogenesis of mesothelioma. This is supported by theobserved recruitment of significant numbers of macrophages and other cells of the immune systemto localised lesions of accumulated asbestos fibres in the pleural andperitoneal cavities of rats. These lesions continued to attract andaccumulate macrophages as the disease progressed, and cellular changeswithin the lesion culminated in a morphologically malignant tumour.
Experimental evidence suggests that asbestos acts as a completecarcinogen with the development of mesothelioma occurring in sequentialstages of initiation and promotion. The molecular mechanisms underlyingthe malignant transformation of normal mesothelial cells by asbestosfibres remain unclear despite the demonstration of its oncogeniccapabilities. However, complete in vitro transformation of normal humanmesothelial cells to malignant phenotype following exposure to asbestosfibres has not yet been achieved. In general, asbestos fibres arethought to act through direct physical interactions with the cells ofthe mesothelium in conjunction with indirect effects followinginteraction with inflammatory cells such as macrophages.
Analysis of the interactions between asbestos fibres and DNA has shown that phagocytosed fibres are able to make contact with chromosomes, often adhering to the chromatinfibres or becoming entangled within the chromosome. This contactbetween the asbestos fibre and the chromosomes or structural proteinsof the spindle apparatus can induce complex abnormalities. The mostcommon abnormality is monosomy of chromosome 22. Other frequent abnormalities include structural rearrangement of 1p, 3p, 9p and 6q chromosome arms.
Common gene abnormalities in mesothelioma cell lines include deletion of the tumor suppressor genes:Neurofibromatosis type 2 at 22q12P16INK4AP14ARF
Asbestos has also been shown to mediate the entry of foreign DNAinto target cells. Incorporation of this foreign DNA may lead tomutations and oncogenesis by several possible mechanisms:Inactivation of tumor suppressor genesActivation of oncogenesActivation of proto-oncogenes due to incorporation of foreign DNA containing a promoter regionActivation of DNA repair enzymes, which may be prone to errorActivation of telomerasePrevention of apoptosis
Asbestos fibres have been shown to alter the function and secretoryproperties of macrophages, ultimately creating conditions which favourthe development of mesothelioma. Following asbestos phagocytosis,macrophages generate increased amounts of hydroxyl radicals, which are normal by-products of cellular anaerobic metabolism. However, these free radicals are also known clastogenicand membrane-active agents thought to promote asbestos carcinogenicity.These oxidants can participate in the oncogenic process by directly andindirectly interacting with DNA, modifying membrane-associated cellularevents, including oncogene activation and perturbation of cellularantioxidant defences.
Asbestos also may possess immunosuppressiveproperties. For example, chrysotile fibres have been shown to depressthe in vitro proliferation of phytohemagglutinin-stimulated peripheralblood lymphocytes, suppress natural killer cell lysis and significantlyreduce lymphokine-activated killer cellviability and recovery. Furthermore, genetic alterations inasbestos-activated macrophages may result in the release of potentmesothelial cell mitogens such as platelet-derived growth factor (PDGF) and transforming growth factor-ß(TGF-ß) which in turn, may induce the chronic stimulation andproliferation of mesothelial cells after injury by asbestos fibres.
Epidemiology
Although reported incidence rates have increased in the past 20years, mesothelioma is still a relatively rare cancer. The incidence isapproximately one per 1,000,000. For comparison, populations with highlevels of smoking can have a lung cancerincidence of over 1,000 per 1,000,000. Incidence of malignantmesothelioma currently ranges from about 7 to 40 per 1,000,000 inindustrialized Western nations, depending on the amount of asbestosexposure of the populations during the past several decades.[5]It has been estimated that incidence may have peaked at 15 per1,000,000 in the United States in 2004. Incidence is expected tocontinue increasing in other parts of the world. Mesothelioma occursmore often in men than in women and risk increases with age, but thisdisease can appear in either men or women at any age. Approximately onefifth to one third of all mesotheliomas are peritoneal.
Between 1940 and 1979, approximately 27.5 million people were occupationally exposed to asbestos in the United States [4].Between 1973 and 1984, there has been a threefold increase in thediagnosis of pleural mesothelioma in Caucasian males. From 1980 to thelate 1990s, the death rate from mesothelioma in the USA increased from2,000 per year to 3,000, with men four times more likely to acquire itthan women. These rates may not be accurate, since it is possible thatmany cases of mesothelioma are misdiagnosed as adenocarcinoma of thelung, which is difficult to differentiate from mesothelioma.
Risk factors
Working with asbestosis the major risk factor for mesothelioma. A history of asbestosexposure exists in almost all cases. However, mesothelioma has beenreported in some individuals without any known exposure to asbestos. Inrare cases, mesothelioma has also been associated with irradiation,intrapleural thorium dioxide (Thorotrast), and inhalation of otherfibrous silicates, such as erionite.
Asbestos is the name of a group of minerals that occur naturally asmasses of strong, flexible fibers that can be separated into thinthreads and woven. Asbestos has been widely used in many industrialproducts, including cement, brake linings, roof shingles, flooringproducts, textiles, and insulation. If tiny asbestos particles float inthe air, especially during the manufacturing process, they may beinhaled or swallowed, and can cause serious health problems. Inaddition to mesothelioma, exposure to asbestos increases the risk oflung cancer, asbestosis (a noncancerous, chronic lung ailment), andother cancers, such as those of the larynx and kidney.
The combination of smoking and asbestos exposure significantly increases a person’s risk of developing cancer of the airways (lung cancer,bronchial carcinoma). The Kent brand of cigarettes used asbestos in itsfilters for the first few years of production in the 1950s and somecases of mesothelioma have resulted. Smoking modern cigarettes does notappear to increase the risk of mesothelioma.
Some studies suggest that simian virus 40 (SV40) may act as a cofactor in the development of mesothelioma.
Exposure
Asbestos was known in antiquity, but it wasn’t mined and widely used commercially until the late 1800s. Its use greatly increased during World War II. Since the early 1940s,millions of American workers have been exposed to asbestos dust.Initially, the risks associated with asbestos exposure were notpublicly known. However, an increased risk of developing mesotheliomawas later found among shipyard workers, people who work in asbestosmines and mills, producers of asbestos products, workers in the heatingand construction industries, and other tradespeople. Today, the U.S. Occupational Safety and Health Administration(OSHA) sets limits for acceptable levels of asbestos exposure in theworkplace, and created guidelines for engineering controls andrespirators, protective clothing, exposure monitoring, hygienefacilities and practices, warning signs, labeling, recordkeeping, andmedical exams. By contrast, the British Government’s Health and Safety Executive(HSE) states formally that any threshold for mesothelioma must be at avery low level and it is widely agreed that if any such threshold doesexist at all, then it cannot currently be quantified. For practicalpurposes, therefore, HSE does not assume that any such thresholdexists. People who work with asbestos wear personal protectiveequipment to lower their risk of exposure.
Occupational
Exposure to asbestos fibres has been recognised as an occupational health hazard since the early 1900s.Several epidemiological studies have associated exposure to asbestoswith the development of lesions such as asbestos bodies in the sputum,pleural plaques, diffuse pleural thickening, asbestosis, carcinoma ofthe lung and larynx, gastrointestinal tumours, and diffuse mesotheliomaof the pleura and peritoneum.
The documented presence of asbestos fibres in water supplies andfood products has fostered concerns about the possible impact oflong-term and, as yet, unknown exposure of the general population tothese fibres. Although many authorities consider brief or transientexposure to asbestos fibres as inconsequential and an unlikely riskfactor, some epidemiologists claim that there is no risk threshold.Cases of mesothelioma have been found in people whose only exposure wasbreathing the air through ventilation systems. Other cases had veryminimal (3 months or less) direct exposure.
Commercial asbestos mining at Wittenoom, Western Australia, occurredbetween 1945 and 1966. A cohort study of miners employed at the minereported that while no deaths occurred within the first 10 years aftercrocidolite exposure, 85 deaths attributable to mesothelioma hadoccurred by 1985. By 1994, 539 reported deaths due to mesothelioma hadbeen reported in Western Australia.
Paraoccupational Secondary Exposure
Family members and others living with asbestos workers have anincreased risk of developing mesothelioma, and possibly other asbestosrelated diseases. This risk may be the result of exposure to asbestosdust brought home on the clothing and hair of asbestos workers. Toreduce the chance of exposing family members to asbestos fibres,asbestos workers are usually required to shower and change theirclothing before leaving the workplace.
Asbestos in buildings
Many building materials used in both public and domestic premisesprior to the banning of asbestos may contain asbestos. Those performingrenovation works or diy activities may expose themselves to asbestosdust. In the UK use of Chrysotile asbestos was banned at the end of1999. Brown and blue asbestos was banned in the UK around 1985.Buildings built or renovated prior to these dates may contain asbestosmaterials.
Environmental Exposure
Incidence of mesothelioma had been found to be higher in populations living near Naturally Occurring Asbestos (NOA).
Treatment
Treatment of MM using conventional therapies has not proved successful and patients have a mediansurvival time of 6 - 12 months after presentation. The clinicalbehaviour of the malignancy is affected by several factors includingthe continuous mesothelial surface of the pleural cavity which favourslocal metastasis via exfoliated cells, invasion to underlying tissueand other organs within the pleural cavity, and the extremely longlatency period between asbestos exposure and development of the disease.
Surgery
Surgery, either by itself or used in combination with pre- andpost-operative adjuvant therapies has proved disappointing. Apleurectomy/decortication is the most common surgery, in which thelining of the chest is removed. Less common is an extrapleuralpneumonectomy (EPP), in which the lung, lining of the inside of thechest, the hemi-diaphragm and the pericardium are removed. It is not possible to remove the entire mesothelium without killing the patient.
Radiation
Wikibooks has a book on the topic ofRadiation Oncology/Lung/Mesothelioma
For patients with localized disease, and who can tolerate a radicalsurgery, radiation is often given post-operatively as a consolidativetreatment. The entire hemi-thorax is treated with radiation therapy,often given simultaneously with chemotherapy. This approach of usingsurgery followed by radiation with chemotherapy has been pioneered bythe thoracic oncology team at Brigham & Women’s Hospital in Boston.[7]Delivering radiation and chemotherapy after a radical surgery has ledto extended life expectancy in selected patient populations with somepatients surviving more than 5 years. As part of a curative approach tomesothelioma, radiotherapy is also commonly applied to the sites of chest drain insertion, in order to prevent growth of the tumor along the track in the chest wall.
Although mesothelioma is generally resistant to curative treatment with radiotherapyalone, palliative treatment regimens are sometimes used to relievesymptoms arising from tumor growth, such as obstruction of a majorblood vessel. Radiation therapy when given alone with curative intenthas never been shown to improve survival from mesothelioma. Thenecessary radiation dose to treat mesothelioma that has not beensurgically removed would be very toxic.
Chemotherapy
In February 2004, the United States Food and Drug Administration approved pemetrexed (brand name Alimta) for treatment of malignant pleural mesothelioma. Pemetrexed is given in combination with cisplatin. Folic acid is also used to reduce the side-effects of pemetrexed.
Immunotherapy
Treatment regimens involving immunotherapy have yielded variable results. For example, intrapleural inoculation of Bacillus Calmette-Guérin(BCG) in an attempt to boost the immune response, was found to be of nobenefit to the patient (while it may benefit patients with bladder cancer). Mesothelioma cells proved susceptible to in vitro lysis by LAK cells following activation by interleukin-2(IL-2), but patients undergoing this particular therapy experiencedmajor side effects. Indeed, this trial was suspended in view of theunacceptably high levels of IL-2 toxicity and the severity of sideeffects such as fever and cachexia. Nonetheless, other trials involvinginterferon alpha have proved more encouraging with 20% of patientsexperiencing a greater than 50% reduction in tumor mass combined withminimal side effects.
Heated Intraoperative Intraperitoneal Chemotherapy
A procedure known as heated intraoperative intraperitonealchemotherapy was developed by Paul Sugarbaker at the Washington CancerInstitute.[7]The surgeon removes as much of the tumor as possible followed by thedirect administration of a chemotherapy agent, heated to between 40 and48°C, in the abdomen. The fluid is perfused for 60 to 120 minutes andthen drained.
This technique permits the administration of high concentrations ofselected drugs into the abdominal and pelvic surfaces. Heating thechemotherapy treatment increases the penetration of the drugs intotissues. Also, heating itself damages the malignant cells more than thenormal cells.
[edit] Prevention & Expectations
What can be done to prevent the disease? Since the 1970s, theEnvironmental Protection Agency and the Occupational Safety and HealthAdministration have regulated the asbestos industry in the U.S. In thepast, asbestos was used as a fire retardant and an insulator. Otherproducts are now used in its place. The controversy involving exposureto different forms of asbestos continues.
There are two major types of asbestos: chrysotile and amphibole.It is thought that exposure to the amphibole form is more likely tocause mesothelioma. However, chrysotile has been used more frequently,hence many mesotheliomas are caused by chrysotile.
Removal is taking place in schools and other public buildingsthroughout the U.S. The hope is that these measures will greatly reducethe occurrence of this cancer.
What are the long-term effects of the disease? A mesotheliomais a highly aggressive tumor that is generally deadly. Currenttreatment of malignant mesothelioma is designed to make the person withcancer comfortable. Although long-term survival cannot usually beexpected, the case of famed paleontologist Stephen Jay Gould is a noted exception.
What are the risks to others? Mesothelioma is not contagiousand cannot be passed from one person to another. The exposure to theasbestos that caused the cancer occurred many years to several decadesbefore the disease appeared. People who live with asbestos workers havea higher risk of getting this cancer.
What happens once treatment is over? Although mesothelioma isvery unpleasant it’s still important for person after treatment is overto keep up all follow-up appointments and that’s vital because furthertesting is always needed to check whether cancer is coming back or toexamine possible side effects that could be rather unpleasant andwhat’s even worse permanent.
Notable people with mesothelioma
Mesothelioma, though rare, has had a number of notable patients. Australian anti-racism activist Bob Bellear died in 2005. British science fiction writer Michael G. Coney, responsible for nearly 100 works also died in 2005. American film and television actor Paul Gleason, perhaps best known for his portrayal of Principal Richard Vernon in the 1985 film The Breakfast Club, died in 2006. Mickie Most, an English record producer, died of mesothelioma in 2003. Paul Rudolph, an American architect known for his cubist building designs, died in 1997.
Bernie Banton was an Australian workers’ rights activist, who fought a long battle for compensation from James Hardieafter he contracted mesothelioma after working for that company. Heclaimed James Hardie knew of the dangers of asbestos before he beganwork with the substance making insulation for power stations.Mesothelioma eventually took his life along with his brothers andhundreds of James Hardie workers. James Hardie made an undisclosedsettlement with Mr Banton only when his mesothelioma had reached itsfinal stages and he was expected to have no more than 48hrs to live.Australian Prime Minister-elect Kevin Rudd mentioned Mr Banton’sextended struggle in his acceptance speech after winning the 2007Australian Federal Election.
Steve McQueenwas diagnosed with peritoneal mesothelioma on December 22, 1979. He wasnot offered surgery or chemotherapy because doctors felt the cancer wastoo advanced. McQueen sought alternative treatments from clinics inMexico. He died of a heart attack on November 7, 1980, in Juárez,Mexico, following cancer surgery. He may have been exposed to asbestoswhile serving with the US Marines as a young adult—asbestos was thencommonly used to insulate ships’ piping—or because of its use as aninsulating material in car racing suits. (It is also reported that he worked in a shipyard during World War II, where he might have been exposed to asbestos.[citation needed]
United States Congressman Bruce Vento died of mesothelioma in 2000. The Bruce Vento Hopebuilder is awarded yearly by his wife at the MARF symposium to persons or organizations who have done the most to support mesothelioma research and advocacy.
After a long period of untreated illness and pain, rock and roll musician and songwriter Warren Zevonwas diagnosed with inoperable mesothelioma in the fall of 2002.Refusing treatments he believed might incapacitate him, Zevon focusedhis energies on recording his final album The Wind including the song Keep me in your heart which speaks of his failing breath. Zevon died at his home in Los Angeles, California, on September 7, 2003.
Although life expectancy with this disease is typically limited, there are notable survivors. In July 1982, Stephen Jay Gould was diagnosed with peritoneal mesothelioma. After his diagnosis, Gould wrote the "The Median Isn’t the Message"[9] for Discovermagazine, in which he argued that statistics such as median survivalare just useful abstractions, not destiny. Gould lived for anothertwenty years eventually succumbing to metastatic adenocarcinoma of thelung, not mesothelioma.
Author Paul Krauswas diagnosed with mesothelioma in June 1997 following an umbilicalhernia operation. His prognosis was "a few months." He continues tosurvive using a variety of integrative and complimentary modalities andhas written a book about his experience.
Legal issues
Main article: asbestos and the law
The first lawsuits against asbestos manufacturers were in 1929.Since then, many lawsuits have been filed against asbestosmanufacturers and employers, for neglecting to implement safetymeasures after the links between asbestos, asbestosis, and mesotheliomabecame known (some reports seem to place this as early as 1898). The liability resulting from the sheer number of lawsuits and people affected has reached billions of dollars.[citation needed]The amounts and method of allocating compensation have been the sourceof many court cases, and government attempts at resolution of existingand future cases.
History
The first lawsuit against asbestos manufacturers was brought in1929. The parties settled that lawsuit, and as part of the agreement,the attorneys agreed not to pursue further cases. It was not until 1960that an article published by Wagner et al first officially establishedmesothelioma as a disease arising from exposure to crocidolite asbestos.[10]The article referred to over 30 case studies of people who had sufferedfrom mesothelioma in South Africa. Some exposures were transient andsome were mine workers. In 1962 McNulty reported the first diagnosedcase of malignant mesothelioma in an Australian asbestos worker. The worker had worked in the mill at the asbestos mine in Wittenoom from 1948 to 1950.
In the town of Wittenoom, asbestos-containing mine waste was used tocover schoolyards and playgrounds. In 1965 an article in the BritishJournal of Industrial Medicine established that people who lived in theneighbourhoods of asbestos factories and mines, but did not work inthem, had contracted mesothelioma.
Despite proof that the dust associated with asbestos mining andmilling causes asbestos related disease, mining began at Wittenoom in1943 and continued until 1966. In 1974 the first public warnings of thedangers of blue asbestos were published in a cover story called "Isthis Killer in Your Home?" in Australia’s Bulletin magazine. In 1978 the Western AustralianGovernment decided to phase out the town of Wittenoom, following thepublication of a Health Dept. booklet, "The Health Hazard atWittenoom", containing the results of air sampling and an appraisal ofworldwide medical information.
By 1979 the first writs for negligence related to Wittenoom wereissued against CSR and its subsidiary ABA, and the Asbestos DiseasesSociety was formed to represent the Wittenoom victims.
Wikipedia
Here Indonesian Pages about Mesothelioma
