Abstract
Background
Asbestos is the primary known cause of malignant mesothelioma. Some cosmetic talc products have been shown to contain asbestos. Recently, repeated exposures to cosmetic talc have been implicated as a cause of mesothelioma.
Methods
Seventy‐five individuals (64 females; 11 males) with malignant mesothelioma, whose only known exposure to asbestos was repeated exposures to cosmetic talcum powders, were reviewed in medical‐legal consultation. Out of the 75 cases, 11 were examined for asbestiform fibers.
Results
All subjects had pathologically confirmed malignant mesothelioma. The mean age at diagnosis was 61 ± 17 years. The mean latency from exposure to diagnosis was 50 ± 13 years. The mean exposure duration was 33 ± 16 years. Four mesotheliomas (5%) occurred in individuals working as barbers/cosmetologists, or in a family member who swept the barber shop. Twelve (16%) occurred in individuals less than 45 years old (10 females; 2 males). Forty‐eight mesotheliomas were pleural (40 females; 8 males), 23 were peritoneal (21 females; 2 males). Two presented with concomitant pleural and peritoneal disease. There was one pericardial, and one testicular mesothelioma. The majority (51) were of the epithelioid histological subtype, followed by 13 biphasic, 8 sarcomatoid, 2 lymphohistiocytoid, and 1 poorly differentiated. Of the 11 individuals whose nontumorous tissues were analyzed for the presence of asbestiform fibers, all showed the presence of anthophyllite and/or tremolite asbestos.
Conclusions
Mesotheliomas can develop following exposures to cosmetic talcum powders. These appear to be attributable to the presence of anthophyllite and tremolite contaminants in cosmetic talcum powder.
Keywords: anthophyllite, females, mesothelioma, peritoneal, pleural, talc, tremolite
1. INTRODUCTION
Asbestos, a generic term for naturally occurring fibrous mineral silicates, is recognized as a carcinogen by the general medical and scientific communities. In 1960, Wagner et al 1 reported a large series of malignant mesotheliomas in individuals who had been exposed to asbestos from a South African asbestos mine. It has been demonstrated that all types of asbestos and even brief and low‐dose exposures are capable of causing malignant mesothelioma. 2 , 3 , 4 In the 1970s, several types of cosmetic talcum powder products were demonstrated to contain asbestos. 5 , 6 , 7 Asbestos fibers in commercial talcum powder have also been shown to become airborne upon application, and repeated exposures to cosmetic talc were implicated as a cause of mesothelioma by Gordon et al. 8 Recently, Moline et al, 9 reported a series of 33 subjects with malignant mesothelioma, whose only known exposure to asbestos was cosmetic talc. We present 75 additional subjects, with malignant mesothelioma, whose only known exposure to asbestos was cosmetic talc.
2. METHODS
One hundred forty subjects with documented exposures to cosmetic talc were initially reviewed. Exposures were identified through sworn deposition testimonies and answers to sworn interrogatories provided from subjects, parents, and spouses. Sixty‐five subjects were excluded due to recalled occupational or paraoccupational exposures to other sources of asbestos. Seventy‐five subjects, whose only known exposure to asbestos was via cosmetic talc, were included for further examination. The asbestos content of talcum products and airborne asbestos concentrations during simulations of the usage of these products was determined in previously published studies. 10 , 11
Tissues from biopsies and/or debulking procedures were examined and the diagnosis of malignant mesothelioma was confirmed by a board‐certified pathologist (JCM, TSE, RLK). Immunohistochemical staining results for BAP‐1 were available in a few cases but was not routinely performed as a part of this study.
No efforts were made to reconstruct levels of exposure but all subjects had been repeatedly exposed over many years. Eleven cases were examined for the presence of asbestiform fibers (aspect ratio, ≥3:1) in sampled tissues. Nine subjects were examined both by analytical transmission electron microscopy (ATEM) and microprobe analysis (MA) (see Table 2), whereas two were examined by scanning electron microscopy (SEM) and MA (results not shown).
Table 2.
Fiber detection in tissue digestion from nine cases of malignant mesothelioma
Concentration (fibers per gram of wet tissue) | Limit of detection (fibers per gram of wet tissue) | Tissue digest weight (g) | ||||
---|---|---|---|---|---|---|
Case | Mesothelioma site | Asbestos type | Tissues examined | Lung, lymph node, omentum, ovary | Lung, lymph node, omentum, ovary | Lung, lymph node, omentum, ovary |
65 | Pleural | Anthophyllite, tremolite | Lung, lymph node | 8625 | 4313 | 0.08, 0.34 |
66 | Pleural | Anthophyllite | Lung, lymph node | 15 333, 23 000 | 7667, 1150 | 0.06, 0.06 |
67 | Peritoneal | Anthophyllite, tremolite | Omentum, lymph node | 1917, 1725 | 639, 1725 | 0.54, 0.20 |
68 | Pleural | Anthophyllite, tremolite | Lymph node | 3044 | 1015 | 0.82, 0.34 |
70 | Pleural | Anthophyllite, amosite, chrysotile | Lymph node | 17 250 | 3450 | 1.06 |
71 | Pleural | Anthophyllite, tremolite | Lung, lymph node | 4313, 857, 3451 | 2156, 857, 575 | 0.16 |
72 | Pleural | Anthophyllite, tremolite | Lymph node | 17 250 | 3450 | 0.02 |
74 | Pleural | Anthophyllite, tremolite | Lung | 2300 | 460 | 2 |
75 | Pleural | Anthophyllite | Lung, ovary | 3450, 2070 | 1150, 2070 | 0.6, 0.2 |
Note: All cases shown were examined by analytical transmission electron microscopy and structures analyzed by microprobe analysis.
3. RESULTS
The pertinent data from the 75 subjects is shown in Table 1. All had pathologically confirmed malignant mesothelioma. Sixty‐four subjects were females, 11 were males. The mean age at diagnosis was 61 ± 17 years, with a range of 14 to 94 years. The mean exposure duration was 33 ± 16 years with a range of exposure from 6 to 65 years. The mean latency from time of first exposure to diagnosis was 50 ± 13 years with a range of 14 to 72 years. A total of 4 of the 75 cases (5%) occurred in barbers/cosmetologists, or in a family member who swept the barber shop. Twelve (16%) were 45 years old or younger (10 females, 2 males) at the time of diagnosis. Forty‐eight mesotheliomas were pleural (40 females; 8 in males); 23 peritoneal (21 females; 2 men). Two presented with both pleural and peritoneal disease. There was one pericardial (woman), and one testicular mesothelioma. The majority, 51 (68%) were of epithelioid subtype, 13 biphasic (17%), 8 sarcomatoid (11%), 2 lymphohistiocytoid (3%), and 1 poorly differentiated (1%). Treatment, therapeutic outcomes, and survival were not determined in this study.
Table 1.
Seventy‐five mesothelioma cases exposed to talcum powder
Case | Sex | Year of diagnosis | Age at diagnosis | Mesothelioma site | Histology | Estimated years of use | Estimated years of latency |
---|---|---|---|---|---|---|---|
1 | F | 2017 | 72 | Pleural | Epithelioid | 20 | 57 |
2 | F | 2014 | 51 | Peritoneal | Epithelioid | 30 | 50 |
3 | F | 2017 | 50 | Pleural | Lymphohistiocytoid | 41 | 50 |
4 | F | 2017 | 57 | Peritoneal | Epithelioid | 30 | 52 |
5 | F | 2015 | 65 | Pleural | Epithelioid | 39 | 62 |
6 | F | 2017 | 39 | Peritoneal | Sarcomatoid | 15 | 39 |
7 | F | 2016 | 29 | Pericardial | Epithelioid | 29 | 29 |
8 | F | 2017 | 94 | Pleural | Epithelioid | 60 | 72 |
9 | F | 2015 | 80 | Pleural | Epithelioid | 19 | 59 |
10 | F | 2016 | 72 | Pleural | Sarcomatoid | 43 | 59 |
11 | F | 2013 | 66 | Peritoneal | Epithelioid | 20 | 52 |
12 | F | 2011 | 48 | Pleural | Lymphohistiocytoid | 13 | 21 |
13 | F | 2010 | 51 | Peritoneal | Epithelioid | 15 | 20 |
14 | F | 2018 | 55 | Peritoneal | Epithelioid | 40 | 42 |
15 | M | 2017 | 81 | Pleural | Sarcomatoid | 60 | 60 |
16 | F | 2018 | 56 | Pleural | Epithelioid | 48 | 52 |
17 | F | 2017 | 32 | Peritoneal | Epithelioid | 25 | 32 |
18 | F | 2017 | 89 | Pleural | Sarcomatoid | 40 | 42 |
19 | F | 2019 | 73 | Peritoneal | Epithelioid | 47 | 56 |
20 | M | 2016 | 70 | Pleural | Poorly differentiated | 50 | 55 |
21 | F | 2015 | 66 | Pleural | Epithelioid | 40 | 43 |
22 | F | 2016 | 45 | Pleural | Epithelioid | 10 | 45 |
23 | F | 2018 | 45 | Peritoneal | Epithelioid | 39 | 45 |
24 | M | 2015 | 67 | Pleural + peritoneal | Epithelioid | 35 | 60 |
25 | M | 2017 | 78 | Peritoneal | Biphasic | 50 | 62 |
26 | F | 2018 | 57 | Peritoneal | Biphasic | 25 | 57 |
27 | F | 2013 | 14 | Peritoneal | Epithelioid | 12 | 14 |
28 | F | 2016 | 67 | Peritoneal | Epithelioid | 15 | 59 |
29 | F | 2018 | 73 | Pleural | Epithelioid | 30 | 65 |
30 | F | 2018 | 76 | Pleural | Biphasic | 60 | 55 |
31 | M | 2017 | 39 | Testis | Epithelioid | 7 | 39 |
32 | F | 2018 | 57 | Pleural | Sarcomatoid | 57 | 57 |
33 | F | 2016 | 68 | Pleural | Epithelioid | 38 | 64 |
34 | F | 2017 | 80 | Pleural | Epithelioid | 50 | 60 |
35 | F | 2016 | 63 | Pleural | Epithelioid | 15 | 54 |
36 | F | 2017 | 58 | Pleural | Biphasic | 20 | 58 |
37 | F | 2017 | 71 | Pleural | Biphasic | 60 | 71 |
38 | F | 2014 | 70 | Pleural | Epithelioid | 41 | 39 |
39 | F | 2016 | 26 | Peritoneal | Epithelioid | 20 | 26 |
40 | F | 2016 | 35 | Pleural | Epithelioid | 35 | 35 |
41 | F | 2017 | 72 | Pleural | Sarcomatoid | 23 | 60 |
42 | F | 2016 | 68 | Peritoneal | Epithelioid | 65 | 68 |
43 | F | 2018 | 77 | Pleural | Biphasic | 30 | 55 |
44 | M | 2015 | 58 | Plural | Biphasic | 6 | 49 |
45 | F | 2017 | 72 | Peritoneal | Biphasic | 30 | 42 |
46 | F | 2017 | 59 | Pleural + peritoneal | Epithelioid | 15 | 44 |
47 | F | 2016 | 80 | Pleural | Biphasic | 16 | 52 |
48 | M | 2019 | 71 | Pleural | Epithelioid | 40 | 57 |
49 | F | 2017 | 72 | Pleural | Biphasic | 58 | 58 |
50 | F | 2017 | 43 | Peritoneal | Epithelioid | 43 | 43 |
51 | F | 2017 | 75 | Peritoneal | Sarcomatoid | 55 | 59 |
52 | F | 2015 | 30 | Pleural | Epithelioid | 20 | 20 |
53 | F | 2017 | 79 | Pleural | Biphasic | 65 | 61 |
54 | F | 2017 | 66 | Peritoneal | Epithelioid | 20 | 60 |
55 | F | 2015 | 64 | Peritoneal | Epithelioid | 40 | 40 |
56 | F | 2017 | 24 | Pleural | Epithelioid | 12 | 24 |
57 | M | 2017 | 72 | Pleural | Epithelioid | 30 | 56 |
58 | M | 2017 | 74 | Peritoneal | Epithelioid | 30 | 52 |
59 | M | 2015 | 30 | Pleural | Epithelioid | 20 | 30 |
60 | F | 2016 | 81 | Pleural | Sarcomatoid | 52 | 52 |
61 | F | 2017 | 58 | Pleural | Epithelioid | 58 | 58 |
62 | F | 2016 | 75 | Pleural | Epithelioid | 8 | 47 |
63 | F | 2011 | 88 | Pleural | Epithelioid | 21 | 71 |
64 | F | 2016 | 73 | Peritoneal | Biphasic | 41 | 60 |
65 a | M | 2017 | 64 | Pleural | Epithelioid | 18 | 40 |
66 a | F | 2014 | 69 | Pleural | Epithelioid | 16 | 60 |
67 a | F | 2014 | 44 | Peritoneal | Epithelioid | 30 | 39 |
68 a | F | 2016 | 68 | Pleural | Epithelioid | 53 | 52 |
69 a | F | 2016 | 72 | Pleural | Epithelioid | 40 | 51 |
70 a | F | 2016 | 67 | Pleural | Epithelioid | 37 | 53 |
71 a | F | 2017 | 58 | Pleural | Epithelioid | 41 | 46 |
72 a | M | 2016 | 44 | Pleural | Epithelioid | 43 | 44 |
73 a | F | 2017 | 51 | Pleural | Epithelioid | 28 | 49 |
74 a | F | 2015 | 47 | Pleural | Epithelioid | 15 | 40 |
75 a | F | 2014 | 62 | Pleural | Biphasic | 14 | 53 |
Tissue analysis performed.
For the 11 subjects whose tissues were examined by ATEM and ASEM, the analysis showed the presence of tremolite and/or anthophyllite in all 11 subjects (Table 2).
4. DISCUSSION
The 75 individuals with malignant mesothelioma caused by asbestos in cosmetic talc is currently the largest series reported to date. Recently, Moline et al reported 33 cases of malignant mesothelioma attributed to exposures to cosmetic talc. Like Moline's work, most of mesotheliomas in the present series occurred in women. Several mesotheliomas occurred specifically in hairdressers/barbers. Similarly, the asbestos fiber types found by ATEM in the tissues examined were comparable to those found in laboratory testing for cosmetic talc. 10 , 11 , 12
Mesothelioma is recognized as a “signal tumor” of asbestos exposure, that is, if a patient has mesothelioma, it should signal an inquiry into potential asbestos exposure. The presence of asbestos in talc deposits has been recognized since the late 1940s. 13 , 14 Since the 1960s, laboratory testing has identified asbestos in samples of cosmetic talc. 15 , 16 Studies have confirmed that the most common types of asbestos present in cosmetic talc are tremolite, anthophyllite, and chrysotile. Industrial asbestos products used in the United States generally contained chrysotile, amosite, and/or crocidolite, 17 and anthophyllite and tremolite were rarely present. 18
While the latency between exposure and diagnosis in the present study is similar to the average latency for the development of mesothelioma (50 years) reported in surveillance epidemiology and end results program (SEER) data, 19 the average age at diagnosis in this report (61 years) is 11 years younger than that in the SEER data (72 years). In addition, fewer than 3% of mesotheliomas in the SEER data occurred in individuals less than 45 years of age, whereas 16% of mesotheliomas of the present study occurred in individuals less than 45 years of age, and 83% of these cases were in women. 20
The present report of 75 cases, together with the 35 cases previously reported 8 , 9 currently brings the number of individuals with confirmed diagnoses of malignant mesothelioma following repeated exposure to cosmetic talcum powder to more than 100. The presence of anthophyllite and tremolite in the fiber analysis of tissues obtained from the 11 subjects in this series, is consistent with a source in cosmetic talc.
Unlike industrial or occupational exposure to asbestos, where materials have been regulated, exposure to asbestos in cosmetic talc has not been widely reported or recognized within the medical community or to the public. Cosmetic talc products are most frequently used by women in the United States, and while the incidence of mesothelioma in women is less than in men, the majority have previously been reported as “idiopathic,” indicating no recognized source of asbestos exposure. The present study supports the contention that asbestos exposure through the use of cosmetic talc accounts may account for an uncertain percentage of these cases.
The present study has several limitations. It is both retrospective and uncontrolled, and the cases were submitted in medico‐legal consultation, all of which potentially introduce bias. However, detailed deposition testimonies provide a level of detail concerning product exposure—including dates of exposure, duration, and frequency—that is rarely obtained in routine medical exposure histories, and which allowed for corroborating witness testimony in some cases. The strengths of the current series include its size, as malignant mesothelioma is a rare disease (1‐2 cases per 100 000), and its novelty, as exposures to cosmetic talc are rarely considered by most medical practitioners when they are eliciting an exposure history to asbestos.
The findings of the present and other recent studies suggest that cosmetic talc may be a cause of malignant mesothelioma. Large‐scale controlled studies will be required to assess the prospective risk of developing mesothelioma following repeated exposures to talc. Although cosmetic talcs are not currently regulated by the Food and Drug Administration, the poor prognosis of malignant mesothelioma may warrant regulation or the withdrawal of cosmetic talcs from the market, as nontoxic alternatives such as corn starch are presently available.
CONFLICTS OF INTEREST
Drs Emory, Maddox, and Kradin have testified in asbestos litigation, primarily for plaintiffs.
DISCLOSURE BY AJIM EDITOR OF RECORD
John D. Meyer declares that he has no conflict of interest in the review and publication decision regarding this article.
AUTHOR CONTRIBUTIONS
JCM and RLK developed the concept and the design of the work. JCM initiated the acquisition and developed the initial data analysis. TSE reviewed the materials, performed the statistical analysis, and was the primary author of the manuscript. RLK revised and gave the final approval of the version to be published.
ETHICS APPROVAL AND INFORMED CONSENT
As these cases were selected from medical‐legal consultation practice and no identifying information was included, there was no formal institutional consent nor informed consent required.
Emory TS, Maddox JC, Kradin RL. Malignant mesothelioma following repeated exposures to cosmetic talc: A case series of 75 patients. Am J Ind Med. 2020;63:484–489. 10.1002/ajim.23106
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