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. 2020 Mar 16;63(6):484–489. doi: 10.1002/ajim.23106

Malignant mesothelioma following repeated exposures to cosmetic talc: A case series of 75 patients

Theresa S Emory 1,, John C Maddox 1, Richard L Kradin 2,3
PMCID: PMC7317550  PMID: 32175619

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
a

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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