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159]
Letters to the Editor - Documenting a Case
Figure 3: The computerized tomography scan of the orbit showing the
evidence of a 2 cm growth on the medial canthus eroding the walls of
maxilla and nasal wall
Ophthalmologic intervention can be done in patients who have
a vision threatening episode due to mass effect. Chemotherapy
being a systemic therapy can be prescribed in these advanced
stage diseases, and radiotherapy is reserved for palliative
purposes. A significant number of patients present with
ocular symptoms first without any evidence of other systemic
complaints.[4] A high index of suspicion on the part of clinician
is therefore required to detect such case at earliest stage.
Screening for carcinoma cervix might be useful as a part of
systemic evaluation in patients who presented with orbital
metastasis with unknown primary in females.[5]
Adenocarcinoma lung in a painter
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DOI: 10.4103/0973-1482.87012
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Sir,
Lung cancer is one of the leading causes of cancer deaths
worldwide. More than 1.1 million cases of lung cancer are
diagnosed annually, and over 1 million deaths are caused by the
disease.[1] The most important risk factor is tobacco smoking.
Several agents encountered in the occupational setting,
such as asbestos, polycyclic aromatic hydrocarbons, arsenic,
beryllium, cadmium, chromium, and nickel compounds, are
established carcinogens that target the lung. Many cohort
358
Orbital mass can originate from cervical malignancy and a high
index of suspicion and good judgment is required to pick up
patients at early stage who presents with orbital mass with
occult primary.
Karuna Singh, Vinay Kumar, Suman Bhasker,
Bidhu Kalyan Mohanti
Department of Radiotherapy and Oncology, All India Institute of Medical
Sciences, New Delhi, India
For correspondence:
Dr. Karuna Singh,
Department of Radiotherapy and Oncology,
All India Institute of Medical Sciences,
New Delhi - 110 029, India.
E-mail: karuna.mamc@gmail.com
REFERENCES
1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM.
Estimates of worldwide burden of cancer in 2008. Int J Cancer
2010;127:2893-917.
2. Shields CL, Shields JA, Peggy M. Tumors metastatic to the orbit.
Ophthal Plast Reconstr Surg 1988;4:73-80.
3. Gosslee JM, Misra RP, Langford MP, Vikovius B, Byrd WA, Flynn SB.
Orbital metastasis of keratinizing squamous cell carcinoma with
giant cells. Int Ophthalmol 2009;29:39-44.
4. Mcculley TJ, Yip CC, Bullock JD, Warwar RE, Hood DL. Cervical
carcinoma metastatic to the orbit. Ophthal Plast Reconstr Surg
2002;5:385-7.
5. Lee HM, Choo CT, Poh WT. Orbital metastasis from carcinoma cervix.
Br J Ophthalmol 1997;4:330-1.
and linkage studies of painters have shown consistent and
significant increases in lung cancer compared with the general
population (IARC monograph volume 98, 2010). The principle
pigment used in paints is white pigment titanium dioxide
(TiO2). The IARC categorized TiO2 as potentially carcinogenic
to humans (group 2B). Although occupational exposure to
TiO2 is extensive, there are few data on the levels and sources
of exposure.[2] There is an evidence of carcinogenicity in
experimental animals for TiO2 but the evidence in humans is
sparse and equivocal.
A 40-year-old male painter by occupation for the past 25 years
presented with 2 months history of cough, breathlessness
and right lateral chest pain. There was no history of fever,
haemoptysis or contact with tuberculosis. He is not a smoker
or alcoholic and there was no history of other comorbid
illness. The general physical examination revealed pulse rate of
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Letters to the Editor - Documenting a Case
Figure 1: (a and b) CT chest showing mass in the right lung (arrow) and right pleural effusion (*)
90/ min, blood pressure of 130/80 mmHg, pallor and there was
no lymph node enlargement. Respiratory system examination
revealed diminished breath sounds and dull percussion note in
the right axillary, right infrascapular area and there were no
added sounds. Abdominal examination showed hepatomegaly
and other system examination were normal.
Laboratory examination revealed normal liver and renal
function tests. The peripheral smear showed haemoglobin
9 mg/dl, total count of 6000/dl with normocytic normochromic
blood picture. The human immunodeficiency virus test (HIV),
hepatitis B surface antigen (HbsAg), antibodies to hepatitis C
virus (anti-HCV) was negative. The chest X-ray showed right
massive pleural effusion. CT chest revealed mass in the right
middle and apical lobe with right pleural effusion [Figures
1a and 1b] and ultrasonography abdomen showed multiple
nodular lesions in the liver suggestive of liver metastases. The
pleural fluid showed elevated protein (6 mg/dl) and cytology
of pleural fluid was suggestive of adenocarcinoma. The lung
biopsy was not done as patient refused to give consent.
Paint is a suspension of finely divided pigment particles in a
liquid composed of a binder and a volatile solvent or water. The
most common pigment employed in paint is the white pigment
TiO2, produced from ilmenite ore or from titanium slag. TiO2
was first produced commercially in 1923, primarily for pigment
production. It is primarily used as whitening and mollifying
agent in paints, varnishes, lacquers, paper, plastics, ceramics,
rubber and printing ink.[3] TiO2 is generally present in paints in
proportions varying between 10% and 20% and probably below
2 mg/cubic mm during most spray paint operations.[2] The spray
painting in closed spaces without protection can lead to the
inhalation of high concentrations of TiO2. The IARC conducts
evaluations of carcinogenic risks of different agents, and
thereby provides the information base for cancer prevention
throughout the world [Table 1].[4] According to IARC (monograph
volume 98, 2010) report, occupational exposure as a painter is
carcinogenic to humans (Group 1). Humans are exposed to TiO2
Journal of Cancer Research and Therapeutics - July-September 2011 - Volume 7 - Issue 3
Table 1: Classification of agents (By IARC Monographs,
Volumes 1-100)
Group Category Agents
1 Carcinogenic to humans 107
2A Probably carcinogenic to humans 58
2B Possibly carcinogenic to humans 249
3 Not classifiable as to its carcinogenicity 512
to humans
4 Probably not carcinogenic to humans 1
via inhalation, ingestion or dermal contact. It has been shown
in experimental rats, that long-term inhalational exposure to
carbon black, TiO2 and talc to produce pulmonary inflammation,
fibrosis and lung tumors.[4] The respiratory effects observed
among groups of TiO2-exposed workers include decline in lung
function, pleural disease with plaques and pleural thickening
and mild fibrotic changes (IARC monograph, volume 93).
There have been three large cohort studies [5-7] among
production workers in the TiO2 industry. The largest, conducted
in six European countries, found a slightly increased risk for
lung cancer compared to the general population.[5] However,
there was no evidence of an exposure response relationship
within the cohort. The other cohort studies,[6,7] both of which
were conducted in the USA, did not report any increased risk for
lung cancer. The recent study conducted in Montreal showed
that people exposed to TiO2 did not experience any excess
risk of lung cancer.[8] The results of the study by Siemiatycki
et al. showed possible increase in lung cancer risk among
subjects with high exposure to TiO2.[9] The cytogenetic studies
on painters reported increased levels of genetic damage, such
as chromosomal aberrations, micronucleus formation, sister
chromatid exchange[10] and single strand DNA breaks.
Our patient occupation was painting mainly interior
painting, spray painting and primer paintings of wooden
blocks and metals for more than 20 years. The predominant
pigment involved in most paints was TiO2. He used to work
predominantly in closed spaces without proper facemask and
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Letters to the Editor - Documenting a Case
more importantly he is not a smoker. Since there was prolonged
exposure to paint for more than 20 years without proper
protection, this would have been predisposed him to develop
lung adenocarcinoma. He presented to us in the terminal stage
of lung carcinoma with metastasis to the liver. He was planned
on palliative chemotherapy after medical oncology consultation
but he did not give consent for further management and
discharged from hospital against medical advice.
In conclusion, painters are at risk of developing lung
carcinoma on prolonged exposure and hence a proper
precaution has to be taken at working place. And also
whether TiO2 is carcinogen to the lung in humans or not is
still unanswered question. More case series studies and case
reports may aid in this regard.
Arinaganhalli Subbanna Praveen Kumar,
Ramalingam Chandramohan, Dharanitragada Krishna
Suri Subrahmanyam, Tarun Kumar Dutta
Department of Medicine, Jawaharlal Institute of Postgraduate Medical
Education and Research, Pondicherry, India
For correspondence:
Dr. A. S. Praveen Kumar,
Department of Medicine, Jawaharlal Institute of Postgraduate Medical
Education and Research, Pondicherry - 605 006, India.
E-mail: jipmer.praveen@gmail.com
Fluorodeoxyglucose positron emission tomography-
computed tomography scan and nuclear magnetic
resonance findings in a case of Stewart-Treves
syndrome
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Website: www.cancerjournal.net
DOI: 10.4103/0973-1482.87014
PMID: ***
Sir,
Stewart-Treves syndrome is a cutaneous angiosarcoma that
develops in long-standing chronic lymphedema. This tumor
develops as a very rare complication in patients suffering from
chronic lymphedema of the upper limb following mastectomy
and axillary lymph node dissection for breast cancer.[1] We
360
REFERENCES
1. Behera D, Balamugesh T. Lung Cancer in India. Indian J Chest Dis
Allied Sci 2004;46:269-81.
2. Boffetta P, Gaborieau V, Nadon L, Parent MF, Weiderpass E,
Siemiatycki J. Exposure to titanium dioxide and risk of lung cancer
in a population-based study from Montreal. Scand J Work Environ
Health 2001;27:227-32.
3. Baan R, Straif K, Grosse Y, Secretan B, El Ghissassi F, Cogliano V, et al.
Carcinogenicity of carbon black, titanium dioxide, and talc. Lancet
Oncol 2006;7:295-6.
4. International Agency for Research on Cancer. Preamble to IARC
monographs on evaluation of carcinogenic risks to humans. Lyon,
France: IARC, 2006.
5. Boffetta P, Soutar A, Cherrie JW, Granath F, Andersen A, Anttila A, et al.
Mortality among workers employed in the titanium dioxide production
industry in Europe. Cancer Causes Control 2004;15:697-706.
6. Chen JL, Fayerweather WE. Epidemiologic study of workers exposed
to titanium dioxide. J Occup Med 1988;30:937-42.
7. Fryzek JP, Chadda B, Marano D, White K, Schweitzer S,
McLaughlin JK. A cohort mortality study among titanium dioxide
manufacturing workers in the United States. J Occup Environ Med
2003;45:400-9.
8. Ramanakumar AV, Parent ME, Latreille B, Siemiatycki J. Risk of lung
cancer following exposure to carbon black, titanium dioxide and
talc: Results from two case-control studies in Montreal. Int J Cancer
2008;122:183-9.
9. Siemiatycki J. Risk factors for cancer in the workplace. Boca Raton
(FL): CRC Press, 1991.
10. Testa A, Festa F, Ranaldi R, Giachelia M, Tirindelli D, De Marco A. A
multi biomarker analysis of DNA damage in automobile painters.
Environ Mol Mutagen 2005;46:182-8.
present FDG PET-CT and NMR imaging characteristics of
this rare complication of lymphedema.
A seventy year old lady, known case of carcinoma right breast,
presented with nodular erythematous lesion over right
arm. Her treatment history included right modified radical
mastectomy (MRM), with axillary lymph node dissection
followed by local radiotherapy seven years ago. Post-surgery
she developed lymphoedema of right arm. FDG PET-CT was
advised to characterize the right arm lesion and to evaluate
the whole body disease status.
Transaxial CT images [Figure 1] demonstrate skin thickening of
medial aspect of right arm. The swollen right arm shows linear
Journal of Cancer Research and Therapeutics - July-September 2011 - Volume 7 - Issue 3