A case-control study of carcinomas of the nose and paranasal sinuses in the woolen textile manufacturing industry

Malignant Versus Benign Tumors of the Sinonasal Cavity: A Case-Control Study on Occupational Etiology

Case-control studies on malignant sinonasal tumors and occupational risk factors are generally weakened by non-occupational confounders and the selection of suitable controls. This study aimed to confirm the association between sinonasal malignant tumors and patients' occupations with consideration for sinonasal inverted papillomas (SNIPs) as a control group. Thirty-two patients affected by adenocarcinoma (ADC) and 21 non-adenocarcinoma epithelial tumors (NAETs) were compared to 65 patients diagnosed with SNIPs. All patients were recruited in the same clinical setting between 2004 and 2016. A questionnaire was used to collect information on non-occupational factors (age, sex, smoking, allergies, and chronic sinusitis) and occupations (wood- and leather-related occupations, textile industry, metal working). Odds ratios (OR) with 95% confidence intervals (CI) associated with selected occupations were obtained by a multinomial and exact logistic regression. Between the three groups of patients, SNIP patients were significantly younger than ADC patients (p = 0.026). The risk of NAET increased in woodworkers (OR = 9.42; CI = 1.94⁻45.6) and metal workers (OR = 5.65; CI = 1.12⁻28.6). The risk of ADC increased in wood (OR = 86.3; CI = 15.2⁻488) and leather workers (OR = 119.4; CI = 11.3⁻1258). On the exact logistic regression, the OR associated to the textile industry was 9.32 (95%CI = 1.10⁻Inf) for ADC, and 7.21 (95%CI = 0.55⁻Inf) for NAET. Comparing sinonasal malignant tumors with controls recruited from the same clinical setting allowed demonstrating an increased risk associated with multiple occupations. Well-matched samples of cases and controls reduced the confounding bias and increased the strength of the association.

Occupational exposure and sinonasal cancer: a systematic review and meta-analysis

Background

Sinonasal cancer (SNC) has been related to occupational exposures, but the relative risk associated to specific jobs and/or carcinogen exposures other than wood and leather dust is generally based on small or inadequate sample sizes and the range of observed estimates is large. This paper is aimed at investigating such relationship through a systematic review of the literature followed by a meta-analysis of studies meeting specific inclusion criteria.

Methods

Systematic search was made with PubMed, Google Scholar and Scopus engines using related keywords. Occupational exposures include wood and leather dust, formaldehyde, nickel and chromium compounds, textile industry, farming and construction. Meta-analysis of published studies after 1985 with a case-control or cohort design was performed, firstly using the fixed-effect model. Heterogeneity was assessed with the Q statistical test and quantified by the I² index. When the heterogeneity hypothesis appeared relevant, the random-effect model was chosen. Sources of heterogeneity were explored using subgroup analyses.

Results

Out of 63 reviewed articles, 28 (11 cohort, 17 case-control) were used in the meta-analysis. Heterogeneity among studies was observed and random-effects models were used. Exposure to wood dust results associated with SNC (RR_pooled = 5.91, 95% CI: 4.31-8.11 for the case-control studies and 1.61, 95% CI: 1.10-2.37 for the cohort studies), as well as to leather dust (11.89, 95% CI: 7.69-18.36). The strongest associations are with adenocarcinomas (29.43, 95% CI: 16.46-52.61 and 35.26, 95% CI: 20.62-60.28 respectively). An increased risk of SNC for exposures to formaldehyde (1.68, 95% CI: 1.37-2.06 for the case control and 1.09, 95% CI: 0.66-1.79 for the cohort studies), textile industry (2.03, 95% CI: 1.47-2.8), construction (1.62, 95% CI: 1.11-2.36) and nickel and chromium compounds (18.0, 95% CI: 14.55-22.27) was found. Subset analyses identified several sources of heterogeneity and an exposure-response relationship was suggested for wood dust (p = 0.001).

Conclusions

By confirming the strength of association between occupational exposure to causal carcinogens and SNC risk, our results may provide indications to the occupational etiology of SNC (not only wood and leather dusts). Future studies could be focused on specific occupational groups to confirm causative agents and to define appropriate preventive measures.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1042-2) contains supplementary material, which is available to authorized users.

Endoscopic skull base surgery for sinonasal malignancy

Management of malignant neoplasms of the sinonasal tract and skull base is hampered by the relative low incidence and pathologic diversity of patient presentations. Many studies have reported successful outcomes in the endoscopic management of malignancy since 1996, and these are summarized in this article. Nonsurgical adjuvant therapies are important for locoregional control because surgery occurs in a restricted anatomic space with close margins to critical structures, and distant disease is an ongoing concern in these disorders. There remains a need for collaborative consistent multicenter reporting, and international registries have been established to assist in such efforts.

Occupational exposure to eight organic dusts and respiratory cancer among Finns

BACKGROUND

There is inconclusive evidence concerning cancer risks of organic dusts.

AIM

The carcinogenic exposures are mainly inhalatory and the authors therefore studied associations between occupational exposure to eight different organic dusts and respiratory cancers in Finland.

METHODS

The authors followed up a cohort of all economically active Finns born between 1906 and 1945 for 30 million person-years during 1971-95. Incident cases of nasal, laryngeal, and lung cancer and mesotheliomas were identified through a record linkage with the Finnish Cancer Registry. Occupations from the population census in 1970 were converted to exposures to eight organic dusts with a job-exposure matrix (FINJEM). Cumulative exposure (CE) was calculated as a product of prevalence, level, and estimated duration of exposure. Standardised incidence ratios (SIR) and 95% confidence intervals (CI) adjusted for age, period, and social class were calculated for each organic dust using the economically active population as the reference.

RESULTS

A total of 20 426 incident cases of respiratory cancer were observed. Slightly increased risk was observed among men exposed to wood dust for nasal cancer (SIR 1.42, 95% CI 0.79 to 2.44). For laryngeal cancer, men exposed to plant dust (mainly grain millers) had a raised SIR in the high exposure class (SIR 3.55, 95% CI 1.30 to 7.72). Men exposed to wood dust had a raised SIR for lung cancer, but only in the low exposure class (SIR 1.11, 95% CI 1.04 to 1.18). Women exposed to wood dust showed an increased SIR for mesotheliomas in the low exposure class (SIR 4.57, 95% CI 1.25 to 11.7) and some excess in the medium exposure category.

CONCLUSIONS

Exposure to organic dusts is unlikely to be a major risk factor of respiratory cancer. Even exposure to wood dust which is a major exposure in Finland seems to have minor effect for nasal cancer. The authors found suggestive evidence that exposure to grain dust may increase the risk of laryngeal cancer, and some support to the hypothesis that exposure to textile dust, and to plant and animal dust (agricultural dusts) may decrease the risk of lung cancer.

Smoking-induced squamous-cell cancer of the nose

Squamous-cell cancer (SCC) isolated to the anterior nose is uncommon. Numerous industrial and environmental contaminants have been implicated as causative factors in nasal carcinoma. The association between nasal cancer and smoking was recognized in the 1980s, but results have not been consistent and no possible mechanisms have been suggested. The case histories of 11 patients with SCC limited to the anterior nasal cavity were reviewed. The authors found no relationship with exposures to chemicals previously implicated in nasal cancer. Nine patients with SCC were exposed to cigarette smoke (mean = 103 pack-years). Cigarette smoke may induce cancer directly, thus affecting the mucosa, or by inducing genetic alterations. The authors favor the former mechanism.

Study of ethmoidal mucosa in a population at occupational high risk of sinonasal adenocarcinoma

The occurrence of nasal adenocarcinomas was first described in 1965. Since 1988 these tumors have been accepted as an occupational disease for woodworkers in Italy. There are several underlying reasons why there is interest in studying the ways in which sinonasal adenocarcinomas occur. Often diagnosed at advanced stages of development because their symptoms are non-specific, these tumors are associated with a high mortality rate. A multidisciplinary study protocol was developed in this investigation. The aim was to identify the factors and conditions that promote sinonasal tumor growth in a population at risk due to occupational exposure to wood dust. Sixty-eight carpenters with a minimum of 10 years exposure to wood dust were studied. The control group comprised 81 volunteers. The patients underwent the following protocol: completion of a case report form, physical examination, evaluation of nasal cavity patency, clinical laboratory tests and histological study of the nasal mucosa. Our study provides significant evidence of the elevated incidence of pavimentous metaplasia in workers occupationally exposed to wood dust. In addition, it underscores a significant deficit of immunoglobulin A in such workers compared to the controls. However, we did not find, as reported elsewhere in the literature, a statistically significant difference between cases and controls as regards nasal symptoms and hyperemia of the nasal mucosa. Our study showed that, even in the absence of evident sinonasal lesions, it is still possible to determine an increased incidence of morphofunctional changes in subjects occupationally exposed to wood dust. Our findings may lead to the identification of occupational groups prone to elevated risk of the disease.

Potential pulmonary effects of man-made organic fiber (MMOF) dusts

In the first half of the twentieth century epidemiologic evidence linked elevated incidences of pulmonary fibrosis and cancer with inhalation of chrysotile and crocidolite asbestos, a family of naturally occurring inorganic fibrous materials. As the serpentine and amphibole forms of asbestos were phased out, synthetic vitreous fibers (SVFs; fiber glass, mineral wool, and refractory fiber) became increasingly utilized, and concerns were raised that they too might cause adverse health effects. Extensive toxicological research on SVFs has demonstrated that their pulmonary effects are directly related to fiber dose in the lung over time. This is the result of deposition (thin fibers deposit in the lower lung more efficiently than thick fibers) and lung-persistence ("biopersistence" is directly related to fiber length and inversely related to dissolution and fragmentation rates). In rat inhalation studies, asbestos was determined to be 7- to 10-fold more biopersistent in the lung than SVFs. Other than its effect on biopersistence, fiber composition did not appear to play a direct role in the biological activity of SVFs. Recently, the utilization of man-made organic fibers (MMOFs) (also referred to by some as synthetic organic fibers) has increased rapidly for a variety of applications. In contrast to SVFs, research on the potential pulmonary effects of MMOFs is relatively limited, because traditionally MMOFs were manufactured in diameters too thick to be respirable (inhalable into the lower lung). However, new developments in the MMOF industry have resulted in the production of increasingly fine-diameter fibers for special applications, and certain post-manufacturing processes (e.g., chopping) generate respirable-sized MMOF dust. Until the mid-1990s, there was no consistent evidence of human health affects attributed to occupational exposure to MMOFs. Very recently, however, a unique form of interstitial lung disease has been reported in nylon flock workers in three different plants, and respirable-sized nylon shreds (including fibers) were identified in workplace air samples. Whether nylon dust or other occupational exposures are responsible for the development of lung disease in these workers remains to be determined. It is also unknown whether the biological mechanisms that determine the respirability and toxicity of SVFs apply to MMOFs. Thus, it is appropriate and timely to review the current data regarding MMOF workplace exposure and pulmonary health effects, including the database on epidemiological, exposure assessment, and toxicology studies.

Sinonasal cancer, occupation, and tobacco smoking in European women and men

BACKGROUND

In this analysis of European case-control studies on sinonasal cancer, we examined the risk for occupation and smoking, by gender and histological type.

METHODS

The pooled data included 104 female and 451 male cases, and 241 female and 1,464 male controls. Lifetime smoking and occupational history were recoded following uniform criteria, and job-exposure matrices were applied for wood and leather dust.

RESULTS

Wood dust exposure was associated with an excess risk in men (OR = 2.36, 95% CI 1.75-3.2) but not in women (OR = 1.17, 95% CI 0.31-4.47). Exposure to leather dust was associated with an excess risk in both genders. Both wood and leather dust were associated with adenocarcinomas rather than squamous cell carcinomas. Excess risks for smoking were higher for squamous cell carcinomas and higher in men than in women.

CONCLUSIONS

In these European populations, occupation was associated with about 11% of all sinonasal cancers in women and 39% in men. This difference can, in part, be attributed to variation in exposure patterns between genders.

Wood dust and nasal cancer risk. A review of the evidence from North America

In this article, biomedical literature assessing risks of nasal cancer and nonmalignant nasal pathology among woodworkers in North America is reviewed in detail and contrasted with experience from Europe and elsewhere. Exceptionally high rates of nasal adenocarcinoma have occurred among European hardwood furniture workers, but the epidemiologic evidence documents a disparity in findings between North America and Europe. Cohort studies of American wood-dust-exposed groups do not reveal excesses of nasal cancer, and wood-dust associations from US and Canadian case-control studies of nasal cancer tend not to be strong and differ across studies. Quantitative wood-dust exposure data are generally unavailable, but general dose information in European studies suggests that the excess risk of nasal cancer is associated with high levels of exposure. There is also an inconsistent association between wood-dust exposure per se and mucostasis or nasal histologic changes, and the mucostasis/metaplasia/dysplasia route to nasal cancer is still an unverified hypothesis. Considering the totality of evidence on the risk of cancer in exposed workers, it appears that wood-dust-related nasal adenocarcinoma essentially can be eliminated in Europe and its occurrence prevented in the United States if wood-dust exposures do not exceed an 8-hour time-weighted average 5 mg/m3 standard.

Intestinal-type sinonasal adenocarcinoma: a sporadic case

A sporadic case of the intestinal-type sinonasal adenocarcinoma is described. The patient was a comparatively young 33-year-old woman employed as a senior biochemical scientific technologist for several years. The light microscopical pattern was that of a papillary-tubular adenocarcinoma with areas of more solid mucinous elements in the deeper parts of the neoplasm. The neoplasm had invaded the nasal septum and reached the left orbit invading the left ethmoidal sinus. The glands were lined by columnar cells with elongated spindle-shaped nuclei and the cells expressed cytokeratin, carcinoembryonic antigen (CEA), Chromogranin A, gastrin and serotonin but not neurone-specific enolase (NSE) nor synaptophysin. Neurosecretory granules were present. There was no history of wood dust inhalation and her exposure to chemicals is of some interest but had probably little or no role in the causation of this neoplasm.

Cancer mortality among shoe manufacturing workers: an analysis of two cohorts

OBJECTIVES

To examine the cancer risk of shoe manufacturing workers and evaluate whether the risk was associated with exposure to leather dust and solvents.

METHODS

Data from two historical cohort studies of shoe workers were expanded and analysed in parallel. A total of 4215 shoemakers from England contributing 103 726 person-years at risk and 2008 shoemakers from Florence, Italy, contributing 54,395 person-years at risk were included in the analysis. Exposure to leather dusts and solvents from glues was evaluated on the basis of job title information. Standardised mortality ratios (SMR) were calculated as ratios of observed deaths (Obs) over expected derived from national mortalities.

RESULTS

Overall mortality was lower than expected in both cohorts (English cohort: Obs 3314, SMR 81, 95% confidence interval (95% CI) 78-84; Florence cohort: Obs 333, SMR 87, 95% CI 78-97). An increased risk of nasal cancer was found (English cohort: Obs 12, SMR 741; Florence cohort: Obs 1, SMR 909). 10 of the 13 cases occurred among English workers employed in the manufacture of welted boots (SMR 926, 95% CI 444-1703), a sector of the industry thought to have had the highest exposure to leather dust. Mortality from leukaemia was not increased in the English cohort (Obs 16, SMR 89), but was increased in the Florence cohort (Obs 8, SMR 214, 95% CI 92-421); and the highest risk was found among shoe workers in Florence who were first exposed between 1950 and 1959 when exposure to benzene was substantial (Obs 3, SMR 536, 95% CI 111-1566). Some evidence for an excess risk of stomach, bladder, and kidney cancer, as well as multiple myeloma and non-Hodgkin's lymphoma was also found in the Florence cohort only among workers employed in jobs with the highest exposure to solvents.

CONCLUSIONS

These findings confirm the associations between exposure to leather dust and nasal cancer and between exposure to benzene and leukaemia in the shoe manufacturing industry and suggest that the risk of other cancers may be increased among workers exposed to solvents or glues.

Wood dust and sino-nasal cancer: pooled reanalysis of twelve case-control studies

In order to examine the relationship between wood dust and sino-nasal cancer, data from 12 case-control studies conducted in seven countries were pooled and reanalyzed. The relative risks associated with wood-related jobs and with exposure to wood dust, measured using a job exposure matrix based on occupation and industry titles, were examined using logistic regression. The combined data set consisted of 680 male cases, 2,349 male controls, 250 female cases, and 787 female controls. A high risk of adenocarcinoma among men was associated with employment in wood-related occupations (odds ratio [OR] = 13.5, 95% confidence interval [CI] = 9.0-20.0) and the risk was greatest among men who had been employed in jobs with the highest wood dust exposure (OR = 45.5, 95% CI = 28.3-72.9) and increased with duration of exposure. The risk of adenocarcinoma also appeared elevated among women employed in wood-related jobs (OR = 2.5, 95% CI = 0.5-12.3), but the small number of exposed cases precluded detailed analysis. Women in wood dust-exposed jobs appeared to have an excess of squamous cell carcinoma (OR = 2.1, 95% CI = 0.8-5.5) which increased with duration of exposure. An increased risk of squamous cell carcinoma in men was seen only among those employed for 30 or more years in jobs with exposure to fresh wood (OR = 2.4, 95% CI = 1.1-5.0). The results of this analysis provide strong support to the association between exposure to wood dust in a variety of occupations and the risk of sino-nasal adenocarcinoma and are consistent with the results of individual participating studies, although the magnitude of the excess risk varied. The evidence in regard to squamous cell carcinomas was ambiguous and there was a great deal of heterogeneity observed in individual study results. This may be due to differences in risk associated with exposure to hardwoods and softwoods or with other, as yet to be identified, aspects of exposure.