Reliability of death certifications for different types of cancer. An autopsy survey

A series of 1000 cases was selected, on the basis of a clinical and/or post-mortem diagnosis of cancer, out of 4927 autopsies performed at the Institute of Pathologic Anatomy and Histopathology of Turin University. The comparison between clinical and post-mortem diagnoses pointed to an overall concordance with regard to the correct identification of a malignancy as the underlying cause of death of 75%; if the correct identification of type and primary site of the tumor was also taken into account, the concordance was only 56%. The rate of false-positive and false-negative diagnoses, the confirmation rate and sensitivity index of clinical diagnoses, and the error of estimate of the overall frequency of the different types of tumors were computed. Pancreas, liver and biliary tract tumors appear to be the most difficult to identify correctly during life; also lung, stomach and colorectal cancers, lymphomas and leukemias show fairly high rate of clinical errors. Breast cancer, tumors of the nervous system and colorectal cancers appear to be overnotified. These results seem to underscore the necessity of being very careful in drawing conclusions on the frequency and distribution of the different types of cancer on the basis of current mortality statistics.

Aortic dissection at autopsy: a fifty-four year survey in Torino

The Authors reviewed the postmortem findings of 36,671 autopsies performed from 1929 to 1982 in the hospitals of Torino with emergency ward. Two hundred and sixty-five cases of Aortic Dissection (A.D.) were found, and studied in relation to their frequency by sex and age, pathology, and antemortem diagnosis. The main outcome of this survey was the increasing frequency of the lesion in the autopsy population during the last 36 years considered, from 1/759 necropsies in 1947-1952, to 1/52 in 1977-1982. These data are discussed in relation to the hypothesis of a possible actual increase of A.D..

Pleural plaques and risk of cancer in Turin, northwestern Italy. An autopsy study

The relationship between the occurrence of neoplastic diseases and the presence of pleural plaques was studied in a series of 1097 autopsies performed in Turin from the adult general population. In men, pleural plaques showed an association with the presence of laryngeal, pulmonary, esophageal, and colorectal cancer. Only cancer of the larynx was strongly related to the occurrence of such pleural changes. This autopsy investigation confirms previous observations by others based on x-ray findings, and suggests that pleural plaques may be regarded as risk indicators of possibly asbestos-related tumors in the general population.

Coated and uncoated lung mineral fibres in subjects with and without pleural plaques at autopsy

The lung concentration of coated and uncoated mineral fibres of more than 10 micron in length was determined by light microscopy in 57 autopsied subjects (23 out of which professionally exposed to asbestos) with pleural plaques but no other asbestos-related diseases. Comparisons were made with 57 controls matched for sex, age and smoking habits, who did not show any asbestos-associated diseases or history of previous occupational exposure. Subjects with pleural plaques had a median concentration of coated fibres consistently greater than that observed in those without. However, no substantial differences were found between the two studied groups when uncoated and total fibres were considered. The present study suggests that the factors related to the fibre coating and to the pleural plaque formation may be indirectly connected, but not necessarily restricted to the number and nature of the fibres, or to the professional or environmental conditions of exposure.

Carbohydrate and lipid metabolism in cirrhosis. Evidence that hepatic uptake of gluconeogenic precursors and of free fatty acids depends on effective hepatic flow

Splanchnic arteriovenous differences for several intermediary metabolites of carbohydrate and lipid metabolism were determined simultaneously with hepatic blood flow in seven normal subjects, eight patients with cirrhosis, and six patients with cirrhosis after surgical portosystemic shunt ( SPSS ) after an overnight fast. Arteriovenous differences in the legs were also determined together with flux measurement. The individual turnover rates of acetoacetate (AcAc) and 3 hydroxybutyrate (beta OHB) were also determined by means of isotopic techniques. Splanchnic gluconeogenic precursors and FFA uptakes were lower in cirrhotic patients with SPSS than in normal subjects (P less than 0.05 and P less than 0.01, respectively). Splanchnic triglyceride output was also lower in cirrhotic patients with SPSS than in normal subjects (P less than 0.01), whereas no significant differences were found for AcAc, beta OHB, and glucose release. In the group of cirrhotic patients without SPSS , those patients with negligible signs of portal systemic shunt and normal splanchnic blood flow had uptake of gluconeogenic precursors and of FFA normal or higher than that of normal subjects, whereas those patients with signs of spontaneous portal systemic shunt behaved like cirrhotic patients with SPSS . Alanine release from the leg was lower in both cirrhotic patient groups. Tracer determined hepatic output of AcAc and beta OHB was higher in cirrhotic patients with SPSS (P less than 0.05). Plasma clearance rates of AcAc and beta OHB were significantly elevated in both cirrhotic patient groups. Close agreement was found between tracer and catheterization techniques in the evaluation of ketone body production in cirrhotic patients with SPSS , whereas in cirrhotic patients without SPSS tracer determined hepatic output was slightly lower, possibly because of extrahepatic splanchnic tissue ketone body uptake. In conclusion, our data in patients with cirrhosis indicate that: 1) splanchnic uptake of gluconeogenic precursors and of FFA was related to the degree of portal systemic shunt, e.g. to the degree of effective hepatic blood flow; 2) liver triglyceride but not ketone body output was decreased by the impaired FFA (and glycerol) liver uptake; 3) the higher circulating levels of gluconeogenic precursors (except alanine) and of FFA appeared at least partially due to lower hepatic removal of these metabolites; and 4) peripheral use of ketone bodies was increased and alanine release from the leg reduced in patients with cirrhosis.

Pleural plaques at autopsy, smoking habits, and asbestos exposure

An investigation was made to correlate post-mortem findings of pleural plaques (PP) with the smoking habits and occupational history of asbestos exposure of 898 adults from the general population. A significant association between PP and smoking was found in middle-aged and elderly men (p less than 0.001). When occupational history was considered, such an association was present in both exposed (p less than 0.01) and non-exposed (p less than 0.05) men aged over 50 years. No association was observed in non-exposed women, while in those exposed, the absolute number of cases was too small to evaluate any relationship. The number of cigarettes smoked did not correlate significantly with the frequency of PP. This autopsy study confirms the association between occurrence of PP and the smoking habits.

Pleural mesothelioma after a short interval from first exposure in the wine filter industry

Pleural mesotheliomas are usually reported after a long interval has passed since first exposure to asbestos. We, however, describe a case observed after a latent period of only 7.5 years in a worker exposed in a factory manufacturing auxiliary products for wine treatment, including chrysotile asbestos filters. The exposure to asbestos lasted 3-4 months per year, during which airborne fiber concentrations ranged from 1 to 4 ff/cc in the patient's workplace. Due to the characteristics of the manufacturing process, the asbestos fibers were very thin in diameter. The patient also suffered from nasal breathing impairment. An examination of the literature showed that asbestos-related mesotheliomas have been reported, albeit rarely, after less than 10 years from onset of exposure. Therefore, it is believed that this case should be related to past exposure to asbestos.

Insulin resistance in Cushing's syndrome

It is well established that cortisol excess causes insulin resistance in man, but the mechanisms responsible for this insulin resistance are poorly understood. We studied five women with Cushing's syndrome with impaired oral glucose tolerance tests and seven normal subjects, plotting the shape of the insulin-induced disposal dose-response curve obtained by means of the euglycemic clamp procedure during four different plasma insulin plateaus at four infusion rates of 21, 73, 760, and 1200 mU/M2 . min. Glucose disposal (M = mg/M2 . min) was calculated as glucose amount infused to maintain euglycemia. In Cushing's syndrome the dose-response curve was shifted to the right in comparison with normal subjects, with a significantly lower M (337 +/- 35 vs. 657 +/- 76 P less than 0.01) during the highest insulin infusion rate [maximal glucose disposal (MGD)] without any significant difference in the levels of insulin half-maximally effective in the stimulation of glucose utilization. Neither erythrocyte nor monocyte maximum insulin receptor binding were different between the two populations. Four Cushing's syndrome patients were studied again after surgical treatment. A marked improvement of MGD was observed without any significant change in insulin-binding capacity. These results, particularly the marked decrease in MGD, a typical feature of postreceptor defects, indicate that cortisol-induced insulin resistance in man is due to an impairment of peripheral insulin action located beyond the hormone-receptor binding step.

Lung asbestos bodies and pleural plaques at autopsy

Examination for lung asbestos bodies and pleural plaques was made in 996 consecutive unselected autopsies in Torino. The prevalence of asbestos bodies was 12.4% and that of pleural plaques 19.1%. Both findings were found with significantly greater frequency in men, and in the age group above 50 years. In addition, their occurrence increased with age up to 70 years, then decreased thereafter. A significant association between the severity of plaque lesions and the presence of asbestos bodies was found, whereas the number of asbestos bodies was not related to the presence of pleural plaques. It is suggested that pleural plaques are more reliable markers of asbestos exposure started many years earlier, and that lung asbestos bodies are more reliable indicators of more recent exposure.

Pleural plaques at autopsy in Turin: a study on 1,019 adult subjects

Hyaline pleural plaques were searched for in 1,019 consecutive autopsies performed on adults in Turin. These pleural lesions were found in 173/706 males and 22/313 females (P less than 0.001). The difference between the sexes was not significant under the age of 50 years but was highly significant (P less than 0.001) in the age groups above 50 years. The severity of the pleural lesions has been graded according to the total area of the plaques. The most severe pleural abnormalities can be considered as connected with previous occupational exposure to asbestos.

[Active tuberculosis unsuspected until autopsy]

A series of 3195 necropsies performed in cases of natural death at the "S. Giovanni" Hospital in Turin, and covering the years 1969-1978, was studied for the prevalence of active tuberculosis. Active tuberculosis was found in 61 cases (1,9%); in 60 a complete clinical history was available. Forty-two out of these 60 cases (70%) were diagnosed only at autopsy, with higher frequency in the old patients. In the 42 patients with undiagnosed active tuberculosis, the acid fast bacilli resulted to have been searched for only in 3 cases, and a chest-film was recorded in 23 cases; in 27 cases of this group, the period between the admission and the death was longer than 8 days (mean 29 days). The clinical diagnosis of active tuberculosis displays intrinsic difficulties; however it must be stressed that an higher proportion of cases could be recognized if one keeps in mind the possibility of this polymorphic disease, so that adequate clinical, laboratory and x-ray investigations should carried out.