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The role of cancer-directed surgery in the treatment of stage I-IIIA malignant pleural mesothelioma (MPM) by histologic subtypes remains controversial. The objective of this study was to evaluate the survival of the different histologic subtypes for stage I-IIIA MPM stratified by cancer-directed surgery and nonoperative management. How is the histologic subtype, clinical stage, and use of cancer-directed surgery for MPM associated with overall survival? Overall survival of patients with stage I-IIIA epithelioid, sarcomatoid, and biphasic MPM in the National Cancer Database from 2004 through 2017 who underwent cancer-directed surgery (ie, surgery with or without chemotherapy or radiation) or chemotherapy with or without radiation (nonoperative management) was evaluated using Kaplan-Meier analysis, multivariable Cox proportional hazards analysis, and propensity score-matched analysis. Of 2,285 patients with stage I-IIIA MPM who met inclusion criteria, histologic subtype was epithelioid in 71% of patients, sarcomatoid in 12% of patients, and biphasic in 17% of patients. Median survival was 20 months in the epithelioid group, 8 months in the sarcomatoid group, and 13 months in the biphasic group (P <.01). Among patients who underwent surgery, median survival was 25 months in the epithelioid group, 8 months in the sarcomatoid group, and 15 months in the biphasic group (P <.01). In multivariable Cox proportional hazards analyses, surgery was associated with improved survival in the epithelioid group (P <.01) but not in the sarcomatoid (P =.63) or biphasic (P =.21) groups. These findings were consistent in propensity score-matched analyses for each MPM histologic type. In this national analysis, cancer-directed surgery was found to be associated with improved survival for stage I-IIIA epithelioid MPM, but not for biphasic or sarcomatoid MPM. [ABSTRACT FROM AUTHOR]

Background: Comprehensive US epidemiologic data for adult pleural disease are not available.Research Question: What are the epidemiologic measures related to adult pleural disease in the United States?Study Design and Methods: Retrospective cohort study using Healthcare Utilization Project databases (2007-2016). Adults (≥ 18 years of age) with malignant pleural mesothelioma, malignant pleural effusion, nonmalignant pleural effusion, empyema, primary and secondary spontaneous pneumothorax, iatrogenic pneumothorax, and pleural TB were studied.Results: In 2016, ED treat-and-discharge (T&D) visits totaled 42,215, accounting for charges of $286.7 million. In 2016, a total of 361,270 hospitalizations occurred, resulting in national costs of $10.1 billion. A total of 64,174 readmissions contributed $1.16 billion in additional national costs. Nonmalignant pleural effusion constituted 85.5% of ED T&D visits, 63.5% of hospitalizations, and 66.3% of 30-day readmissions. Contemporary sex distribution (male to female ratio) in primary spontaneous pneumothorax (2.1:1) differs from older estimates (6.2:1). Decadal analyses of annual hospitalization rates/100,000 adult population (2007 vs 2016) showed a significant (P < .001) decrease for malignant pleural mesothelioma (1.3 vs 1.09, respectively), malignant pleural effusion (33.4 vs 31.9, respectively), iatrogenic pneumothorax (17.9 vs 13.9, respectively), and pleural TB (0.20 vs 0.09, respectively) and an increase for empyema (8.1 vs 11.1, respectively) and nonmalignant pleural effusion (78.1 vs 100.1, respectively). Empyema hospitalizations have high costs per case ($38,591) and length of stay (13.8 days). The mean proportion of readmissions attributed to a pleural cause varied widely: malignant pleural mesothelioma, 49%; malignant pleural effusion, 45%; nonmalignant pleural effusion, 31%; empyema, 27%; primary spontaneous pneumothorax, 27%; secondary spontaneous pneumothorax, 27%; and iatrogenic pneumothorax, 20%. Secondary spontaneous pneumothorax had the shortest time to readmission in 2016 (10.3 days, 95% CI, 8.8-11.8 days).Interpretation: Significant epidemiologic trends and changes in various pleural diseases were observed. The analysis identifies multiple opportunities for improvement in management of pleural diseases. [ABSTRACT FROM AUTHOR]

Malignant pleural effusion is common in mesothelioma. We report a case of viscous recurrent malignant mesothelioma pleural effusion. The viscosity was due to the presence of hyaluronic acid and resulted in prolonged drainage time. The use of intrapleural hyaluronidase significantly reduced fluid viscosity and drainage duration. No adverse reactions were noted. This novel case highlights the feasibility and safety of the use of intrapleural hyaluronidase in the management of hyaluronic acid-rich viscous malignant pleural effusion. [ABSTRACT FROM AUTHOR]

Background: Pleural biopsies in patients with suspected malignant pleural mesothelioma (MPM) are often inconclusive resulting in repeat diagnostic procedures. Confocal laser endomicroscopy (CLE) enables real-time imaging on a cellular level. We investigated pleural CLE imaging as a biopsy guidance technique to distinguish malignant from benign pleural disease.Methods: Prospective, multicenter study in patients with (suspected) MPM based on PET-CT imaging who were scheduled for pleural biopsies. Patients received 2.5 mL fluorescein intravenously preceding the procedure. In vivo through-the-needle CLE imaging of the pleura and ex vivo CLE imaging of the biopsies were correlated with histology. CLE characteristics for various pleural entities were identified, and their interpretability was tested by CLE video scoring by multiple blinded raters.Results: CLE imaging was successfully obtained in 19 of 20 diagnostic pleural biopsy procedures (thoracoscopy: n = 4, surgical excision: n = 3, CT scan: n = 3, ultrasound: n = 9, esophageal ultrasound guided: n = 1) in 15 patients. CLE videos (n = 89) and corresponding pleural biopsies (n = 105) were obtained. No study-related adverse events occurred. Tumor deposits of MPM were distinguished from areas with pleural fibrosis based on CLE imaging and recognized by raters (n = 3) (interobserver agreement, 0.56; 95% CI, 0.49-0.64).Conclusions: CLE imaging was feasible and safe regardless of the biopsy method. Real-time visualization of pleural abnormalities in epithelial and sarcomatoid MPM could be distinguished from pleural fibrosis. Therefore, CLE has potential as a guidance biopsy tool to reduce the current substantial rate of repeat biopsy procedures by identification of areas with malignant cells in vivo (smart needle).Trial Registry: ClinicalTrials.gov; No.: NCT02689050; URL: www.clinicaltrials.gov. [ABSTRACT FROM AUTHOR]

Malignant pleural mesothelioma is a highly aggressive tumor associated with asbestos exposure. There are few effective treatment options for mesothelioma, and patients have a very poor prognosis with a median survival of < 12 months from diagnosis. Biomarkers have been proposed as a cost-effective means of cancer management, and the search for a mesothelioma biomarker has been ongoing for the last 30 years. Many traditional soluble (glyco)protein biomarkers have been evaluated over this time, and an ever-increasing list of new biomarkers, including messenger RNA, DNA, microRNA, and antibodies, is being reported from biomarker discovery projects. To date, soluble mesothelin is the only tumor biomarker to receive US Food and Drug Administration approval for clinical use in mesothelioma. Mesothelin is a glycoprotein normally expressed on the surface of mesothelial cells, and in the cancerous state it can be present in circulation. Mesothelin has a limited expression on normal, nonmalignant tissue and is thus an attractive therapeutic target for mesothelin-positive tumors. In this review we will focus on the discovery and clinical usages of mesothelin and provide an update on other mesothelioma biomarkers and show how such biomarker studies might impact on the management of this deadly tumor in the future. [ABSTRACT FROM AUTHOR]

Dendritic cells (DCs) are potent antigen-presenting cells. Because of their particular ability to initiate and regulate cell mediated and humoral immune responses, there is considerable interest in the role that DCs play in the pathogenesis of various lung diseases, especially those in which there is an excessive immune response to specific antigens (as in asthma) or a deficient immune response (as in lung cancer). A number of DC subpopulations have been defined in the lungs, including myeloid or conventional DCs that initiate T-cell immunity and antibody production and plasmacytoid DCs that have an important role in antiviral immunity and immune tolerance. Although an extensive body of literature has documented the role that DCs play in experimental models of lung disease, this review will highlight recent advances in our understanding of DC function in human disease, including asthma, COPD, antimicrobial immunity, and lung cancer. The future is likely to see new approaches whereby antigens and small molecules are targeted to receptors on particular DC subpopulations in order to modify pulmonary immune responses. [ABSTRACT FROM AUTHOR]

Background: Malignant pleural effusion (MPE) is common. Existing literature on pleural fluid compositions is restricted to cross-sectional sampling with little information on longitudinal changes of fluid biochemistry and cytokines with disease progression. Indwelling pleural catheters provide the unique opportunity for repeated sampling and longitudinal evaluation of MPE, which may provide insight into tumor pathobiology.Methods: We collected 638 MPE samples from 103 patients managed with indwelling pleural catheters over 95 days (median, range 0-735 days) and analyzed them for protein, pH, lactate dehydrogenase, and glucose levels. Peripheral blood was quantified for hematocrit, platelets, leukocytes, protein, and albumin. Cytokine levels (monocyte chemotactic protein [MCP]-1; vascular endothelial growth factor; interleukin-6, -8, and -10; tumor necrosis factor-α; and interferon-gamma) were determined in 298 samples from 35 patients with mesothelioma. Longitudinal changes of all parameters were analyzed using a linear mixed model.Results: Significant decreases were observed over time in pleural fluid protein by 8 g/L per 100 days (SE, 1.32; P < .0001) and pH (0.04/100 days; SE, 0.02; P = .0203), accompanied by a nonsignificant rise in lactate dehydrogenase. The ratio of pleural fluid to serum protein decreased by 0.06/100 days (SE, 0.02; P = .04). MPEs from mesothelioma (n = 63) had lower pleural fluid glucose (P = .0104) at baseline and a faster rate of decline in glucose (P = .0423) when compared with non-mesothelioma effusions (n = 38). A progressive rise in mesothelioma pleural fluid concentration of [log] MCP-1 ([log] 0.37 pg/mL per 100 days; SE, 0.13; P = .0046), but not of other cytokines, was observed.Conclusions: MPE fluids become less exudative and more acidic over the disease course. The rise in MCP-1 levels suggests a pathobiological role in MPE. [ABSTRACT FROM AUTHOR]

The article discusses a study that determined the association of catheter tract metastases (CTMs) with the use of indwelling pleural catheters (IPCs). Reviewed were data on CTM of patients with inserted IPCs on the tunneled subcutaneous tract or the insertion site for a period of 44 months. Results showed that CTM is not common among patients with IPCs but it can lead to the complication of metastatic carcinomas and mesotheliomas as to the duration of interval after insertion of IPC.

The article discusses a research study which found that micro-ribonucleic acid 1 (miR-1) induces growth arrest and apoptosis in malignant pleural mesothelioma (MPM). The researchers observed the expression level of miR-1 between patients with tumors and those with normal pleural specimens. They assessed transduced MPM cells cell cycle-related, proapoptotic and anti-apoptotic genes to validate observations of miR-1 induced apoptosis.

The article discusses a study on the association between the risk of malignant mesothelioma (MM) and pleural plaques (PPs) and the proximity of birthplace to ophiolites. The study involved subjects from the province of Sivas, Turkey who were either diagnosed with MM/PPs or prostate/breast cancer from 2000 to 2010. It was found that the birthplaces of patients with MM or PPs were significantly nearer to ophiolites compared with that of cancer patients.

The article focuses on immunohistochemical approaches to differentiating primary pulmonary from metastatic adenocarcinomas, mesotheliomas from carcinomas and different types of spindle cell neoplasms. It presents typical immunohistochemistry (IHC) staining reactivities observed in association with individual types of tumor. The role of IHC in directing therapeutic decision making and in the analysis of biomarkers is discussed.

The article presents a study which described the anatomic features of patients with malignant pleural mesothelioma (MPM) at postmortem. The results showed that tumor dissemination in extrathoracic sites was common in patients and almost all organs were involved. Extrathoracic dissemination of mesothelioma was found to be common and often underrecognized. The researchers did not find anatomic cause of death in the majority of patients.

The article presents a study that examined the effect of clinical covariates on biomarkers levels and their diagnostic and prognostic value. The study covered 594 patients, including 106 with mesothelioma and 488 control subjects. It identified which covariates were independently associated with soluble mesothelin and megakaryocyte potentiating factor levels using multiple linear regression and analyses.

The article discusses research on chromosomal aberrations detected by fluorescence in situ hybridization (FISH) while diagnosing malignant mesothelioma (MM) in effusion cytology. Multitarget FISH assay was used to analyze 52 effusions of biopsy-proven MM and 28 benign effusions. It was determined that tumor suppressor genes on the 9p21 chromosomal region are inactivated by promoter methylation in the subset of FISH-negative MM.

The article presents a case study of a 48-year-old nonsmoking woman with progressive dyspnea for three months. The patient's medical history was significant for stage 3b nodular sclerosing Hodgkin lymphoma. A low-grade enhancement in several thoracic and abdominal regions was found through a PET scan. She was diagnosed for peritoneal mesothelioma and possible pleural mesothelioma.

The article provides an update on biomarkers and treatment for malignant pleural mesothelioma. Soluble mesothelin-related peptide and osteopontin biomarkers may predict which asbestos-exposed individuals develop mesothelioma. A multimodality approach is encouraged as surgery cannot eliminate all residual microscopic disease. Mesothelioma biology and molecularly targeted agents can be considered.

The article presents a study of an elderly man with chest pain and progressive miliary infiltrates. His medical history and physical examination are presented. Laboratory findings and imaging are discussed. He was diagnosed of miliary metastatic epithelioid mesothelioma, a rare tumor of which most are associated with prior exposure to asbestos.

The article discusses the study which aims to determine the CA125 which improves the sensitivity of mesothelin in diagnosing mesothelioma. The study shows that combining CA125 and mesothelin serum levels does not improve the accuracy of diagnosis of malignant mesothelioma over the mesothelin marker. Moreover, the use of mesothelin and CA125 biomakers increases the number of patients who can be monitored.

The article presents a study which provides evidence-based background and recommendations for the development of American College of Chest Physicians (ACCP) guidelines for the diagnosis and management of lung cancer. Results reveal that pathologic assessment is a crucial component for the diagnosis, management, and prognosis of lung cancer. Researchers also noted that selective diagnostic techniques and decision analysis will increase diagnostic accuracy.

The article examines the age and sex difference in malignant mesothelioma after residential exposure to blue asbestos.The incident number of malignant mesotheliomas that have occurred in residents of the town who did not work at the mine or mill is determined. Former residents of a crocidolite mining town have a high rate of mesothelioma. The rate is higher in male subjects and those more than 15 years of age at first exposure.

This article presents a study, which investigates the prognostic significance of vascular endothelial growth factor (VEGF), tumor necrosis (TN), and mitotic activity index (MAI) in malignant mesothelioma. The study also demonstrates the association between VEGF staining, TN, and MAI in malignant mesothelioma. Forty patients with a diagnosis of malignant mesothelioma were selected from the archives of the Department of Pathology in Atatürk Chest Diseases and Chest Surgery Education and Research Hospital between 1996 and 2003. The tumors were subclassified, according to the criteria given by the Work Health Organization, into epithelioid, sarcomatoid, and biphasic subtypes. Immunostaining of VEGF expression was performed using the streptavidin-biotin method with a rabbit polyclonal antibody.

Study objectives: Although the sentinel lymph node (SLN) concept has traditionally been applied to solid organs, we hypothesized that the pleural space might drain into a specific SLN group. The identification of such a nodal group could assist in the staging and treatment of pleural-based diseases, such as mesothelioma, or other lung cancers with visceral pleural invasion. The purpose of this study was to determine whether the pleural space has an SLN group. Design: Sixteen rats underwent tight or left pleural space injection of a novel lymph tracer, quantum dots (QDs), which have a hydrodynamic diameter of 15 nm and fluoresce in the near-infrared (NIR) spectrum. Nodal uptake of the entire thorax was imaged with a custom system that simultaneously acquired color video, NIR fluorescence of the QDs, and a merged picture of the two in real-time. Six pigs underwent right or left pleural space injection of QDs and similar imaging. Measurements and results: In the rat, the QDs drained solely to the highest superior mediastinal lymph node group, corresponding to lymph node station 1, according the regional lymph node classification for lung of the American joint Committee on Cancer. In one rat, the injection of QDs in the left pleural space resulted in migration to the contralateral station 1 lymph node group. The injection of QDs in the right or left pleural space of the pig resulted in migration solely to the ipsilateral highest superior mediastinal lymph node group. Conclusions: NIR fluorescence imaging in two species demonstrated that the highest superior mediastinal lymph nodes of station 1 are the SLNs of the pleural space. This study also provides intraoperative feasibility and proof of the concept for identifying lymph nodes communicating with the pleural space on a patient-specific basis, in real-time, and with high sensitivity. [ABSTRACT FROM AUTHOR]

The diagnosis and management of malignant pleural mesothelioma are major challenges that often frustrate both patient and clinician alike. Occupational asbestos exposure to crocidolite or amosite forms of the fiber is the most important known risk factor in North America and Western Europe. Other mineral fibers such as erionite, a naturally occurring fibrous zeolite crystal, are associated with mesothelioma in volcanic tuffs of the Cappadocia region of central Anatolia in Turkey. In addition, other possible factors such as the presence of simian virus 40 and genetic susceptibility have been associated recently with the development of mesothelioma in animal models. These latter findings are increasing our understanding of this disease. In addition, the discovery of elevated levels of various markers such as folic acid receptor a, cyclooxygenase 2, and multidrug resistance proteins 1 and 2 in mesothelioma tissue have opened up new areas of potential diagnostic and therapeutic importance. However, traditional treatment modalities- surgery, radiotherapy, and chemotherapy-have evolved slowly, and few gains in therapeutic efficacy have occurred. Recently, however, continuing research efforts have led to novel treatment strategies that are changing the way clinicians view a disease that has traditionally been managed with almost universal therapeutic nihilism. This review explores our current knowledge of this disease and presents current and novel therapeutic strategies. [ABSTRACT FROM AUTHOR]

Study Objective: We investigated the gene expression profiles of malignant pleural mesothelioma (MPM) specimens to identify novel genes that are potentially involved in the oncogenic transformation of human pleural cells.Design: Complementary DNA (cDNA) microarray transcriptional profiling studies of 10 MPM cell lines and 4 MPM primary tumor specimens were performed using hierarchic clustering. To confirm microarray data, we used real-time polymerase chain reaction and immunoblotting.Results: Cluster analysis differentiated among epithelial (E), sarcomatoid, and biphasic MPM variants. Expression profiling identified common overexpressed or underexpressed genes in MPM. Notably, matriptase messenger RNA was found to be overexpressed by 826-fold in E MPM, with protein expression subsequently confirmed by immunoblot analysis. This recently characterized trypsin-like serine protease has been implicated in tumor invasion and metastasis of E-derived cancers, but has not been described until now in MPM. We also identified other novel genes, such as insulin-like growth factor binding protein 5 and a cDNA clone similar to proteolipid MAL2.Conclusions: Thus, further large-scale profiling of MPM may elucidate previously unrecognized molecular mechanisms by identifying novel genes that are involved in malignant transformation. Our study has now found matriptase to be one of these mesothelioma-associated genes, with potential pathogenic and therapeutic significance. [ABSTRACT FROM AUTHOR]

Editorial. Looks into the role of gene-environment interaction in malignant pleural mesothelioma. Etiology, incidence and severity of malignant pleural mesothelioma; Application of microarray technology in studies to identify specific gene expression changes in mesothelioma compared with normal mesothelial cells; Abnormalities common in mesothelioma cell lines.

Objectives: Malignant mesothelioma (MM) is a fatal tumor of increasing incidence related to asbestos exposure. Microscopic tumor necrosis (TN) is a poor prognostic factor in solid tumors, but it has not been characterized in MM. We wished to evaluate the incidence of TN in MM and its correlations with clinicopathologic factors, angiogenesis, and survival.Methods: TN was graded in 171 routine formalin-fixed, paraffin-embedded hematoxylin-eosin-stained tumor sections by two independent observers. Angiogenesis was assessed by the microvessel count (MVC) of CD34 immunostained sections. TN was correlated with survival by Kaplan-Meier and log-rank analysis, and stepwise, multivariate Cox models were used to compare TN with angiogenesis and established prognostic factors and prognostic scoring systems.Results: TN was identified in 39 cases (22.8%) and correlated with low hemoglobin (p = 0.01), thrombocytosis (p = 0.04), and high MVC (p = 0.02). TN was a poor prognostic factor in univariate analysis (p = 0.008). Patients with TN had a median survival of 5.3 months vs 8.3 months in negative cases. Independent indicators of poor prognosis in multivariate analysis were nonepithelioid cell type (p = 0.0001), performance status > 0 (p = 0.007), and increasing MVC (p = 0.004) but not TN. TN contributed independently to the European Organisation for Research and Treatment of Cancer (EORTC) [p = 0.03] and to the Cancer and Leukemia Group B (CALGB) [p = 0.03] prognostic groups in respective multivariate Cox analyses.Conclusions: TN correlates with angiogenesis and is a poor prognostic factor in MM. TN contributes to the EORTC and CALGB prognostic scoring systems. [ABSTRACT FROM AUTHOR]

Study objectives: Sialomucin complex (SMC) is a heterodimeric glycoprotein, and is found on the surfaces of the mesothelia of the pleura, pericardium, and peritoneum. Sialomueins play a significant role in adhesion as well as in defense. In this study, we hypothesized that pleural mesothelial cells (PMCs) express SMC and thus prevent the adherence of ovarian cancer cells (HTB-77) to the pleura. Methods: PMCs were plated, and the adherence of HTB-77 cells was observed using a cytofluor. The PMC monolayer was pretreated with sialidase, and HTB-77 adherence was observed using cytofluor. In another set of HTB-77 cells, adherence was observed when the PMC monolayer was pretreated with supernatants of HTB-77 cells. Last, supernatants of HTB-77 cells were assayed for sialidase activity. Results: The removal of SMC by sialidase greatly increased the adherence of HTB-77 cells to the PMC monolayer, which was statistically significant (p < 0.05). Similar results were obtained when the PMC monolayer was pretreated with the supernatants of HTB-77 cells. Supernatants of HTB-77 cells showed the presence of sialidase. Conclusions: The presence of SMC on the PMC acts as a defense layer, and its removal by sialidase increases the susceptibility of the PMC layer to the adherence of malignant cells and to increased metastasis. HTB-77 cells also express sialidase, which by its action on the monolayer aids in the adherence of tumor cells to the pleural surface. [ABSTRACT FROM AUTHOR]

Despite many years of clinical research, there is still no effective therapy for malignant pleural mesothelioma (MPM). Untreated, the prognosis is poor, with a median survival of < 1 year. Single-agent or combination chemotherapy as well as radiotherapy have not shown persistent improvements in response or survival. In general, MPM is a disease confined to the pleural cavity for a long time before metastasizing. Therefore, focus on local treatment seems rational. Surgical resection has been considered the mainstay of treatment by some. However, surgery alone results in high recurrence rates, and the survival benefit remains questionable. In recent years, the emphasis has been on surgery combined with adjuvant therapies. In this article, the present state of surgical management of MPM will be reviewed. [ABSTRACT FROM AUTHOR]

Constrictive cardiac physiology typically does not occur in the absence of parietal pericardium. However, we report eight patients who, after left extrapleural pneumonectomy and removal of the parietal pericardium for malignancy, presented with dyspnea, jugular venous distension, and peripheral or generalized edema unresponsive to diuretics. Cardiac decortication (epicardiectomy) was performed whereby a thickened peel encasing the heart was surgically excised, resulting in vigorous contraction and expansion of the heart. In one patient, decortication occurred early after pneumonectomy and was incomplete. Acute signs of inflammation were present, and recurrence necessitated repeat decortication. When patients present with dyspnea, hepatojugular reflux, and peripheral edema refractory to diuretics, constrictive cardiac physiology should be considered in the differential diagnosis, even in the absence of parietal pericardium. [ABSTRACT FROM AUTHOR]

Study objectives: This study examines the incidence of malignant pleural mesothelioma (MPM) in a rural population of Turkey with environmental exposure to asbestos-contaminated soil mixtures (white soil). Design: A field-based epidemiologic study. Setting and subjects: A cohort of villagers (the "Eskisehir" cohort) from 11 villages around Eskisehir in central Anatolia, who had been environmentally exposed to asbestos due to the use of white soil. Measurements: The mineral content and asbestos contamination of the white soil used in these villages was determined, as well as airborne fiber concentrations. Cohort members' details of age, sex, ambient exposure data, duration of residence in the villages, and hospital records, including pathologic diagnosis, were recorded. Results: The Eskisehir cohort consisted of 1,886 villagers. During the observation time, 377 deaths occurred and 24 MPM eases were diagnosed. Average annual mesothelioma incidence rates were 114.8/100,000 for men and 159.8/100,000 for women. Conclusions: These data indicate that the risk of mesothelioma is 88.3 times greater in men and 799 times greater in women, respectively, in comparison to world background incidence rates. [ABSTRACT FROM AUTHOR]