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To cite this article: V. Courtney Broaddus , Jeffrey I. Everitt , Brad Black & Agnes B. Kane (2011) Non-Neoplastic and
Neoplastic Pleural Endpoints Following Fiber Exposure, Journal of Toxicology and Environmental Health, Part B: Critical
Reviews, 14:1-4, 153-178, DOI: 10.1080/10937404.2011.556049
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Journal of Toxicology and Environmental Health, Part B, 14:153–178, 2011
Copyright © Taylor & Francis Group, LLC
ISSN: 1093-7404 print / 1521-6950 online
DOI: 10.1080/10937404.2011.556049
plaques, fibrosis, and benign effusions, as well as with diffuse malignant pleural mesothe-
lioma. Translocation and retention of fibers are fundamental processes in understanding the
interactions between the dose and dimensions of fibers retained at this anatomic site and
the subsequent pathological reactions. The initial interaction of fibers with target cells in
the pleura has been studied in cellular models in vitro and in experimental studies in vivo.
The proposed biological mechanisms responsible for non-neoplastic and neoplastic pleural
diseases and the physical and chemical properties of asbestos fibers relevant to these mecha-
nisms are critically reviewed. Understanding mechanisms of asbestos fiber toxicity may help
us anticipate the problems from future exposures both to asbestos and to novel fibrous mate-
rials such as nanotubes. Gaps in our understanding have been outlined as guides for future
research.
Dr. Broaddus acknowledges research support from the Department of Defense (PR 080717) and Dr. Kane acknowledges research
support from the National Institute of Environmental Health Sciences (RO1 ES016178 and P42 ES013660).
Address correspondence to Agnes B. Kane, Brown University, Department of Pathology and Laboratory Medicine, Box G-E5, 70
Ship Street, Providence, RI 02912, USA. E-mail: agnes_kane@brown.edu
153
154 V. C. BROADDUS ET AL.
Intercostal
microvessels
Lymphatic
Bronchial
microvessels
FIGURE 1. Fluid turnover and lymphatic drainage from the pleural space. In the normal pleural space (shown here), as in other interstitial
spaces of the body, liquid slowly filters from systemic capillaries and is absorbed via lymphatics (solid arrows). In the pleural space, the
capillary filtrate from systemic capillaries moves across a permeable pleural membrane toward the lower pressure pleural space and is
absorbed via the parietal pleural lymphatics. From there, liquid moves via lymphatic propulsion to the central veins. When interstitial
edema forms in the adjacent lung, some of that excess liquid moves across the visceral pleura into the pleural space. Asbestos fibers
may follow similar routes from the lung to the pleura and are thought to lodge in the parietal pleura preferentially at sites of lymphatic
drainage.
organs, exudative effusions may form; these unknown. It is postulated that asbestos fibers
effusions contain elevated levels of protein due may migrate to the lung interstitium and vis-
to the increased leakage across capillaries with ceral pleura by a paracellular route or by direct
increased permeability (Mutsaers et al., 2004). penetration across injured alveolar epithelial
Excess fluid in any part of the body may find cells (Miserocchi et al., 2008). Fibers may be
its way to the pleural space via the intersti- transported to the pleural space via the lym-
tial tissues along pressure gradients and by phatics and bloodstream (Oberdörster et al.,
moving across the permeable pleural mem- 1983). Fibers may translocate by themselves
branes. The normal and pathological paths by or within macrophages. Although studies of
which liquid, cells, and particles enter and exit asbestos fiber movement have not been pos-
the pleural space suggest pathways by which sible due to technical limitations, it is likely that
asbestos fibers may also enter and exit or fail asbestos fibers translocate to the pleural space
to exit the pleural space. The study of the passively in the same manner as interstitial
physiology of the pleural space is challeng- fluid. This process may be enhanced by lung
ing; even when using laboratory animal studies, inflammation induced by asbestos fibers or by
analyses of the pleural space are limited by mixed dust exposures that increase interstitial
the narrowness of the space and the difficulty fluid accumulation and thus fluid movement
in sampling without inducing inflammation or along the interstitial spaces to the pleural space
injury. (Miserocchi et al., 2008).
There are thus few studies that investi-
gated the translocation of fibers from the lung
Pathways Leading to Translocation of into the pleural space. Even in the few exist-
Fibers to the Pleura ing studies, data from animal studies may have
The route of translocation of fibers from limited relevance for humans because of the
the lungs to the visceral pleura, into the different visceral pleural anatomy in rodents.
pleural space, and to the parietal pleura is In the rodent, the visceral pleura is “thin,”
PLEURAL ENDPOINTS FOLLOWING FIBER EXPOSURE 155
consisting mostly of a mesothelial layer and be important aspects of their potential toxicity
basement membrane lying directly over the (Dodson et al., 2003; Suzuki & Kohyama,
alveoli. There is little submesothelial connec- 1991). Pathologic tissue responses such as
tive tissue and no pleural vasculature. In sheep edema, inflammation, or fibrosis might poten-
and humans and other large mammals, the tially affect translocation and retention of par-
visceral pleura is “thick” and has a signifi- ticulates in the body, as well as properties
cant submesothelial connective tissue space, of particles themselves including dose, dimen-
containing nerves and systemic blood vessels sions and biopersistence. Although similarities
(Figure 1). In contrast to the visceral pleura, the exist between animal models and humans
parietal pleura in different species has a con- concerning physiological processes such as
stant and similar anatomy (Figure 1; Light & interstitial fluid dynamics and lymphatic flow,
Broaddus, 2010). Thus, due to differences in there are also anatomical differences such as
the visceral pleura, one might postulate a dif- in visceral pleural thickness (Tyler, 1983), as
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ference between rodents and humans in the well as physiological differences such as of
movement of the fibers into the pleural space. macrophage size and function, that need to be
Due to similarities in the parietal pleura, one taken into account when comparing across ani-
might suggest that the localization, accumula- mal species and when extrapolating from ani-
tion, and actions of fibers in the parietal pleura mals to humans (Jarabek et al., 2005; Maxim &
might be similar. McConnell, 2001). Rodents and humans also
These questions have been almost impossi- differ in particle respirability (Mossman et al.,
ble to address using current technology but it is 2011) and this limits the use of rodent mod-
hoped that new tools and imaging techniques els for human risk assessment based on fiber
such as nuclear magnetic resonance (NMR) dimensions (Lippmann & Schlesinger, 1984;
spectroscopy or two-photon microscopy can Lippmann et al., 1980).
be developed to provide data on (1) how fibers Biopersistence of fibers in the lung
distribute in the lungs and pleura, (2) the ulti- parenchyma also influences the fiber dose
mate destination of fibers, (3) how fiber move- that is ultimately translocated to the pleura.
ment is enhanced, and (4) whether fibers are Biopersistence in the lung is dependent on
translocated and retained differently in animals (1) site and rate of deposition, (2) pulmonary
and humans. Such techniques could be inva- clearance parameters, (3) solubility in lung flu-
sive, using labeled fibers that could be traced, ids, (4) breakage rate and patterns, and (5) rates
for use in animal studies, and noninvasive for of fiber translocation and retention. Surface
clinical studies of those exposed to asbestos. chemistry and diameter are important determi-
This imaging information on fiber localiza- nants of solubility. Much of the knowledge base
tion would enhance diagnosis and follow-up concerning the role of biopersistence is actually
of subjects exposed to asbestos, such as in derived from studies of synthetic vitreous fibers
directing where to sample tissues to assess (Bernstein, 2007; Oberdörster, 2000).
fiber dosimetry, and how to determine pre- Fiber characteristics also affect clearance
neoplastic biomarkers (Greillier et al., 2008) from the lung and translocation to the pleura.
that might lead to intervention and preven- Macrophage-mediated particle clearance in
tion of non-neoplastic and neoplastic pleural the lung is likely to influence translocation of
diseases. particles to interstitial sites. There are important
interspecies differences in particle clearance, as
well as in biological effects of high pulmonary
Pleural Fiber Dosimetry in Rodents concentrations of particles, in humans and
Translocation and retention of fibrous par- in different animal species (Bermudez et al.,
ticulates from initial sites of pulmonary depo- 2002; Oberdörster, 2002). In addition, the
sition to extrapulmonary sites are believed to method of dose administration in experimental
156 V. C. BROADDUS ET AL.
animals is shown to influence pleural pathol- synthetic vitreous fiber exposure, displayed
ogy outcomes following particle exposure. In greater translocation of fibers to the pleura than
silica-exposed rats, pleural granulomas devel- did similarly exposed rats (Gelzleichter et al.,
oped in animals following inhalation, but not 1999). The greater translocation in the Syrian
after instillation, and the different response was golden hamster may thus have accounted
likely due to differences in kinetics of particle for its greater susceptibility to fiber-induced
delivery and lymphatic clearance (Henderson toxicity.
et al., 1995).
The effects of asbestos may be altered
when asbestos is mixed with other partic-
ulates, a situation common in occupational Pleural Fiber Dosimetry in Humans
and environmental exposures. Studies by Davis There is virtually no knowledge of the
and colleagues (1991) showed that coex- kinetics of fiber translocation and retention in
the human pleura and there are few pleural
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1. The source of tissue samples ranged from Some investigators only count fibers longer
pleural biopsies obtained during diagnos- than 5 μm; however, the majority of
tic thoracoscopy (Boutin & Rey, 1993); to asbestos fibers in human tissue samples are
surgical specimens including needle biop- shorter than 5 μm (Dodson & Atkinson,
sies, wedge biopsies, or pneumonectomy 2006).
or pleural decortication samples; and to 8. Tissue preparation techniques may intro-
pleural and lung tissues obtained during duce artifacts due to tissue drying or trau-
autopsy examination (Roggli & Sharma, matic disruption of fiber bundles (Dodson &
2004). Atkinson, 2006).
2. Regardless of the source of tissue, sampling
is a potential source of error since there Finally, although quantitation of human
is significant variation in anatomical distri- lung and pleural asbestos fiber burden is
bution of fibers, especially in the parietal the only technique available to assess the
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pleura (Roggli, 1992; Boutin et al., 1996; dose delivered to and retained at the target
Mitchev, et al., 2002). tissue, there are additional considerations
3. Tissues may be contaminated during surgical in interpretation of these data. Tissue fiber
resection or at autopsy due to fibers present burden depends on the time since cessation of
in fixatives, in specimen containers, on sur- exposure. In addition, the fiber burden and the
gical gloves, or on dissecting instruments types of fibers in the lung may not reflect the
(Roggli & Sharma, 2004). fiber burden in the pleura. For example, shorter
4. Light microscopy is inadequate for iden- uncoated fibers are more readily cleared from
tification and counting of asbestos fibers. the lungs; however, while these fibers may be
Dodson and Atkinson (2006) recommend decreasing in the lungs, they may be accumu-
analytical transmission electron microscopy lating in the pleura and extrapulmonary sites
in combination with x-ray energy-dispersive (Holt, 1981) and be associated with develop-
analysis and selected area diffraction tech- ment of disease at these sites (Dodson &
niques for specific mineralogical identifi- Hammer, 2006; Dodson & Atkinson,
cation. Both coated and uncoated fibers, 2006).
as well as particulates, should be ana- It is important to note that the lungs of nor-
lyzed and quantitated (Dodson & Atkinson, mal control cases evaluated at autopsy contain
2006). significant numbers of commercial and non-
5. A systematic approach to counting fibers commercial asbestos fibers, as well as other
of all dimensions and analysis of lung fiber particulate and fibrous minerals. This is note-
burdens needs to be used, as described by worthy especially in lungs from those who
the European Respiratory Society (DeVuyst resided in urban settings (Table 1). By com-
et al., 1988). paring lung fiber burdens between those with
6. Appropriate control populations need to be pleural mesothelioma and those without, inves-
used because there is significant variability tigators showed that, although there is overlap,
in human lung fiber burdens (Roggli, 1990). there is an increased risk for mesothelioma,
A systematic analysis of lung asbestos fiber with an elevated lung burden of certain fibers,
burdens in workers with asbestos-related such as crocidolite, amosite, and tremolite;
disease, people with asbestos exposure in due to its lower biopersistence, chrysotile may
households or in buildings, and control not be reliably analyzed by autopsy studies
cases revealed a wide range of counts (Table 2).
with considerable overlap between workers, In contrast to these and other studies of
other asbestos-exposed cases, and controls fiber burdens in the lung, only a few stud-
(Roggli & Sharma, 2004). ies have reported asbestos fiber burdens in
7. The criteria used to define and count the pleura. In those few studies that analyzed
asbestos fibers need to be stated explicitly. pleural fiber burden, the results from lung and
158 V. C. BROADDUS ET AL.
TABLE 1. Asbestos Fiber Content in Lung Tissue of an Urban and found mostly short chrysotile asbestos
Population
fibers.
Fiber type Fiber number/g wet lung Dodson et al. (1990) analyzed lung tissue,
lymph nodes, and pleural plaques obtained at
Chrysotile asbestos fibers 130.0 × 103
Antigorite 2.5 × 103 autopsy from eight shipyard workers in Italy.
Noncommercial amphiboles: Data showed both chrysotile and amphibole
Tremolite 15.0 × 103 asbestos fibers in the lungs; however, chrysotile
Actinolite 5.1 × 103
Anthophyllite 3.7 × 103 asbestos fibers were the most frequent type
Commercial amphiboles: of asbestos found in pleural plaques. Most
Amosite and crocidolite 1.1 × 103 fibers in the lymph nodes and pleural plaques
Note. Analysis of 21 urban cases using analytical transmis- were shorter than 5 μm, although some fibers
sion electron microscopy with analysis of all fibers longer than longer than 8 μm were present at these sites.
1 μm revealed these average fiber numbers/g wet lung. (Churg & More recently, Suzuki and his coworkers (2005)
Warnock, 1980).
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translocate to the pleural spaces. These regions pleural disease, whether neoplastic or
are called “black spots” due to localized non-neoplastic.
accumulation of carbon particles and are sites
of lymphatic drainage located in the lower Knowledge and Data Gaps in Fiber
coastal regions of the parietal pleura and on Translocation and Dosimetry
the superior dome of the diaphragm. Using In considering the data existing on the sub-
transmission electron microscopy, Boutin et al. ject of fiber translocation and dosimetry, there
(1996) identified numerous amphibole as are numerous gaps in the knowledge base that
well as chrysotile fibers at black spots, and may be amenable to newer methods.
22.5% were ≥5 μm long. The mean asbestos
fiber concentration in the 8 exposed cases (a) There is a significant lack of understanding
was 12.4 ± 9.8 × 106 fibers/g dry lung tissue, of the contributions of the various potential
4.1 ± 1.9 × 106 fibers/g black spots on the routes of fiber translocation, including
parietal pleura, and 0.5 ± 0.2 × 106 fibers/g
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is little understanding of how dose, sur- for the visceral and parietal pleura, and these
face properties, and biopersistence of short, tissues are sites for inflammatory, fibroprolif-
thin fibers affect the exposure-response erative, and neoplastic diseases in humans
relationship with respect to non-neoplastic and in experimental animals. Non-neoplastic
pleural outcomes in mixed exposures. This asbestos-associated diseases of the pleura in
need is made more urgent with recent humans include benign asbestos-related pleu-
findings concerning the pleural effects of ral effusion, pleural plaques, diffuse pleural
engineered fibrous nanomaterials such as thickening, and rounded atelectasis (Chapman
instilled (Poland et al., 2008) and inhaled et al., 2003; Nishimura & Broaddus, 1998).
(Ryman-Rasmussen et al., 2009) carbon Pleural fibrotic and inflammatory lesions
nanotubes in mice. develop in rodents in response to inhaled
(d) There is a significant lack of information cor- fibers, but these have not been categorized
relating kinetics with pathological outcomes into separate lesion types as is the case in
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in the pleura following experimental fiber humans and often have not been described
exposures in laboratory animals. Maxim and separately from pulmonary parenchymal fibro-
McConnell (2001) suggested that humans sis by toxicologic pathologists. It is noteworthy
and rats are similar in pathological responses that significant pleural lesions similar to human
to fibers with respect to pulmonary fibrosis pleural fibrotic lesions were found in chronic
outcomes; as yet, there are no comparable rodent inhalation bioassays with synthetic vit-
data for pleural fibrosis. reous fibers as well as with asbestos fibers
(e) There is need to develop fiber size separa- (McConnell et al., 1999).
tion methods to enable mechanistic studies Mesothelial cells, resident and elicited
of characterized fiber preparations. This will inflammatory cells, and pleural fibroblasts are
allow an understanding of the role of fiber believed to be important effector cells in
size and dimension on cellular targets of the pathogenesis of asbestos-induced non-
pleural disease. neoplastic pleural diseases. Mesothelial pro-
(f) In general, it is not understood how inhala- genitor cells may also participate in pleural
tion of fibers leads ultimately to pleural repair and disease (Herrick & Mutsaers, 2004).
disease. To date there have been few inhala- There have been numerous studies both in
tion studies with well-characterized aerosols vivo in experimental animals and in vitro using
of different asbestos fiber types in exper- human and animal cell culture systems that
imental animals. Most inhalation bioassays review the cellular interactions in pleural tis-
have been long-term hazard assessment sues and in the pleural space (Chapman et al.,
studies in animal models; otherwise, studies 2003; Mutsaers et al., 2004, 2006; Robledo &
have relied on short-term instillation stud- Mossman, 1999). It is known that following
ies in rodents or in vitro studies. The cost, inhalation and instillation of asbestos fibers
complexity, and specialized requirements into the lung, there are rapid alterations in
of inhalation studies with fibers have not both resident and elicited populations of pleu-
allowed routine state-of-the-art fiber inhala- ral inflammatory cells and mesothelial cells.
tion exposures in support of mechanistic Pleural inflammatory cell changes were pro-
studies. duced in rats in association with translocation
of asbestos fibers (Choe et al., 1997) or fol-
lowing particulate-induced pulmonary inflam-
INTERACTION OF FIBERS WITH mation itself (Lehnert et al., 1985). Changes
TARGET CELLS IN THE PLEURA were noted in mesothelial cells of the vis-
ceral pleura at early time points following
Cellular Interactions asbestos instillation and inhalation (Adamson,
For reasons yet to be fully elucidated, 1997; Dodson & Ford, 1985), and interac-
fibrous particulates have an unusual affinity tions between pleural inflammatory cells and
PLEURAL ENDPOINTS FOLLOWING FIBER EXPOSURE 161
mesothelial cells are believed to be important (Fubini, 1997) as well as from cellular responses
in the development of fiber-induced pleu- are believed to be important in both neo-
ral injury and disease. Rat and rabbit pleu- plastic and non-neoplastic asbestos-associated
ral mesothelial cells are known to release pleural disease (Janssen-Heininger et al., 2008;
chemoattractants for inflammatory cells follow- Shukla et al., 2003a). Although the limitations
ing exposure to asbestos (Boylan et al., 1992; of cell culture systems for particulate studies
Hill et al., 2003; Tanaka et al., 2000), and pleu- have been well described, it is recognized that
ral macrophage-derived mediators can modu- much of the mechanistic understanding of how
late mesothelial cell function (Baumann et al., fibers interact with mesothelial cells and pro-
1993, 1996). duce fiber-induced effects derives from in vitro
experiments (Donaldson et al., 2009).
During the past two decades, there has Pleural Cell Biology and Asbestos Fiber
been a great increase in our knowledge of Exposure
the importance of the mesothelial cell in fiber- (a) Fibers may translocate to the pleural space
induced pleural disease. It has become appar- and are postulated to induce pleural dis-
ent that these cells play a central dynamic role ease by direct interaction with pleural cells.
in the control of injury and repair processes that However, some pleural conditions such as
take place in the pleural and other serosal tis- inflammation or fibrosis may be influenced
sues (Mutsaers et al., 2004). Mesothelial cells by fibers and their actions in the neighboring
are a unique cell type originating from meso- lung. The relative contribution of direct fiber
derm and vested with a number of impor- exposure versus indirect signaling effects on
tant specialized functions including release mesothelial cells is not known.
of pro- and anti-inflammatory and other (b) There is still much to know about how
immunomodulatory mediators; secretion of fiber mineralogy, dimensions, physicochem-
factors that promote deposition and clear- ical properties, and biopersistence con-
ance of fibrin; and synthesis of growth factors tribute to induction and progression of
and extracellular matrix proteins that aid in pleural lesions.
serosal repair (Jantz & Antony, 2008). Asbestos (c) There is need for better development
may injure pleural mesothelial cells either of biomarkers of pleural disease and
by direct or indirect mechanisms, including assessment of pleural changes in exper-
(1) injury by free radicals, (2) inflammasome imental animal models. Although bron-
activation, (3) alterations of intracellular sig- choalveolar lavage fluid (BALF) analysis
naling pathways, (4) release of cytokines and has been routinely utilized in experimental
chemokines, (5) physical disruption of chro- studies of the lung, pleural lavage has not
mosomes, (6) alterations in growth factors, and been routinely used to assess changes in
(7) changes in coagulation and fibrinolysis the pleural space. Advancing understanding
pathways (Manning et al., 2002; Mutsaers of pleural disease will require better use
et al., 2004; Robledo & Mossman, 1999). of pleural endpoints in acute and chronic
Mesothelial cells internalize the fibers via inte- studies of fiber exposure.
grins or other receptors, and uptake of the (d) The major target of asbestos in the pleural
fibers was found in some studies to be nec- space is thought to be the mesothelial
essary for adverse effects of the fibers such cell. The contribution of the inflamma-
as reactive oxygen species (ROS) generation, tory pleural cells including macrophages is
DNA damage, and apoptosis (Liu et al., 2000). less well understood. In addition, there is
Reactive oxygen species derived directly from a need to develop additional understand-
the surface chemistry of fibers themselves ing of possible mesothelial progenitor cells
162 V. C. BROADDUS ET AL.
asbestos toxicity. A systematic analysis using ties of inhaled particles believed to be impor-
analytical transmission electron microscopy tant in their disease-inducing abilities such as
could quantitate the dimensions and types the surface properties relevant for oxidant gen-
of mineral particles and fibers that are eration (Fubini, 1997) and the chemical proper-
translocated to and retained in the pleura ties relevant for biopersistence (Bernstein et al.,
(both visceral and parietal) of control indi- 2001, 2005; Bernstein, 2007; Mossman et al.,
viduals and patients with asbestos-related 2011).
pleural diseases. Such studies may also help It is noteworthy that up until now
identify whether fibers are located predom- biopersistence studies focused on the lung
inately intracellularly or extracellularly, and parenchyma. There are few pleural fiber bur-
identify the target cells. den or pleural biopersistence investigations in
(f) The role of the specific arms of the inflam- either experimental animals or humans.
matory response can now be studied using
mice with genetically engineered deletion of
specific cell types or inflammatory cytokines. Fiber Type and Potency
Such studies can be used to indicate the role In rodent studies in which high concentra-
of inflammation in producing the various tions of fibers were instilled or implanted in
fiber-induced pleural diseases and whether the pleural space, all mineralogical forms of
particular inflammatory mechanisms might asbestos fibers were produced pleural fibrosis
be a therapeutic target. and malignant mesothelioma. In an inhalation
(g) Noninvasive techniques for assessing fiber study in rats using well-characterized aerosols
burden or the tissue reaction to fibers would and state-of-the-art methods to assess retained
be of inestimable value in investigating the lung burdens, Bernstein et al. (1995) found
natural history of pleural reactions in ani- that chrysotile exposure failed to induce pleu-
mals and in humans over the decades of ral lesions despite producing severe pulmonary
tumor development. Novel imaging tech- fibrosis (asbestosis) and lung tumors (Mast
niques could ultimately serve as a tool for et al., 1994). This appears to correlate with
following those at risk and testing strategies human epidemiologic studies because recent
for intervention. analysis suggests that most asbestos-associated
mesotheliomas are due to amphibole expo-
sure (Berman & Crump, 2008; Mossman et al.,
Biological Mechanisms Responsible for 2011).
Non-Neoplastic Pleural Disease While there is a general lack of under-
It has generally been accepted from stud- standing of comparative pleural potency of
ies of animal models of asbestos fiber exposure different asbestos fiber types, a reanalysis of
that inflammatory changes in the lung and previous asbestos fiber inhalation studies in
PLEURAL ENDPOINTS FOLLOWING FIBER EXPOSURE 163
rats compared size, shape, and mineralogy of pleural fibroproliferative changes following
with lung tumor and mesothelioma outcomes asbestos and synthetic vitreous fiber inhalation
(Berman et al., 1995). In this study, multivari- (Everitt et al., 1997; Gelzleichter et al., 1999;
ate measures of exposure were identified that Mast et al., 1994; McConnell et al., 1999).
described the lung tumor responses in 13 pre- As described earlier, mesothelial cell
vious asbestos (chrysotile, amosite, crocidolite, responses to translocated fibers and/or
tremolite) inhalation experiments in AF/HAN responses to inflammatory mediators released
rats. Due to limitations in the characteriza- from lung parenchymal and pleural cells are
tion of asbestos fiber dimensions in the original believed to be important in the pathogenesis of
studies, new exposure measures were devel- pleural fibrosis and asbestos-associated pleurisy
oped from samples of the original dusts that (Mutsaers et al., 2004; Robledo & Mossman,
were regenerated and analyzed by transmis- 1994). Mesothelial cells are known to phagocy-
sion electron microscopy using a direct transfer tize asbestos fibers (Boylan et al., 1995), a step
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technique. Structures contributing to lung can- that may then lead to oxidant-induced signaling
cer risk appeared to be long (≥20 μm) and pathways, altered cell proliferation, apoptosis
thin (≤0.4 μm) fibers. The analysis did not find (Liu et al., 2000; Shukla et al., 2003b), necrosis
significant mineralogical differences in potency (Yang et al., 2010), and release of chemokines
across asbestos types for pulmonary tumors and cytokines that mediate pleural inflamma-
but noted that amphibole asbestos was more tion (Jantz & Antony, 2008). A variety of growth
potent than chrysotile in induction of malignant factors are associated with pleural fibrosis,
mesothelioma. especially transforming growth factor (TGF)-β1
(Decologne et al., 2007; Mutsaers et al.,
2006).
Proposed Mechanisms for
Asbestos-Associated Non-Neoplastic
Pleural Lesions in Rodents Proposed Mechanisms for
Although the rodent visceral pleura differs Asbestos-Associated Non-Neoplastic
markedly from that of humans in thickness and Pleural Disease in Humans
anatomy (Tyler, 1983), the rodent parietal pleura The nonmalignant manifestations of
and the resident pleural inflammatory cells are asbestos in the pleura include benign asbestos
similar to those of humans (Everitt et al., 1997; pleurisy, pleural plaques, diffuse pleural fibro-
Gelzleichter et al., 1996). In rodents, asbestos sis, and rounded atelectasis (ATS Official
and synthetic vitreous fiber exposure by inhala- Statement, 2004; Nishimura & Broaddus
tion or instillation resulted in pleural inflam- 1998). Although these nonmalignant pleural
matory and fibrotic changes (McConnell et al., diseases may themselves produce symptoms,
1999). In animal models of asbestos-induced especially diffuse pleural fibrosis, these are
lung cancer and mesothelioma, inflammation important clinically because the symptoms
and fibrosis always preceded the development identify people who have had significant expo-
of oncogenic outcomes (Greim et al., 2001), sure to asbestos and often mimic and require
and these processes may share some mech- diagnostic workups to exclude malignancy.
anistic underpinnings. Similarly, it is worthy of These diseases are also important for research
note that in the rodent fiber inhalation bioassays by giving insight into fiber toxicology and
conducted to date, pleural inflammatory and pathogenesis and by identifying groups for
fibroproliferative lesions were accompanied which development of biomarkers and early
by pulmonary parenchymal changes. Recently, intervention for diagnosis or treatment are
there have been a number of chronic studies warranted.
that suggested that the Syrian golden hamster Benign asbestos pleurisy may develop as
may be particularly susceptible to the devel- early as 10 yr after exposure (ATS, 2004).
opment of pleural mesothelioma as well as Because it usually produces no apparent
164 V. C. BROADDUS ET AL.
fibers. In general, plaques develop 20–30 yr anisms and suggest possible interventions in
after initial exposure (Nishimura & Broaddus, exposed populations.
1998; ATS, 2004). Plaques are usually located Rounded atelectasis is thought to be a
on the parietal pleura or on the dome of the consequence of any type of pleuritis and pleu-
diaphragm and appear as circumscribed areas ral fibrosis and represents a folding of the
of collagen deposition without inflammation. lung within a region of pleural thickening. It
Plaques may be associated with decreases in may resemble a mass and thus raise concern
lung function and symptoms of dyspnea, but for lung cancer. Little is known regarding the
most individuals with pleural plaques alone dis- pathogenesis of this entity (Hillerdal, 1989).
play no apparent symptoms and no obvious Diffuse pleural thickening is a diffuse,
impaired lung function. Although localized and not circumscribed, thickening of the pleura
unilateral pleural thickening may have other that develops approximately 30 yr following
causes such as prior tuberculosis, trauma, or exposure (Nishimura & Broaddus, 1998; ATS,
talc instillation, multiple and bilateral pleu- 2004). Unlike pleural plaques, diffuse thicken-
ral plaques, particularly when calcified, are ing mostly affects the visceral pleura. Diffuse
considered to be pathognomonic for asbestos pleural thickening is associated with clinically
or erionite exposure (Nishimura & Broaddus, significant ventilatory impairment, pulmonary
1998). Of note, those subjects without plaques restriction, and low lung volumes. Diffuse pleu-
may also have significant asbestos exposure; it ral thickening may coexist with pleural plaques,
is not known why some exposed individuals and may be associated with a higher fiber bur-
form plaques and others do not. den than is found with pleural plaques alone
Plaques are biomarkers for asbestos or eri- (Stephens et al., 1987). The relationship of
onite exposure and of elevated fiber burden in diffuse pleural thickening to asbestos-induced
the lung (Churg, 1982; Kishimoto et al., 1989; fibrosis of the lungs is not known. The types of
Roggli & Sanders, 2000). It is not known how asbestos fibers likely to produce diffuse pleu-
pleural plaques correlate with pleural fiber bur- ral thickening are not known. In one study, the
den. Different fiber types may play a role in fibers found in the pleura were short chrysotile
plaque formation: Plaques have been associ- fibers, while the fibers in the lungs were longer
ated with the presence of high aspect ratio and thinner amphiboles (Gibbs et al., 1991).
amphiboles in the lung (Churg, 1982, 1983, As with other non-neoplastic asbestos-induced
1994), but in at least one study, only chrysotile pleural disease, diffuse pleural thickening raises
fibers were found in the plaques themselves concerns for underlying mesothelioma. If lung
(Churg, 1982). function is severely compromised, the patient
The biologic response to asbestos fibers in may undergo decortication or removal of the
individuals with pleural plaques may differ from pleura; nevertheless, removal of the thick-
those without plaques. In animal studies pleural ened pleura may not improve lung function
PLEURAL ENDPOINTS FOLLOWING FIBER EXPOSURE 165
due to accompanying fibrosis of the underly- and nonmalignant respiratory morbidity and
ing lung. mortality at relatively low lifetime cumulative
These non-neoplastic pleural pathologies fiber exposure levels.
are particularly common in those exposed to
amphibole fibers in Libby, MT (Peipins et al.,
2003), suggesting that these fibers may exert Knowledge and Data Gaps
unique toxicity for the pleura. Libby amphi- in Nonmalignant Pleural Disease
bole is a mixture of winchite, richterite, and in Humans
tremolite, in decreasing order of abundance Unanswered questions regarding nonma-
(Meeker et al., 2003). In 1980, a morbidity lignant pleural disease include:
study was carried out on workers who had
used Libby vermiculite as an inert carrier for (a) Pleural plaques have been associated with
various types of lawn-care products (Lockey long amphibole fibers in the lung and with
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et al., 1984). Libby vermiculite was found short chrysotile fibers in the pleura. Thus,
to contain asbestiform minerals. In the work- it is not known which types of asbestos
ers exposed to Libby vermiculite, workplace fibers induce pleural plaques and how pleu-
exposures were associated with bloody pleu- ral plaques correlate with pleural (not lung)
ral effusions and localized pleural thickening. A fiber burden.
follow-up study of the worker cohort 25 years (b) The fiber burden and fiber types in the
after discontinuation of Libby vermiculite min- pleura of those with pleural disease have not
ing in 1980 demonstrated an elevated preva- been documented. Fiber burden in the lung
lence of pleural changes, increasing from 2% may not correlate with that in the pleura:
in 1980 to 29% (80 of 280 workers) in 2005 Low counts in the lung may be associated
(Rohs et al., 2005). Of workers with a low life- with high counts in the pleura if fibers have
time cumulative fiber exposure (CFE) of only translocated to the pleura; fiber types found
<2.2 fibers/cc-yr, as many as 20% displayed in the lung may be the ones that are retained
pleural changes. A significant CFE response at this site, whereas different fibers may
relationship was demonstrated between per- translocate to the pleura and induce dis-
cent pleural changes, which ranged from 7 ease there. Autopsy studies might be used to
to 54%, and the lowest to the highest CFE compare lung and pleural fiber burdens and
quartile. The mean CFE (SD) related to local- relative distribution of different fiber types
ized pleural thickening, diffuse pleural thick- and sizes in these different locations.
ening, and interstitial fibrosis in vermiculite (c) Most studies of pleural fiber burden reported
workers with no historical exposure to com- the presence of short chrysotile fibers, and
mercial asbestos was 3.45 (4.95), 8 (5.32), yet the role of these short chrysotile fibers
and 11.37 (6.82) fiber-cc/yr, respectively (Rohs in pleural disease has not been established.
et al., 2005). This relationship was confirmed Because most pleural disease has been
by Whitehouse (2004), who demonstrated attributed to high aspect ratio amphibole
progressive loss of lung function in Libby fibers, it is not known whether the short
residents with and without reported occupa- chrysotile fibers are pathogenic, either alone
tional exposure who had predominantly pleu- or by enhancing the toxicity of longer amphi-
ral changes. Studies of Libby miners and millers bole fibers, or whether they are acting as
demonstrated an association between Libby bystanders. These fibers may be located out-
amphibole exposure and increased incidence side the area of interest, corresponding to
of nonmalignant respiratory disease mortality the “black spots” where pathogenic fibers
at a CFE of less than 4.5 fiber/cc-yr (Sullivan, are located. Further animal studies using
2007). In summary, studies of workers exposed well-characterized short chrysotile fibers in
to the Libby amphibole indicate the propensity the pleural space would be valuable in
for these amphiboles to induce pleural disease addressing this important issue.
166 V. C. BROADDUS ET AL.
Mesothelioma
FIGURE 2. Proposed mechanisms for asbestos-induced mesothelioma. Asbestos fibers are thought to lead to mesothelioma via
mechanisms as outlined in this algorithm. Asbestos fibers enter the pleural space, where they interact with pleural macrophages and
mesothelial cells and induce an influx of inflammatory cells. These early interactions result in release of reactive oxygen and nitrogen
species (ROS, RNS), cytokines, and growth factors that may mediate indirect effects on mesothelial cells. The fibers may also act directly
on mesothelial cells by inducing DNA damage, interrupting chromosomal segregation, or inducing apoptosis or necrosis. Such direct and
indirect actions lead to chronic stimulation and injury of the mesothelium that may proceed over decades by a multistep path to cancer.
Key steps in the development of cancer include genetic and epigenetic alterations leading to sustained cell proliferation, resistance to
apoptosis, and inactivation of tumor suppressor genes.
168 V. C. BROADDUS ET AL.
talline silica, or metals in the occupational unknown. The ability of different fiber types
environment. to induce specific genetic and epigenetic
(b) The role of SV40 virus as a cofactor with alterations characteristic of diffuse malig-
asbestos fibers in the development of dif- nant mesothelioma needs to be determined
fuse malignant mesothelioma is controversial (Andujar et al., 2007).
(Gazdar et al., 2002). Mechanistic studies (f) Chronic rodent inhalation assays are expen-
in cell cultures and in rodents suggest that sive, technically demanding, and not suit-
SV40 viral oncoproteins induce mesothe- able for mechanistic studies because only
lial cell transformation and diffuse malignant a minority of rats develop diffuse malignant
mesothelioma, although human epidemi- mesothelioma following inhalation. Current
ological studies do not support a causal screening assays for fiber toxicity use short-
association (Weiner & Neragi-Miandoab, term in vitro or in vivo assays; however, it is
2009). Additional epidemiological studies difficult to extrapolate from acute, high-dose
using specific serological markers for SV40 exposures to chronic or repeated, low-dose
virus infections are needed (Kean et al., exposures in vivo. A new toxicologic screen-
2009). ing strategy needs to be developed and
(c) The physical and chemical properties of validated to assess potential carcinogenic-
mineral fibers associated with carcinogenic- ity of naturally occurring mineral fibers and
ity include surface chemistry and reactivity, engineered fibrous nanomaterials.
surface area, fiber dimensions, and bioper- (g) Mesothelial cells are mobile and appear to
sistence. The relative importance of these be able to detach and relocate at other sites
different properties with respect to car- in the pleural space (Foley-Comer et al.,
cinogenic potency is uncertain and may 2002). Mesothelioma is also associated with
depend on the geological source of the mobile spheroids, clumps of malignant cells
fibrous mineral and its associated con- floating in the pleural fluid; such spheroids
taminants. Commercial asbestos fibers and appear to remain viable and resistant to
erionite fibers have been most widely apoptosis (Barbone et al., 2008; Daubriac
studied. Noncommercial amphibole fibers, et al., 2009). It is not known whether this
other naturally occurring asbestiform fibers, mobility may allow preneoplastic cells to
and newly engineered fibrous nanomaterials move from areas of asbestos accumulation
(Jaurand et al., 2009; Sanchez et al., 2009) to other areas where mesothelioma may
need to be well characterized and their develop. If so, and if new technologies are
potential for translocation and persistence in developed that will allow one to distinguish
the pleura must be determined. malignant mesothelial cells from reactive
(d) The potential for any natural or engineered benign mesothelial cells, pleural fluid could
fibrous material with physicochemical be sampled for preneoplastic mesothelial
170 V. C. BROADDUS ET AL.
cells in order to identify individuals at risk for gene alterations in refractory ceramic
developing diffuse malignant mesothelioma. fibre-induced murine mesothelioma reveal
(h) New immunohistochemical and molecu- mineral fibre-induced mesothelioma
lar markers of preneoplastic and neoplastic identities. Carcinogenesis 28:1599–1605.
lesions would improve early diagnosis and Apostolou, S., Balsara, B. R., and Testa, J. R.
therapy of diffuse malignant mesothelioma 2005. Cytogenetics of malignant mesothe-
(Husain et al., 2009). lioma. Malignant mesothelioma. In Advances
(i) Populations exposed to asbestos or asbesti- in pathogenesis, diagnosis and translational
form fibers from Libby MT, workers in therapies, eds. H. I. Pass, N. J. Vogelzang,
certain trades, those exposed on 9/11 at and M. Carbone, vol, 6, pp. 101–111. New
Ground Zero, or those with known high York: Springer Science and Business Media.
exposure (e.g., those with bilateral pleu- Aust, A. E., Cook, P. M., and Dodson, R. F.
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knowledge can be gained about the natu- Mammalian target of rapamycin con-
ral history of asbestos-induced pleural dis- tributes to the acquired apoptotic resistance
ease in order to understand preneoplastic of human mesothelioma multicellular
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