SCIENTIFIC REVIEW 1:

MICRONUCLEUS TEST FOR SCREENING

NASOPHARYNGEAL CARCINOMA AMONG
HEALTH WORKERS EXPOSED TO
FORMALDEHYDE
Presented by:
Jovita Krisita (NPM: 1906345452)

Advisor:
dr. Muhammad Ilyas, Sp. Ok., Subsp. Toksi-KO (K)
TABLE OF CONTENTS

01. INTRODUCTION
02. LITERATURE REVIEW
03. JOURNAL REVIEW

04. DISCUSSION

05. CONCLUSION &

RECOMMENDATION
INTRODUCTION
Formaldehyde, in the form of 10% buffered-neutral
formalin (NBF).
It is used as a fixative for biological specimens, a
bacteriostatic for embalming fluids, and a disinfectant
for dental tools  found in pathology and histology
laboratories, morgues, operating rooms, pharmacies,
and dental practices.

https://
www.buanalaboratories.co.
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INTRODUCTION
• Formaldehyde exposure studies among health care workers revealed
that airborne formaldehyde frequently exceeded recommended
occupational exposure limits
• Bellisario et.al (2016): operating room nurses who worked with
formaldehyde  2 times higher than their co-workers who did not use
formaldehyde in their work procedures
• Adamović et al. (2019): mean range of formaldehyde exposure in an
anatomy laboratory  0,54-3,45 ppm (working with dry and wet
specimen in preparation and storage activities)
• Ghelli et al. (2022): pathologist were 3 times higher exposure
(median=0,045 ppm) than control group with no task requiring
https:// formaldehyde or other carcinogenic compounds
www.buanalaboratories.co.
id/image-product/img3321-
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INTRODUCTION
• Inhalation is known to be the main route of
exposure of formaldehyde although ingestion or
direct dermal contact may also occur from acute
poisoning incidents.
• Chronic exposure to formaldehyde is already
classified by The IARC as group 1 carcinogen with
sufficient evidence for nasopharyngeal carcinoma
and the EC as category 1B (carcinogenic by
inhalation)

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INTRODUCTION
• NPC: a cancer arising from the nasopharynx epithelium cells 
estimated at 12.000 new cases per year
• The cause of nasopharyngeal carcinoma is multifactorial 
occupational factor from formaldehyde exposure  inhaled
formaldehyde contacts directly with nasopharynx, mouth, salivary
gland, nasal cavity and larynx  react with biomacromolecules
such as proteins, DNA, and RNA, potentially causing abnormal
DNA methylation
• Hauptmann et al. (2004): follow-up study on workers exposed to
formaldehyde and discovered that the adjusted relative risk for
NPC is 4 times higher in workers with cumulative exposure greater
than 5,5 ppm-year compared to their colleagues with lower
cumulative exposure
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cancer&psig=AOvVaw3rndstIRMgOlgjMsl1eZ6K&ust=1667539471383000&source=image
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INTRODUCTION
• Cytokinesis-Block Micronucleus (CBMN) is a micronucleus
(MN) assay  used in formaldehyde exposure studies to
determine its potential carcinogenicity
• MN is a small and round-shape body visible in the
cytoplasm of cells that contained chromatin caused by DNA
damage or genomic instability
• Costa et al. (2019): MN in peripheral blood lymphocyte
(MNL) approximately 1,6-time higher and around 4,1-times
in buccal cells among anatomy-pathology professionals
who were exposed to formaldehyde (mean concentration of
0,38 ppm) compared to control subjects.
Picture taken from:
Mukh Syaifudin, Vira Putri Defiyandra and Siti
Nurhayati et al. Micronucleus Assay-based
Evaluation of Radiosensitivity of Lymphocytes
among Inhabitants Living in High Background
Radiation Area of Mamuju, West Sulawesi,
Indonesia. Genome Integrity. Vol. 9. DOI:
10.4103/genint.genint_2_18
Problem Statement
Clinical question:
Is micronucleus (MN) test can be used for nasopharyngeal carcinoma screening among health care
workers exposed to formaldehyde?

Population : health care worker, healthcare workers, health care personnel with
formaldehyde exposure in the workplace
Intervention : micronucleus test, MN test
Comparison :-
Outcome : nasopharyngeal cancer, nasopharyngeal carcinoma
Objectives
General Objectives
To evaluate the use of micronucleus (MN) test for screening nasopharyngeal carcinoma among
health care workers exposed to formaldehyde.

Specific Objectives
• To identify characteristics of formaldehyde.
• To identify occupational formaldehyde’s exposure in health care workers.
• To review the use of micronucleus test as screening for formaldehyde exposure among health
care workers.
LITERATURE
REVIEW

FORMALDEHYDE EXPOSURE OF NASOPHARYNGEAL

FORMALDEHYDE IN CARCINOMA
HEALTH CARE
WORKERS
• The medical usage of formaldehyde began in 1892
by Jean Auguste Trillat who observed that
formaldehyde hardened soft tissues and triggered
coagulation.
• Formaldehyde, as 10% neutral-buffered formalin
(NBF) solution, has been regarded as the gold
standard fixative worldwide since it is the most
effective substance for preserving tissue
permanently
 Metabolism Pathway of Formaldehyde

• Absorption: directly started since it is inhaled and reaches

the nasal cavity, mouth, salivary gland, nasopharynx, and
larynx  22-42% will be removed by mucus flow as part of
the mucociliary apparatus’s defence mechanism system
• Distribution: human body tissue & blood cells; biological half-
life of only 1-1.5 mins

• Metabolism: rapid  changed into formate directly by

mitochondrial aldehyde dehydrogenase class 2 (ALDH2);
Glutathione (GSH) will also detoxify formaldehyde to
formate; methanol via the cytosolic alcohol dehydrogenase
(ADH1); forms methylol derivatives with primary and
secondary amines, thiols, hydroxyls, and amides

• Excretion: formate ion together with tetrahydrofolate (THF)

will form 10-formyl tetrahydrofolate (10-formyl-THF  form
CO2 and exhaled out from the lungs  small amount of
formate will form formate salts, formic acid and several other
metabolites which will be excreted through urine.
Classification of Formaldehyde Hazard Formaldehyde’s OELs In International Organizations
Statements and Government
Biomonitoring
• Exposure: exogenous formaldehyde concentration detection as a biomarker of exposure is difficult
because only a small amount of inhaled formaldehyde enters the bloodstream and is quickly
metabolized  formic acid is considered not a specific biomarker for formaldehyde since it may be
produced from other substrate of metabolism and influenced by multi factors such as smoking, diet and
nutritional status.
• Effects: micronucleus (MN) test is considered to be a sensitive and reliable biomarker for
formaldehyde’s genotoxicity effect  Cytokinesis-Block Micronucleus (CBMN) and buccal MN cytome
(BMCyt) test are some of micronucleus (MN) test types that use peripheral blood lymphocytes (MNL),
buccal cells (MNB) or nasal cells formaldehyde exposed workers with longer duration of exposure
between 2-31 years was found to have higher formation of MN in the cells of nasal and oral mucosa.
• Susceptibility: polymorphisms in CYP2E1 and GSTP1 metabolic genes enzyme
JOURNAL REVIEW
Literature Search Literature Search Result
Method

Critical Appraisal Characteristic of the

Studies
Literature Search Method
• Search for published
studies: PubMed, Science
Direct, and ProQuest
databases
• Search keywords:
“formaldehyde”,
“micronucleus”,
“nasopharyngeal
carcinoma” and
“nasopharyngeal cancer” in
all fields combined with the
Boolean operator “AND”
and “OR” on August 11th,
2022.
Inclusion criteria:
Research articles (case
report, cross-sectional,
cohort, case-control studies)
exploring micronucleus test
in relation with
formaldehyde exposure in
humans published within 10
years period have been
included
Exclusion criteria: non-
occupational studies and
published in languages
other than English
• critical appraisal process 
using critical appraisal tools
from Joanna Briggs
Institute (JBI) adjusted to
each study design
• data extraction:
characteristics of the
studies  publication year
and authors name, study
design, levels of evidence
(category JBI 2014 for
diagnosis), sample size,
working context & main
conclusions for each paper
Literature Search Result
We found results of 35 studies by using our search strategy
 Reference Number

Critical Appraisal Checklist (46) 2016- (47) 2019-

Fenech et.al Hopf et.al
Systematic Review
Critical Appraisal & Meta-Analysis Is the review question clearly and explicitly
stated? 1 1
Case control studies Studies
Were the inclusion criteria appropriate for
Reference Number 1 1
the review question?
(42) (43) (44) (45)
Critical Appraisal Checklist
2013–Costa 2013–Ladeira 2019-Costa 2019-Wang Was the search strategy appropriate? 1 1
et al. et al. et al. et al
Were the groups comparable other
Were the sources and resources used to
search for studies adequate? 1 1
than the presence of disease in cases
or the absence of disease in 1 1 1 1
Were the criteria for appraising studies
controls? appropriate? 1 1
Were cases and controls matched
1 0 1 1 Was critical appraisal conducted by two or
appropriately? Unclear Unclear
more reviewers independently?
Were the same criteria used for
1 1 1 1 Were there methods to minimize errors in
identification of cases and controls? Unclear Unclear
data extraction?
Was exposure measured in a
standard, valid and reliable way? 1 1 1 1 Were the methods used to combine studies
appropriate? 1 1
Was exposure measured in the same
way for cases and controls? 1 Unclear 1 1 Was the likelihood of publication bias
assessed? Unclear 1
Were confounding factors identified? 1 1 1 1
Were recommendations for policy and/or
Were strategies to deal with practice supported by the reported data?
confounding factors stated? 1 Unclear 1 1 1 1

Were outcomes assessed in a

Were the specific directives for new
standard, valid and reliable way for 1 1 1 1 1 1
cases and controls?
research appropriate?
Was the exposure period of interest Overall appraisal (include/exclude/seek Included, Included,
long enough, to be meaningful? 1 Unclear 1 1
further info) skor 8/11 skor 9/11
Was appropriate statistical analysis
used? 1 1 1 1

Overall appraisal Included, Included, Included, Included,

(include/exclude/seek further info) skor 10/10 skor 6/10 skor 10/10 skor 10/10
Characteristic of the Studies
• Formaldehyde exposed groups in this study: hospital pathology laboratories workers (anatomy, histology,
biomedical), research laboratories, related factories workers (formaldehyde, formaldehyde based-resin,
other formaldehyde related-chemicals)
• mean level of formaldehyde for TWA8H was 0,41 (0,16-0,74 by calculating average value of
formaldehyde mean level from all studies.
• mean MN frequency (‰) was 3,39 (1,55-6,27) calculated from five studies that stated MN frequency (‰)
in their papers.
Characteristic of the Studies (1)
Title Cytogenetic and Immunological Effects Associated with Occupational Formaldehyde Exposure
Authors Costa S, García-lestón J, Coelho M, Coelho P, Silva S, Porto B, et al.
Published year 2013
Study Design Case-control JBI’s Levels of Evidence 3b
Sample Size 70 subjects (35 exposed, 35 control)
Working Context • Exposed: hospital pathology anatomy workers (working at least 1 year) located in Portugal
• Control (non-exposed): hospital administrative office without occupational exposure history to
formaldehyde (the same hospital with exposed)
• The mean level of formaldehyde: 0.36 ± 0.03 ppm (range 0.23–0.69 ppm)
• The peak emission of formaldehyde (2 routine tasks): macroscopic examination of FA-preserved
specimens, and disposal of specimens and waste solutions
Main Conclusions MN frequency was significantly 2.5-fold higher in formaldehyde-exposed workers than in unexposed
individuals
Characteristic of the Studies (2)
Title Case-Control Research Article The Influence of Genetic Polymorphisms in XRCC3 and ADH5 GENES
on the Frequency of Genotoxicity Biomarkers in Workers Exposed to Formaldehyde
Authors Ladeira C, Viegas S, Carolino E, Gomes MC, Brito M
Published year 2013
Study Design Case-control JBI’s Levels of Evidence 3b
Sample Size 126 subjects (54 exposed, 82 with no known exposure)
Working Context • Exposed: histopathology workers at six hospital laboratories located in Portugal (Lisbon and Tagus
Valley region)
• Control (no known exposure to formaldehyde): administrative staff members
• The mean level of formaldehyde: 0.16 ppm (min–max: 0.04–0.51 ppm)
• The mean ceiling concentration: 1.14 ppm (min–max: 0.18–2.93 ppm)
• The highest formaldehyde concentration: macroscopic examination of biological samples
Main Conclusions • Mean MN lymphocyte was significantly increased in formaldehyde exposed group (4.00+0.52
(range:0–14)) compared to control (0.83+ 0.18 (range:0–7).
• Mean MN buccal cells was significantly increased in formaldehyde exposed group (1.00+0.267
(range:0–9)) compared to control (0.17+ 0.06 (range:0–2).
Characteristic of the Studies (3)
Title A systematic review of the association between occupational exposure to formaldehyde and effects on
chromosomal DNA damage measured using the cytokinesis-block micronucleus assay in lymphocytes
Authors Fenech M, Nersesyan A, Knasmueller S
Published year 2016
Study Design Systematic Review JBI’s Levels of Evidence 3a
Sample Size 1.565 subjects from 21 reviewed studies (785 exposed, 780 controls): Pathlab: 446 exposed, 506
controls; Plyres: 339 exposed, 274 controls
Working Context • Exposure type: biomedical pathology or research settings workers (Pathlab), workers from plywood
and resin manufactures (Plyres)
• The mean concentration of formaldehyde: 0.74 ppm (range: 0.05–2.60 ppm)
• Mean exposure period of 6 years
Main Conclusions • Significant increases (doubling; P<0,0001) in lymphocyte MN frequency (a biomarker of chromosome
breakage or loss), in exposed subjects relative to controls; considered suitable to measure
genotoxicity of formaldehyde exposure (R = 0.529, P = 0.017)
• Duration of formaldehyde is correlated with increase in lymphocyte MN frequency in the exposed
subjects relative to controls (R = 0.779, P < 0.0001)
Characteristic of the Studies (4)
Title Occupational exposure to formaldehyde and early biomarkers of cancer risk , immunotoxicity and
susceptibility
Authors Costa S, Costa C, Madureira J, Valdiglesias V, Teixeira-gomes A, Guedes P, et al
Published year 2019
Study Design Case-control JBI’s Levels of Evidence 3b
Sample Size 172 subjects (85 exposed; 87 non-exposed control)
Working Context • Exposed: workers from 9 hospital anatomy-pathology laboratories, working for at least one year
• Non-exposed control: employees working in the same area in administrative offices and without occupational
exposure history to formaldehyde
• The mean TWA-level of worker's exposure to formaldehyde: 0.38 ± 0.03 ppm (range 0.08–1.39 ppm)
• The peak emission of formaldehyde: macroscopic examination of formaldehyde-preserved specimens (range 0.3–3.2
ppm) and disposal of specimens and waste solutions (range 0.3–2.8 ppm).
Main Conclusions Cytogenetic alterations were significantly increased in the formaldehyde-exposed workers compared to control subjects;
MNL frequency is +1.6-times higher in the exposed workers compared to control subjects; MNB is around 4.1-times
higher in exposed compared to control; Significant positive correlation was found between MNL and MNB frequencies (r
= 0.359, p < 0.001).
• Positive significant correlation between MNL frequencies and exposure duration (r = 0.277, p = 0.011) and MNB and
formaldehyde-level of exposure (r = 0.2407, p = 0.001)
• Confounder for MNL and MNB is age (above 35 years old); significant positive correlation between age and MNL
frequency (r = 0.287, P < 0.001) and MNB frequency (r = 0.319, P < 0.001); smoking habits (pack-years) found to
have significant positive association with MNB frequencies (r = 0.195, P = 0.025).
Characteristic of the Studies (5)
Title Biological monitoring of workers exposed to carcinogens using the buccal micronucleus approach : A
systematic review and meta-analysis
Authors Hopf NB, Bolognesi C, Danuser B, Wild P
Published year 2019
Study Design Systematic Review JBI’s Levels of Evidence 3a
Sample Size 352 subjects from 3 reviewed studies (164 exposed, 188 controls)
Working Context • Exposed: workers from anatomy, pathology, histopathology laboratories; workers from formaldehyde
and formaldehyde-based resins production factory
• Control: university and hospital administrative staff
• Formaldehyde’s air concentrations: ranging between 0.16–0.21 ppm
Main Conclusions • I2: 4.8 (95% CI:2.19-10.60) for frequency ratio formaldehyde exposure and MNL, measured in the
formaldehyde target organ: nasopharyngeal and sino-nasal area
• Egger's test was significant for the formaldehyde exposure category
Characteristic of the Studies (6)
Title Determination of benchmark dose based on adduct and micronucleus formations in formaldehyde-
exposed workers
Authors Wang K, Wang T, Xu J, Zhu Y, Jian L, Au W, et al
Published year 2019
Study Design Case-control JBI’s Levels of Evidence 3b
Sample Size 200 male subjects (100 exposed; 100 non exposed), matched by age
Working Context • Exposed: workers from a chemical factory in Shanghai (China) with 4 different work conditions: production
examination (level of formaldehyde: 0.06 (0.01-0.15)); glue spraying (levels of formaldehyde: 0.25 (0.2-0.49));
coating (levels of formaldehyde: 0.1 (0.067-0.15)); workplace inspection (levels of formaldehyde: 0.09 (0.05-
0.2))
• Control: workers from the same company in logistic workshop (levels of formaldehyde: 0.01 (0-0.01)
Main Conclusions • Significant MN frequency (%) increase approximately 3-times higher in formaldehyde exposed workers
(3.05+1.47) compared to control group (1.71+0.96)
• Dose-response relationship between FA-HAS concentrations and MN frequencies was found (R2 = 0.59, p <
0.001)
• Chromosome damage was defined as micronucleus frequency ≥3‰
• The BMD of formaldehyde CED was 0.067 mg/m3-year (0.055 ppm-year) and the BMDL was 0.042 mg/m3-
year (0.034 ppm-year).
DISCUSSION
to evaluate the use of micronucleus test as screening method for nasopharyngeal carcinoma among
health care workers exposed to formaldehyde

formaldehyde exist in indoor workplace air in high concentration, inhalation being the most
common routes of exposure

laboratories workers from anatomy, histology, biomedical, research) are highly exposed to
formaldehyde compared to other health care workers (range 0.3–3.2 ppm)

average TWA8H of formaldehyde was 0,41 (range: 0,16-0,74)  above The ACGIH’s TLV-TWA of
0,1 ppm --> Formaldehyde’s Ceiling average was 1,14 (range: 0,18-2,93)  exceeded both
ACGIH & Indonesia’s regulations STEL of 0,3 ppm
MN test is significantly related with formaldehyde exposures 4 times higher in exposed
groups than control (low & high concentration)  at least once in a year, also as baseline
 CONCLUSION
MN test was valid and important to be used
for screening genotoxicity effect (NPC) from
chronic and/or cumulative inhaled-
formaldehyde exposure among health care
workers: laboratories workers (pathology
anatomy, histology) also surgical nurses.
RECOMMENDATIO
N
Included MN test for routine medical check up for formaldehyde potentially
exposed health care workers as screening for genotoxicity effect at least
once in a year.
RECOMMENDATIO
N
Included MN test for routine medical check up for formaldehyde potentially
exposed health care workers as screening for genotoxicity effect at least
once in a year

Health care facilities should update their health risk assessment and conduct
exposure monitoring regularly regarding formaldehyde classification as
carcinogenic for human with sufficient evidence to nasopharyngeal
carcinoma to enable adequate risk management