MPM in Turkey; Incidence

Cappadocia and Erionite Related Cancers Library

Lecture Salih Emri M. D. Hacettepe Universityauthor School of MedicineOnline Departmentby of Chest Diseases,© Ankara Turkey.

ESCMID Cappadocia Library

Lecture author • The Cappadocia, “Katpatuka” in Old Persian, means land of beautiful horses. Onlineby © • The eruptions of two volcanoes on the Anatolian plateau caused the region to be covered with thick stratum of lava, volcanic ashes and a dense tuff of zeolite layer formed on the surface.

• ArchaelogicalESCMID records indicate that the region was populated by Hitties, Phrygians, Persians, and Romans. Cappadocia Library • After Christianity was accepted as a religion, a monastic life in the region started about 350 AD. Lecture

• From the 14th century on, author the Ottomans replaced the Seljucks in rullingOnline the by region. ©

ESCMID MPM in Cappadocia Library

Lecture author • Following initialOnline observationsby of cases of malignant pleural ©mesothelioma in Karain village of Central Anatolia (1,2).

1. Baris Yi, et al. Kanser 1975; 5: 1-4 2. Baris Yi, ESCMIDet al. Thorax 1978; 33: 181-192. MPM in Cappadocia Library • An international team of investigators from the Hacettepe University, the MRC Pneumoconiosis Unit from Cardiff, and IARC from Lyon carried outLecture an environmental and epidemiological survey in 4 villages in the same area during the periodauthor 1979-1983 (1). Onlineby ©

1. Baris Yi, et al. Int J Cancer 1987; 39: 10-17. ESCMID In the Cappadocia region of Central Anatolia there are three villages, Karain, Tuzköy, and Sarihidir, where 50% of deaths are caused by MPM(1). Library

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1. Baris YI, et al. Int J Cancer 1987; 39: 10-17. ESCMID Library

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ESCMID Tuzköy village (population ~ 1,300) Library

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ESCMID Like many other places in Cappodocia, these villages are characterised by ancient rock dwellings and caves dug in soft volcanic tuff. Library

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Karain village (population ~ 150) ESCMID Library

What is the cause of MPM epidemic in thoseLecture villages? author Onlineby ©

Rock dwellings in Sarihidir village ESCMID MPM in Cappadocia • Erionite fibers, which are Library formed by bundles of individual fibrils with a diameter of approximately 0.5 µm, measure 5-6µm in diameter and are 30- 40µm long (1). Lecture

• Three types of erionite author have been described: erionite-Na, erionite-K,Online by and erionite-Ca, all are© considered carcinogens Fig 1: Erionite bundle. Dogan AU et al, Environ Geochem Health (2-5). 2008, 30:367-381..

1. Coombs DS and et al. The Canadian Minerologist 1997; 33: 1571-1606, 2. Maltoni C, et al. Environ Res 1982; 29: 238-244. 3. Wagner JC, et al. Br J Cancer 1985; 51: 727-730. 4. Passaglia E, et al.ESCMID Am Minrologist 1998; 83: 577-589. 5. IARC 1987;42:287. MPM in Cappadocia

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Lecture author Fig 1. fibrous zeolite(erionite) rocks from the quarry which had been used to built houses in these villagesOnlineby ©

Fig 2. Representative SEM image of Cappadocian Erionite from a rock sample. From A. Umran Dogan

ESCMID Fig 4. Single erionite fibre in lung tissue Library

LectureWhite woolly aspect of the mineral author Onlineby

Houses constructed with bricks containing ESCMIDerionite fibres

TUZKÖY Library Erionite is the only zeolite whose evidence of carcinogenity has been evaluated and classifed as a human Lecture carcinogen Group-I so far !.. author IARC 1987;42:287. Onlineby ©

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ESCMIDProf. Baris and Prof. Wagner , IMIG meeting in Paris, 1995. Why is Erionite so Carcinogenic to the Pleura?

• Erionite, which is Library fibrous in nature, has a hexagonal structure with an internal surface of 200 m2/g, Lecture which is 20 times larger than that of author crocidolite and allows it to adsorb smallOnline by molecules and to have© a high catalytic activity. Fig 1. Erionite Molecular Structure

1. Coffin DL, et al. IARC Sci Publ 1989; 90:167-172. 2. Dogan UA.CancerESCMID Research 2006. Why is Erionite so Carcinogenic to the Pleura?

• Erionite induces more reactive oxygen free radicals than Library asbestos and glass fibers that can cause DNA damage or the initial step of genotoxicity(1). • Erionite (2-16µg/cm2) is mutagenic and mutagenic potential significantly Lecture increases in the presence of iron (20µM) in vitro studies (2). author • Erionite increases the balance between cell proliferarion and apoptosis and lower amountsOnline by of erionite compared to © crocidolite are required to induce c-jun mRNA ,a mechanisim linked to fiber carcinogenesis(3) 1. Maples KR,ESCMID and Johnson NF. Carcinogenesis 1992; 13: 2035-2039. 2. Fach E, et al. Environment international 2002;103: 1-8. 3. Timblin CR, et al. Toxicol Appl Pharmacol 1998; 151: 88-97. Types of Erionite Exposure

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Lecture author Onlineby • Exposure to erionite© fibers occurs in the houses and annexes and, also in the streets of the villages. ESCMID 1. Karakoca Y,et al. Indoor Built Environ 1997; 6: 100-105. MPM in Cappadocia- Fibre Analysis Studies in Zeolite Villages: Library The levels of airborne erionite fibers in erionite villages were extremely low ranging from 0.005 toLecture 1 fibre.ml-1 before and after sweeping the floors author Onlineby © 1. Simonato L, et al. IARC Scientific Publication No.90, 1989.

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By contrast, extremely low erionite levels haveLecture produced…. author Onlineby ©

ESCMID Fibre Analysis Studies in Zeolite Villages

• Erionite retention is in the same range as tremolite in the Library BALF of tremolite exposed subjects analysed by TEM.

• The geometric mean of lung erionite tissue fibre content was higher in patients from zeolite Lecture tremolite villages(130x106 fibres.g-1 dry lung) than in the pts from asbestos villages (11x106 author 1 fibre.g- dry lung). Onlineby • The environment in tremolite© villages was 8-1020 times more dustier

Fig. 1: The cumulative curve for concentration of 1. Dumortier P, et al. Occup Environ Med 2001;58:261-266. 2. Karakoca Y,et al. Indoor Built Environ 1997; 6: 100-105 FBs in the erionite group is compared with the 3. Simonato L, et al. iARC Scientific Publication No.90, 1989. curves recorded for concentration of ABs in ESCMID control and tremolite group. 4. Pooley FD. Dust and Disease. 1979. 5. Sebastien P, et al. Lab invest 1981; 44: 420-425. These studies clearly suggestLibrary higher potency of erionite in the lung than that of asbestos !.. Lecture author Onlineby ©

ESCMID MPM in Cappadocia- Mortality Studies: Prospective Study of Mesothelioma Mortality in Turkish Villages with Exposure to Fibrous Zeolite Library • It was found that 119 of 372 deaths (44.5%) among 891 villagers(over 20 y-old) residing in Karain, Sarihidir, and in Karlik(control village) were due to MM betweenLecture 1979-2003(1). • Villages born cohort ageauthor adjusted mortality rate(no.of deaths per 100,000 people per year) Onlineby No of Death(%)© ratio to Denmark to World Karain 82/179(46) 485 700 Sarihidir 35/109(32) 200 Karlik 2/84(2) 10 ESCMID 1. Baris YI, and Grandjean P. J Natl Cancer Inst 2006;98:414-417. MPM in Cappadocia-incidence:

• It was estimated that a cumulative dose of 1 Library fiber/ml-year induces a pleural mesothelioma rate of 996 per 100,000 person-year in the population exposed to Lecture erionite in erionite villages (1). author • The magnitude of Onlinethis by risk is much higher than that of workers exposed© to asbestos fibers(2).

1. Baris YI, et al. Int J Cancer 1987; 39: 10-17. 2. SimonatoESCMID L, et al. IARC Scientific Publication No.90, 1989. Erionite related malignant diseases:

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Among the malignant diseases caused by erionite, MPM is the major problem in the exposed population.ESCMID MPM in Cappadocia- Mortality Studies Library • Up to 38% of deaths in Tuzköy between 1980 and 1994 were due to malignant pleural or peritoneal mesothelioma. Lecture • Incidence of non- author mesoteliomal malignancies were also found highOnline in by erionite villages. Cancer rates in these villages is ©~ 1000 times more than the normal. ESCMID 1. Baris B, et al. J Environ Pathol Toxicol Oncol 1996; 15: 183-189. MPM in Turkey; Incidence:

• A total of 506 new mesothelioma Librarycases was reported (464 pleural, 42 peritoneal) for the year 2000 (1). • Female/Male ratio was 213/293 (0.7). • Mean Age, in years andLecture (age range) was: 9 55.6 for the total (range: 24-88), 9 55.8 (range: 26-83) for males,author 9 55.5 (range: 24-88) for females. • No history of occupationalOnlineby exposure to either asbestos or erionite.© • Six percent of cases (30/506) was reported from the erionite villages.

1. Emri S, and Demir AU. MPM in Turkey, 2000-2002. 2nd Heilderberg Thoracic OncologyESCMID Symposium, May 10-12, 2002. MPM in Cappadocia- Simian virus 40

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Fig 1.Polyacrylamide gel electrophoresis showing Fig 2. Polyacrylamide gel electrophoresis showing the the amplified 338 base pair segment from the C’ amplified 574 base pair and segment from the N’ terminal terminal region of the SV 40 Tag gene. regionauthor of the SV 40 Tag gene. • A recent study showed that SV 40 was not a co- factor in the developmentOnlineby of Turkish mesotheliomas. © • This may be related to the fact that contaminated vaccines were not administrated in Turkey. ESCMID 1. Emri S,et al. Anticancer Research. 2000; 20: 891-894. MPM in Cappadocia Relationship between antioxidant vitamin levels and MPM

Table 1.β-Carotene, α-Tocopherol, Ascorbic Acid and Retinol in Serum by Groups (mean±SE). Group n (%) β-Carotene(µg/ml) α-Tocopherol(µg/ml) AscorbicLibrary Acid(µg/ml) Retinol(µg/ml)

Tuzköy Control 59 (37) 0.62±0.01 26.2±0.2 49.1±0.4 2.53±0.03 (erionite village)

Kureysler Control 35 (22) 0.46±0.01 22.8±0.3 32.7±0.6 2.09±0.04 (asbestos village) Ankara Control 24 (15) 0.63±0.02 26.2±0.4 Lecture49.05±0.7 2.54±0.05 MPM patients 42 (26) 0.38±0.01 21.3±0.2 author30.4±0.5 2.04±0.03

• Lowest levels of β-carotene, ascorbic acid, and alpha-tocopherol were found in MPM patients (MPM vs control groupsOnline combined,by p<0.0001 for each antioxidant vitamins). © • Post Hoc tests (Student Newman-Kuels test) indicated no significant difference between antioxidant levels of Tuzköy and Ankara groups.

• MPM was associated with low levels of ascorbic acid (OR 1.36; 95%Cl:1.1 to 1.6) and alpha-tocopherol (OR 1.71;95%Cl:1.2 to 2.6) in the logistic regression model. (Correct classificationESCMID rate = 90.6%). 1. Emri S, et al. Lung Cancer 2003; 41(suppl 2); s219 (abstract P-510). MPM in Cappadocia-Biological behaviour: Ras Oncoprotein Expression Library

Lecture author Fig 1. Positively stained tumor cells in case 3 Fig 2. Representative immunoblots of p21 ras-negative plasma İndicating Ras expression.Inset: Positive control showing (Lane 1), p21ras-positive plasma (Lane 3,4,5) and molecular dense staining Onlinebymarker (Lane M). • Ras oncoprotein expression© was found in 27 % of the erionite induced mesotheliomas and in 6 % of the asbestos induced mesotheliomas (P=0.17).ESCMID 1. Olut A, et al. Respir Med 2001; 95: 697-698. MPM in Cappadocia-Biological behaviour Library • Flow cytometric DNA analysis of 40 MPM pts revealed a significantly higher aneuploidy in the erionite-Lecture related cases (72.7 % in 11 pts) than in the asbestos- related cases (13.8 % authorin 29 pts) . • Though not significant,Onlineby MPM due to erionite exposure© seems to have higher proliferation rate (SPF).

1. EmriESCMID S, and et al. Lung Cancer 2001;33: 109-114. MPM in Cappadocia- Treatment and Prognosis:

• We showed a survival Median OS(mo, 95%CI):10±(6-14) Library Erionite: 8±2(3-13), 1-y sur 30.0% advantage in patients Asbestos: 14 ±3(9-19), 1-y sur 51.9% with MPM caused by exposure to asbestos compared to erionite. Lecture • The carcinogenic properties of erionite authorand/or a genetic factor Onlineby in the pathogenesis of erionite induced © mesothelioma may play a role in its diverse biologic behavior. ESCMID 1. Emri S, and et al. Lung Cancer 2001;33: 109-114. Library

There are some outstanding questions!..Lecture author Onlineby ©

ESCMID Why such a potent carcinogen would specifically cause MPM? Library

Lecture author Onlineby © •Large graveyard in one of the Cancer Villages, > 50% of deaths are due to ESCMIDmesothelioma Why about 50% of villagers appeared to suffer no 9consequence from exposure to such a potent 8 carcinogen was also unknown? 7 Library 6 5 Tuzköy Karain 4 Sarihidir 3 Karacaören Yesilöz 2 Lecture Karlik Boyali 1 Cökek 0 author 1994 1995 1996 1997 Onlineby • it should be noted that mesothelioma cases are more prevalent in the erionite villages compared© to the nearby villages. No mesotheliomas were found in Karlik which is 3 km. away from Karain and is built the same stones used in Karain. (2).

1. Emri S, et al. Toxicology Letters 2002; 127: 251-257. 2. Dogan AU. Cappadocian mesothelioma villages.The symposium on nutrition,environment, and cancer. March 31- April 3, ESCMID2002, Ankara, Turkey. Why the disease is more frequent with certain families? Library

Lecture author From Dr. Baris Onlineby From Dr. Baris Certain families more susceptible to erionite© No MPM occurred in some familes carcinogenesis

•Individuals in adjacent houses in the same village seem to have a very differentESCMID incidence of mesothelioma, despite similar exposure, which suggests that other factors also contribute. Library

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ESCMID Members of National Mesothelioma Committee were in Loyola University Is there a possible geneticLibrary factor for susceptibility to erionite carcinogenicity in the erionite Lecture villages? author Onlineby ©

ESCMID MPM in Cappadocia- Genetic studies- I Association between HLA distribution and malignant pleural mesothelioma

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• Association between HLA distrubutionauthor and MPM was investigated by a case-control study of 31 MPM pts, and two control groups of 119 Tuzköy inhabitants andOnline 118 healthyby renal donors(1). • HLA-B41, -B58 and –DR16 antigens were significantly more common in the malignant pleural mesothelioma© patients as compared to that of the control groups.

• We found that HLA-A11,-B27, and –DQ7 antigens were significantly higher in a selected group of Tuzköy inhabitants than in the control groups.ESCMID 1.Karakoca Y, et al.Int J Tuberc Lung Dis 1998; 2: 1017-1022. MPM in Cappadocia- Genetic studies-II Genetic mapping study Library • Analysis of a six- generation extended pedigree of 526 individuals showed that Lecture MPM was genetically transmitted. author • It was suggested that vertical transmissionOnline ofby MPM occurs probably© in an autosomal dominant way. ESCMID 1. Hammady i-Roushdy, et al. Lancet 2001; 357:444-445. Together these results suggestedLibrary that MPM was caused by the interaction of erionite with unknown geneticLecture trait (geneXenvironmentauthor interaction). Onlineby ©

ESCMID Why such a potent carcinogen does not cause MPM in other parts of the World? Western US (Intermountain West),Japan, Mexico,Library New Zealand, and Tanzania…….

Answers: Lecture1. Especially for US, all have been told that these are authorsparsely populated areas 2. Another equally plausible explaniton could be Onlineby diagnostic © misclassification?

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İlgren EB and et al, recently reported a mesothelioma cluster in the Southern part of the State of Zacatecas.This is the first study that came from outside of Turkey…ESCMID Relocation of Sarihidir Village on the other Bank of Kizilirmak (Red River) might Influence the MPM Epidemic ? Library

The village was moved to an erionite free place in 1960 and built with bricks and cement, therefore reducing, but not ESCMIDeliminating, erionite exposure. Cohort Study of Sarihidir Village (1970-2001) Comparison of the three cohorts for the proportions of alive, death due to malignant mesothelioma and death due to another cause). Library Birth groups N Median Age Death Cumulative risk of Proportional (yr) death mortality % at entry Total MM Total MM MM/Total

1935-1945 58 29.7 13 6 0.38 0.18 46.2 1946-1955 83 18.0 8 Lecture3 0.19 0.07 37.5 1956-1965 63 10.9 2 0 0.07 0 0.0* author * p: 0.002 Onlineby 1. 18 of 63 people in the last birth© group are from Bostan family and they were born and raised outside the village of old Sahidir, no MM have developed in this group. 2. We have to follow up the cohort for 20-40 years for a definitive conclusion. ESCMID Library

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ESCMID What should we do to prevent the people to get diseased? Library • Diminish or totally eliminate environmental exposure through educating villagers to avoid using asbestosLecture contaminated soil for whitewashing, wall plastering and relocating the erionite authorvillagers to an erionite free area.Onlineby ©

ESCMID Can we detect early casesLibrary by screening biomamerker measurerment or low dose CT Lecture screening ? author Onlineby ©

ESCMID Screening , early detection and treatment of patients from high risk regions Library • Mean serum SMRP levels were higher in MPM compared with lung cancer (5.67 ± 0.82 nM [mean ± standard error of Lecturethe mean vs 1.99 ± 0.43 nM, p < 0.001), and stage authorI MPM SMRP levels (n = 12; 2.09 ± 0.41 nM) were Onlineby significantly higher than those in asbestos- © exposed individuals (0.99 ± 0.09 nM, p = 0.02, respectively). Fig 1. Soluble mesothelin-related peptide (SMRP) levels for groups studied. Bars represent mean ± standard error ESCMIDof the mean. (Adeno = adenocarcinoma; LCa = lung carcinoma; MPM = Harvey I. Pass and et al. Ann Thorac malignant pleural mesothelioma.) Surg 2008;85:265-72 ELISA (test 1, 06/13/2006)

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0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 Individuals from Turkey (May 2006) MM patients Control (1-69) Lecture (70-80) (81-88)

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0 1 3 5 7 9111315171921232527293133353739414345474951535557596163656769717375777981838587 ESCMID Individuals from Tuzkoy (12 years ago) MM patients Control (1-72) (73-80) (81-88) MPM in Cappadocia- Conclusions Library

• If we succeed in identifying putative mesothelioma susceptibilityLecture gene(s) that renders certain families more susceptible to erionite carcinogenecity, we canauthor prevent or at least reduce the incidenceOnlineby of mesothelioma in future generations.This same© gene/s may be the target of asbestos and SV40 in sporadic MPM cases in the Western World ESCMID Library

ESCMID Fairy Chimneys in Cappadocia