Documents in witness’ file

6-7

Witness has a cover letter, dated 6/25/2007, which is one page long, and a three-page report transcribed on 12/1/2007. Witness does not have any cover letters or reports. The cover letter from the law firm was dated 7/2/2006, which was from Melanie Lane. The cover letter is marked as Exhibit A. Witness has not had any other conversations or materials concerning the case sent to him prior to 6/25/2007. Witness’ first knowledge of the existence of the matter came when he received the letter from the law firm.

Pathology slides and report

8

After receiving the letter, witness reviewed the pathology slides and the pathology reports corresponding to the slides, and drafted a report and letter and completed the case.

Conversations

8-9

Witness spoke to Maxmillian this morning for about 5 minutes. They discussed that this case was coming up today, and briefly about whether this was a primary pericardial mesothelioma or a plural mesothelioma. Maxmillian also told witness that John Jones was extensively exposed to asbestos for about 30 years, and used a lot of wallboard that contained chrysotile asbestos. That was the only conversation that witness had with anyone regarding the Jones case.

December 1, 2007 report

10

After reviewing the materials, witness transcribed the report summarizing his conclusions and findings on 12/1/2007. That is the only report that he has prepared in this case. The information he received from Maxmillian this morning concerning asbestos exposure is the first time that witness has had any information concerning Jones’ alleged asbestos exposure.

Plaque caused by asbestos

10-11

Witness noted in his report and cover letter that the biopsy tissue that was labeled pericardial tumor had the appearance of plaque caused by asbestos. As to what plaque looks like when caused by asbestos, there are two causes: one is asbestos, the dominant cause; and the other is by eronite, a fiber very similar to asbestos. It is uncommon for plaque to appear on the pericardium compared to the pleura, but witness has seen so many cases over his career that it does not faze him anymore. Plaque can occur anyplace that asbestos is translocated, including the surfaces of the spleen and liver in the abdominal cavity.

An asbestos fiber sufficient to cause plaque would translocate to the pericardium primarily through the lymphatic system, because the pericardium, including the visceral pericardium and the parietal pericardium, are extensively involved with the lymphatic channels. 

Plaque caused by eronite

12-13

Witness has never seen an eronite-caused plaque. What he has read is that people exposed to eronite in an occupation setting like in Turkey, they can develop plaques on their pleura and pericardium just like in people who are exposed to asbestos in the United States and other countries. Eronite is a cause of mesothelioma, but not in the United States. Eronite is a form of fibrous zeolite. Zeolite is the broad category of which eronite is an example of, specifically a fibrous zeolite. Most of the zeolite used in the United States is in a very fine, granular, non-fibrous form. It is used extensively as a filtering-type substance. Many industries use zeolite as a filtering substance, particularly in the beer-making industry. Witness does not think eronite is used because it is his understanding that eronite specifically refers to a form of fibrous zeolite.

Differential diagnosis, epithelial mesothelioma and adeno-carcinoma

14-15

The pleural fluid cytology and the pericardial fluid cell block preparation showed malignant epithelial cells from which witness arrived at a differential diagnosis between epithelial mesothelioma and adenocarcinoma on the pericardial fluid and the pleural fluid. Witness has not ruled out adenocarcinoma as to what this tumor is. You could have involvement of the pericardium by a primary pericardial mesothelioma, which is extremely rare. There have only been about 150 cases of pericardial mesothelioma that is primary pericardial mesothelioma reported in world’s literature. The most common epithelial tumor that you would find involving the pericardium would be a metastatic cancer, and specifically a metastatic adenocarcinoma. The most likely primary source would be a metastatic adenocarcinoma from the lung. The other situation that can happen, which is not uncommon, is for primary pleural mesotheliomas to invade the pericardium, and the pericardium could be involved in an invasive or metastatic pleural epithelial mesothelioma.

Making diagnosis based on materials

18

As a pathologist, witness would know from the materials that he has been provided whether this is a metastatic adenocarcinoma from the lung area to the pericardium by evaluating the cells through either immunohistochemistry or electron microscopy and to determine what their immunohistochemistry profile was or their

ultrastructural appearance was, and base his diagnosis on those types of studies. A CT scan or x-ray might show a tumor in the lung that would be metastatic to the pericardium. Witness has not been provided with any information regarding CT scans or x-ray reports.

Causes of mesothelioma of the pericardium

18-19

Mesothelioma of the pericardium is caused by the same things as other types of mesothelioma, which is primarily asbestos. There probably would be more pericardial mesotheliomas in which a cause was not known, because of insufficient investigation. There have been documented cases of primary pericardial mesothelioma in people who have been exposed to asbestos. There is one spectacular case, reported by Dr. Andrew Flane, of a person who had an unrelenting pericardial effusion, and they performed a pericardiodesis on the patient, which is similar to a pleurodesis. In this case, however, they put talc in the pericardial cavity, rather than in the pleural cavity. It turned out that the talc contained tremolite asbestos. That individual developed primary pericardial mesothelioma 15 years after the talc had been instilled into the pericardial cavity. That report is published and shows what you would expect. The big concern right now is of doing talc pleurodesis is, and many of the surgeon’s reports now say that asbestos-free talc was instilled into the pleural cavity.