1 15 5 https://www.nal.usda.gov/exhibits/speccoll/files/original/7b982586fc4da1dc4c6be53fcac84b2c.pdf 304d1826437992bbdc8e1342914d875f PDF Text Text Itom ID Number 01764 Author Fingerhut, Marilyn A. Corporate Author ROpOrt/ArtiOlO TltlO Review of Exposure and Pathology Data for Seven Cases Reported as Soft Tissue Sarcoma Among Persons Occupational^ Exposed to DioxinContaminated Herbicides Journal/Book Title 1984 Year Month/Day Color ' Number of Images 17 Descpipton Notes Monday, June 11, 2001 Page 1765 of 1793 �187 REVIEW OF EXPOSURE AND PATHOLOGY DATA FOR SEVEN CASES REPORTED AS SOFT TISSUE SARCOMA AMONG PERSONS OCCUPATIONALLY EXPOSED TO DIOXIN-CONTAMINATED HERBICIDES Marilyn, A. Fingerhut, Ph.D* William E. Halperin, M.D., M.P.H.* Patricia A. Honchar, Ph.D* Alexander B. Smith, M.D., M.S.* David H. Groth, M.D.* William 0. Russell, M.D.** *National Institute for Occupational Safety and Health Cincinnati, Ohio 45226 **North Ridge General Hospital and Cancer Foundation, Fort Lauderdale, Florida 33334 This paper is a work of the U.S. Government; therefore copyright does not apply. From Public Health Risks of the Dioxins, proceedings of a symposium held on . October 19-20, 1983 at The Rockefeller University, New York City. Edited by William W. Lowrance. Published by William Kaufmann, Los Altos, California, 1984. �188 Fingerhutetal. Data from two Swedish studies (1,2) and a review of four U.S. studies (3) of dioxin-exposed workers have suggested that occupational exposure to dioxin-contaminated products is associated with an increased risk of soft tissue sarcoma (STS). Soft tissue sarcomas are malignant neoplasms arising throughout the body from mesenchymal supporting tissue other than bone (4). The principal types of histopathologic subtypes and their frequencies 'are listed in Table 1. : Table 1. Histopathologic varieties of sarcoma of soft tissue.* r > tPercentage of Histopathological Variety Total Cases r Rhabdomyosarcoma 19.2 "' Fibrosarcoma 19.0 Liposarcoma 18.2 Malignant fibrohistiocytoma 10.5 Sarcoma of Soft Tissue, type unspecified 10.0 Synovial sarcoma 6.9 Leiomyosarcoma 6.5 Malignant schwannoma 4.9 Angiosarcoma 2.7 Other types 1.9 * Table presented in Suit, H.D., Sarcoma of soft tissue, CA-A Cancer Journal for Clinicians 1978; 28:284-295. The percentages were derived from a study of 1,215 sarcomas by the Task Force for Sarcoma of Soft Tissue of the American joint Committee on Cancer (5). Dioxins are generated as unintended contaminants during the chemical manufacture of chlorinated phenoxy acetic acids and chlorinated phenols. The most toxic of the 75 dioxin isomers, 2,3,7,8-tetrachlorodibenzodioxin (2,3,7,8-TCDD), is generated during �Review of Reported Soft, Tissue Sarcoma Cases 189 the production of trichlorophenol (TCP) and its derivative, the herbicide 2/4,5-trichlorophenoxyacetic acid (2,4,5-T). Industrial workers who produce chlorinated phenoxy acetic acids and chlorophenols, and herbicide applicators who spray these products, potentially have been exposed to the products and their dioxin contaminants. In 1977, several cases of soft tissue sarcoma were reported among Swedish lumberjacks who had had prior exposure to phenoxy herbicides. This clinical observation led researchers in Sweden to conduct two separate case control studies (1,2). Both studies found that persons with occupational exposure to phenoxy acids or chlorophenols had a fivefold increased risk of developing a soft tissue sarcoma. At" about the same time, four studies (6-9) were conducted in~j> U.S. manufacturing plants of workers exposed to the herbicide 2,4,5-T and its chemical precursor, trichlorophenol. The dioxin isomer contaminating these products is the most toxic form, 2,3,7,8-TCDD. None of the four studies found any statistically significant excess in total mortality or in death from cancer which was attributed to dioxin exposure. However, each cohort was small and of insufficient statistical power to allow adequate evaluation of rare causes of death. Honchar (3) reviewed the deaths in the four cohorts, and found that three (2.9%) of the total 105 deaths in the merged cohorts were reported to be from soft tissue sarcoma. Based on national statistics, only 0.07% of deaths was expected to be due to this cause. Table 2 lists these three deaths as Cases 1 to 3. Subsequently, Dr. Ralph Cook of Dow Chemical Company reported a fourth, living person in one of these cohorts as having a soft tissue sarcoma (10). This individual, Case 4, is now deceased. Dr. Marion Moses of Mt. Sinai reported an additional case of soft tissue sarcoma in an individual (Case 5) employed at one of the same four chemical manufacturing sites (11). Subsequently, two additional persons, Cases 6 and 7, were reported to have soft tissue sarcomas (12). They worked at a chemical manufacturing site which produced 2,4,5-T, but which had not been previously studied, and their exposures had not been confirmed at the time of the reports. �190 Fingerhutetal. Table 2. Exposure data from original publications for the seven U.S. workers. Case Number Type of Exposure Type of Report Reference TCP Mortality Study Zack, J. and Suskind, R.S, Journal of Occupational Medicine 1980; 22;11-14. 2,4,5-T Mortality Study Zack, J. and Gaffey, W.R. Environmental Science Research 1983; 26;575-591. TCP Mortality Study Cook, R.R. et al. Journal of Occupational Medicine T980; 22:530-32. TCP Case Report Cook, R.R. Lancet 1981,; i:618-619. ^ TCP, 2,4,5-T Case Report Moses, M. and Selikoff, I.J. Lancet 1981; i: 1370. 6 Chlorophenols Case Report Johnson, F.E. et al. Lancet 1981; i:40. 7 Chlorophenols Case Report Johnson, F.E. et al. Lancet 1981; i:40. We have obtained detailed employment records, medical and pathological reports, tissue specimens and death certificates for these seven individuals and present here detailed descriptions of our occupational and pathologic reviews. We hope, through this report, to focus attention on the problems associated with the study of soft tissue sarcomas in dioxin-exposed populations. In addition to our work at the National Institute for Occupational Safety and Health (NIOSH), studies of the health effects of dioxin are underway at the Centers for Disease Control (CDC), the Veterans Administration (VA), the National Institutes of Health (NIH), and various state agencies in this country. Other organizations, both here and abroad, are also conducting studies of soft tissue sarcoma, and the International Agency for Research on Cancer (IARC) of the World Health Organization is considering an International Dioxin Registry. �Review of Reported Soft Tissue Sarcoma Cases 191 EXPOSURE DATA FOR THE SEVEN CASES Table 3 presents the exposure history of each individual. We used a rigorous criterion of exposure. An individual was considered exposed to products contaminated with 2,3,7,8-TCDD if he had a company record of assignment to a department producing trichlorophenol or 2,4,5-T. Table 3. Work history information for the seven U.S. workers. 'Duration of Exposure (Years) Case Number Facility Years of Employment 1 A 1946-1978 TCP Operator 1.9 •" 2 A 1946-1972 2,4,5-T Operator 2.0 3 B 1950-1975 Maintenance 3.5 4 B 1951-1982 TCP Operator Plant Mechanic (TCP Department) 19.0 job Title 5 A 1943-1975 Maintenance Service 6 C 1978-1980 Production Worker 7 C 1951-1980 Production Worker 11 days The work histories confirmed the original reports that Cases 1, 2, and 4 were production workers assigned to the trichlorophenol or 2,4,5-T departments. Case 3 was a maintenance worker identified by the company as assigned to a building where trichlorophenol was produced. Case 5 was a maintenance and service worker for 32 years in a chemical manufacturing site which produced trichlorophenol, 2,4,5-T, and many other chemicals, but he had no record of specific assignment to a trichlorophenol or 2,4,5-T department. Case 6 worked two and one-half years in a plant which made 2,4,5-T. He was a production worker but had no record of assignment to the 2,4,5-T area. Case 7 is the father of Case 6 and was a production worker at the same facility for 29 years. His work history showed no record of assignment to the 2,4,5-T area, although he did work for 11 days �192 Fingerbut etal. following hire in 1951 in a pentachlorophenol area. Pentachlorophenol is contaminated with hexa-, hepta- and octachlorinated isomers of dioxin, but does not contain 2,3,7,8-TCDD. These last three individuals illustrate some of the difficulties encountered in attempting to verify exposure in chemical workers. In general, production workers qlo have records of regular assignment to specific departments within <|:omplex chemical manufacturing plants, although their records do not show temporary changes in assignments. However, maintenance workers such as Case 5 often work throughout an entire facility and never have recorded assignments in specific departments From our examination of their work histories we concluded that these three workers did not meet our stringent criterion of exposure, they had no recordsjof assignment to a 2,4,5-T or trichlorophenol process. However, absence of such documentation does not eliminate i ' the possibility than they were exposed to dioxin contaminated products during their routine activities. PATHOLOGY DATA FOR THE SEVEN CASES Table 4 summarizes clinical observations obtained from company medical records, hospital records, and pathology reports for the seven individuals. All cases were reported to have soft tissue sarcomas. Table 4. Medical information for the seven U.S. Case Number Tumor 1 Malignant fibrous histiocytoma Onset of Tumor workers. Age at Onset Chloracne 1978 58 yes yes Adenocarcinoma, bladder Liposarcoma, rectum 1958 34 1972 49 3 Fibrosarcoma 1973 52 dermatitis 4 Malignant fibrous histiocytoma 1979 58 yes Neurogenic sarcoma 1980 57 no 2 �Review of Reported Soft Tissue Sarcoma Cases 193 Table 4. Continued. Case Number Tumor 6 Fibrosarcomatous mesothelioma 1980 33 no Liposarcoma 1980 53 no 7 Onset of Tumor Age at Onset Chloracne Cases 1, 2, and 4 had records of diagnosed chloracne. Case 3 had dermatitis of the face and neck while assigned to the trichlorophenol building during a period when 49 trichlorophenol workers developed chloracne (8). But no chloracne was found in the records of Cases 5, 6, and .7. V Table 5 presents data on the latency of the tumors (time from first exposure to diagnosis of the tumor) for each individual. Table 5. Latency of tumors for seven U.S. workers. Case Number First Assignment to 2,4,5-T or TCP Department STS Tumor Onset Latency* (Years) Age at Onset 1 1949 1978 29 58 2 1950 1971 21 49 3 1964 1973 9 52 4 1951 1979 28 58 5 never 1980 N.A.** 57 6 never 1980 N.A. 33 7 never 1980 N.A. 53 * Time from first exposure to onset of tumor. ** Not applicable. Adequate latency for development of cancer was experienced by the four individuals with records of assignment to trichlorophenol or 2,4,5-T departments (Cases 1 to 4). Since no records of specific departmental assignment to TCP or 2,4,5-T departments exist for the �194 Fingertmt et al. remaining three individuals, latency cannot be assigned for exposure to 2,3,7,8-TCDD, DEATH CERTIFICATE DATA VS. PATHOLOGIC DIAGNOSES AND ICD CODING CATEGORIES Table 6 compares the diagnoses made by the attending pathologists with the information on the death certificates. Table 6. Comparison of death certificate data with original pathologic diagnoses for the seven U.S. workers. 1 Case Number Death Certificate 1 Malignant fibrous histiocytoma Malignant fibrous histiocytoma 2 Liposarcoma Liposarcoma 3 Pibrosarcoma Fibrosarcoma 4 Malignant fibrous histiocytoma Malignant fibrous histiocytoma 5 Carcinomatosis Myxoid neurogenic sarcoma Metastatic mesothelioma Fibrosarcoma consistent with fibrosarcomatous mesothelioma N.A.* Myxoid liposarcoma 7 * Not applicable. Original Pathology " Individual is alive, Of the six deceased cases, all of whom had hospital diagnoses of soft tissue sarcoma, only four had soft tissue sarcoma noted on their death certificates (Cases 1 to 4). A similar finding was noted in a study of the accuracy of death certificates conducted by Percy et al. in 1981 (13). They reviewed almost 50,000 hospital diagnoses and death certificates and found that of 252 soft tissue sarcomas diagnosed in hospital records, only 142 death certificates for those individuals (55%) reported the soft tissue sarcomas. Hence using �Review of Reported Soft Tissue Sarcoma Cases 195 death certificates as the primary source of cases may lead to underascertainment of cases. We found in our review that all four death certificates with notations of soft tissue sarcoma (Cases 1 to 4) belonged to persons who had diagnoses of soft tissue sarcoma made by the attending pathologists. In contrast, Percy (13) found in her large study that only 56% of death certificates with notation of soft tissue sarcoma were supported by hospital records with the diagnoses of soft tissue sarcoma. Hence using death certificates as the primary source of cases and not confirming hospital or pathologic information may lead to overascertainment. Researchers conducting epidemiologic studies should be fully aware of possible underascertainment or overascertainment. Table 7 illustrates another issue in the use of death certificate data: consistency in classification by nosologists, the experts who code cause of death from death certificates according to the rules of the International Classification of Disease System (14). Table 7. Comparison of death certificate information and nosologic coding of the information. Case Number 1 ICD Category* Original Honchar Publication** Review*** Death Certificate Malignant fibrous histiocytoma 173.9 171 * World Health Organization, Manual of the International Statistical Classification Diseases, injuries and Causes of Death, Geneva. Ninth Revision, 1975. ** Zack, J.A. and Suskind, R.S. 1980; 22:11-14. Journal of Occupational Medicine *** Honchar, P.A. and Halperin, W.E. Lancet 1981; i:26S-269. Case 1 was reported in the original publication as having a malignant fibrous histiocytoma, which was coded in ICD Category 173.9, "Other malignant neoplasm of skin, site unspecified". Honchar indicated in �196 Rngerhutfital. her review (3) that the choice of her nosologist was ICD 171, "Malignant neoplasm of connective and other soft tissue". Misclassification in ICD categories could introduce significant error. The data in Table 7 suggest that coding by more than one trained nosologist may be desirable. Another important issue of classification not addressed by this review has serious implications for studies of soft tissue sarcoma. The international Classification of Disease System is a site-oriented classification scheme. Therefore, sarcomas that develop in the parenchymatoas organs such as the uterus or stomach are coded into the ICD categories for the organ site. Only soft tissue sarcomas of the supporting tissue of the body not specified as arising in organs are coded in the ICD Category 171. It is possible, therefore, to select soft tissue sarcoma cases for case control studies in two ways. For the early Swedish studies (1,2) cases were selected by their histopathologic characteristics; approximately 60% of these cases are coded in categories other than ICD 171 (15). A current case control study in New Zealand (16) includes only soft tissue sarcoma cases coded as ICD 171. Such differences in study design must be recognized when evaluating results. The problem presented by the ICD dual classification scheme is slightly different for cohort mortality studies. It is possible to compare sarcomas coded as ICD 171 with those arising in the national population; however, we are not aware of population rates for soft tissue sarcoma coded into other ICD categories. ORIGINAL REPORT DATA VS. NEW REVIEW DATA Table 8 compares the original pathologic diagnoses for the seven individuals with the diagnoses selected in two independent pathologic reviews of tissue specimens. �Review of Reported Soft Tissue Sarcoma Cases 197 Table 8. Comparison of the original pathology reports with reports of two reviewers.* Original Pathology Case Number Review #1 Review #2 Malignant fibrous histiocytoma Malignant fibrous histiocytoma Malignant fibrous histiocytoma Invasive pleomorphic liposarcoma Poorly differentiated carcinoma Carcinoma, poorly differentiated Fibrosarcoma Clear cell carcinoma spindle cell with spindling, renal renal carcinoma 4 Malignant fibrous histiocytoma Malignant fibrous histiocytoma Malignant ' schwannoma 5 Myxoid neurogenic sarcoma Leiomyosarcoma Malignant fibroh ist iocy tomcux Malignant schwannoma Malignant schwannoma 6 Fibrosarcoma Liposarcoma Myxoid liposarcoma Myxoid . liposarcoma * The tissue specimens were reviewed by one of the authors (W.O.R.) and also by Franz M. Enzinger, M.D. and Sharon M. Weiss, M.D. of the Armed Forces Institute of Pathology, Washington, DC. Although all seven individuals received diagnoses of soft tissue sarcoma by the original pathologists, only five of the cases were diagnosed as soft tissue sarcoma in each of the two reviews. In both reviews Cases 2 and 3 were identified as carcinomas rather than sarcomas. These results indicate that review of tissue specimens by pathologists with expertise in diagnosing soft tissue sarcomas is necessary for epidemiologic studies. A difficult problem arises for cohort mortality studies because there is no comparison group for cases ascertained by expert pathologists. Rates of disease commonly used for comparison are those taken from compilations of population rates based on information from death certificates. The adequacy of diagnosis of histological subtypes of soft tissue sarcoma is another issue raised by the data in Table 8. Although the original pathologists and the reviewers all agreed that five individuals had soft tissue sarcomas, they agreed on the histological subtype for only two individuals, Cases 1 and 7. Even the expert �198 Ftagerhutetal. reviewers disagreed on subtype diagnoses for Cases 4 and 5. Because of the difficulties involved in diagnosing the histological subtypes, particularly when only a limited amount of tissue is available for review, we recommend that epidemiologic studies continue to focus on the outcome soft tissue sarcoma, and assess the distribution of subtypes only cautiously and with a recognition of the limitations involved. The next two tables summarize the exposure histories and the pathologic findings and compare them to the information published in the original reports. Table 9 presents data for the four production workers identified in company studies (6-10) as, 2,4,5-T/ or >• trichlorophenol-exposed workers. r •X Table 9. Comparison of original reports with results from this review for production workers identified by companies as TCP* or 2,4,5-T workers. Case Number Reported Exposure This Original Review Reoort Cause of death Original This Report Review 1 TCP TCP STS STS 2 2,4,5-T 2,4,5-T STS Carcinoma 3 TCP TCP STS Carcinoma 4 TCP TCP STS STS * Terms: TCP, trichlorophenol; 2,4,5-T, 2,4,5-trichlorophenoxyacetic acid; STS, soft tissue sarcoma. The reported exposures were confirmed by documentation that the four individuals had been assigned to 2,4,5-T or TCP processes. All had been reported as having soft tissue sarcomas, but we report that the two expert pathologists confirm that only two individuals (Cases 1 and 4) had soft tissue sarcomas. Both of these individuals worked in trichlorophenol processes, had diagnosed chloracne, and were present during incidents of unusual operating conditions with probable exposure to 2,3,7,8-TCDD. The histological subtype of malignant fibrous histiocytona was selected by all three pathologists for Case 1. Case 4 also received a diagnosis of malignant fibrous �Bevlew of Reported Soft Tissue Sarcoma Cases 199 histiocytoma from the original pathologist and one reviewer. The second reviewer identified the subtype as a neurogenic schwannoma. Table 10 presents the same comparison for the three individuals originally described in case reports by physicians (11,12). Table 10. Comparison of original reports with results from this review for production workers originally described as case reports by physicians. Case Number Reported Exposure Original This Report Review Pathologic Diagnosis Original This / Report Review 5 Possibly 2,4,5-T,* TCP None STS STS 6 Possibly chlorophenols None STS STS 7 Possibly chlorophenols PCP STS STS * Terms: 2,4,5-T, 2,4,5-trichlorophenoxyacetic acid; TCP, trichlorophenol; PCP, pentachlorophenol; STS, soft tissue sarcoma. Review of the tissue specimens for all three workers were confirmed that they had soft tissue sarcomas. Examination of the work history records of the individuals did not document assignment to 2,4,5-T or trichlorophenol departments. However, Case 7 worked briefly upon hire in a pentachlorophenol department. CONCLUSION Swedish research (1,2) has drawn attention to the issue of soft tissue sarcoma and dioxin exposure. While each of the original four U.S. studies (6-9) reported non-positive findings, a reanalysis (3) and further reports (10,11) strengthened the suspicion that an association might exist. Honchar (3) and Cook (10) called for detailed examination of the data. We present the detailed assessment of exposure history and pathologic diagnosis and report that of the four soft tissue sarcoma cases identified by death certificates among �200 Fingerhut et al. the TCP and 2,4,5-T workers, two are confirmed following pathologic review of tissues as soft tissue sarcoma. It Is not possible to use our data to draw a definitive conclusion regarding the suspected association because we are not aware of any population rates for soft tissue sarcoma based upon pathologic review of tissue specimens. Cases 5, 6 and 7 were originally described in.the literature as individual case reports. All three are confirmed as cases of soft tissue sarcoma. Our review of their work histories did not find any record of assignment to 2,4,5-T or trichlorophenol departments, although Case 7 worked briefly in a pentachlorogfhenol department/ a product contaminated with isomers of dioxin considered to be less toxic than 2,3,7,8-TCDD. Although these workers do not meet our , stringent criterion of exposure by virtue of assignment 'to a 2,4,5-T or TCP department, we cannot exclude the possibility that they had undocumented contact with 2,4,5-T or TCP. This review examines the complexities in evaluating the dioxin exposure of individuals and the pathologic diagnoses of soft tissue sarcoma. It emphasizes the need for carefully-designed large epidemiologic studies to adequately assess whether there is an association of soft tissue sarcoma with exposure to dioxincontaminated products. We have shown that the use of the death certificate, even with the original pathologic diagnosis may lead to overascertainment or underascertainment of cases of soft tissue sarcoma. Finally, we reassert that further research, particularly the completion of National Institute for Occupational Safety and Health studies based upon approximately 6,000 U.S. workers, is necessary to confirm or refute the association first suggested in the Swedish studies. ABSTRACT We have reviewed medical and exposure records and pathology specimens of seven U.S. chemical workers reported in the.literature to be cases of soft tissue sarcoma (STS) and to have had dioxin exposure. The cases were of interest because two Swedish studies demonstrated a strong association between STS and dioxin exposure. �Review of Reported Soft Tissue Sarcoma Cases 201 Four U.S. workers from four small mortality cohorts had been reported to have died of soft tissue sarcoma. We found that these individuals had employment records of assignment to production of TCP and 2,4,5-T which are contaminated with the most toxic dioxin isomer, 2,3,7,8-tetrachlorodibenzo-p-dioxin (2,3 ,1,8-TCDD), but pathologic review of their tissue indicates that only two are cases of soft tissue sarcoma. Three additional individuals had been described by physicians as case reports. They are confirmed as cases of soft tissue sarcoma, but we did not find any record of assignment to these production departments. One person worked briefly in the production of pentachlorophenol, which is contaminated with other isomers of. i ' dioxin. We suggest that identification of cases of STS through either .death certificates alone or through pathology records can lead to errors of ascertainment. We reassert that further research, particularly the completion of studies by the National Institute for Occupational Safety and Health based upon approximately 6,000 U.S. workers, is necessary to confirm or refute the association first suggested in the Swedish studies. �202 Fingerhut et al. REFERENCES 1. Hardell, L. and Sandstrom, A. Case-Control Study: Soft-Tissue Sarcomas and Exposure to Phenoxyacetic Acids or Chlorophenols. British Journal of Cancer 1979; 39:711-717. 2. Eriksson, FT., Berg, N., Hardell, L., Moller, T. and Alexson, o. Soft-Tissue Sarcomas and Exposure to Chemical Substances: A Case-Referent Study. British Journal of Industrial Medicine 1981; 38:27-33. 3. Honchar, P.A., and Halperin, W.E. 2,4 ,5-Trichloropl^enol and £oft Tissue Sarcoma. Lancet 1981; i:268-269. 4. Suit, H.D. Sarcoma of Soft Tissue. Clinicians 1978; 28:284-295. 5. Russell, W.o. et al. CA-A Cancer Journal for- A Clinical and Pathological Staging System for Soft Tissue Sarcomas. Cancer 1977; 40:1562-1570. 6. Zack, J.A. and Suskind, R.S. The Mortality Experience of Workers Exposed to Tetrachlorodibenzodioxin in a Trichlorophenol Process, journal of Occupational Medicine 1980; 22:11-14. 7. ott, M.G., Holder, B.B. and Olson, R.D. A Mortality Analysis of Employees Engaged in the Manufacture of 2,4,5-Trichlorophenoxyacetic Acid. Journal of Occupational Medicine 1980; 22:47-50. 8. Cook, R.R., Townsend, J.C. and Ott, M.G. Mortality Experience of Employees Exposed to 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD). Journal of Occupational Medicine 1980; 22:530-532. 9. Zack., J.A. and Gaffey, W.R. A Mortality Study of Workers Employed at The Monsanto Company plant in Nitro, West Virginia. Environmental Science Research 1983; 26:575-591. �Review of Reported Soft Tissue Sarcoma Cases 10. Cook, R.R. Dioxin, Chloracne and Soft Tissue Sarcoma. 203 Lancet 1981; 1:618-619. 11. Moses, M. and Selikoff, I.J. Soft Tissue Sarcomas, Phenoxy Herbicides and Chlorinated Phenols. Lancet 1981; i:1370. 12. Johnson, P.E., Kugler, N.A. and Brown, s.M. and Chlorinated Phenols. Soft Tissue Sarcomas Lancet 1981; i:40. 13. Percy, C., Stanek, E. and Gloeckler, L. Accuracy of Cancer Death Certificates and Its Effect on Cancer Mortality Statistics. American Journal of Public Health 1981; 71:242-250'. 14. World Health Organization, Manual of the International Statistical _ . „ __ _ B ^ « _ ^ « _ ~ w ^ _ B v w ^ _ ^ ___ —.^^—^^^ff^—i- Classification of Diseases, Injuries and Causes of Death (1975) Ninth Revision. Geneva, 1977. 15. Summarized from Exhibit 1299, prepared by L. Hardell for the U.S. Environmental Protection Agency, October 24, 1979. 16. Smith, A.H. et al. Do Agricultural Chemicals Cause Soft Tissue Sarcoma? initial Findings of a Case Control Study in New Zealand. Community Health Studies 1982; 6:114-119. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 066 Folder The folder containing the original item. 1764 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Fingerhut, Marilyn A. William E. Halperin Patricia A. Honchar Alexander B. Smith David H. Groth William O. Russell Date A point or period of time associated with an event in the lifecycle of the resource 1984 Title A name given to the resource Review of Exposure and Pathology Data for Seven Cases Reported as Soft Tissue Sarcoma Among Persons Occupationally Exposed to Dioxin-Contaminated Herbicides Subject The topic of the resource Sweden industrial exposure cancer risk assessment ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 065 Folder The folder containing the original item. 1760 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Hobson, Lawrence B. Description An account of the resource <strong>Corporate Author: </strong>Agent Orange Projects Office, VA Title A name given to the resource Epidemiology of Soft-Tissue Sarcoma and Related Human Research (as related to herbicide exposure) Subject The topic of the resource soft tissue sarcoma Sweden ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 036 Folder The folder containing the original item. 0755 Series The series number of the original item. Series III Subseries I Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Hobson, Lawrence B. Description An account of the resource <strong>Corporate Author: </strong>Agent Orange Projects Office, VA Date A point or period of time associated with an event in the lifecycle of the resource March 5 1983 Title A name given to the resource Epidemiology of Soft-tissue Sarcoma and Related Human Research (as related to herbicide exposure) Subject The topic of the resource soft tissue sarcoma Sweden ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 028 Folder The folder containing the original item. 0439 Series The series number of the original item. Series III Subseries I Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Source A related resource from which the described resource is derived The Lancet Date A point or period of time associated with an event in the lifecycle of the resource May 8 1982 Title A name given to the resource Phenoxy Herbicides, Trichlorophenols, and Soft-tissue Sarcomas Subject The topic of the resource soft tissue sarcoma Sweden industrial exposure cancer risk assessment ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 027 Folder The folder containing the original item. 0397 Series The series number of the original item. Series III Subseries I Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Source A related resource from which the described resource is derived BioScience Date A point or period of time associated with an event in the lifecycle of the resource 1978-10-01 Title A name given to the resource Biology Briefs: 2,4,5-T Called Safe Subject The topic of the resource CAST Sweden herbicide regulation Great Britain ao_seriesIII