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UNLABELLED Study Type - Therapy (case series). Level of Evidence 4. What's known on the subject? and What does the study add? Mesothelioma of the tunica vaginalis testis is a rare tumour. From 2000 to 2010, 13 mesothelioma of the tunica vaginalis testis cases were reported in the most populated and industrialized region in Italy. Asbestos exposure was documented in two-thirds of these cases. OBJECTIVE • To describe cases of mesothelioma of the tunica vaginalis testis (MTVT) recorded in the Lombardy Mesothelioma Registry between 2000 and 2010. METHODS • The Lombardy Mesothelioma Registry, established in 2000, collects data regarding all incident cases of mesothelioma of the pleura, peritoneum, pericardium and tunica vaginalis testis that have been diagnosed in the population of the Lombardy region. • These data include a detailed clinical report and a complete occupational history for each MTVT patient, with the latter including details of the industrial sector involved, the patient's job, and the specific tasks performed. To address the potential for asbestos exposure outside the work environment, the residential history, lifestyle habits and hobbies of the patient, as well as job information for all subjects living with the patient, are also collected. • Records were reviewed and discussed by a panel of experts. RESULTS • Thirteen cases of MTVT were reported between 2000 and 2010. • The age-standardized incidence rate of MTVT for the Lombardy region of Italy is 0.2 cases per million individuals/year. • Asbestos exposure was documented in 8 of the 12 (67%) interviewed cases. CONCLUSIONS • Asbestos exposure was associated with a higher proportion of MTVT cases than previously reported in the literature. These results confirm the aetiological role for asbestos in the pathogenesis of MTVT. • The results of this study also highlight the importance of obtaining detailed occupational histories and lifestyle habits from patients, particularly by trained interviewers.

Pericardial mesothelioma (PM) accounts for 0.7% of all malignant mesotheliomas. Although asbestos exposure is a recognized etiological factor for pleural and peritoneal mesotheliomas, its role in the development of PM is controversial. The aim of this study is to describe the characteristics of PM cases occurred in Lombardy, a highly industrialized Region of Northern Italy. From the Lombardy Mesothelioma Registry we selected the incident cases of PM registered in the Lombardy Region between 2000 and 2009 and we abstracted clinical characteristics and history of asbestos exposure. We identified 8 cases (6 men and 2 women), with a median age at diagnosis of 55.5 years, representing 0.3% of all mesothelioma cases (n = 3059). The age-standardized incidence rate was 0.09 per million/year. Occupational exposure to asbestos was documented in 5 of the 7 cases for which we obtained an interview. Our findings support the role of asbestos in the pathogenesis of PM.

We read the interesting Review Article by Slootweg et al. [1] recently published in this Journal. We concur on the importance of an accurate morphology definition of sinonasal cancers (SNC), which is crucial not only for therapeutic decisions but also from the etiologic point of view. In fact, sinonasal carcinomas are strongly associated with occupational exposures, in particular wood and leather dusts and nickel compounds [2]. In Italy since 2008 incidence and etiology of primary epithelial tumors of nasal cavity and paranasal sinuses are surveyed through a nationwide cancer registry. The Lombardy Registry of Sinonasal Cancers was established at the end of 2007 in the most populated (almost 10 million residents at the 2011 census) and industrialized Italian region [3]. It collects all epithelial SNC cases occurring among residents in the region at the time of first diagnosis. The primary sources of information on SNC cases are the departments of pathology, otolaryngology, maxillofacial surgery, and radiotherapy in over 100 hospitals. Histological types are defined according to the World Health Organization (WHO) Classification [4]. Occupational exposure to selected agents is collected through a standardized questionnaire administered to patients or their next of kins by trained interviewers. In the period 2008–2012 we recorded 255 SNC cases with median age at diagnosis of 68 years, 167 (65.5 %) among males, and 88 (34.5 %) among females. Using the European population as standard, the SNC incidence rates (9million) are 6.8 (95 % CI 5.7–8.2) in men and 2.6 (95 % CI 1.9–3.4) in women. The anatomical site mostly affected was the nasal cavity, with 54 cases in males (32.3 %) and 32 (36.4 %) in females, followed by the maxillary sinus, 35 cases (21.0 %) in males and 25 (28.4 %) in females. The ethmoidal sinus was rarely involved in females (7 cases, 8.0 %) while there were 37 cases (22.2 %) in males. The most frequent morphology was squamous cell carcinoma, with a similar distribution across gender, 73 cases (43.7 %) in males and 41 (46.6 %) in females. Conversely, adenocarcinomas were twice as frequent in men (53 cases, 31.7 %) than in women (13 cases, 14.8 %). The majority of adenocarcinomas were intestinal-type adenocarcinomas (ITAC), 37 (22.2 %) in men and 8 (9.1 %) in women. There was a strong association between anatomical site and morphology. Out of 114 squamous cell carcinomas, 52 (45.6 %) originated from the nasal cavity, while among 66 adenocarcinoma cases 27 (40.9 %) were located in the ethmoidal sinus. The higher rates in men and the different distribution of SNC site and morphology between men and women most probably reflect differences in previous exposure to carcinogens. In fact, among the 66 subjects with adenocarcinoma, occupational exposure was recorded for the majority (50, or 75.8 %). Of these, 33 (50 %) had been ever exposed to wood dust and 19 (28.8 %) to leather dust. Conversely, the proportion of subjects ever exposed was about 10 % for squamous cell carcinoma and about 20 % for other morphologies. Although lower, the proportion of subjects with squamous cell carcinoma or other C. Mensi (&) L. Riboldi C. Sieno P. A. Bertazzi D. Consonni Department of Preventive Medicine, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Via San Barnaba 8, 20122 Milan, Italy e-mail: carolina.mensi@unimi.it

We examined occupational exposures among subjects with sinonasal cancer (SNC) recorded in a population-based registry in the Lombardy Region, the most populated and industrialized Italian region. The registry collects complete clinical information and exposure to carcinogens regarding all SNC cases occurring in the population of the region. In the period 2008–2011, we recorded 210 SNC cases (137 men, 73 women). The most frequent occupational exposures were to wood (44 cases, 21.0%) and leather dust (29 cases, 13.8%), especially among men: 39 cases (28.5%) to wood and 23 cases (16.8%) to leather dust. Exposure to other agents was infrequent (

The sinonasal cancer (SNC) are a rare tumors characterized by high occupational etiologic fraction. For this reason their incidence and etiology can be actively monitored by a dedicated cancer registry. The National Registry of these tumours is situated at the Italian Institute for Occupational Safety and Prevention (ISPESL) and is based on Regional Operating Centres (ROCs). In Lombardy Region the ROC has been established at the end of 2007 with the purpose to make a systematic surveillance and therefore to support in the most suitable way the scientific research and the prevention actions in the high risk working sectors. The aims of this surveillance are: to estimate the regional incidence of SNC, to define different sources of occupational and environmental exposure both known (wood, leather, nickel, chromium) and unknown. The registry collects all the new incident cases of epithelial SNC occurring in residents in Lombardy Region since 01.01.2008. The regional Registry is managed according to National Guidelines. Until January 2010 we received 596 cases of suspected SNC; only 91 (15%) of these were actually incident cases according to the inclusion criteria of the Registry, and they were preferentially adenocarcinoma and squamous carcinoma. In 2008 the regional age-standardized incidence rate of SNC for males and females, respectively, is 0.8 and 0.5 per 100,000. Occupational or environmental exposure to wood or leather dust is ascertained in over the 50% of cases. The occupational exposure to leather dust was duo to work in shoe factories. Our preliminary findings confirm that occupational exposure to wood and leather dusts are the more relevant risk factors for SNC. The study of occupational sectors and job activity in cases without such exposure could suggest new etiologic hypothesis.

Study Type - Therapy (case series). Level of Evidence 4. What's known on the subject? and What does the study add? Mesothelioma of the tunica vaginalis testis is a rare tumour. From 2000 to 2010, 13 mesothelioma of the tunica vaginalis testis cases were reported in the most populated and industrialized region in Italy. Asbestos exposure was documented in two-thirds of these cases.• To describe cases of mesothelioma of the tunica vaginalis testis (MTVT) recorded in the Lombardy Mesothelioma Registry between 2000 and 2010.• The Lombardy Mesothelioma Registry, established in 2000, collects data regarding all incident cases of mesothelioma of the pleura, peritoneum, pericardium and tunica vaginalis testis that have been diagnosed in the population of the Lombardy region. • These data include a detailed clinical report and a complete occupational history for each MTVT patient, with the latter including details of the industrial sector involved, the patient's job, and the specific tasks performed. To address the potential for asbestos exposure outside the work environment, the residential history, lifestyle habits and hobbies of the patient, as well as job information for all subjects living with the patient, are also collected. • Records were reviewed and discussed by a panel of experts.• Thirteen cases of MTVT were reported between 2000 and 2010. • The age-standardized incidence rate of MTVT for the Lombardy region of Italy is 0.2 cases per million individuals/year. • Asbestos exposure was documented in 8 of the 12 (67%) interviewed cases.• Asbestos exposure was associated with a higher proportion of MTVT cases than previously reported in the literature. These results confirm the aetiological role for asbestos in the pathogenesis of MTVT. • The results of this study also highlight the importance of obtaining detailed occupational histories and lifestyle habits from patients, particularly by trained interviewers.

Objectives The Lombardy Mesothelioma Registry (RML) was established in 2000 in the most populated (9 100 000 residents) and industrialised region of Italy. We evaluated the trend of malignant mesothelioma (MM) in 2000-07 and the sources of asbestos exposure collected from the patient/next-of-kin by a standardised questionnaire. Methods We calculated age-standardised rates (standard: Europe) and analysed the number of cases/year using Poisson regression. We evaluated asbestos exposure profile (occupational, non-occupational, unlikely/unknown) using multinomial logistic regression. Results We recorded 2462 verified MM cases (1574 men, 888 women). The age-standardised rates (×100 000/year) were 3.6 (men) and 1.4 (women). In both genders, we found a 3.0% increase of MM cases/year (p=0.001). Interview was obtained in 2333 cases (94.7%) and directly from patients in 1282. Occupational exposure was found for 1124 (71.4%) men and 322 (36.3%) women. Non-occupational asbestos exposure was more frequent among women (No. 118, 13.3%) than in men (No. 51, 3.2%). We did not find evidence of exposure to asbestos in 399 men (25.3%) and 448 women (50.4%). The exposure profile did not vary over years (p=0.49). Direct interviews were more likely to identify asbestos exposure (p Conclusions The MM burden in Lombardy (among the highest in Italy), are increasing. This increase is real and not due to ascertainment bias. Asbestos exposure was mainly occupational and more frequent among men; we found no variation of the exposure profiles over time. This work was supported by Regione Lombardia Conv. 14013/RU01/06/2010

The LMR collects all in-cident cases of malignant mesothelioma of thepleura, peritoneum, pericardium, and tunica vagi-nalis of testis that have been diagnosed in peopleresiding in the Lombardy region (a region with anestimated total population of 9.1 million) in thenorth of Italy.Cases are actively reported to the LMR by themain services including pathology, pneumology,surgery, and oncology departments of each re-gional hospital. For each case the disease his-tory, radiological and histological reports, andclinical records were collected. Asbestos expo-sure history was obtained from patients (or his/her next to kin) through a standardized ques-tionnaire administered by trained interviewers.All records were reviewed by a panel composedof a pneumologist, oncologist, pathologist, oc-cupational health physician, industrial hygienistand epidemiologist.