Chimney sweeps' carcinoma

Chimney sweeps' cancer, also called soot wart or scrotal cancer, is a

In 1922, R.D. Passey, a research physician at Guy's Hospital in London produced malignant skin tumors in mice exposed to an extract made from soot, demonstrating the presence of carcinogenic substances in soot which were the likely cause of cancer of the scrotum in chimney sweeps.^[5][7]

In the 1930s,

The initial lesion is small and painless. It is often described as an itchy sore, wart, or pimple. Often times it may bleed due to scratching.[8]

Socio-historical context

A housing tax, created during the 17th century in England, limited the number of fireplaces per house.^[9] To avoid this tax several chimney pipes would be connected to a single fireplace, resulting in angled pipes.^[9] The odd chimney structures resulted in complex mechanical cleaning methods.^[9] As a result, it was not uncommon for young boys to be hired as chimney sweeps in England in the 1700s and 1800s. Typically, those hired were orphans or children from poor families.^[10] Young children, between the ages 5 and 11, were often hired for their ability to fit through the narrow chimney chutes.

Chimney sweeping was a common practice across Europe and North America.^[10] The disease was mostly found in the United Kingdom, where climbing boys were used. The most likely reason for the high prevalence of the disease in the UK was that chimney chutes were narrower.^[10] Another reason can be attributed to poor hygiene standards in the 18th century: during this time, hygiene standards were lacking and bathing once a year was not uncommon.^[10] Families often shared sleeping blankets and these blankets were often the ones used by the chimney sweeper to collect soot, resulting in further repeated soot exposure.^[9] It was also not uncommon for children to work naked. The lack in hygiene standards coupled with working naked allowed for repeated skin exposure to toxins in chimney soot, a possible cause for this disease.^[10]

In the United States, enslaved black children were hired from their owners and used in the same way, and were still climbing after 1875.^[11]

Sir Percivall Pott

It is a disease which always makes it first attack on the inferior part of the scrotum where it produces a superficial, painful ragged ill-looking sore with hard rising edges.....in no great length of time it pervades the skin, dartos and the membranes of the scrotum, and seizes the testicle, which it inlarges [sic], hardens and renders truly and thoroughly distempered. Whence it makes its way up the spermatic process into the abdomen.^[13]

He comments on the life of the boys:

The fate of these people seems peculiarly hard … they are treated with great brutality … they are thrust up narrow and sometimes hot chimnies [sic], where they are bruised burned and almost suffocated; and when they get to puberty they become … liable to a most noisome, painful and fatal disease.

The suspected carcinogen was coal tar, and possibly arsenic.^[14][15]

Diagnosis

Diagnosis of scrotal carcinoma is by biopsy of the scrotal lesion.^[2] There are several different tests involved in staging, including MRI of the scrotum and abdominopelviscrotal ultrasound.^[2] Ray and Whitmore proposed a staging system based on the level of metastasis.^[16] It is the most commonly used system.

There are four stages of the cancer, listed as Stage A through to Stage D.^[2] Under Stage A there are two substages, Stage A1 and Stage A2.^[2] Stage A1 is when the disease is localized in the scrotum.^[2] Stage A2 is when the disease moves to surrounding areas, including the penis, testis, pubic bone, and perineum.^[2] During Stage B, the disease metastasizes regionally.^[2] At this point in the disease, the cancer and/or tumor is resectable.^[2] At Stage C, the disease further metastasizes, however, at this point is it no longer resectable.^[2] Distant metastasis occurs during Stage D of the disease. At this point, it moves past the regional nodes, which is rare.^[2]

Prognosis

Chimney sweeps' carcinoma prognosis depends heavily upon the presence or absence of lymph node involvement.^[2] Removing the tumor during initial surgery is a leading factor in prognosis.^[2]

Survival rate is based upon spread to lymph nodes. There is an about 25% 5-year survival rate in cases in which the inguinal lymph nodes are involved.^[2] There is no survival rate if external iliac lymph nodes are involved.^[2]

Treatment

Treatment was by surgery.^[17] More specifically, wide excision with a 2-3cm margin.^[2] It is also recommended that the surrounding subcutaneous tissue is removed with the tumor itself.^[2] Scrotal contents are usually only removed if involved through the tumor.^[2] Radiation therapy and chemotherapy can also be considered.^[16]

Prevention

Incidence of chimney sweeps' carcinoma was reduced when protective work clothes were introduced.

However, these laws were typically ignored due to lack of enforcement strategies.^[10] In 1863, the Children's Employment Commission evaluated child employment to ensure the Acts set in place were followed.^[9] Their report showed that child employment even had increased since the introduction of the Act of 1840.^[9]

Related diseases

Decades later, it was noticed to occur amongst gas plant and