The Medical Journal of Basra University 2002 Abstract: Mesotheliomas are rare tumours. While the benign type is curable by surgery, the malignant forms are difficult to diagnose and treat with a bad prognosis even with modern multimodality treatment. Herein we report four cases of mesothelioma in Iraqi housewives (3 pleural and one pericardial). The diagnosis and treatment of these cases are discussed with review of literature. The primary pericardial mesothelioma has presented as cardiac tamponade. Such presentation was reported only once before in the literature. The three cases of pleural mesotheliomas represented all types i.e., the localized benign, localized malignant and the diffuse malignant. Although exposure to asbestos is reported in 72 -95% of the malignant varieties; none of our patients had such an exposure.

1. 3/(85$/$1'3(5,$5',$/0(627+(/,20$
$ 5(32572)$6(6
%
'U$EGXOVDODP7DKD
$%675$7
0HVRWKHOLRPDV DUH UDUH WXPRXUV :KLOH WKH EHQLJQ WSH LV FXUDEOH E VXUJHU WKH PDOLJQDQW
IRUPVDUHGLIILFXOWWRGLDJQRVHDQGWUHDWZLWKDEDGSURJQRVLVHYHQZLWKPRGHUQPXOWLPRGDOLW
WUHDWPHQW+HUHLQZHUHSRUWIRXUFDVHVRIPHVRWKHOLRPDLQ,UDTLKRXVHZLYHVSOHXUDODQGRQH
SHULFDUGLDO

2. 7KHGLDJQRVLVDQGWUHDWPHQWRIWKHVHFDVHVDUHGLVFXVVHGZLWKUHYLHZRIOLWHUDWXUH7KH
SULPDU SHULFDUGLDO PHVRWKHOLRPD KDV SUHVHQWHG DV FDUGLDF WDPSRQDGH 6XFK SUHVHQWDWLRQ ZDV
UHSRUWHGRQORQFHEHIRUHLQWKHOLWHUDWXUH7KHWKUHHFDVHVRISOHXUDOPHVRWKHOLRPDVUHSUHVHQWHGDOO
WSHVLHWKHORFDOL]HGEHQLJQORFDOL]HGPDOLJQDQWDQGWKHGLIIXVHPDOLJQDQW$OWKRXJKH[SRVXUHWR
DVEHVWRV LV UHSRUWHG LQ RI WKH PDOLJQDQW YDULHWLHV QRQH RI RXU SDWLHQWV KDG VXFK DQ
H[SRVXUH
,QWURGXFWLRQ
3ULPDUSOHXUDOQHRSODVPVDUHUDUHFRPSDUHGZLWKPHWDVWDWLFOHVLRQV0HVRWKHOLRPDVDULVHIURP
PHVRWKHOLDOFHOOVWKDWOLQHWKHSOHXUDOSHULWRQHDODQGSHULFDUGLDOFDYLWLHV

3. OLQLFDOOWKHUHDUHWZR
IRUPVRIPHVRWKHOLRPDORFDOL]HGDQGGLIIXVHOVSUHDGLQJ$OPRVWDOOGLIIXVHPHVRWKHOLRPDVDUH
PDOLJQDQWZKLOHPRVWORFDOL]HGIRUPVDUHEHQLJQ

4. ([SRVXUHWRDVEHVWRVLVUHSRUWHGLQRI
PDOLJQDQWPHVRWKHOLRPD

5. 7KHEHQLJQSOHXUDOPHVRWKHOLRPDLVFXUDEOHEVXUJHUKRZHYHUWKH
PDOLJQDQW IRUPV DUH GLIILFXOW WR GLDJQRVH DQG WUHDW ZLWK D EDG SURJQRVLV HYHQ ZLWK PRGHUQ
PXOWLPRGDOLW WUHDWPHQW

6. 3ULPDU SHULFDUGLDO PHVRWKHOLRPD LV D YHU UDUH WXPRXU

7. DUGLDFWDPSRQDGHDVLWVLQLWLDOPDQLIHVWDWLRQKDVEHHQUHSRUWHGRQORQFHEHIRUHLQWKHPHGLFDO
OLWHUDWXUH

8. +HUHLQZHUHSRUWIRXUFDVHVRIPHVRWKHOLRPDLQKRXVHZLYHVIURPWKHVRXWKRI,UDT
RQH SHULFDUGLDO DQG WKUHH SOHXUDO UHSUHVHQWLQJ DOO WSHV LH WKH ORFDOL]HG EHQLJQ ORFDOL]HG
PDOLJQDQWDQGWKHGLIIXVHPDOLJQDQW

9. 7KHSDWLHQWVZHUHPDQDJHGLQWKH6HFWLRQRIDUGLRWKRUDFLF
DQG 9DVFXODU 6XUJHU RI %DVUDK 7HDFKLQJ +RVSLWDO LQ WKH HDU 7KH SUH LQWUD DQG
SRVWRSHUDWLYHILQGLQJVLQWKHVHFDVHVDUHFRPSDUHGZLWKRWKHUUHSRUWVLQWKHOLWHUDWXUH
DVHORFDOL]HGEHQLJQSOHXUDOPHVRWKHOLRPD

10. $HDUROGQRQVPRNHUKRXVHZLIHIURP%DVUDK4XUQDSUHVHQWHGZLWKOHIWVLGHGFKHVWSDLQ
IRU GDV6KHORRNHGZHOOKHVWH[DPLQDWLRQZDVQRUPDO7KHSXOVHZDVUHJXODUZLWKIUHTXHQW
YHQWULFXODUHFWRSLFEHDWV+E JGO(65 PPKU7KHIURQWDOFKHVWUDGLRJUDSKVKRZHGD
ZHOOGHILQHGURXQGHGKRPRJHQRXVRSDFLWQHDUWKHOHIWFDUGLDFERUGHU)LJ

11. 7KHODWHUDOYLHZ)LJ

12. VKRZHGWKHRSDFLWLQWKHOLQJXOD7KHLQLWLDOLPSUHVVLRQZDVSXOPRQDUKGDWLGFVW(*ZDV
QRUPDODSDUWIURPYHQWULFXODUHFWRSLFEHDWV(FKRFDUGLRJUDSKUHSRUWHGDELJFVWLFPDVVVHSDUDWH
IURPEXWFORVHWRWKHKHDUW)LEHURSWLFEURQFKRVFRSZDVSHUIRUPHGWZLFH7KHILUVWEURQFKRVFRS
ZDVQRUPDO6KHGHYHORSHGPLOGKDHPRSWVLVZKLOHZDLWLQJIRUVXUJHUWKXVEURQFKRVFRSZDV
UHSHDWHGDQGUHYHDOHGDVWUHDNRIDQROGEORRGFRPLQJIURP/8/SURSHUEURQFKXV7KHSDWLHQW
XQGHUZHQWDQH[SORUDWRUOHIWWKRUDFRWRPIRUOHIWOXQJPDVVDVVRFLDWHGZLWKKDHPRSWVLV

13. 7KH
OXQJZDVFRPSOHWHOQRUPDODSDUWIURPELJURXQGHGVROLGPDVV[FP)LJ

14. DWWDFKHGEDYHU
ILQHSHGLFOHWRWKHYLVFHUDOSOHXUDRI/8/7KHUHZHUHPDQSURPLQHQWEORRGYHVVHOVRQLWVVXUIDFH
7KH PDVV ZDV UHVHFWHG HDVLO E OLJDWLRQ DQG GLYLVLRQ RI LWV SHGLFOH 7KHUH ZDV QR REYLRXV
SXOPRQDU OHVLRQ 7KH ELRSV UHVXOW ZDV D ORFDOL]HG EHQLJQ PHVRWKHOLRPD 7KH SDWLHQW LV LQ D
SHUIHFWKHDOWKPRQWKVDIWHUVXUJHU)LJ

15. VKRZVWKHSRVWRSHUDWLYHFKHVWILOP)LJ

16. LVWKH
SRVWRSHUDWLYHSDWLHQWV SKRWRJUDSK
DVHORFDOL]HGPDOLJQDQWPHVRWKHOLRPD

17. $HDUROGIHPDOHIURP%DVUDK.DUPDQRQVPRNHUKDVEHHQUHIHUUHGWRXVDVDFDVHRI
FRPSOLFDWHGSXOPRQDUKGDWLGFVW

18. 6KHFRPSODLQHGRIVHYHUHULJKWVLGHGFKHVWSDLQEXWQR
EURQFKLDOVPSWRPVOLNHFRXJKRUH[SHFWRUDWLRQ2QH[DPLQDWLRQVKHORRNHGLOOVOLJKWOSDOHDQG
ZDVLQSDLQ+E JGO(65 PPKU)URQWDOFKHVWUDGLRJUDSK)LJ

19. VKRZHGDELJURXQGHG
KRPRJHQRXVRSDFLWLQULJKWORZHUSXOPRQDU]RQHZLWKDVPRRWKFRQYH[XSSHUERUGHUEHVLGH
REOLWHUDWHGULJKWFRVWRSKUHQLFDQJOHVXJJHVWLYHRISOHXUDOHIIXVLRQ7KHODWHUDOYLHZ)LJ

20. ORFDWHG
WKH RSDFLWWRWKHUHJLRQRIWKHPLGGOHOREHKHVWVRQRJUDSKUHYHDOHGDFRPSOH[PDVVWKRXJKWWR
EH DFRPSOLFDWHGKGDWLGFVW$EGRPLQDOXOWUDVRQRJUDSKUHYHDOHGDQRUPDOOLYHUZLWKQRVSDFH
RFFXSLQJ OHVLRQ )LEHU RSWLF EURQFKRVFRS ZDV QRUPDO 7KH SDWLHQW ZDV H[SORUHG YLD ULJKW
WKRUDFRWRP ZLWK VXVSLFLRQ RI D PDVV LQ WKH PLGGOH OREH 2Q RSHQLQJ WKH FKHVW WKHUH ZDV D
KDHPRWKRUD[RIPRGHUDWHTXDQWLWDQGDZHOOGHILQHGVROLGURXQGHGPDVV[FP)LJ

21. DQG
)LJ

22. DWWDFKHGWRWKHFKHVWZDOODQWHULRUODULVLQJIURPWKHSDULHWDOSOHXUDEDZLGHEDVHLH
VHVVLOH7KHOXQJZDVFRPSUHVVHGEWKHWXPRXUEXWRWKHUZLVHQRUPDO7KHVXUIDFHRIWKHPDVV
FRQWDLQHGPDQELJEORRGYHVVHOV7KHEORRGZDVVXFNHG7KHPDVVZDVUHVHFWHGHDVLOWKHUHZDV
QR LQYDVLRQ RI FKHVW ZDOO 7KH SDWLHQW KDG D VPRRWK SRVWRSHUDWLYH FRXUVH )LJ

23. VKRZV WKH
SRVWRSHUDWLYH FKHVW UDGLRJUDSK 7KH FKHVW SDLQ GLVDSSHDUHG 7KH ELRSV UHVXOW ZDV ORFDOL]HG
PDOLJQDQWPHVRWKHOLRPD7KHSDWLHQWZDVVXEMHFWHGWRGHHS[UDWKHUDS6KHZDVVHHQPRQWKV
SRVWRSHUDWLYHOLQDYHUJRRGKHDOWKEXWVKHGHYHORSHGHYLGHQFHRIUHFXUUHQFHODWHURQLHFKHVW
SDLQZLWKDSXOPRQDULQILOWUDWHWKHUHIRUHVKHZDVJLYHQFKHPRWKHUDSHXWLFGUXJV
DVHGLIIXVHPDOLJQDQWSOHXUDOPHVRWKHOLRPD

24. $ QRQVPRNHUODGHDUROGIURP2PDUDSUHVHQWHGZLWKH[HUVLRQDOGVSQRHDULJKWVLGHG
FKHVWSDLQDQGGUFRXJKIRUPRQWKV6KHKDGKLVWRURIULJKWVLGHGSOHXUDOHIIXVLRQRQHHDU
HDUOLHUZKLFKZDVGUDLQHGEDWXEHWKRUDFRVWRPDQGFRQVLGHUHGWXEHUFXORXVRQODERUDWRUDQG
FOLQLFDOJURXQGVLHVHURXVIOXLGZLWKKLJKOPSKRFWHFRXQW6KHKDGUHFHLYHGDIXOOFRXUVHRI
DQWLWXEHUFXORXVGUXJVEXWVKHZDVORVWIRUIROORZXS6KHKDGGXOOQHVVWRSHUFXVVLRQDQGUHGXFHG
LQWHQVLWRIQRUPDOYHVLFXODUEUHDWKVRXQGVRQULJKWFKHVW7KHWUDFKHDZDVFHQWUDO7KHILQJHUV
ZHUHQRWFOXEEHG(65 PPKUKHVWUDGLRJUDSKILJ

25. VKRZHGKHWHURJHQHRXVRSDFLILFDWLRQ
RI ULJKW OXQJ ZLWK SOHXUDOEDVHG URXQGHG PDVVHV 7KRUDFHQWHVLV ZDV QHJDWLYH )LEHU RSWLF
EURQFKRVFRSUHYHDOHGVHYHUHVWHQRVLVRIEURQFKXVLQWHUPHGLXV%URQFKLDOZDVKDQGEUXVKFWRORJ
ZDVQHJDWLYHIRUPDOLJQDQF05,VXJJHVWHGDSOHXUDOWXPRXULQYROYLQJWKHOXQJ([SORUDWRUULJKW
WKRUDFRWRPYLDWKHWKVSDFHUHYHDOHGWKLFNHQHGDGKHUHQWSDULHWDODQGYLVFHUDOSOHXUDHZLWKKDUG
URXQGHG PDVVHVLQYDGLQJWKHOXQJ7ZRSLHFHVRISOHXUDZHUHELRSVLHGVKRZLQJGLIIXVHPDOLJQDQW
PHVRWKHOLRPD7KHSDWLHQWUHFHLYHGUDGLRDQGFKHPRWKHUDS7KHSDWLHQWLVVHHQIHZPRQWKVODWHU
ZLWK VLJQVRIDGYDQFHGGLVHDVHLHLQFUHDVLQJGVSQRHDDQGFRXJKZLWKLQYROYHPHQWRIERWKOXQJV
DVH PDOLJQDQWSHULFDUGLDOPHVRWKHOLRPD

26. $HDUROGIHPDOHSDWLHQWSUHVHQWHGZLWKVKRUWQHVVRIEUHDWKDQGGUFRXJKIRUPRQWKV6KH
KDG QR IHYHU EXW DEXVHG VWHURLGV IRU RQH HDU 2Q SKVLFDO H[DPLQDWLRQ VKH ZDV PRGHUDWHO
GVSQRLFZLWKGLVWHQGHGQHFNYHLQVDQGIDLQWKHDUWVRXQGVEXWKDGQRPXUPXUVKHVWUDGLRJUDSK
VKRZHGDKXJHJOREXODUFDUGLDFVKDGRZILJ

27. (FKRFDUGLRJUDSKUHYHDOHGDKXJHIUHHSHULFDUGLDO
HIIXVLRQZLWKQRUPDOYDOYHV6WUDZFRORXUHGIOXLGZDVREWDLQHGEVXE[SKRLGSHULFDUGLRFHQWHVLV
2SHQ SHULFDUGLRVWRP XQGHU JHQHUDO DQDHVWKHVLD ZDV SHUIRUPHG OHIW DQWHULRU WK VSDFH
WKRUDFRWRP

28. +XJHYROXPHRIIOXLGZDVGUDLQHG7KHSHULFDUGLXPZDVQRUPDOORRNLQJ7ZRSLHFHV
ZHUH REWDLQHG IRU ELRSV $ WXEH GUDLQ ZDV SODFHG LQ WKH OHIW SOHXUDO VSDFH 7KH SDWLHQW KDG
GUDPDWLF LPSURYHPHQW SRVWRSHUDWLYHO DQG OHIW WKH KRVSLWDO RQ WKH WK SRVWRSHUDWLYH GD 7KH
SRVWRSHUDWLYHFKHVWUDGLRJUDSKVKRZHGDQRUPDOVL]HGKHDUWILJ

29. %RWKWKHODERUDWRUVWXGRI
WKH SHULFDUGLDO DVSLUDWH DQG WKH ELRSV UHVXOWV ZHUH QRUPDO VKRZLQJ QR HYLGHQFH RI 7% RU
PDOLJQDQF

30. +RZHYHUWKHSDWLHQWZDVSUHVFULEHGDQWLWXEHUFXORXVGUXJVRQKRVSLWDOGLVFKDUJH7KH
SDWLHQWZDVVHHQZHHNVODWHUZLWKUHFROOHFWLRQRIIOXLG)LJ

31. WKDWLQGLFDWHGQRUHVSRQVHWR
DQWLWXEHUFXORXVGUXJV7KHSDWLHQWKDGD7VFDQRIWKHFKHVW)LJ

32. SULRUWRH[SORUDWLRQYLD
PHGLDQ VWHUQRWRP LQ DQRWKHU KRVSLWDO 8QIRUWXQDWHO WKHUH ZDV D WXPRXU RI SHULFDUGLXP
LQILOWUDWLQJWKHPXVFOHRIWKHULJKWYHQWULFOHDVVRFLDWHGZLWKKXJHDPRXQWRIEORRGHIIXVLRQ7RWDO
SHULFDUGLHFWRP DQG GHEXONLQJ RI WXPRXU ZHUH GRQH 7KH ELRSV UHVXOW ZDV PDOLJQDQW
PHVRWKHOLRPD RI SHULFDUGLXP )LJ

33. VKRZV WKH SRVWRSHUDWLYH FKHVW ILOP 6KH ZDV VWDUWHG RQ
FKHPRWKHUDSSRVWRSHUDWLYHO7KHSDWLHQWGLGQRWDWWHQGUHJXODUIROORZXSYLVLWV

34. 'LVFXVVLRQ
7KHVWLPXOXVWRZULWHWKLVSDSHUZDVWKHSUHVHQWDWLRQRIIRXUFRQVHFXWLYHSDWLHQWVZLWKWKRUDFLF
PHVRWKHOLRPDVRYHUDVKRUWWLPHIHZPRQWKV

35. ,WZDVIHOWWKDWWKHVXEMHFWGHVHUYHVVWXG
7KHVHUDUHWXPRXUVKDYHDYDULDEOHPLFURVFRSLFDSSHDUDQFHDVWKHWDNHRULJLQIURPDOOWKUHH
JHUPODHUV

36. 3OHXUDOPHVRWKHOLRPDLVHLWKHUEHQLJQLQ

37. RUPDOLJQDQW(DFKFDQEH
ORFDOL]HGRUGLIIXVH

38. 7KHUHSRUWHGLQFLGHQFHRIGLIIXVHPDOLJQDQWPHVRWKHOLRPDLVWR
QHZ FDVHVSHUPLOOLRQSHUHDU

39. 0DOLJQDQWSOHXUDOPHVRWKHOLRPDLVDQDVEHVWRVUHODWHGGLVHDVH

40. $VEHVWRVVHHPVWRDFWDVDQ
LQLWLDWRU

41. ,WRFFXUVSULPDULOLQLQGLYLGXDOVZKRDUHH[SRVHGWRDVEHVWRVHLWKHULQWKHZRUNSODFH
RU KRPH

42. 7KH KLJKHVW LQFLGHQFH RI PHVRWKHOLRPD LQ ERWK JHQGHUV UHJLVWHUHG E DQFHU
5HJLVWULHVDOORYHUWKHZRUOGLVFXUUHQWOUHFRUGHGDPRQJWKHSRSXODWLRQRI*HQRDDQG7ULHVWH
ZKHUHODUJHVKLSEXLOGLQJSODQWVDUHORFDWHG

43. $EDQRIDVEHVWRVXVHKDVEHHQLQWURGXFHGLQ,WDOLQ

44. +RZHYHUPDOLJQDQWSOHXUDOPHVRWKHOLRPDZLWKRXWDVEHVWRVH[SRVXUHGRRFFXU

45. )LYH
FDVHVRISOHXUDOPHVRWKHOLRPDLQKRXVHZLYHVZHUHUHSRUWHGIURP*HUPDQZKLFKZHUHDWWULEXWHG
WR LQKDODWLYH KRXVHKROG FRQWDFW ZLWK DVEHVWRV EDVHG RQ WKH FOHDQLQJ RI DVEHVWRV FRQWDPLQDWHG
ZRUNFORWKHVRIWKHKXVEDQGV

46. $QDGYDQFHGFDVHRIELODWHUDOPHVRWKHOLRPDLQYROYLQJOXQJDQG
SOHXUDZDVUHSRUWHGIURP,QGLDLQUROGPDOHQRQVPRNHUDQGOHFWXUHUZKRZDVQHYHUH[SRVHG
WR DVEHVWRV

47. DVHLQRXUSDSHUDOVRKDGQRGRFXPHQWHGH[SRVXUHWRDVEHVWRV1RQHRIKHU
IDPLOPHPEHUVZDVVLPLODUOH[SRVHGZKLFKPDNHVKHUDUDUHFDVH
'LIIXVHPDOLJQDQWPHVRWKHOLRPDLVWKUHHWRILYHWLPHVPRUHFRPPRQLQPHQWKDQZRPHQ

48. 7KXV FDVHLVDJDLQUDUHIRULWVRFFXUUHQFHLQDIHPDOH$VWXGIURP,WDOGHPRQVWUDWHGWKDW
PHVRWKHOLRPD ZDV KLJKHU DPRQJ IHPDOHV WKDQ PDOHV LQ WKH VWXG DUHD EXW DOO FDVHV KDG EHHQ
RFFXSDWLRQDOOH[SRVHGWRDVEHVWRV7KHLQFUHPHQWZDVIROGDPRQJPDOHVDQGDPRUHWKDQIROG
DPRQJ IHPDOHVLQWKHSHULRGRIWR

49. 7KH GLDJQRVLVLVGLIILFXOW7KHVPSWRPVDUHSRRUZLWKPRVWRIWHQFKURQLFSOHXUDOHIIXVLRQZLWK
GVSQRHDDVVRFLDWHGZLWKORFDOL]HGFKHVWSDLQ

50. 7KXVWKHLQLWLDOSUHVHQWDWLRQPDEHQRQVSHFLILF
7KHUHLVDORQJODWHQFSHULRGEHWZHHQRQVHWRIVPSWRPVDQGWLPHRIGLDJQRVLV7KHUHIRUHWKH
SURJQRVLVRIWKLVGHDGOGLVHDVHLVSRRU

51. DVHSUHVHQWHGZLWKSOHXUDOHIIXVLRQZKLFKZDV
FRQVLGHUHGWXEHUFXORXVRQFOLQLFDODQGODEEDVHV$QWLWXEHUFXORXVGUXJVZHUHJLYHQEXWVKHGLGQRW
DWWHQGDWIROORZXSXQWLOWKHGLVHDVHDGYDQFHG%HFDXVHDOOUHSRUWHGWUHDWPHQWPRGDOLWLHVDUHQRW
YHUVDWLVIDFWRUPDQSKVLFLDQVEHOLHYHWKDWVXSSRUWLYHFDUHUHPDLQVWKHEHVWIRUPRIWUHDWPHQW

52. 'LIIXVHPDOLJQDQWPHVRWKHOLRPDLVHSLWKHOLDOLQVDUFRPDWRXVLQDQGPL[HGLQRI
FDVHV

53. 'LIIHUHQWLDWLRQRIWKHHSLWKHOLDOYDULDQWIURPWKHPRUHFRPPRQPHWDVWDWLFDGHQRFDUFLQRPD
LV GLIILFXOWLWUHTXLUHVVSHFLDOVWDLQVLPPXQRORJLFWHFKQLTXHVDQGHOHFWURQPLFURVFRS

54. /RFDOL]HGEHQLJQPHVRWKHOLRPDVDUHUDUHWXPRXUV7KHDUHJHQHUDOODVPSWRPDWLFXQOHVVYHU
ODUJH

55. 7KHDUHQRWDVVRFLDWHGZLWKDVEHVWRVH[SRVXUH

56. 7KHSUHVHQWDVURXQGHGRSDFLWLHV
LQWKHFKHVWILOP

57. +SRJOFHPLDDQGKSHUWURSKLFSXOPRQDURVWHRDUWKURSDWKDUHXVXDOO
DVVRFLDWHGZLWKEHQLJQWXPRXUVODUJHUWKDQFPDQGDUHFRPSOHWHOUHOLHYHGEVXUJHU DQG

58. DVHQLFHOGHPRQVWUDWHGWKHIHDWXUHVDERYHH[FHSWODFNRIKSRJOFHPLDDQGILQJHUFOXEELQJD
VLJQ RIKSHUWURSKLFSXOPRQDURVWHRDUWKURSDWK

59. 7KHSDWLHQWZDVDVPSWRPDWLFDSDUWIURPPLOG
FKHVW SDLQ 7KH YHQWULFXODU HFWRSLF EHDWV FRXOG EH GXH WR SUHVVXUH RI WKH PDVV RQ WKH KHDUW
5DGLRORJLFDOOLWDSSHDUHGDVURXQGHGRSDFLW8QIRUWXQDWHOFKHVWVRQRJUDSKGHVFULEHGWKHOHVLRQ
DV EHLQJFVWLFWKHUHIRUHSXOPRQDUKGDWLGFVWZDVVXVSHFWHGDQGWKXVSHUFXWDQHRXV)1$ZDV
DYRLGHG7KHRFFXUUHQFHRIPLOGKDHPRSWVLVZKLOHZDLWLQJIRUVXUJHUIDYRUHGWKLVSRVVLELOLW7KH
SDWLHQWZDVWKXVH[SORUHGVXVSHFWLQJWKHHQGHPLFKGDWLGFVW7KHLQWUDRSHUDWLYHILQGLQJVZHUH
WSLFDOLHZHOOHQFDSVXODWHGSHGXQFXODWHGVROLGURXQGHGPDVVDULVLQJIURPYLVFHUDOSOHXUDWKH
VLWH RI RULJLQ LQ RI FDVHV

60. 7KHUH ZDV QR REYLRXV SXOPRQDU OHVLRQ WR H[SODLQ WKH
KDHPRSWVLV 5HVHFWLRQ LV FXUDEOH

61. DV LW LV LQ RXU SDWLHQW ZKR LV YHU ZHOO RQH HDU
SRVWRSHUDWLYHO
0DOLJQDQWPHVRWKHOLRPDLVORFDOL]HGLQRIFDVHV

62. ,WRIWHQSUHVHQWVDVVPSWRPDWLFPDVVHV

63. DVHKDGVHYHUHFKHVWSDLQDVWKHSUHVHQWLQJFRPSODLQWEHVLGHSDOORUDQGSRRUJHQHUDOKHDOWK
$OWKRXJK WKH FKHVW ILOP VKRZHG URXQGHG RSDFLW WKRXJKW WR EH D KGDWLG FVW E WKH UHIHUULQJ
SKVLFLDQ DQG WKH FKHVW VRQRJUDSKHU V UHSRUW RI FRPSOLFDWHG KGDWLG FVW WKH PRVW SUREDEOH
GLDJQRVLVLQRXUYLHZZDVPDOLJQDQWOXQJWXPRXUEDVHGRQWKHFOLQLFDOLPSUHVVLRQ7KHSDWLHQWZDV
IRXQGWRKDYHDELJVROLGPDVVDVVRFLDWHGZLWKKDHPRWKRUD[7KHPDVVDULVHGIURPWKHSDULHWDO
SOHXUDKHQFHWKHVHYHUHFKHVWSDLQZKLFKGLVDSSHDUHGSRVWRSHUDWLYHO,WZDVVHVVLOHUDWKHUWKDQ
SHGXQFXODWHGDIHDWXUHRIPDOLJQDQF

64. 7KHKDHPRWKRUD[FRXOGKDYHDULVHGIURPWKHHQJRUJHG
ELJEORRGYHVVHOVRQWKHVXUIDFHRIWKHPDVV7KHWXPRXUZDVUHVHFWHGLQWRWRHDVLO6XFKWXPRXUV
DUHWUHDWHGZLWKZLGHORFDOH[FLVLRQDVVXUYLYDOGHSHQGVRQFRPSOHWHQHVVRIUHVHFWLRQ

65. 'HVSLWH
FRPSOHWHVXUJLFDOUHVHFWLRQDQGSRVWRSHUDWLYHUDGLRWKHUDSWKHSDWLHQWGLGZHOOIRUWKUHHPRQWKV
RQO 7KHFKHVWSDLQUHFXUUHGWRJHWKHUZLWKULJKWORZHU]RQHSXOPRQDULQILOWUDWH7KLVVXSSRUWVWKH
ZHOONQRZQSRRUSURJQRVLVRIWKHGLVHDVH

66. 3ULPDUSHULFDUGLDOQHRSODVPVDUHYHUUDUH$ERXWKDOIDUHPDOLJQDQWZLWKPHVRWKHOLRPDWKH
PRVWFRPPRQYDULDQW,WLVRIWHQGLVFRYHUHGODWHLQDSDWLHQW
VFOLQLFDOFRXUVHRUDWDXWRSV0RVW
PHVRWKHOLRPDVDUHGLIIXVHDQGPDHQFDVHWKHHQWLUHKHDUWLQILOWUDWHWKHVXSHUILFLDOPRFDUGLXPRU
PHWDVWDVL]HWRPHGLDVWLQDOOPSKQRGHVDQGOXQJV7KHVHWXPRXUVPDFDXVHGHDWKEPRFDUGLDO
UHVWULFWLRQ

67. DUGLDFWDPSRQDGHDVWKHLQLWLDOPDQLIHVWDWLRQRISULPDUSHULFDUGLDOPHVRWKHOLRPD
KDV EHHQUHSRUWHGRQORQFHEHIRUHLQWKHPHGLFDOOLWHUDWXUH

68. WKXVRXUFDVHPDEHWKHVHFRQG

69. RQFOXVLRQV
3OHXUDOPHVRWKHOLRPVDUHUDUHWXPRXUV7KLVSDSHUUHSRUWVFDVHVUHSUHVHQWLQJWKHWKUHHNQRZQ
WSHVLHWKHORFDOL]HGEHQLJQORFDOL]HGPDOLJQDQWDQGGLIIXVHPDOLJQDQWPHVRWKHOLRPDV
3ULPDUSHULFDUGLDOPHVRWKHOLRPDLVYHUUDUH2QHFDVHLVUHSRUWHGKHUH
$OOSDWLHQWVZHUHKRXVHZLYHVIURPWKHVRXWKRI,UDTSUHVHQWHGLQWKHHDU
1RH[SRVXUHWRDVEHVWRVZDVGRFXPHQWHGLQWKHSDWLHQWZLWKGLIIXVHPDOLJQDQWPHVRWKHOLRPD
7KH ORFDOL]HG PHVRWKHOLRPDV PD PLPLF SXOPRQDU KGDWLG FVW UDGLRJUDSKLFDOO +RZHYHU
FDUHIXOKLVWRUSKVLFDOH[DPLQDWLRQDQGVRPHLQYHVWLJDWLRQVPDHQDEOHDFRUUHFWSUHRSHUDWLYH
GLDJQRVLV
$OWKRXJKWXEHUFXORXVSOHXUDOHIIXVLRQLVFRPPRQWKHPDOLJQDQWDHWLRORJLHVOLNHGLIIXVHSOHXUDO
PHVRWKHOLRPDVVKRXOGQRWEHIRUJRWWHQ
7KHSDWLHQWZLWKSULPDUSHULFDUGLDOPHVRWKHOLRPDKDVSUHVHQWHGLQLWLDOODVFDUGLDFWDPSRQDGH
2QORQHSUHYLRXVFDVHVLPLODUOSUHVHQWHGKDVEHHQUHSRUWHGEHIRUHWKXVRXUFDVHPDEHMXVWWKH
VHFRQG
:KLOH WKH EHQLJQ PHVRWKHOLRPD LV FXUDEOH E VXUJHU WKH PDOLJQDQW IRUPV DUH GLIILFXOW WR
GLDJQRVHDQGWUHDWZLWKDEDGSURJQRVLVHYHQZLWKWKHPRGHUQPXOWLPRGDOLWWUHDWPHQW
:HIHHOWKDWWKHDHWLRORJRIPDQPDOLJQDQFLHVLQFOXGLQJPHVRWKHOLRPDKDYHFKDQJHGDIWHUWKH
$PHULFDQDJJUHVVLRQRQRXUFRXQWULQDSRLQWWKDWGHVHUYHVVWXG
5HIHUHQFHV
5REELQ*RKHQ7RP5'HPHHVWHUDQG(GZLQ/DIDQWDLQH3ULPDUSOHXUDOPHVRWKHOLRPDVLQ
6XUJHURIWKHKHVW(GLWHGE'DYLG6DELVWRQ-UDQG)UDQN6SHQFHU:%6DXQGHUVRWK
HGLWLRQ9ROS
*URVV*RXSLO05XIILH30DOLJQDQWSOHXUDOPHVRWKHOLRPD%XOODQFHU2FW6XSSO
-RVHSK /RLFHUR 0HVRWKHOLRPD LQ *OHQQ
V 7KRUDFLF DQG DUGLRYDVFXODU 6XUJHU (GLWHG E
$UWKXU(%DXHZLWK$OH[DQGHU6*HKD*UDHPH/+DPPRQG+LOOHO/DNVDQG.HLWK61DXQKHLP
$SSOHWRQ /DQJHR9ROS
3OHXUDOWXPRXUVLQ%DLO /RYH
V6KRUW3UDFWLFHRI6XUJHU(GLWHGE$-+DUGLQJ5DLQVDQG
KDUOHV90DQQWKHGLWLRQ+./HZLV RS
5$ODUN 7XPRXUV RI WKH SOHXUD LQ (VVHQWLDO 6XUJLFDO 3UDFWLFH (GLWHG E $XVFKLHUL
*5*LOHVDQG$50RRVD:ULJKW/RQGRQS

70. 'DYLG-6XJDUEDNHU0LFKDHO)5HHGDQG6FRWW-6ZDQVRQ0HVRWKHOLRPDLQ6DELVWRQ7H[WERRN
RI6XUJHU7KH%LRORJLFDO%DVLVRI0RGHUQ6XUJLFDO3UDFWLFHWKHGLWLRQE6DELVWRQ'DQG
/HUL+.LP:%6DXQGHUVR
6WHLQ0 1HXPDQ$ 'DOH- 'UXPHD. %HQ,W]KDN2 %DU6KDORP5 *ROGVFKHU' +DLP
1DUGLDF WDPSRQDGH DV WKH LQLWLDO PDQLIHVWDWLRQ RI SULPDU SHULFDUGLDO PHVRWKHOLRPD 0HG
3HGLDWU2QFRO0DU

71. 0HUOHU(/DJD]LR%LJJHUL$7UHQGVLQPRUWDOLWIURPSULPDUSOHXUDOWXPRXUDQGLQFLGHQFH
RISOHXUDOPHVRWKHOLRPDLQ,WDODSDUWLFXODUOVHULRXVVLWXDWLRQ(SLGHPLRO3UHY2FW'HF

72. 3ODFLGL'3RUUX6$OHVVLR/$UHSRUWRIFDVHVRISOHXUDOPHVRWKHOLRPDZLWKXQXVXDODVEHVWRV
H[SRVXUH0HG/DY6HS2FW

73. .XPDU5*DXU610DOLJQDQWSOHXUDOPHVRWKHOLRPDZLWKRXWDVEHVWRVH[SRVXUH,QGLDQ-KHVW
'LV$OOLHG6FL-DQ0DU

74. 6FKQHLGHU- :RLWRZLW]+-$VEHVWRV UHODWHG PHVRWKHOLRPD LQ KRXVHZLYHV IURP LQGRRU DLU
SROOXWLRQ=HQWUDEO+J8PZHOWPHG0DU

75. %DUEHLUL3*0LJOLRUL00HUOHU(7KHLQFLGHQFHRIPDOLJQDQWPHVRWKHOLRPD

76. DQG
DVEHVWRVH[SRVXUHLQWKHSRSXODWLRQRIDQDUHDQHLERXULQJ/DNH,VHRQRUWKHUQ,WDO0HG/DY
1RY'HF

77. 5XII6 'LHWULFK0 %DKU5%HQLJQ SOHXUDO PHVRWKHOLRPD 5HSRUW RI FDVHV /DQJHQEHFNV
$UFKBKLU

78. 2UHRSRXORV* 0LFNOHERURXJK/ 'DQLHO/ 'H6D0 0HUFKDQW1 %XWDQ- 3ULPDU
SHULFDUGLDOPHVRWKHOLRPDSUHVHQWLQJDVFRQVWULFWLYHSHULFDUGLWLVDQ-DUGLRO'HF

79. )LJ )LJ )LJ )LJ
)LJ )LJ )LJ )LJ
)LJ )LJ )LJ )LJ
)LJ )LJ
)LJ )LJ