FILED: ALBANY COUNTY CLERK 01/24/2024 03:32 PM
`NYSCEF DOC. NO. 632
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`INDEX NO. 908796-22
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`RECEIVED NYSCEF: 01/24/2024
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`Professor Richard L. Attanoos BSc, MBBS, FRCPath
`APC (Pathology) Ltd
`Boverton Park House
`Boverton
`Vale of Glamorgan
`CF61 1UH
`
`Tel: 00 44 1446 792292
`drattanoos@yahoo.co.uk
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`January 12, 2024
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`Deborah L. Zueger
`Willcox & Savage
`Wells Fargo Centre
`440 Monticello Avenue
`Norfolk
`VA 23510
`
`Dear Mrs Zueger
`
`Re: Mark Sarro
`
`Thank you for referring the case of Mr Sarro for my evaluation.
`
`At your request I have examined the following materials enclosed with your letter
`dated September 8, 2023:
`
`
`1. Complaint
`2. First Amended Complaint
`3. Second Amended Complaint
`4. Third Amended Complaint
`5. Plaintiff’s Responses to Defendants’ First Set of Interrogatories
`6. Discovery Deposition of Mark J. Sarro, Vols. I through IV
`7. De Bene Esse Deposition of Mark J. Sarro, 2/22/2023
`8. Report by Kenneth S. Garza, 2/14/2023
`9. Medical records for Mark Sarro (see Appendix 1)
`
`
`In addition, I have examined the following materials enclosed with your letter dated
`November 10, 2023:
`
`
`1. Digital pathology from Memorial Sloan Kettering Cancer Center – 11 whole
`slide scanned images on Aperio ImageScope -Accession S22-81443 H&E’s
`1_1, MLA, WT-1, BAP-1, TTF-1, PD-L1, D2-40, Mesothelin, ALK.
`
`
`
`
`1
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`

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`FILED: ALBANY COUNTY CLERK 01/24/2024 03:32 PM
`NYSCEF DOC. NO. 632
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`INDEX NO. 908796-22
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`RECEIVED NYSCEF: 01/24/2024
`
`2. Additional medical records from Memorial Sloan Kettering Cancer Center – 35
`pages
`
`
`In addition, I have examined the following materials enclosed with your letter dated
`November 30, 2023:
`
`
`1. Pathology from Westchester Hospital – 16 unstained slides Accession S22-
`5949 A3 x3, A4x3, A5x2, A6x2, A7x3, BFS1x3.
`
`
`In addition, I have examined the following materials enclosed with your letter dated
`January 9, 2024:
`
`
`1. Report of Dr Alexander PhD MSPH dated December 12, 2023
`
`Work and Exposure History
`
`This is set out in the various pleadings as well as in testimony transcripts and in
`excerpts of the expert report and in the medical records.
`
`In response to interrogatory #2, it is stated that Mr Sarro was born in Bronx, New
`York on October 6, 1954 in Bronx, NY. It is detailed that he married Honora Sarro on
`March 15, 1977. In his deposition, Mr Sarro stated that his wife worked as a Professor
`at the University of Maryland in USERRA. She had also worked as a teacher of
`government equivalency programs to the troops in the Army at four or five military
`posts in Europe. Mr Sarro stated since 1980, his mother worked as an actuary.
`
`In response to interrogatory #3, it is stated that Mr Sarro’s father was Joseph Sarro
`born 1922 and that his mother was Antoinette Sarro born December 19, 1926. It is
`stated that their address was 2754 Springhust Street, Yorktown Heights, New York
`10598. It is detailed that his mother had died of complications of old age in 2017, at
`the age of 91. His father had died on January 26, 1973 aged 51 with an enlarged heart.
`
`In his deposition, Mr Sarro detailed that his father had worked as a law secretary or
`lawyer for the Supreme Court. He stated that his mother worked as a teacher. Mr Sarro
`stated that his brother Robert had died from lung cancer at the age of 67–68. Mr Sarro
`stated Mr Sarro stated that his brother Matthew had a history of prostate or colon
`cancer.
`
`In response to interrogatory #4, it is stated that Mr Sarro has two children – Thomas
`Sarro, born October 22, 1986; and Caitlyn Sarro, born July 3, 1990.
`
`In his deposition, Mr Sarro stated that his son had neurofibromatosis 1.
`
`In response to interrogatory #5, it is detailed that Mr Sarro resided at multiple
`addresses including – Bronx, NY (1954-1966; 1972-1976); Yorktown Hots, NY
`(1966-1972) Fort Knox, KY (1976-1977); Mainz-Gonsenheim, Germany (1977-
`2
`
`
`
`

`

`FILED: ALBANY COUNTY CLERK 01/24/2024 03:32 PM
`NYSCEF DOC. NO. 632
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`INDEX NO. 908796-22
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`RECEIVED NYSCEF: 01/24/2024
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`1980); Brooklyn, NY (1980-1984); Mt. Kisco, NY (1984-1990); Yorktown Heights,
`NY (1990-present).
`
`Education - In his deposition, Mr Sarro stated he graduated from Yorktown High
`School in 1972. Mr Sarro served in the military and continued in the United States
`Armed Reserves when at Fordham University in the mid-1970s completing a degree
`in political science. Mr. Sarro next served in the United States Army from 1976 to
`1980. He attended law school at Fordham from 1980 to 1983 and earned a Juris
`Doctor degree.
`
`In response to interrogatory #13, the employment history is listed in ‘Chart A’ and in
`his deposition:
`
`1970s:
`
`Mr Sarro worked as an attendant/assistant at a Mobil Gas Station
`in Yorktown Heights, NY
`
`
`
`Asbestos materials allegedly used on this job: brakes, clutches,
`engines.
`
`In his deposition, Mr Sarro stated he starting working at Mobil
`when he was 16 years old in approximately October 1970. He
`worked during high school part-time during weekdays and
`weekends. Mr Sarro worked as a gofer for the mechanics, on tire
`work, pumping gas, and also swept the floors, cleared garbage
`and picked up things. He stated he cleaned for approximately 30
`minutes each time. The Mobil Gas Station had a machine shop
`with two bays and performed brake, clutch, and gasket work. He
`estimated approximately seven brake jobs were performed each
`week during his shifts. Mr Sarro described removing the brake
`drums/shoes. He was also responsible for wire brushing or
`sandpapering the brakes to remove the glaze. He recalled
`primarily working on drum brakes. He recalled brakes by Bendix,
`American Brake Block, Carlisle, Rockwell, Eaton, Wagner, EIS
`and NAPA. He only recalled Borg-Warner clutches. Mr Sarro
`stated the machine shop did between 4-6 clutch jobs a week, in
`which he assisted by removing the glaze as with brakes. The
`machine shop also did tune-up work and replaced head gaskets.
`Mr Sarro described removing old gaskets. He did not install new
`gaskets. He stated he believed the tow trucks had Cummins
`engines.
`
`Mr Sarro worked as a truck driver for an electrical subcontractor
`
`In his deposition, Mr Sarro stated he worked for Luna Electric, a
`public works contractor, as a gofer in the parts department with
`
`3
`
`
`1970s:
`
`Summer 1973:
`
`
`
`

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`FILED: ALBANY COUNTY CLERK 01/24/2024 03:32 PM
`NYSCEF DOC. NO. 632
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`INDEX NO. 908796-22
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`RECEIVED NYSCEF: 01/24/2024
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`delivery to job sites. He recalled Luna Electric built the White
`Plains Courthouse and Woodbourne Prison. The company did
`electrical wiring work. Mr Sarro stated he transported wire, tools
`as well as concrete and PVC pipe to work sites but did not handle
`the pipe materials. He did not claim asbestos exposure while
`delivering parts to work sites.
`
`Mr Sarro worked as a mechanized armor/calvary officer;
`battalion maintenance officer for the United States Army in
`Germany
`
`Asbestos materials allegedly used on this job: brakes, clutches,
`engines.
`
`In his deposition, Mr Sarro stated he served in the Army Reserves
`while at Fordham University. He was stationed at Fort Dix, Fort
`Benning as well as in Georgia and Florida. He saw active duty at
`Fort Knox in 1976 after graduating college. Mr Sarro served in
`the United States Army from 1976 to 1980. Mr. Sarro stated he
`attended motor officer school which consisted of an initial three-
`week mixed classroom and hands-on course. He estimated there
`were around 10 mechanics there. He recalled performing brake
`work on Jeeps under supervision. Mr Sarro stated he sanded new
`brakes and did clean-up work. The mechanics at the maintenance
`facility did oil changes, brake, clutch, and gasket work including
`on trucks. Mr Sarro was stationed in Germany in around March
`1977 at the Robert E. Lee barracks in Mainz, Gonsenheim. He
`worked at a two-bay facility, involving in parts, inspection work
`and technical assistance. His desk was close to mechanics
`performing brake, clutch, and gasket work on Jeeps and trucks.
`He stated he believed the truck engines were made by Cummins.
`He estimated he performed four brake jobs over the six to none
`months in combat support. He also stated he did clean-up work
`alongside others. During this period, Mr Sarro also described
`working in a large battalion maintenance facility called the white
`elephant which was up to 400 x 60 feet which had been a World
`War II horse barn. The area could hold around 50 vehicles. He
`recalled Jeeps, trucks, and tanks undergoing work and that
`maintenance work was performed both inside and outside. Mr.
`Sarro stated he did battalion training exercises for approximately
`six to eight weeks. Mr Sarro later stated he also served in
`Roosendaal in Holland for two-three weeks periodically over an
`18-month time.
`
`4
`
`
`1972-1980:
`
`
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`
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`
`
`

`

`FILED: ALBANY COUNTY CLERK 01/24/2024 03:32 PM
`NYSCEF DOC. NO. 632
`
`INDEX NO. 908796-22
`
`RECEIVED NYSCEF: 01/24/2024
`
`1980-present:
`
`Mr Sarro worked as a staff officer at New York National Guard
`in Bay Ridge, NY, and Staten Island, NY
`
`
`
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`
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`
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`1980-1989:
`
`
`1990-1993:
`
`
`1993-2009:
`
`
`2002-2009:
`
`
`
`
`
`Asbestos materials allegedly used on this job: brakes, clutches
`
`In his deposition, Mr Sarro stated he joined the tank unit of the
`New York Army National Guard in 1980. He detailed he served
`around five days per month and did inventory work on
`equipment. Mr Sarro stated he participated in one brake job on a
`Jeep during this time. He also recalled supervising a clutch and
`brake job on a two-and-a-half-ton truck. Mr Sarro worked with
`tanks when he did annual training at Fort Drum. He also did
`training at some time at Fort Dix.
`
`In his deposition, Mr Sarro stated he had separation papers from
`the National Guard in 1990. He believed he enlisted in the New
`York Guard in 1998. Mr Sarro worked as the operations officer
`for the New York Guard Task Force during 9/11 running
`logistical sites outside the city and was not at Ground Zero.
`He did not believe he had asbestos exposure from military
`vehicles while in the New York Guard. His enlistment ended in
`October 2022.
`
`Mr Sarro worked as an attorney at Ross & Cohen in New York,
`NY. There is no alleged asbestos exposure. Mr Sarro stated this
`was a commercial litigation firm involved in the construction
`industry.
`
`Mr Sarro worked as in-house general counsel at Saturn
`Construction, Inc./Cappelli Development in Valhalla, NY. There
`is no alleged asbestos exposure. Mr Sarro stated he visited
`construction sites while at Saturn including the VA Hospital in
`Roxbury, Massachusetts, a prison in Newtown, Connecticut, and
`a jail in Riverhead, Long Island.
`
`Mr Sarro worked as an attorney/owner at Mark J. Sarro, P.C in
`Crestwood, NY. There is no alleged asbestos exposure. Mr Sarro
`stated he worked in real estate and construction law and did not
`visit construction sites during this time.
`
`Mr Sarro worked as an equity partner at McDonough Marcus
`Cohn Tretter Heller & Kanca, LLP in New Rochelle, NY. There
`is no alleged asbestos exposure.
`
`5
`
`

`

`FILED: ALBANY COUNTY CLERK 01/24/2024 03:32 PM
`NYSCEF DOC. NO. 632
`
`INDEX NO. 908796-22
`
`RECEIVED NYSCEF: 01/24/2024
`
`2009-2015:
`
`
`2015-present:
`
`Mr Sarro worked as a founding member/attorney at Raneri,
`Light, Sarro, O’Dell, PLLC in White Plains, NY. There is no
`alleged asbestos exposure.
`
`Mr Sarro works as an attorney at Sarro & Sarro, PLLC in
`Westchester, NY. There is no alleged asbestos exposure. Mr
`Sarro stated he worked with his sister.
`
` 1954.
`
`
`
`In the Medical notes of Dr Sabari (Medical Oncologist, NYU Langone Health) on
`October 14, 2022 it is detailed ‘significant asbestos exposure as a construction
`attorney, concrete factories/plants; renovations; armories, and depleted uranium
`munitions exposure, he also notes a significant family history of neurofibromatosis 1
`(NF 1) in his 35-year-old son followed here at NYU; maternal first cousin with NF1.
`No known family history of BAP 1/NF2 loss.’
`
`In the Medical records of Memorial Hospital for Cancer and Allied diseases, it is
`stated ‘Occupation: Construction attorney’
`
`Clinical History
`
`Mr Sarro was born in Bronx, New York on
`
`Mr Sarro had a long history of hydrocele with noted periodic aspirations since 2007.
`He was recommended hydrocelectomy, but opted to continue with aspirations.
`
`Mr Sarro presented to Dr Axelrod (Urologist, CareMount Medical) on June 13, 2022
`for hydrocele aspiration. They discussed hydrocelectomy, and he planned to consider
`the procedure.
`
`Mr Sarro was reviewed by Dr Ennis (Westchester Health) on August 16, 2022 for
`preoperative examination. Laboratory tests and urinalysis were ordered.
`
`Mr Sarro was admitted to Northern Westchester Hospital on August 29, 2022 to
`undergo a left hydrocelectomy, performed by Dr Axelrod. At operation, the hydrocele
`sac was opened, and a portion was excised and sent for pathology. There was
`inflammation seen in the region of the epididymis. A sample sent for frozen section
`showed no evidence of malignancy. He was detailed to have tolerated the procedure
`well with no complications.
`
`Surgical Pathology (Accession S22-5949) by Dr Buyuk on September 27, 2022:
`
`‘Final Pathologic Diagnosis
`
`A. Portion of left hydrocele sac
`
`
`
`6
`
`

`

`FILED: ALBANY COUNTY CLERK 01/24/2024 03:32 PM
`NYSCEF DOC. NO. 632
`
`INDEX NO. 908796-22
`
`RECEIVED NYSCEF: 01/24/2024
`
`- Atypical mesothelial proliferation seen in a hydrocele sac.
`- See comments.
`
`B. Inflammatory mass involving left epididymis
`- Adenomatoid tumor.
`- See comments.
`
`Comments:
`- The sections show an exuberant mesothelial proliferation with marked cytological
`atypia. Immunohistochemical studies WT-1, D2-40 and calretinin support mesothelial
`origin. Features suspicious for infiltrative growth pattern appreciated. Case is being
`sent for expert opinion at Northwell Health Laboratories and their interpretation will
`follow in an addendum.’
`
`Addendum reported by Dr Borczuk on September 30, 2022 stated:
`
`‘Addendum 1
`A. Portion of left hydrocele sac and B. inflammatory mass of left epididymis:
`- Mesothelioma, epithelioid type, with areas of expansile nodular growth. IHC is
`positive for calretinin, WT1 and D240. Immunohistochemistry for BAP1 shows loss
`of nuclear reactivity, which is in support of the result.
`
`Comment: Slides were sent in consultation to evaluate an atypical mesothelial
`proliferation. Both specimens part A and part B show an atypical mesothelial
`proliferation which in part A has extensive surface growth with papillary and
`micropapillary structures as well as an infiltrative growth in the wall which is
`predominantly tubulopapillary/tubular. Nuclear grade is grade 2 and mitotic activity
`is low with the highest mitotic rate seen is 1 mitosis in 2 mm² or 10 high-power fields.
`Necrosis is not present. No spindle cell/sarcomatoid component is seen. In part B the
`mesothelial proliferation is tubulocystic with somewhat lower nuclear grade, and as
`such as mimics an adenomatoid tumor. However, in light of the specimen in part A
`and also the loss of BAP 1 immunoreactivity in Part B, both specimens represent
`involvement by a malignant mesothelioma, epithelioid type. Clinical evaluation is
`needed to determine whether this is a primary mesothelioma of the tunica vaginalis or
`whether this represents extension from a primary peritoneal mesothelioma.’
`
`Mr Sarro was reviewed by Dr Axelrod (Urologist, Optum Medical Care) on
`September 14, 2022 as part of post-operative follow-up. He was detailed to be doing
`well and planned for follow-up in one-two months.
`
`CT chest/abdomen/pelvis (examination date October 11, 2022) by Dr Brodoff stated:
`
`‘Impression:
`
`
`
`7
`
`

`

`FILED: ALBANY COUNTY CLERK 01/24/2024 03:32 PM
`NYSCEF DOC. NO. 632
`
`INDEX NO. 908796-22
`
`RECEIVED NYSCEF: 01/24/2024
`
`1. Right pulmonary nodule suspicious for neoplastic process such as metastatic
`disease. Further evaluation could include PET CT, short interval follow-up and/or
`biopsy.
`
`Probably bilateral complex renal cysts. Suggest attention on follow-up.
`
` 3
`
` cm hypodense left adrenal nodule most likely lipid rich adenoma. Correlate
`clinically. Recommend attention on follow-up imaging.
`
`Thyroidectomy.
`
`Additional findings as described.’
`
`Mr Sarro was reviewed by Dr Sabari (Medical Oncologist, NYU Langone Health) on
`October 14, 2022 for treatment recommendations for his testicular epithelioid
`mesothelioma. He was noted to have worsening swelling in the left testes, with
`discomfort, and difficulty with urination. He was recommended an MRI brain to
`complete staging. His pathology was requested to be read and confirmed at NYU, and
`he was scheduled for a PET/CT.
`
`Mr Sarro had a telephone encounter with Dr Sabari (Medical Oncologist, NYU
`Langone Health) on October 25, 2022 to discuss PET/CT results. His results were
`concerning for metastatic disease to the lung and he was recommended for a
`interventional radiology CT guided biopsy for histologic confirmation. He was
`awaiting an appointment at MSKCC and wished to hold-off at this time.
`
`Mr Sarro was reviewed by Dr Matulewicz (Urologist, Memorial Hospital for Cancer
`and Allied Diseases) on October 27, 2022 for surgical and overall management of his
`mesothelioma. He was recommended IR biopsy of lung nodules. Dr Matulewicz
`planned to discussed with thoracic oncology the role for systemic treatment vs. lung
`resection, pending biopsy. They discussed the role of aggressive surgical resection
`including completion orchiectomy with hemi-scrotectomy followed by retro peritoneal
`lymph node dissection, pelvic lymph node dissection, and possibly inguinal lymph
`node dissection, pending determination of the nature of his lung masses.
`
`PET/CT (examination date November 8, 2022) reported by Dr Wray stated:
`
`‘Impression:
`1. Hypermetabolic left testicle, suspicious for malignancy. FDG avid scrotal fluid,
`possible involved.
`
`2. Hyper metabolic right lung nodules, suspicious for metastatic disease.
`
`3. FDG avid left adrenal hypodense mass, possible adenoma.’
`
`
`
`
`8
`
`

`

`FILED: ALBANY COUNTY CLERK 01/24/2024 03:32 PM
`NYSCEF DOC. NO. 632
`
`INDEX NO. 908796-22
`
`RECEIVED NYSCEF: 01/24/2024
`
`CT chest (examination date November 8, 2022) reported by Dr Fuqua stated:
`
`‘Impression:
`1. Several bilateral pulmonary nodules, larger of which are suspicious for
`metastases.’
`
`Mr Sarro was reviewed by Dr Matulewicz (Urologist, Memorial Hospital for Cancer
`and Allied Diseases) on November 9, 2022 for further management of his
`mesothelioma. Staging remained unclear, so they were unable to finalize a treatment
`plan. He wished to postpone his scheduled orchiectomy and scrotectomy, until he had
`undergone his lung biopsy.
`
`Memorial Hospital for Cancer and Allied Diseases-Lung biopsy–pathology report not
`available
`
`Mr Sarro was admitted to Northern Westchester Hospital on December 13, 2022 with
`unexplained bradycardia, without any accompanying symptoms. He was placed on
`cardiac monitoring. Orders were placed for troponin, PT with INR, RVP, and EKG.
`Cardiologist Dr Lieb, was consulted and he was cleared for discharge and planned for
`outpatient follow-up with cardiology.
`
`Mr Sarro was reviewed by Dr Zauderer at Memorial Sloan Kettering Cancer Center
`on April 24, 2023 for the management of his malignant epithelioid mesothelioma of
`the left tunica vaginalis. He was continuing on systemic therapy with Platinum,
`Pemetrexed and bevacizumab. He had tolerated the last cycle with milder nausea
`although had fatigue. ECOG performance status 1. He was considered to have done
`well on 5 cycles and would continue with cycle 6 with review to transition to
`maintenance therapy.
`
`Testicular ultrasound (examination date May 10, 2023) reported by Dr Sutton stated:
`
`‘Impression:
`Since March 23, 2023, decreased left scrotal extra testicular mass, which is again
`inseparable from the epididymis top no intratesticular mass.’
`
`CT chest abdomen and pelvis (examination date May 10, 2023) reported by Dr
`Teicher stated:
`
`‘Impression:
`1. Since CT scan March 23, 2023, slight decrease in size of right upper lobe nodules,
`one of which is a proven metastasis. Tiny right upper lobe lesion is unchanged and
`there is a new nodule in the superior segment of the left lower lobe, possible
`metastasis.
`
`2. Unchanged left adrenal adenoma.
`
`
`
`9
`
`

`

`FILED: ALBANY COUNTY CLERK 01/24/2024 03:32 PM
`NYSCEF DOC. NO. 632
`
`INDEX NO. 908796-22
`
`RECEIVED NYSCEF: 01/24/2024
`
`
`3. Bilateral renal cysts are unchanged with a minimally complex septated cystic mass
`in the right kidney with a small calcification.
`
`Mr Sarro was reviewed by Dr Zauderer at Memorial Sloan Kettering Cancer Center
`on May 15, 2023 and detailed to continue to tolerate chemotherapy well. He reported
`symptoms of ‘chemo brain’ and had completed 6 cycles of treatment. Mr Sarro was in
`agreement with transition into maintenance monotherapy. A 3 week review was
`planned.
`
`Mr Sarro was reviewed by NP Alison Massey at Memorial Sloan Kettering Cancer
`Center on June 5, 2023 and noted to be feeling better since switching to maintenance
`therapy although had continued fatigue. He was working part-time. His paternal
`cousin had been diagnosed with pancreatic cancer.
`
`Testicular ultrasound (examination date June 23, 2023) reported by Dr Paroder stated:
`
`‘Impression: Since May 10, 2023, unchanged left scrotal extra testicular mass
`inseparable from the epididymis and additional small extratesticular nodule lateral to
`the left testicle.’
`
`CT chest abdomen pelvis (examination date June 23, 2023) reported by Dr
`Plodkowski stated:
`
`‘Impression:
`1.Since May 10, 2023, couple pulmonary metastasis are slightly decreased.’
`
`Mr Sarro was reviewed by NP Alison Massey at Memorial Sloan Kettering Cancer
`Center on June 26, 2023 and was detailed to feel well overall with less fatigue. He
`would continue on maintenance bevacizumab therapy.
`
`Mr Sarro was reviewed by Dr Zauderer at Memorial Sloan Kettering Cancer Center
`on July 17, 2023 and detailed to be feeling well on maintenance therapy. A 3 week
`review was planned.
`
`Mr Sarro was reviewed by Dr Zauderer at Memorial Sloan Kettering Cancer Center
`on August 7, 2023 and detailed to be feeling well with improved fatigue. He would
`remain on current therapy. A 3 week review was planned.
`
`Testicular ultrasound (examination date August 26, 2023) reported by Dr Brennan
`stated:
`
`‘Impression:
`
`
`
`10
`
`

`

`FILED: ALBANY COUNTY CLERK 01/24/2024 03:32 PM
`NYSCEF DOC. NO. 632
`
`INDEX NO. 908796-22
`
`RECEIVED NYSCEF: 01/24/2024
`
`Since June 23, 2023, no significant change in the lobulated left scrotal extra testicular
`mass inseparable from the epididymis. Additional smaller left extratesticular nodule
`decreased slightly.’
`
`CT chest abdomen and pelvis (examination date August 26, 2023) reported by Dr
`Ginsberg stated:
`
`‘Impression:
`1. Since June 23, 2023, unchanged right upper lobe metastasis, and nearly resolved
`other right upper lobe nodule.’
`
`Mr Sarro was reviewed by Dr Zauderer at Memorial Sloan Kettering Cancer Center
`on August 28, 2023 and detailed to be feeling well with no new issues. Imaging was
`reviewed. Maintenance therapy with bevacizumab would be continued.
`
`The medical records do not extend beyond this point.
`
`
`Past Medical and Surgical History
`
`Hearing loss (2014); Adenomatous colon polyps; Diverticulosis (2012); Essential
`hypertension (2017); Mixed hyperlipidemia; Diet controlled diabetes mellitus;
`Hydrocele; Hypothyroidism; Obesity (2014); Obstructive sleep apnoea
`
`Accession CN080043100
`Thyroid FNA – Nodular goiter. Follicular cells in a background of macrophages and
`colloid
`
`Accession BS08-21763
`Thyroidectomy – Adenomatoid nodules, some with areas of degeneration consistent
`with prior biopsy procedure; One benign perithyroid lymph node.
`
`Accession S12-660
`Descending colon polyp – Adenomatoid colonic polyp
`Rectal polyp – Hyperplastic colonic polyp
`
`
`Family History
`
`Prostate cancer
`
`Lung cancer
`
`Leukemia
`
`
`
`
`
`
`Brother
`
`Brother, paternal uncle
`
`
`
`
`
`Niece
`
`
`
`11
`
`

`

`FILED: ALBANY COUNTY CLERK 01/24/2024 03:32 PM
`NYSCEF DOC. NO. 632
`
`INDEX NO. 908796-22
`
`RECEIVED NYSCEF: 01/24/2024
`
`
`
`Paternal cousin
`
`Pancreatic cancer
`
`Neurofibromatosis 1
`
`
`Smoking History
`
`Mr Sarro is a former smoker of cigarettes at a rate of 2.00 packs/day. He quit
`smoking in 1992.
`
`In response to interrogatory #22, it is stated that from 1969-1972, 1975-1977, and
`1980-1986, Mr Sarro smoked approximately two packs of cigarettes per day. It is
`further stated that from 1980-2022, Mr Sarro smoked approximately twelve cigars per
`year.
`
`
`Pathological Examination
`
`Son
`
` I
`
` received 11 whole slide scanned images on Aperio ImageScope digitised pathology
`for Accession S22-81443 H&E’s 1_1, MLA, WT-1, BAP-1, TTF-1, PD-L1, D2-40,
`Mesothelin ALK, from Memorial Sloan Kettering Cancer Center and 16 unstained
`slides Accession S22-5949 A3 x3, A4x3, A5x2, A6x2, A7x3, BFS1x3 from
`Westchester Hospital – in the Cardiff laboratory (E 23.3231) I requested routine H&E
`stains on A3, A4, A5, A6, A7, BFS 1.
`
`By light microscopy Accession S22-5949 A comprised strips of thickened fibrous
`tissue with a surface atypical epithelioid mesothelial proliferations and showing
`invasion of fibrous stroma. The epithelioid cells have regular nuclei with distinct
`nucleoli, sparse mitotic activity and no necrosis. The features are of low-grade atypia.
`No spindle cell/sarcomatoid component is seen and there exist no areas with epithelial
`lines of differentiation. Specimen B comprises a nodule of tumour exhibiting sheets
`of epithelioid cells with low-grade atypia.
`
`The tumour cells are detailed to be positive for calretinin, WT1 and D2-40 with loss of
`nuclear expression of BAP-1.
`
`The morphology and immunophenotype is that of mesothelioma, epithelioid type,
`low-grade. The tissue sample is from hydrocoele sac. Clinical evaluation with tumour
`distribution confirms this as a primary mesothelioma of the tunica vaginalis testis.
`
`Examination of the 11 whole slide scanned images on Aperio ImageScope of
`Accession S22-81443 from Memorial Sloan Kettering Cancer Center. This represents
`the biopsy of lung. The scanned images show a malignant epithelioid neoplasm with
`solid and acinar formations. The tumour cells are positive for WT 1, D2–40 and
`
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`mesothelin. The tumour cells were negative for TTF-1, PDL1 and ALK. BAP-1
`showed loss of expression in tumour cells.
`
`Given the clinical context, the morphology and immunophenotype would be
`consistent with metastatic epithelioid mesothelioma from the primary tumour site–
`tunica vaginalis testis.
`
`No asbestos bodies are seen in any of the slides examined.
`
`Summary and Opinion
`
`All opinions are expressed with a reasonable degree of medical certainty and subject
`to the information present at the time of construction of the report. I reserve the right
`to re-consider my opinions if further materials and information become available.
`
`Mr Sarro has contracted diffuse mesothelioma, epithelioid type, low-grade, of the
`tunica vaginalis testis. The tumour has metastasised with involvement in the lungs.
`
`Mr Sarro has no reported biomarkers of prior significant exposure to amphibole
`asbestos. There is no reported diffuse interstitial fibrosis consistent with asbestosis, no
`references to pleural plaques, and no asbestos bodies are seen in the tissue examined.
`
`My opinions in relation to the specific causation of Mr Sarro’ s diffuse mesothelioma
`are discussed below:
`
`First, with respect to ambient background exposures - It is well recognised that
`mineral fibres including asbestos are ubiquitous in the ambient environment, present
`in air, water, and soil across various geographic locations. Historical ambient airborne
`asbestos levels in U.S. cities of 0.02 f/cc or 0.03 f/cc have been reported (Mangold
`1982, Mangold 1983; Abelmann, 2015). The Agency for Toxic Substances and
`Disease Registry (ATSDR, 2001) concluded that the estimated range of indoor
`ambient asbestos concentrations is 0.00003 – 0.006 fibres per cc, which corresponded
`to a cumulative lifetime exposure range of 0.002 – 0.4 fibre per cc years. There is no
`evidence that these ambient asbestos exposures have any significance with respect to
`the development of any asbestos related disease (WHO 1998; ATSDR 2001; Price,
`2004; Teta, 2008; Glynn, 2018; Keeton, 2018).
`
`With respect to control reference ranges – these are established within individual
`analytical laboratories performing fibre burden analyses (because inter-laboratory
`variations in fibre counts exist) and the significance of an individual exposure may
`then be determined by benchmarking the case to the established laboratory control
`population (Gylseth, 1984; DeVuyst, 1998; Srebro, 1995; Dodson, 1999; Gibbs, 2005;
`Roggli, 2015; Attanoos, 2016). The control population represents, most closely, only
`subjects with ambient asbestos exposure and no increased risk of asbestos related
`disease (Attanoos, 2019).
`
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`The scientific evidence correlating cumulative asbestos exposure with disease has
`been extensively established in occupational settings which are many orders of
`magnitude above background ambient exposure levels. Numerous analytical
`laboratories have made correlations between retained amphibole asbestos fibre
`concentrations in lungs of asbestos exposed workers and asbestos related disease
`(Wagner, 1986; Churg, 1994; Roggli, 2002).
`
`With respect to host defence mechanisms - The lung is exposed to, and equipped to
`handle, a wide variety of particulates present in the environment including various
`respirable minerals. The inhalation of airborne particles does not necessarily induce
`disease, even at high exposures because there are host defence mechanisms which
`assist in limiting deep inhalation of particles or facilitate particle clearance. There are
`three broad categories of defence mechanisms: (1) physical barriers in the upper
`respiratory tract (nasal hairs, respiratory epithelial lined nasal cavity and oropharynx
`with mucus) to block mineral particle penetration; (2) processes in the trachea and
`bronchi that prevent fibre from reaching the deep alveolated lung; and (3) cellular
`defence processes within the body including the lung, pleura and peritoneum
`
`The respiratory tract is lined by a specialised layer of cells – with hair-like structures
`(“cilia”) that are covered by a mucus layer. These cells move back and forth in a
`unidirectional manner in order to transport inhaled substances toward the mouth
`where they can eventually either be expectorated or swallowed. This system is
`commonly known as the mucociliary escalator.
`
`In the deep alveolated lung, and in the serosal cavities there are specialised cells called
`macrophages which engulf inhaled particulates and destroy them using intracellular
`enzymatic digestion. Macrophage function allows for the break-down products of the
`degradation process to the lymphatic circulation which represents the main system of
`clearance. Lymphatic drainage is then to lymph nodes, via thoracic duct and
`circulatory system.
`
`With respect to the causation of Mr Sarro’s diffuse mesothelioma, I will state:
`
`It is recognised that there are a number of causes for diffuse pleural and peritoneal
`mesothelioma (Attanoos, 1997; Craighead, 2008; IARC, 2012; Carbone, 2013;
`Roggli, 2014; WHO/IARC, 2015; Attanoos, 2018; Carbone, 2019; Attanoos, 2020;
`Carbone, 2020; WHO/IARC 2021; Carbone 2022; Price 2022; Moolgavkar 2023).
`
`Diffuse mesotheliomas are variably associated with prior asbestos exposure and the
`strength of the association varies with anatomical tumour site, sex, and asbestos fibre
`type (Attanoos, 1997; Attanoos, 2018, Carbone, 2019; Carbone 2020; Attanoos,
`2020). The relationship between asbestos, its associated lung fibrosis/asbestosis and
`mesothelioma has also evolved over time (Attanoos, 2018; Roggli 2023).
`
`
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`FILED: ALBANY COUNTY CLERK 01/24/2024 03:32 PM
`NYSCEF DOC. NO. 632
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`INDEX NO. 908796-22
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`RECEIVED NYSCEF: 01/24/2024
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`For pleural mesothelioma arising in men, the epidemiological and mineralogical
`studies show that commercial amphibole asbestos cause the majority of such