The higher percentage of MPeM in all
The higher percentage of MPeM in all MM cases in the female Amiloride HCL with respect to the males could be due, in part, to the role of the misclassification of the ovarian tumours, as well as of other abdomen contiguous tumours [, , ]. Ovarian tumours are much more frequent than MPeM and were reported in 2008 as the second leading cause of gynaecological cancer death worldwide : therefore a small percentage of cases of a more frequent cancer misclassified as cases of a very rare cancer could decrease the ratio .
Ten municipalities out of 17 were located in NW and NE Regions. Apart from Casale Monferrato (asbestos-cement plant that constituted the majority of the workforce), no other municipalities showed excesses in both genders (Table 1).
In 3 municipalities (2 in NW and NE, one in C) the excess was detected in only women : in one of these (Bologna) railway carriages construction and repair activities are located), textile industry in Firenze and Grugliasco; in the latter, where the industry used asbestos-materials, also MM and MPM excesses were found only in women  widely employed in textile industry.
Excesses of MPeM mortality in male population only were detected in eleven municipalities. In 8 out of these, activities representing known sources of asbestos exposure were identified: asbestos-cement plants operating in the past in Broni and Bari, shipyards in Sestri Levante, where one of the oldest and biggest Italian shipyards has been operating since 1898, shipbuilding and repair in Ronchi de’ Legionari, Gorizia, Livorno and Castellammare di Stabia; Fidenza is close to a municipality where an old oil refinery was located. In these industries the work-force was characterized by a high percentage of men. In 3 municipalities with excess of MPeM mortality in male population no asbestos exposure sources have been identified. An asbestos-cement plant was operating in the past in Syracuse, and a railway carriages asbestos removal facility in Avellino, where the excesses were observed in overall population. The excesses in areas characterized by the presence of shipyards and shipbuilding and repair are in agreement with the several articles that have documented the presence of asbestos-containing materials in vessels and the risk of mesothelioma in ship-workers, as reported in previous paper .
Cluster analysis, besides confirming some findings of SMR municipal analysis, i.e. the excesses in Casale Monferrato, Sestri Levante, Gorizia and Castellammare, provided evidence of excess risk in Chiuro, near a talc mine operating in the past. Three clusters (Casale Monferrato, Gorizia, Castellammare di Stabia) correspond to the areas that generated significant clusters of MPM mortality , even if including a lower number of municipalities.
The present first investigation of MPeM mortality, by municipality of residence at national level detected significant excesses in areas with higher frequency of MPM and, supposedly, with higher impact of asbestos, in agreement with the literature . In a few cases, the excess of MPeM was not associated with a concurrent MPM excess. Our results concerning Northern Italy are consistent with the location of major industrial settings in this area of the country.
Conclusions In general terms, most municipalities where excesses of MPeM were observed are also characterized by excesses of MPM. One hypothesis is that asbestos exposure levels might have been particularly elevated . The present results confirm the need to include in the national epidemiological surveillance plan of MM mortality, MPM and MPeM, separately. Considering the peculiarities of MPeM epidemiology, it is warranted to develop a specific focus on MPeM mortality, using the information of concordance (or lack of concordance) with MPM mortality integrated with the incidence date of ReNaM, in order to advance in the understanding of determinants of mesothelioma sites in asbestos carcinogenicity.