JK Amorosa

State of the Art Imaging of Occupational Lung Disease Cox, C et al Radiology 2014, 270: 681-696

Team approach: occupational med physician, pulmonologist, radiologist

Exposure hx, PE, Lab, Pulmonary function, imaging, bronchoscopy/Sx

Asbestos

fibrous mineral: amphiboles/ banned since 1970s chrysotile fibers still used in:

construction materials: roofing, siding shingles, pipe and boiler insulation, floor/ ceiling tiles

carcinogen years following asbestos exposure

Asbestos

undisturbed asbestos-containing materials: no health risk

damaged or disturbed, or deteriorate over time and release asbestos fibers into building air: health risk

WHO

200,000 people die each year from cancers related to their workplaces, mainly from inhaling asbestos fibers and second-hand tobacco smoke.

125 million people worldwide are exposed to asbestos at work and every 10th lung cancer death is related to occupational hazards, which amount to at least 90,000 deaths each year.

Occupational Lung DiseasesOccupational Lung Diseases

Occupations at Risk

Asbestos Exposure

Occupations Miners Millers Cement workers Construction Demolition Railroad workers Pipe fitters Shipyard workers Fertilizer manufacturers Brake repair Pharmaceuticals Diesel exhaust Fire fighters Aircraft workers

Plastics Steel workers Explosives Ceramics Fuels Sanders Welders Polishers Paint Boiler makers Bleach Textiles Chrome plating Floor tilers Paper industry

Pigments Oil/ Petroleum Refinery workers Chemistry Electronics Dye Bricklayers Farmers US Navy Sewer cleaners Atomic

energy Roofers Rubber

Asbestos: mineral

Composition: Silicon Oxygen Hydrogen Calcium Sodium Metals:

magnesium, iron

Characteristics: Strength Flexibility Low electrical

conductivity Resistant to heat

and chemicals Greek origin

means: inextinguishable, or indestructible

Occupational Lung Diseases Occupational lung diseases are caused

by inhaled particles,mists, vapors or gases while at work.

Asbestos Exposure

in 3000 commercial products

1940 - 1979 US 27 million people occupational exposure to asbestos

7% were engaged in primary mining, milling, and manufacturing of asbestos products

P N E U M O C O N I O S I S

LUNG DUST

Asbestos exposure

Pleural manifestations

Pulmonary manifestations

ASBESTOS EXPOSURE-Pleural

1.1. Pleural plaquesPleural plaques

2.2. Pleural effusion, benignPleural effusion, benign

3.3. MesotheliomaMesothelioma

4.4. Rounded atelectasis – always Rounded atelectasis – always associated with chronic pleural associated with chronic pleural processprocess

Asbestos Related Lung Disease: Asbestosis

Asbestosis is the term reserved for pulmonary fibrosis caused by the inhalation of asbestos fibers. Subpleural lower lobes areas - mostly

Malignant masses: lung ca

Benign mass: rounded atelectasis, pleural thickening, mass contains low density centrally, has comet tail containing crowded vessels and bronchi

Dx: Asbestos related pleural plaques, marker of exposure, usually asymptomatic

Findings: Calcified

pleural plaques

Findings: calcified pleural plaques

Judith K Amorosa

Location of pleural plaque

1991 1998

Pleural effusion

55 yo man with R chest pain

59 yo man with dull R chest pain

19971995

Mesothelioma

Pleural Based Masses, Ddx: mesothelioma or metastatic lung ca

50+ male with shoulder pain

Dx: mesothelioma

Suspect mesothelioma

Chest X-ray CT PET MR chest wall and diaphragmatic

involvement

Localized malignant mesothelioma (stage I)

Unilateral parietal or visceral pleura and pericardium

Advanced malignant mesothelioma (stage II,stage III, and stage IV) stage II, cancer in ipsilateral pleura, pericardium In stage III, cancer has spread to any of the following

areas: The chest wall. The mediastinum. The heart. Beyond the diaphragm. The peritoneum.

Cancer may have also spread to lymph nodes on the other side of the chest or outside the chest.

In stage IV, cancer has spread to distant organs or tissues.

49 yo woman with a pelvic mass

Metastatic ovarian ca

Rounded Atelectasis

Broncho-vascular bundle, “comet sign”

Rounded atelectasis

Asbestos related pleural plaques, rounded atelectasis, fibrosis: asbestosis

Asbestos Related Lung Disease: Asbestosis

Asbestosis is the term reserved for pulmonary fibrosis caused by the inhalation of asbestos fibers. Subpleural lower lobes areas - mostly

Malignant masses: lung ca

Benign mass: rounded atelectasis, pleural thickening, mass contains low density centrally, has comet tail containing crowded vessels and bronchi

Dx: Asbestosis and Pleural plaques

Pattern: Rounded atelectasis

Asbestos exposure

Atypical

Silicosis

83 m

Emphysema, plaques, asbestosis,Lung ca

Asbestosis; Ddx:IPF, scleroderma

Development of lung disease is dependent on Intensity of

exposure Duration of

exposure Physiologic and

biologic susceptibility of host

HRCT: Septal and centrilobular thickening, long scars, parenchymal bands, subpleural lines, honeycombing

Radiograph: lower and mid lung zone reticulo-nodular process, causing “shaggy” heart border, honeycomb

AsbestosisAsbestosis

Judith K Amorosa

Dx: Asbestosis

Findings: Calc

plaques Pulmona

ry fibrosis

Judith K Amorosa

Lung Cancer

NIOSH: National Institute of

Occupational Safety and Health

Silicosis

Silicosis

Small well-defined nodules of 2 to 5mm in diameter in both lungs

Upper lobe predominanceNodules may be calcifiedCentrilobular and subpleural distributionSometimes random distributionIrregular conglomerate masses, known as progressive massive fibrosisOften hilar and mediastinal lymphnodes.

Miliary pattern: TB, histo, coccydio, mets, silicosis

Judith K Amorosa

Alveolitis – acute silicosis

Dx: Complicated Silicosis, CWPPMF or conglomerate massesFindings:

Upper lobe symmetrical masses

Upper lung nodules

Complicated silicosis: PMF

Silicosis, complicated (PMF, Conglomerate mass), Ddx: Sarcoid, TB

 Complicated silicosis in a 58-year-old man.

Kim K et al. Radiographics 2001;21:1371-1391

©2001 by Radiological Society of North America

Pattern

Silicosis- upper lung nodules

Asbestosis -lower lung linear opacities

Pattern: Consolidation

Acute silicosis Hypersensitivity pn Ardystil syndrome (Spain-

printing fabric by spraying with pulverized dyes)

Flockworkers lung disease (Rhode Island car upholstery)

radiologyassistant

Acute exposure-inhalation to aerosolized (airborne) fibers, fumes, mists, dust – toxins, chemicals

Pattern: GG

Acute Silicosis Hypersensitivity pn Hard metal Flockworkers lung Indium-tin oxide

Rarely Chronic beryllium Asbestosis Siderosis Accelerated

silicosis

HP glassblower

60 m GG pattern

Pattern: crazy paving

Acute silicosis Indium-tin oxide (ITO)

Eosinophilic Pneumonia

Pattern: centrilobular nodules Acute silicosis Hypersensitivity pn Siderosis Flock workers lung Ardyll syndrome ITO Byssinosis Accelerated

silicosis

Rarely: Chronic silicosis CWP(Coal

Workers’s P) Aluminosis Hard metal lung

radiologyassistant

Hard Metal Lung Disease(HMLD), also called Giant cell Interstitial Pneumonia (GIP)

Characterized by “cannibalistic” multinucleated giant cells in airspaces on BAL

Powdered tungsten carbide and cobalt

Called sintered carbides, hard as diamond

Pattern: Perilymphatic/subpleural nodules

Chronic Silicosis CWP Chronic beryllium

dis Talcosis Calcinosis Stannosis

HMLD Aluminosis Accelerated

silicosis Asbestosis

Pattern: Fibrosis (UIP, NSIP patterns)

Asbestosis Hypersensitivity pn

Atypical Chronic silicosis CWP Chronic beryllium HMLD Siderosis Ardystil S Flock workers lung ITO Aluminosis

Pattern: Masses

Complicated silicosis (PMF)

CWP Talcosis

Atypical Siderosis Chronic beryllium

disease

Pleural Plaque

Etiologies of Interstitial Pulmonary fibrosis include

1. Scleroderma2. Idiopathic3. Asbestosis4. Silicosis

Acute Hypersensitivity Pneumonia

83 f

AIP vs HP

In the secondary Pulmonary Lobule the bronchiole is located

1. Along the pulmonary vein

2. Along the interlobular septum

3. Along the pulmonary artery

American Journal of Roentgenology. 2001;177: 501-519. 10.2214/ajr.177.3.1770501

Sequiosis (red wood)

Judith K Amorosa

Mushroom workers’ pneumoconiosis isorgani

c

Secondary pulmonary lobule

supplied by terminal

bronchiole in the center, parallelled by the centrilobular artery Pulmonary veins & lymphatics run in the periphery of

the lobule within the interlobular septa

Hypersensitivity pneumonitis

Respiratory bronchiolitis in smokers

infectious airways diseases (endobronchial spread of tuberculosis or nontuberculous mycobacteria, bronchopneumonia)

Uncommon in bronchioloalveolar carcinoma, pulmonary edema, vasculitis

Organic Pneumoconiosis is1. Asbestosis2. Mushroom worker’s

disease3. Silicosis4. Berylliosis

Asbesto

sis

Mush

room w

orke...

Silic

osis

Berylliosis

0% 0%0%0%

Silicotic nodules

1. Peribronchiolar2. Upper lobes and

perihilar3. Lower lobes4. Coalesce: PMF

Peribro

nchiola...

Upper l

obes an...

Lower lo

bes

Coalesce: P

MF

0% 0%0%0%

Organic Pneumoconiosis is1. Asbestosis2. Mushroom worker’s

disease3. Silicosis4. Berylliosis

Asbesto

sis

Mush

room w

orke...

Silic

osis

Berylliosis

0% 0%0%0%

Subacute HP

Ill defined centrilobular GGO nodules

Relative sparing c air-trapping

Eur Respir Rev June 1, 2010 vol. 19 no. 116 97-108

Organic

Hay Malt Mushroom Barley Cotton (byssinosis) flax

Pneumoconiosis - most common

Asbestosis Berylliosis Byssinosis CWP (Coal Workers Pneumoconiosis) Silicosis

Kun –Kim et al November 2001 RadioGraphics, 21, 1371-1391.

Reactions

Acute Inflammation Edema

Chronic Fibrosis Granuloma

jd.

jd

jd

Jd Ddx: Sarcoidosis, Complex silicosis

Siderosis

Iron ore miners Welders Steel workers

Fibrosis Obstructive airway

disease Lung ca

Byssinosis (brown lung)

Exposure to dust from cotton, hemp and flax

Causes blockage of small airways

?? Endotoxin release from cell walls of Gm-bacteria

Flockworkers lung disease At Microfibres Inc in Rhode Island

two young men developed interstitial lung disease

Plant made carpet-like material for car upholstery. Workers cut long nylon strands into short nylon fibers called flock. The fragments were in the respirable size and were inhaled by the workers

ITO Indium tin oxide

Transparent , colorless, when deposited as a thin film on glass, it acts as an electrical conductor

Used for display technology: LCD, plasma, electroluminescent, touch screen technology

ABR questions about

application, analysis, management