Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
김 정 숙([email protected])
동국대학교 일산병원
Contents
General information of asbestos
Asbestosis
Asbestos-related Lung cancer
Pleural plaque
Diffuse pleural thickening
MPM (malignant pleural mesothelioma)
Asbestos
Serpentile (사문석계 ): chrysotile (백석면)
Amphibole (각섬석계):amosite (갈석면)
crocidolite (청석면)
anthrophyllite (직섬석석면)
tremolite (투각섬석면)
actinolite (양기석석면)
Asbestos use in Korea
Production in domestic mine:Started in 1930s, closed in 1990
Highest production: 15,933 tons in 1982
Chrysotile, some tremolite
Import: mostly from Canada (Chrysotile)
Highest consumption:
95,000 tons in 1992
Ban: 2009
Total use:
2.0 ~ 2.4 M ton in total
Asbestos Mines and Factories in Korea
Asbestos mine
Asbestos factory
Asbestos mine direction
Asbestos factory
directional distribution
www.krcard.org
Background
1990. MBC news: 부산 제일화학(석면방직공장)
2007. Neighborhood problem around a factory:
Malignant mesothelioma x 10
2009 & 2010. Neighborhood problem around mines & factories:
Pleural plaque; 2.8 ~ 11.5%
Asbestosis; 1.3 ~ 2.9%
2010. Asbestos damage relief act
(석면피해구제법)
2011. Asbestos safety management act(석면안전관리법)
Background
직업성 보상(산재) 환경적 보상
보상관련 규정
주체 고용노동부 환경부
주관 근로복지공단 환경공단
직업력/노출력 명확 ?
보상액 >>>
판정 기준 CXR (ILO standard film) CT (early minimal Ds.)
영상의학과 역할 <<
Future Estimated Incidence
Asbestos consumption: 200 M ton
Malignant mesothelioma: 11,760 (1 case/170ton)
peak 520 case/year
Asbestos related lung cancer:
11,760 (equal to MM)
Japan; 30% of MM
France; 200% of MM
Asbestosis: 9,408
France; 80% of MM
Pleural disease: 117,600
France; 10 fold of MM
Kim, 2008
MM: Future Estimated Incidence
1950 1970 1990 2010
1990 2010 2030 20501970
: Netherlands
: Japan
: Korea
1990
2009
2010
2045
1965
1991
1975
2005
1990
2017
2000
2030
Industry
ExpansionPeak MM rising
Asbestos
banMM peak
Netherlands 1950 1965 1990 1991 2017
Japan 1960 1975 2000 2005 2030
Korea 1970 1990 2010 2009 2045(?)
Paek, 2008
Asbestos-related Diseases
Parenchymal abnormality: asbestosis
lung cancer
Pleural abnormality: benign pleural effusion
pleural plaques
diffuse pleural thickening
malignant mesothelioma
round atelectasis
AbnormalityLatency
(years)
Approximate frequency in
asbestos-exposed workers (%)
Benign pleural effusion 5 ~ 20 3%
Pleural plaques 15 ~ 30 16 ~ 80%
Calcified pleural plaque 20 ~ 40 10 ~ 50%
Diffuse pleural thickening 10 ~ 40 7 ~ 13%
Asbestosis 20 ~ 40 15 ~ 30%
Lung cancer > 15 20 ~ 40% (lifetime risk)
Malignant mesothelioma 15 ~ 40 10% (lifetime risk)
Asbestosis
Diffuse interstitial pneumonitis and fibrosis
caused by inhalation of asbestos fibers
m/significant change in lung parenchyma
Exposed to high dust concentration
for a prolonged period
Correlation btw. the presence and severity of pleural
disease and asbestosis (dose-related ds.)
Criteria for Dx. of nonmalignant ARLD by ATS: 2004
• Evidence of structural pathology consistent with ARLD as documented by imaging or histology
• Evidence of causation by asbestos as documented by the occupational and environmental history, markers of exposure (usu. pl. palques), recovery of asbestos bodies or other means
• Exclusion of alternative plausible causes for the findings
Am J Respir Crit Care Med 2004;170:691
Asbestosis
Evidence of structural change (one or more)
1. Imaging: CXR, HRCT etc.(s, t, r opacities, greater 1/1)
2. Histology: asbestosis on tissue microscopic exam.
Evidence of plausible causation (one or more)
1. Occu., Envir Hx. of exposure (w/ plausible latency)
2. Markers of exposure (e.g., pleural plaques)
3. Recovery of asbestos bodies
Evidence of functional impairment (one or more / not require)1. Signs & Sx.(including crackles): not specific
2. Change in ventilatory function (restrictive, obstructive patterns)
3. Impaired gas exchange (e.g., reduced diffusing capacity)
4. Inflammation (e.g., by BAL)
5. Exercise testing
Am J Respir Crit Care Med 2004;170:691
Criteria for Dx. of nonmalignant ARLD
Asbestosis
CXR: no known pathognomonic radiographic findings
Early; small irregular opacities
w/ fine reticular densities
Advanced; honeycombing
lung bases
pleural plaque (+): 90%
Courtesy of Dr. I Ebihara, Research Center for Occ. Ds.
Courtesy of Dr. I Ebihara, Research Center for Occ. Ds.
Courtesy of Dr. I Ebihara, Research Center for Occ. Ds.
Asbestosis: problems of CXR
18% of pts. with biopsy proved pulmonary fibrosis
has no identifiable radiographic abnormalities
early minimal change: CXR (-)
80% of pts. had chest radiographic findings
(according to the ILO classification)
that did not correlate with the histopathologic
grades
Kipen HM et al. Br J Ind Med 1987;44:96-100
Materials and Method
Retrospective review of the CT images
200 Asbestosis
11 IPF
From 2011 Jan. to 2013 May,
asbestosis compensated by the asbestos damage relief
law in Korea and IPF were enrolled from nationwide
hospitals.
This subject is supported by Korea Ministry of Environment
as "The Environmental Health Action Program"
Asbestosis
CT
Early: subpleural dotlike or branching opacities
subpleural curvilinear lines
parenchymal bands
parenchymal changes adjacent plaque
intralobular interstitial thickening (intralobular lines)
interlobular septal thickening
Advanced: honeycombing,
traction bronchiectasis & bronchiolectasis
*patch GGO (ground-glass opacities)
Site: lower, posterior, subpleural (peripheral) portionAkira M et al. AJR 2003;181:163-169
Asbestosis
Subpleural dotlike opacities (97.5% vs. zero)
CT: centrilobular nodular lesion
a few millimeters from pleura
but seldom touch it
Path.: peribronchiolar nodular fibrosis
w/ subsequent involv. of alveolar duct
Subpleural dotlike opacities
Subpleural dotlike opacities
Asbestosis
Subpleural curvilinear lines (17% vs. zero)
CT: linear areas of increased attenuation
within 1 cm of the pleura
& parallel to the inner chest wall
Path.: peribronchiolar fibrotic thickening
w/ flattening & collapse of alveoli
Subpleural curvilinear lines
Subpleural curvilinear lines vs. Dependent atelectasis
Subpleural curvilinear lines
Asbestosis
Parenchymal bands (50.5% vs. zero) CT: linear, nontapering densities (2 ~ 5 cm)
extend through the lung to contact the pleural
surface
Path.: subpleural fibrosis extended bronchovascular
sheath
Parenchymal bands
Parenchymal bands
Asbestosis
Parenchymal changes adjacent plaque (39.5% vs.
zero)
Parenchymal bands; 54.4%
Rounded atelectasis; 8.9%
P-bands (54.4%)
Parenchymal changes adjacent plaque (39.5% vs. zero)
R-atelectasis (8.9%)
Parenchymal changes adjacent plaque (39.5% vs. zero)
Asbestosis
Intralobular interstitial thickening (95% vs. 100%) CT: a fine weblike or netlike appearance to
lobular parenchyma
sometimes connected to the most pph. PA brs.
Path.: peribronchiolar fibrosis
Interlobular septal thickening (92.5% vs. 100%) CT: short lines contacting the pleural surface
perpendicularly or multiple polygonal lines
Path.: thickening of interlobular septa
Intralobular intersititial thickening
Intralobular lines & interlobular septal thickening
Asbestosis
CT
Advanced: honeycombing,
traction bronchiectasis & bronchiolectasis
*patch GGO (ground-glass opacities)
Site: lower, posterior, subpleural (peripheral) portion
Honeycombing (17.5% vs. 81.8%)
Traction Be (43.5% vs. 100%)
GGO (15.5% vs. 100%)
Courtesy of Dr. I Ebihara, Research Center for Occ. Ds.
Courtesy of Dr. I Ebihara, Research Center for Occ. Ds.
DDx. Asbestosis vs. IPF
Clinical, radiologic, and histopathologic features:
same as other forms of diffuse IPF
Prognosis & Tx.:
- Asbestosis; gradual onset
very slow or absent of progression
removal from exposure
- IPF; more variable and rapid onset & progression
steroid + cyclophosphamide or azathioprine
DDx. Asbestosis vs. IPF
Asbestosis: subpleural dotlike or branching opacities
subpleural curvilinear lines
parenchymal bands
parenchymal changes adjacent plaque
parietal pleural thickening (78~83% vs. 4%)
IPF: honeycombing
visible intalobular bronchioles
bronchiolectasis within consolidation
Both: GGO, interlobular septal thickeningAkira M et al. AJR 2003181:163-169
DDx. Asbestosis vs. IPF
Asbestosis: subpleural dotlike or branching opacities
parenchymal band
parenchymal changes adjacent plaque
pleural plaque
Hx. of asbestos exposure
subpleural curvilinear line
honeycombing (?)
Differentiate Asbestosis from IPF
Lung cancer: m/prevalent malignant asbestos-related
pathology
ARLC: a/w asbestos exposure in a dose-response
relationship; 3-8% of all lung cancers
ARLC: a highly delayed onset of 20 to 40 years
following initial exposure
No significant differences between ARLC and non-ARLC regarding
cell type or location.
Asbestos-related Lung Cancer (ARLC)
Prazakova S, et al. Clin Respir J 2014;8:1
Nielsen LS, et al. Archives of envir & occ health 2014;69:191
All 4 major histologic types
The greater the exposure to asbestos,
the higher the risk for lung cancer
: 20-25% of heavily exposed pts.
Minimum lag-time: 10 yrs.
Cigarette smoking: synergistic effect
This subject is supported by Korea Ministry of Environment
as "The Environmental Health Action Program"
Asbestos-related Lung Cancer (ARLC)
Asbestosis & Lung cancer
Relative risk of Lung cancer
- low level asbestos exposure: slight increase
- high level asbestos exposure: higher
pts. w/ Asbestosis: 2.3 ~ 9.0
pts. w/o Asbestosis: 1.4 ~ 3.7
Asbestos fiber burden (carcinogen)
Fibrosis
Scand J Work Environ Health 1997 ; 23: 311-316
Prognosis of ARLC
5 year survival: 9%
Limitation: low operability
d/t restrictive PFT
d/t asbestosis or plaque
67/M, Slate factory worker for 20yrs.
67/M, Slate factory worker for 20yrs.
• 75-year-old male with adenocarcinoma in left upper lobe
• Residence near the asbestos mine from the birth
• 55-year-old male with squamous cell carcinoma in left upper lobe
• Construction worker for 24 years
Radiologic diagnostic Guideline of ARLC
Pleural Plaque Asbestosis Approval
Specific Specific Approval
Nonspecific fibrosis Approval
None Approval
Equivocal or None Specific Approval
Nonspecific fibrosis Refer to exposure Hx.
None Refer to exposure Hx.
Asbestos-related Pleural Diseases
Pleural plaque: m/c
Diffuse pleural thickening: less/common
Benign asbestos-related pleural effusion:
least/common
Malig. mesothelioma: least/common, m/feared
Round atelectasis: an effect of asbestos-induced
pleural disease
Pleural Plaques
Circumscribed areas of fibrous thickening
m/c manifestation
A marker of exposure
Increases incidence with dose
but no linear correlation
btw. plaque severity & total dust exposure
Pleural Plaques
Involvement: parietal pleura, interlobar fissure (+)
visceral pleura (-/+)
Bilateral, symmetric
Discontinous in early stage
Site: lower half of thorax (6th~9th ribs)
paravertebral pleura
diaphragmatic pleura; pathognomonic
mediastinal pleura; 40% on CT
spare the apices and costophrenic sulci
Pleural Plaques
CXR: difficult identification of noncalcified plaque
focal smooth areas of pleural thickening
paralleling the inner margin of
the lateral thoracic wall
Sensitivity: 50%-80%
CT: smooth and sharply defined thickening
70/M, Chemical plant worker for 38 yrs.
Plaque
Courtesy of Dr. I Ebihara, Research Center for Occ. Ds.
Thick section CT vs. HRCT
Courtesy of Dr. Kim Y. Ewha Womans Univ.
Supine HRCT vs. Prone HRCT
Courtesy of Dr. Kim Y. Ewha Womans Univ.
DDx. Noncalcified Pleural Plaques
CXR: Normal extrapleural fat
Muscles; serratus anterior m.
CT: Visceral pleural thickening
Muscles; transverse thoracis m.
subcostalis m.
Intercostal veins
DDx. Visceral Pleural Thickening
Parietal PT: smooth and sharply defined app.
Visceral PT: ill-defined or irregular appearance
because of fibrosis of adjacent lung
parenchyma
DDx. Muscles
Muscles: smooth, uniform in thickness,
bilateral symmetric
- transverse thoracis m.; anterior
at the level of the heart and adjacent
to the lower sternum or xiphoid process
internal to the anterior ends
of ribs or costal cartilage
- subcostalis m.; posterior
internal to one or more ribs
Innermost intercostal m.
Inner & outer intercostal m.
Transversus thoracis m.
Transversus thoracis m.
Subcostalis m. & intercostal vein
Subcostalis m. Intercostal vss.
Calcified Pleural Plaques
Ca++ of plaque: 10-15%, over 20 years
In profile: linear areas of calcific density
along the chest wall
En face: irregularly outlined areas of Ca++,
sometimes “holly leaf” appearance
DDx. Calcified Pleural Plaques
Infectious diseases, esp. Tbc. pleurisy
Diffuse Pleural Thickening
Less common
Usually related to a previous asbestos-related effusion
Often a/w round atelectasis
Restrictive PFT: FVC and DLco ↓
Diffuse Pleural Thickening
ILO: PT extending out of the costophrenic angle and
a/w blunting of the sulcus
McLoud et al.: non-interrupted pleural density
extending over at least ¼ of the chest wall,
w/ or w/o CPA obliteration
Abercle et al.: at least 5cm in lateral dimension &
8cm in craniocaudal dimension
more significant functional impairment
most useful
Diffuse Pleural Thickening
CXR: PT extends up the lateral chest wall
from the obliterated CPA
maximum ≧ 5 mm
bilateral 1/4 or more of lateral chest wall
unilateral 1/2 or more of lateral chest wall
CT: PT extends more than 8cm craniocaudally,
5cm width
3mm thickness
Malignant mesothelioma
m/c primary neoplasm of the pleura
Latent period: minimum 10yrs. / 30 ~ 40 yrs.
Risk of MM in an asbestos worker: 10% over lifetime
Attributable risk by asbestos: 80~90%
occur w/ low asbestos exposure
Smoking: no influence
Peritoneal MM.: higher level of exposure than
pleural MM.
Occ. / Envir. Exposure Frequency Comments
Construction, Demolition 79
Automobile repair 15 Changing break lining
Shipbuilding repair, making 12
Asbestos textile 8 Weaving
Refinery 4
Asbestos cement 3 Construction material production
Boiler maker 3 Changing heat insulation
Environmental exposure 86Residence of A-mine or demolition,
repairing slate building
Others 77 Policeman, officer, teacher, farmer, etc.
Total 287
Chest Radiograph
Unilateral pleural effusion: 30~80%
Diffuse pleural thickening: ~60%
Pleural mass: 45~60%
Contracted ipsilateral hemithorax
w/ or w/o mediastinal shifting
CT
Unilateral pleural effusion
• Can be the only finding of early stage of MPM
Pleural thickening
• Nodular, discontinuous, circumferential or rind-like
• Mediastinal, fissural, diaphramatic pleura
Pleural mass ( > 3 cm)
Contracted ipsilateral hemithorax
Mediastinal shifting
Nodular & discontinuous pleural thickeningUnilateral pleural effusion
Circumferential pleural thickening Fissural pleural thickening
Pleural mass Contacted hemithorax
Other additional CT findings
Pleural plaque
Asbestosis
Pleural plaques
LNs in MPM
Internal mammary lymph nodes; 52%
Cardiophrenic lymph nodes; 46%
Retropleural lymph nodes
*Bronchopulmonary or hilar lymph nodes; rare
Internal mammary lymph node Cardiophrenic lymph node
Imaging findings of MPM
Unilateral pleural effusion
Pleural thickening
Pleural mass
Contracted ipsilateral hemithorax (46% vs. 21%)
LN: frequent internal mammary & cardiophrenic LN
rare bronchopulmonary & hilar LNs
Pleural plaque
Materials and Method
From 1997 to 2012, pathologically confirmed MPM and MPD
cases were enrolled from nationwide tertiary hospitals.
Lung pathologists firstly reviewed the pathologic data to
confirm the diagnosis.
Cases without thoracic MDCT scans were excluded.
Retrospective review of the CT images of 194 patients; 134 MPM
60 MPD
All 194 cases were histologically confirmed by; Sonography-guided needle biopsy of the pleura
Thoracoscopic pleural biopsy
Open thoracotomy
3rd WCTI. Kim et al, Multidetector CT findings regarding differential diagnosis of malignant pleural
mesothelioma and metastatic pleural disease: a preliminary report
MPM MPD
Pleural thickening circumferential discontinuous
Diaphragmatic pleura >
Fissural pleura >
Pericardial involv. >
Lymph node <
Lung metastasis <
Plaques + -
Asbestosis + / - -
Asbestos exposure + -
MPM vs. MPD
Diagnostic Checklists of *ARDs.
CT FindingsPlaque or
Asbestosis감별 추가
UIP/IPF pattern + Asbestosis
Lung cancer + Asbestos-related Lung ca.
Malig. pleural ds. + Malig. Mesothelioma
*ARDs.: Asbestos-related diseases
참고문헌 CT characteristics of pleural plaques related to occupational or environmental
asbestos exposure from South Korean asbestos mines. KJR 2015;16(5):1142
석면관련폐암의영상진단. 대한영상의학회지 2015;73(6):347
CT findings in people who were environmentally exposed to asbestos in Korea.
JKMS 2015;30:1896
Multidetector CT findings and differential diagnoses of malignant pleural
mesothelioma and metastatic pleural diseases in Korea. KJR 2016;17(4):545
Radiologic diagnosis of asbestosis in Korea. KJR 2016;17(5):674
참고 web site
Guidelines for the use of the ILO international classification of radiographs of
pneumoconiosis, revised edition 2011
http://www.ilo.org/safesork/info/publications/WCMS-168260/lang--fr/index.htm
대한흉부영상의학회석면질환연구회 http://kstr.radiology.or.kr/
석면피해구제센터 http://www.env-relief.or.kr