Idiopathic Interstitial Pneumonia20pl... · 2018. 3. 29. · Asbestos use in Korea Production in...

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.

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

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

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%)

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


Asbestosis: subpleural dotlike or branching opacities

subpleural curvilinear lines

parenchymal bands


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

Asbestosis: subpleural dotlike or branching opacities

parenchymal band


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.

• 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

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.

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 ↓


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


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

([email protected])

Idiopathic Interstitial Pneumonia20pl... · 2018. 3. 29. · Asbestos use in Korea Production in...

Documents

Transcript of Idiopathic Interstitial Pneumonia20pl... · 2018. 3. 29. · Asbestos use in Korea Production in...