Radiology of Asbestos-related Diseases

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1 8/25/03 9/19/03 Radiology of Asbestos-related Diseases Joan S. Hu,, Harvard Medical School Year III Gillian Lieberman, M.D.

2 Asbestos-related conditions I. Benign Pleural Disease II. III. IV. A. Pleural effusion B. Pleural plaques C. Diffuse pleural thickening D. Round atelectasis Asbestosis Malignant mesothelioma Bronchogenic carcinoma 2

3 Asbestos silicate mineral Fire-resistant, resistant, thermal & electrical insulator Insulation, brake pads, floor tiles, electric wiring, paints, cements. Serpentine fibers: chrysotile (>90%) curly & flexible Amphibole fibers: crocidolite, amosite stiff and straight Coated w/ ferritin ferruginous bodies 3

4 Imaging Modalities Chest radiograph: Screening tool International classification system for PA CXR in reference to standard radiographs Parenchymal dz: : shape, size, profusion Pleural thickening: site, width, extent, calcification HRCT: more sensitive than radiography 97% sens., 100% spec. in detection of pleural dz No international std Reserved for further eval: : clarifying pleural thickening, staging mesothelioma & lung CA, planning biopsy 4

5 I. Pleural effusion Earliest, w/n 10 yrs of exposure Hemorrhagic exudates Resolve over few MO s Diffuse pleural thickening often follows 5

6 Pt BR Pleural Effusion Bilateral pleural effusion Layered pleural effusion PA L lateral decubitus 6

7 Pleural Effusion Pt BR Pleural calcifications & thickening Pleural effusion Pleural thickening 7

8 DDx of Exudative Pleural Effusion Parapneumonic effusion TB Malignancy PE Pancreatitis Connective tissue dz Trauma Azotemia drugs 8

9 II. Pleural Plaques Fibrosis due to inflam.. reaction Usu. asymptomatic yrs after exposure 10-15% 15% calcify Conv. CT 95% sensitive, CXR 59%; HRCT 100%. 9

10 Distribution of plaques Usually from parietal pleura: Posterolateral chest wall th ribs Lateral chest wall 6-96 th ribs Dome of diaphragm (pathognomonic( pathognomonic) Mediastinal pleura Apices & costophrenic angles spared CT: anterior & paravertebral plaques Visceral plaques assoc d w/ parenchymal dz: Hairy plaques Extensive opacities 10

11 Pt WB Pleural Plaques pleural plaques 11

12 Pt SS Pleural Plaques Pleural plaques 12

13 Pt JT Pleural plaques Bilateral pleural plaques 13

14 Pleural Plaques Pt JT Calcified pleural plaques 14

15 Pleural Plaques Pt SS Calcification Pleural plaques calcification 15

16 DDx Pleural Plaques Adipose tissue (HRCT) Rib fracture Companion shadows for ribs (soft tissue) Pleural masses, e.g. mets 16

17 III. Diffuse Pleural Thickening Less specific for asbestos exposure Benign effusion inflam., thickening & fibrosis of visc.. pleura (lymphatics( lymphatics) fusion w/ parietal pleura Costophrenic angles & apices Irregular margins, continuous sheets, involves interlobar fissures (visc( visc.. pl.), resp. impairment: vs. plaques CT more sens.. & spec. than CXR (100% vs. 70%) 17

18 Diffuse Pleural Thickening Pt JM2 Pleural thickening 18

19 Diffuse Pleural Thickening Pt BR Pleural thickening 19

20 Diffuse Pleural Thickening Pt WB Pleural thickening 20

21 DDx Diffuse Pleural Thickening Organizing effusion Chronic infxn,, e.g. TB Connective tissue dz Talcosis Pleural mets mesothelioma 21

22 IV. Round Atelectasis Inflam rxn & fibrosis in pleura fibrous tissue contracts pleura folds into lung atelectasis aka asbestosis pseudotumor or Blesovsky Sx comet tail of bronchovascular struc s Usu w/ pleural thickening, volume loss Stable or shrinks w/ time MRI: T1 signal similar to liver; vasculature, visc.. pleura U/S: echogenic visc.. pleura 22

23 Pt BR Round Atelectasis CT supine Rounded atelectasis Pleural thickening Comet tail HRCT prone 23

24 Round Atelectasis Pt WB Round atelectasis w/ comet tail Pleural thickening 24

25 DDx Round Atelectasis Lung CA Pseudotumor (pleural effusion) Infection (e.g. round pneumonia, aspergillosis, histoplasmosis,, TB) sequestration 25

26 V. Asbestosis Lung fibrosis caused by asbestos dusts, +/- pleural fibrosis Dose responsive Lag yrs (short as 3 yrs w/ heavy expo) Neutrophils & macrophages release fibrogenic mediators fibrosis spreads from resp. bronchioles & alveolar ducts Lower lobes & subpleural middle lobe & lingula upper lobe in advanced dz 7-17% honeycombing (adv. dz) 26

27 CXR features of Asbestosis Ground Glass Opacities Small nodules Shaggy cardiac silhouette Ill-defined diaphragmatic contours Adv. dz: : honeycombing, volume loss 80% coexisting pleural dz (100% HRCT) Fibrous bands radiate inward from pleura 27

28 Pt JM2 Asbestosis Pleural thickening Shaggy cardiac silhouette Interstitial fibrosis Pleural plaques 28

29 HRCT for Asbestosis More sensitive than CXR Interstitial lines Parenchymal bands Early: subpleural curvilinear opacity (peribronchiolar fibrosis) GGO (alv( alv.. wall fibrosis) Subpleural dotlike nodular opacities Thickened interlobular septa Honeycombing 29

30 Pt JM2 Asbestosis GGO honeycombing Calcified pleural plaques 30

31 Asbestosis Pt WB Parenchymal band Septal thickening Pleural thickening 31

32 DDx Asbestosis Usual interstitial pneumonitis: Idiopathic pulmonary fibrosis Chronic drug toxicity Fibrosis due to collagen vascular dz (e.g. RA) 32

33 VI. Malignant Mesothelioma Pleura & peritoneum, can pericardium or tunica vaginalis testis Most common primary neoplasm of pleura Crocidolite, amosite Latency yrs Most pts die w/n 1 yr of dx. Either pleural layer CXR: usu. w/ effusion, pleural thickening retraction of chest wall Direct spread into surrounding mesothelial sacs, LN, hematogenous met 33

34 Malignant Mesothelioma Pt LF mesothelioma Pleural plaque 34

35 CT: Malignant Mesothelioma contraction of hemithorax,, extension along fissures, invasion. Nonaxial planes & MR for assessing infradiaphragmatic & chest wall invasion. 35

36 Malignant Mesothelioma Pt LF Mesothelioma (nodular thickening of pleura Pleural effusion 36

37 Pt LF Invasion Loculated pleural effusion Endobronchial invasion of distal left main bronchus Pericardial invasion 37

38 Infradiaphragmatic Invasion Pt LF Left diaphragm spleen Possible infradiaphragmatic extension adj. to spleen 38

39 DDx Malignant Mesothelioma Benign Pleural thickening infxn Diffuse pleural thickening Met adenoca Benign mesothelioma (solitary fibrous tumor) 39

40 VII. Bronchogenic Carcinoma Amphiboles (10-50x greater risk) Risk w/ combined asbestos exposure & smoking is multiplicative Variable latent period (~10-30 yrs) Anywhere in lungs 40

41 Pt JM1 Bronchogenic CA Bronchogenic CA 41

42 Pt JM1 Lymphadenopathy in Bronchogenic CA lymphadenopathy 42

43 Pt JM1 Metastasis met Met with blood products T2 susce 43

44 Bronchogenic CA Pt MF RUL adenoca 44

45 Fluorine-18 Fluorodeoxyglucose PET: Uptake of FDG in malignant mesothelioma & bronchogenic carcinoma much greater than benign pleural dz Nodal dz Less anatomic detail 45

46 F-18 FDG PET Tumor Pt MF Imaging Mediastinal lymph nodes CA 46

47 After Chemo- & Radiation Pt MF Therapy CA with spiculation 47

48 18-F F FDG PET after Chemo- Pt MF & Radiation Therapy Lymph nodes Esophagus, radiation induced changes Significant decrease in size & FDG intensity of mass 48

49 DDx Bronchogenic CA Pseudotumor Sequestration Round atelectasis Infection (fungal, granulomatous,, e.g. TB) Sarcoid Scarring Hamartoma Intrapulmonary lymph node AVM 49

50 Other Asbestos-related Diseases Peritoneal mesothelioma CA larynx & kidney Nodular pulmonary amyloidosis (?) 50

51 Review : I. Pleural Effusion Pt BR 51

52 Review: II. Pleural plaques Pt SS 52

53 Review: III. Diffuse Pleural Thickening Pt BR 53

54 Review: IV. Round Atelectasis Pt WB 54

55 Review: V. Asbestosis Pt JM2 55

56 Review: Pt LF VI. Malignant Mesothelioma 56

57 Review: Pt MF VII. Bronchogenic CA 57

58 Review: VIII. F-18 F FDG Pt MF PET Tumor Imaging 58

59 References Akira M, Yamamoto S, Inoue Y, Sakatani M. High-resolution CT of asbestosis and idiopathic pulmonary fibrosis. AJR Am J Roentgenol Jul;181(1): Begin R, Ostiguy G, Filion R, Groleau S. Recent advances in the early diagnosis of asbestosis. Semin Roentgenol Apr;27(2): Gamsu G. Computed tomography and high-resolution computed tomography of pneumoconioses. Occup Med Jul;33(7): Kim KI, Kim CW, Lee MK, Lee KS, Park CK, Choi SJ, Kim JG. Imaging of occupational lung disease. Radiographics Nov-Dec;21(6):1371 Dec;21(6): King, T.E. Jr. Asbestosis. UpToDate.com. Roach HD, Davies GJ, Attanoos R, Crane M, Adams H, Phillips S. Asbestos: when the dust settles an imaging review of asbestos-related disease. Radiographics Oct;22 Spec No:S Staples CA. Computed tomography in the evaluation of benign asbestos- related disorders. Radiol Clin North Am Nov;30(6): Stark, Paul. Imaging of pleural plaques, thickening, and tumors. UpToDate.com. 59

60 Acknowledgements Many thanks to: Dr. Michael Stella Pamela Lepkowski Dr. Hiroto Hatabu Larry Barbaras Dr. Gillian Lieberman Thanks for all your help! 60

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