Radiology of Occupational Chest Disease A. Solomon L. Kr,eel Editors Radiology of Occupational Chest Disease With 225 Illustrations Springer-Verlag New York Berlin Heidelberg London Paris Tokyo Albert Solomon, M.D. Professor and Head of Department of Radiology, Tel-Aviv Medical Center, Ichilov Hospital, 64-239 Tel-Aviv, Israel Louis Kreel, M.D. Professor, Newham Hospital, Plaistow, London NWll 7JB, U.K. Library of Congress Cataloging-in-Publication Data Radiology of occupational chest disease / A. Solomon, L. Kreel, editors. p. cm. Includes index. I. Lungs-Dust diseases-Diagnosis. 2. Lungs-Radiography. 3. Occupational diseases - Diagn,osis. I. Solomon, A. (Albert) II. Kreel, Louis. [DNLM: I. Lung Diseases-radiography. 2. Occupational Diseases. WF 600 R129] RC773.R23 1989 616.2'40757-dcl9 DNLMIDLC 88-38205 © 1989 by Springer-Verlag New York Inc. Softcover reprint of the hardcover 1st edition 1989 All rights reserved. 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The publisher makes no war ranty, express or implied, with respect to the material contained herein. Typeset by Publishers Service, Bozeman, Montana. 9 8 7 6 5 4 3 2 I ISBN-13:978-1-4612-8161-0 e-ISBN-13:978-1-4612-3574-3 DOl: 10.1007/978-1-4612-3574-3 Introduction This text is in no danger of incomplete identification of where it should fit in the bibliographical spectrum of radiological monographs. It can be placed in many areas - radiology of the chest, !lccupational diseases, pneumoconioses, clinical medicine. In each, it would be informative and helpful. In part, this is inherent in the subject but, equally, it reflects the good judgment ofthe editors in selecting both subjects to be covered and contri butors who could succeed in their delineation in terms of current usage and current issues. Radiology of lung diseases has deep roots. Roentgen announced his dis covery of x-rays in 1895. By the next year, the new technique was used to study lung disease. On October 1, 1896, Francis H. Williams was able to report in the Boston Medical and Surgical Journal, "I have examined about 40 cases of pulmonary tuberculosis ... " In his classic text, The Roentgen Rays in Medicine and Surgery, published in 1901, thoracic diseases took pride of place in the 658-page volume. It is of further interest that just as Glyn Thomas here emphasizes the importance of technique, so did Wil liams in his writings. Solomon and Kreel are perceptive descendants in another way, to our immense advantage, with their clear judgment that the radiological descriptions be focused on and judged by their clinical applicability. This takes us back even further. The first monograph on illness in an occupa tional group was Paracelsus' monograph Diseases ofM iners, written during the 1530s (but not published until 1567). The first group of occupational diseases reported, then, were the pneumoconioses and their status more than 400 years later is detailed here. Laced through the pages that follow are three governing themes that not only make their study profitable in terms of data and knowledge but also encourage their practical utilization for clinical management, public health, and prevention of disease. A central perspective is the epidemiological background against which observations are presented and evaluated. With occupational lung disease, as with pulmonary medicine in general, we have learned not only to judge radiological findings in relation to the individual patient but also to see where they fit in broader population terms. The radiologist, as do the vi Introduction pathologist and the clinician, frequently now contributes to epidemio logical research. Witness the extensive discussion in this volume of the International Labour Office (lLO) Classification, where the radiologist voluntarily accepts the constraint of describing what is seen in statistical terms and is concerned not only about what is seen on the film but also about selective bias in the population studied. This has long been a concern ofthe ILO in its efforts to provide suitable classifications for radiographs of the pneumoconioses. This was true for the 1930 Johannesburg classification's emphasis on silicosis, the later 1950 Sydney and 1958 Geneva classifications' focus on coal workers' pneumo coniosis, as well as the 1971 and 1980 classifications extending radiologi cal categorizations to encompass asbestos-associated disease. Indeed, the ILO has clearly stated the purpose of its Classifications - "for epidemiolog ical use." The capable authors have seen to it that clinical relevance is no mere correlation of associations between clinical abnormalities and x-ray shadows. Rather, significant current issues are presented, with the poten tial contributions of radiological findings. [Williams had, in a way,_ promised this (in 1901), with his remark that "X-rays are a most effective method of showing how great a role the imagination may play when using auscultation and percussion:'] Thus, we have discussion of the critically important concepts of latency; dose/disease response relationships (quite different in coal workers' res piratory disease and asbestotic pleural pulmonary disease); the recent rec ognition of the importance of small airways disease even in the absence of cigarette smoking; differentiation between diseases included in "cm-onic obstructive pulmonary disease" and the pneumoconioses; discrepancies between radiological, clinical, and pathological changes; the importance of neoplasms, especially bronchogenic carcinoma and pleural mesothelioma; and similar problems. Radiological/clinical discussions include the rela tionship between the microscopic fibrosis seen in cigarette smokers' lungs and the pneumoconiotic fibrosis observed in dust diseases, debated for a decade and clarified only recently by the radiological studies of CastalIan and his colleagues and the analytical discussions in 1988 of Blanc and Gamsu. Issues such as the possible importance of different fiber types; "Caplan's syndrome" and rheumatoid pleural-pulmonary disease among dust-exposed individuals; the growing recognition of the clinical and func tional importance of pleural fibrosis, particularly when diffuse; the func tional importance of visceral pleural fibrosis (as well as parietal); pseudotumors or "folded lung;" and the occurrence of pneumoconioses with less widespread exposure to such dusts as bentonite, talc, kaolin, and beryllium. Brief exposure potentially producing mesothelioma is noted with the concomitant knowledge that fibrotic changes in the lung paren chyma or pleura may be minimal or absent. There is also discussion of such less commonly acknowledged differences between silicosis and asbestosis as acute pneumoconiosis in the former, but very rare in the latter, as well as the same generalization for pulmonary tuberculosis complicating silico sis but not increased with asbestos exposure. I well remember the first meeting, at Mount Sinai, of the Working Group established by the International Union Against Cancer (lUCC). Clinicians Introduction vii and radiologists such as Eugene Pendergrass, G.K. Sluis-Cremer, and Ben jamin Felson were gently guided along epidemiological lines by the skill and good humor of lnhn Gilson, toward the development of an extended Classification of Radiographs of Pneumoconiosis. After additional meet ings in Cincinnati at the U.S. Public Health Service's laboratories, this became the V/C Classification (VICC/Cincinnati), and later evolved into the ILO's 1971 and 1980 Classifications. This volume brings us many steps further, to the integration of clinical and radiological understandings. In this, it is a culmination of almost 100 years of medical advances and, by its example of continuity, provides the foundation for the additional progress that will be made. Irving 1. Selikoff, M. D. Mount Sinai School of Medicine of the City Vniversity of New York Preface The chest radiograph is crucial in monitoring the effect of occupational exposure. Not all radiographic changes are accompanied by pulmonary impairment, nor in fact are the changes necessariIY.a result of inhalation of offending particles; for example, advancing age and smoking, in the absence of dust exposure, may lead to the development of irregular opaci ties in the lung and cause confusion in monitoring the worker at risk. Although the body can adapt to most minor respiratory insults encountered daily, there are still many occupations where workers are exposed to high concentrations of inhaled agents, causing a pathological lung response and associated radiographic changes. The chest radiograph in the pneumo conioses is valuable because there is a relationship between the extent and the profusion of opacities present in the radiograph and the retention of lung dust. This relationship is particularly reliable in coal worker's pneumoconiosis. Immunological responses may occur as a result of inhaled organic and nonorganic particles; in this regard the host reaction is unpredictable. Accurate assessment of the chest radiograph requires an awareness of these variations. An international coding system for recording lung changes following occupational exposure has been provided by the International Labour Organization classification. Familiarity with the classification and its application permits a standard reporting of chest radiographs and a univer sal means of communication. The contributors to this book are well versed in the interpretation of chest roentgenograms associated with occupational diseases. Their collec tive expertise is offered to encourage both clinicians and radiologists to expand their interest in the complexities of occupational chest diseases. Acknowledgments: The editors wish to acknowledge the Medical Bureau for Occupational Diseases, Johannesburg, South Africa, Vincent Wright Radiologic Museum of the Bureau for Occupational Diseases, and Mr. Cecil M. Weintraub, Surgeon and Photographer, for their assistance in the preparation of this book. Albert Solomon Contents Foreword by Irving 1. Selik.off . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Preface. . . . . . . . . ....' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Contributors ............................................ Xl Radiography of Occupational Chest Diseases ............. . R. Glyn Thomas 2 Classifying Radiographs of the Pneumoconioses. . . . . . . . . . . . 9 R. Glyn Thomas 3 Clinical and Functional Aspects of Occupational Chest Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Jeffrey A. Golden and Gerald L. Baum 4 Radiological Features of Asbestosis. . . . . . . . . . . . . . . . . . . . . . 47 Albert Solomon and Gerhard K. Sluis-Cremer 5 The Radiographic Features of Coal Work.ers' Pneumoconiosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 W.K.C. Morgan 6 Radiological Features of Silicosis. . . . . . . . . . . . . . . . . . . . . . .. 101 Gerhard K. Sluis-Cremer and Albert Solomon 7 Nonmining Inhalation of Silica and the Silicates. . . . . . . . . . .. 143 David S. Feigin 8 Beryllium-Induced Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 165 Howard Naidech, Robert M. Steiner, Jan Lieber, and Stephanie Flick.er 9 Occupational Diseases Due to Organic and Metallic Inhalants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 173 C. Molina and D. Caillaud 10 Occupational Asthma 201 A.B. Zwi and S. Zwi Index. . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .... . . . . . . . . .. . . . .. 207 Contributors Gerald L. Baum Professor of Medicine, Sadder School of Medicine, Tel-Aviv Univer sity; Director, Pulmonary Division of the- Chaim Sheba Medical Center, Tel-Hashomer, Israel D. Caillaud Assistant Professor in Pneumology, Consultant in Respiratory Disease, University de Clermont-Ferrand I, Clermont-Ferrand, France David S. Feigin Clinical Professor of Radiology, University of California, San Diego; Assistant Chief, Radiology Service, Veterans Administration Medical Center, San Diego, California, USA Stephanie Flicker Chairman, Department of Radiology, Deborah Heart and Lung Center, Brown Mills, New Jersey, USA R. Glyn Thomas Honorary Lecturer in Radiology, Faculty of Medicine, University of Witwatersrand, Johannesburg, South Africa; Chief Radiologist, Rand Mutual Hospital and Chamber of Mines of South Africa, Johannes burg, South Africa Jeffrey A. Golden Clinical Consultant in Pulmonary Diseases, and Adjunct Associate Professor of Medicine, University of California, San Francisco, California, USA Jan Lieber Professor of Occupational Medicine, College of Medicine and Dentis try of New Jersey Rutgers Medical School, Piscataway, New Jersey, USA; Formerly Professor of Occupational Medicine, Jefferson Medi cal College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA xiv Contributors W.K.C. Morgan Professor of Medicine, University of Western Ontario, Ontario, Canada; Director, Chest Disease Service, University Hospital, Lon don, Ontario, Canada; President, Canadian Thoracic Society C. Molina Professor of Pneumqlogy and Clinical Immunology; Head, Depart ment of Respiratory Diseases, University de Clermont-Ferrand I, Clermont-Ferrand, France; Chief of Research Center for Respiratory Allergy; Member of the Ministry Committee for Occupational Dis eases in Agriculture, France Howard Naidech Department of Radiology, Deborah Heart and Lung Center, Brown Mills, New Jersey, USA Gerhard K. Sluis-Cremer Director of Epidemiology Research Unit, Medical Bureau for Occupa tional Diseases, Johannesburg, South Africa Albert Solomon Director, Radiology Department, Tel-Aviv Medical Center, and Associate Professor of Radiology, Sadder School of Medicine, Tel Aviv University; Member of Pneumoconiosis Panel of the Ministries of Health and Labor, Tel-Aviv, Israel; Previously Chief Radiologist, Baragwanath Hospital, and Professor of Radiology, University of Wit watersrand, and part-time Consultant of the Medical Bureau for Occupational Diseases, Johannesburg, South Africa Robert M. Steiner Professor of Radiology, Associate Professor of Medicine, and Chief of Section of Thoracic Radiology, and Co-Director of the Division of Diagnostic Radiology at Thomas Jefferson University, Philadelphia, Pennsylvania, USA A.B. Zwi Epidemiology Unit, National Center for Occupational Health, and Department of Community Health, University of Witwatersrand, Johannesburg, South Africa S. Zwi Professor of Pulmonology, Department of Medicine, Johannesburg Hospital, and University of Witwatersrand Medical School, Johannes burg, South Africa