Home sweet home! Greenbrier River West Virginia
Attualità in tema di Pneumoconiosi Siena, Italy 24 September 2010
2010 ILO Classification System The Digital World of Chest Imaging & HRCT of the Thorax John E. Parker, M. D. Pulmonary and Critical Care Medicine NIOSH & WVU Attualità in tema di Pneumoconiosi Siena, Italy September 2010
Presentation Objectives Review the role of chest radiography in dust diseases – silicosis and asbestos related diseases Demonstrate chest radiographic patterns in dust diseases, along with pathologic correlations Forecast the use of digital chest radiographs by the ILO in the year 2010 Outline the benefits and limitations thoracic HRCT See some wildlife photographs, look at a few international landmark structures or international icons
Stonehenge
Roles for Chest Radiography Important tool for clinical evaluation of pulmonary diseases Especially - infectious lung diseases Diffuse lung diseases or the interstitial lung diseases Neoplastic diseases Useful in clinical care, assisting in both diagnosis and evaluating response to therapy Found application in epidemiologic and research for occupational and environmental lung disorders
0/0 ILO
Normal Alveoli and Interlobular Septa
Lung Disease Injury Patterns Are Complex. However, Practice in Their Recognition Will Improve Your Clinical Skills!
Silicotic Nodule & Coal macule anthrosilicosis (CWP)
Asbestosis and Fibrosis
Typical Fibrosis Pathology Trichrome H&E
Chest Radiography in Dust Exposed Workers Chest radiography has been useful tool in screening and surveillance of dust exposed workers Chest radiograph has been helpful in exposure response relationships Although a helpful tool, improvement is possible Documents failures of dust control
Limitations of Radiographic Imaging Imperfect tool, not diagnostic gold standard Airway disorders not always seen Functional impairment not well evaluated or assessed Cannot provide certainty about the etiology of observed findings due to limited lung response patterns
International Training Activities for the ILO Classification System ILO programs sponsored at over two dozen sites in Asia, South America, Africa and Europe A strong national training program in Italy - 1998, 2002, 2004, 2006, 2008, & 2010 National workshops in Brazil, Chile, Ecuador, Argentina, and Germany ROLDS in South Africa -- Neil White
ROLDS in South Africa – Dr. Neil White and colleagues R adiological O ccupational L ung D isease S urveillance training program High quality digitally scanned radiographs Self-directed computerized distance learning activity Included a symposium as well as an assessment of classification skills Future plans for web based training, stymied by the tragic premature death of Dr. White
Summary -- Digital Radiography Traditional film screen radiography (FSR) is becoming obsolete in some nations and replaced by digital radiography both DR and CR technologies Several studies in Japan and the US have shown near equivalence for analogue (FSR) and digital radiography Laney & Franzblau & Takashima Ref. times 3
Summary -- Digital Radiography NIOSH workshop March of 2008, endorses digital radiography for pneumoconisis ILO guidelines to add a new chapter addressing digital radiography Expectation of new digital standards to be introduced in 2010
What About A Role for Computed Tomography Becoming more widely available Exquisite detail of pulmonary parenchyma and other structures, the best study during life for pleural abnormalities Good anatomical correlation with pathological findings Major linitation is radiation exposure and cost
HRCT and CT Advantages Visualize parenchyma even when pleural shadows are competing on the PA image See pleural surfaces in more detail, clearly superior to PA radiograph for recognition Identify other diseases, emphysema May clarify presence or absence of abnormalities on low profusion PA films
Septal Structures Secondary lobules Lobular Structures from Netter and Mueller
Asbestosis - subpleural dot - subpleural curvilinear line - inter- and intralobular lines - ground glass opacity
Pathologic-radiologic correlation Asbestos fibers in the lung SEM German source Dr. K. Hering Krokydolith Chrysotil
Pleural plaques The prevalence of plaques varies considerably in populations This variation is due primarily to fiber type – amphiboles more injurious than chrysotile Plaques for the most part are markers of exposure and cause little or no clinical disease Occasionally extensive plaques may produce functional lung restriction
CT-PB and table top plaque parietal pleural surface Visceral extension of Parietal plaque parenchymal bands Table top
HRCT Classification Standardization Project International effort--Japan, Germany, Finland, France, Belgium, US, UK Similar, but distinct from the ILO chest radiographic classification system Standardizes imaging parameters Features a standardized reading sheet
HRCT Classification Standardization Efforts Includes written guidelines Introduces candidate reference films Adopted and used in Germany by legislation Used for ILD/DPLD research in the USA
C T - C l a s s i f i c a t i o n N a me / N o . C T - N o . / D a t e N o . s l i c e s S e q u e n t a l i S l c e i t h i c k n e s s S i n g l e s l i c e s p i r . W i n d o w Mu l t s l i i c e s p i r a l s e t i n g s C T - F I N D I N G 2 0 0 1 s I t h e f i m l c o mp l e t e l y n e g a t i v e ? N o Y e s P r e d o mi n a n t Z o n e s / P r o f u s i o n S i z e N o Y e s R P = < 1 . 5 mm U 0 1 2 W e l d e f i l n e d Q = 1 . 5 - 3 mm M 0 1 2 r o u n d e d o p a c i t i e s R = > 3 - 1 0 mm L 0 1 2 N o Y e s P r e d o mi n a n t G r a d e T y p e N o Y e s R n t r a l I o b u l a r U 0 1 2 I r r e g u l a r a n d / o r l i n e a r o p a c i t i e s I n t e r l o b u l a r M 0 1 2 N o Y e s L 0 1 2 Lung R n h o mo g e n e o u s I G r o u n d g l a s s 0 1 2 a t t e n u a t i o n U o p a c i t y g r a d e M 0 1 2 N o Y e s N o Y e s L 0 1 2 R L R H o n e y c o mb i n g E mp h y s e ma U 0 1 2 3 0 1 2 3 U 0 1 2 g r a d e M 0 1 2 3 0 1 2 3 g r a d e M 0 1 2 N o Y e s L 0 1 2 3 0 1 2 3 N o Y e s L 0 1 2 G r S u m a d e R L L a r A U
Jack Parker: CT-Classification of Occupational and Environmental Respiratory Diseases: R0/Irr0
CT-Classification of Occupational and Environmental Respiratory Diseases: R0/Irr0
CT-Classification of Occupational and Environmental Respiratory Diseases: RGr2Q
CT-Classification of Occupational and Environmental Respiratory Diseases: RGr2Q
CT-Classification of Occupational and Environmental Respiratory Diseases: IrrGr1
Pathologic-radiologic correlation German Source Hering KG, Müller K-M
CT-Classification of Occupational and Environmental Respiratory Diseases: IrrGr2
CT-Classification of Occupational and Environmental Respiratory Diseases: IrrGr2
CT-Classification of Occupational and Environmental Respiratory Diseases: Pleura - parietal type, width b
CT-Classification of Occupational and Environmental Respiratory Diseases: Pleura - parietal and visceral type, width c
Extra Pleural Fat
CT-Classification of Occupational Respiratory Diseases: FP-Extrapleural fat
CT-Classification of Occupational Respiratory Diseases: Emphysema Grade 3
CT-Classification of Occupational Respiratory Diseases: Honeycombing grades 1-3 HC Grade 3 HC Grade 2 HC Grade 1
CT-Classification of Occupational Respiratory Diseases: Rounded Atelectasis
Limitations of HRCT and CT Cost for scanners and operation prohibitive for some nations and some settings Radiation dose concerns Not recommended for screening Not a panacea for drawing the line between disease and health Cannot distinguish occupational from non occupational etiology of findings
Positron Emission Tomography with CT Overlay PET scan lights up metabolically active tissues Can then overlay CT scan abnormality Positive in lung cancer, lymphoma, sarcoidosis Also PET images are positive lesions in progressive massive fibrosis
The future in imaging? Take advantage of digital systems for imaging and data acquisition/manipulation Improve training and quality assurance using computer technologies Further improvements in CT scanning and harmonization of classification systems Develop PET scanning or other technologies to identify inflammation
The home stretch! Greenbrier River West Virginia
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