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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

• ccupational 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

H&E Trichrome

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

• bserved 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

 Radiological Occupational Lung Disease

Surveillance 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

• ther 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

Krokydolith Chrysotil Pathologic-radiologic correlation Asbestos fibers in the lung SEM German source Dr. K. Hering

Pleural plaques

Plaques for the most part are markers of exposure and cause little

• r no clinical disease

Occasionally extensive plaques may produce functional lung restriction

The prevalence of plaques varies considerably in populations This variation is due primarily to fiber type –amphiboles more injurious than chrysotile

CT-PB and table top plaque parietal pleural surface

Visceral extension of parenchymal bands Parietal plaque 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 l i c e t h i c k n e s s W i n d o w s e t i n g s C T - F I N D I N G 2 0 0 1

Lung

W e l l d e f i n e d r o u n d e d

• p a c i

t i e s I r r e g u l a r a n d /

• r

l i n e a r

• p a c i

t i e s G r a d e Z o n e s / P r o f u s i

• n

L M U R 1 1 1 2 2 2 L a r R L U G r o u n d g l a s s

• p a c i

t y g r a d e I n h o mo g e n e o u s a t t e n u a t i

• n

E mp h y s e ma g r a d e H o n e y c o mb i n g g r a d e L M U R 1 1 1 2 2 2 I n t r a l

• b u l

a r N o I n t e r l

• b u l

a r Y e s P r e d o mi n a n t T y p e N o Y e s N o Y e s N o Y e s N o Y e s N o Y e s N o Y e s A P = < 1 . 5 mm N o Q = 1 . 5

• 3

mm Y e s P r e d o mi n a n t S i z e R = > 3

• 1 0

mm I s t h e f i l m c o mp l e t e l y n e g a t i v e ? N o Y e s L M U R 1 1 1 2 2 2 L M U R 1 1 1 2 2 2 S u m G r a d e L M U R L 1 1 1 2 2 2 3 3 3 1 1 1 2 2 2 3 3 3 S e q u e n t i a l S i n g l e s l i c e s p i r . Mu l t i s l i c e s p i r a l

CT-Classification of Occupational and Environmental Respiratory Diseases: R0/Irr0

Jack Parker:

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 1 HC Grade 2 HC Grade 3

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

• ccupational 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