Document MoKaKMOb9068zN89GbV6gDxXa

Thorax 1992;47:645-650 645 High resolution computed tomographic assessment of asbestosis and cryptogenic fibrosing r alveolitis: a comparative study | EXHIBIT . ,':N Al-Jarad, B Strickland, M C Pearson, M B Rubens, R M Rudd Abstract High resolution computed tomography is Background .The aim. of this study was particularly valuable in the early detection of to compare./the distribution and con- lung' fibrosis in asbestos workers in whom the figurationVoflung opacities in patients chest radiograph appears normal or shows . 'with .cryptogenic fibrosing alveolitis and only pleural disease.7'" Yoshimura et aln and ' asbestosis by .high' resolution computed Akira el at" have correlated the types of tomography. shadows seen in the high resolution computed Methods, Eighteen patients with ` tomogram' in patients with asbestosis with the Cryptogenic fibrosing alveolitis and 24 histological findings at necropsy. ' 'Vtfr--\'ijjhi0sls were studied/';..Two.. The differentiation between asbestosis and ' independent observers assessed th'd type cryptogenic fibrosing alveolitis- is often ' "and.distributions of opacities ' in the difficult, particularly when the extent of ' upper, middle, and lower zones of the occupational asbestos exposure is unclear. computed;tomogram. The' potential value of high resolution Results? 4?i?|ier zone fibrdsis occurred in computed tomography in differentiating these " J' . pati'ente with' cryptogenic diseases has not been assessed specifically, ln- -fib`rosuig:!nlveolitis and in six" of'.'.the onc''study computed tomographic features .24.;0atimp?,witli asbestosis. .A' specific were investigated in 118 patients with different pattern^in-^hich fibrosis' was'distiibiited types'ofintc'rstitial fibrosis, who later had open . . posteriorly/in 'the lower zones, laterally lung1 biopsy.' High resolution computed in;the middle zones, and anteriorly in the tomography gave the correct diagnosis in 76% ' upper-zones was seen in 11 patients with of cases compared with 57% of cases by plain .f cryptqgentc fibrosing .alveolitis and..in chest radiography.'1 The computed tomo vSbu'r'jwith asbestosis. Band like intra- graphic changes' in patients with asbestosis in., pulmonary opacities, often merging with' that study were described as being the same as .the,'pleura, were seen in 19 patients with those' in patients with cryptogenic fibrosing asbestosis but;in; only two' with crypto- alveolitis with the addition of bilateral pleural gehic fibrosing alveolitis- Areas with thickening,1' but only two patients with a reticular-/ pattern and ' a con<ient asbestosis were included. or ground glass pattern were; the Wc compared the findings ofhigh resolution. 'commonest features. of cryptogenic ' computed tomography in patients with , - . .'"'fibrosing alveolitis "(15 and 14 patients cryptogenic fibrosing alveolitis and asbestosis respectively) but were uncotritrion' in to determine whether there are differences asbestosis. .(four ajid -three patients). other than . frequency of associated pleural Pleural thickening dr plaques were seen changes. in 21 patients with asbestosis and in none with cryptogenic fibrosing alveolitis.. Conclusion Apart from showing Methods .' pleural- disease high resolution com patients ''' puted tomography Showed that cpUfiuent We ' studied 18 patients with cryptogenic (ground glass) opacities are common in fibrosing alveolitis (four women and 14 men, cryptogenic fibroking alveolitis and rare mean age'57 (range 33-75) years) and 24 men in a.sbestosis whereas thick, .band like with asbestosis (mean age 59 (34-75) years)- opacities' are common in asbestosis and Asbestosis was diagnosed when fine mid to late London Chest rare in cryptogenic fibrosing alveolitis. inspiratory crackles and pulmonary opacities of Hospital, London U2 9JX X A1 Jarad M C Pearson M B Rubens k -Vt Rudd High resolution computed tomography is superior to chest radiography in investigating interstitial lung disease because there is less Table l Mean 195% confidence intervalI age and pack years of smoking in patients with asbesrosis and cryptogenic fibrosing alveolitis. Difference between groups not significant Royal Brompton and National Heart Hospital, London StV3 6HP P Strickland . X.-pnm reque-as to: "-K.MRuJd w.vritd I March 1MU2 superimposirion of structures,, which allows a better assessment of the type, distribution, and severity of parenchymal abnormalities than is possible by chest radiography.' Several recent studies have described the computed tomographic appearance of various diffuse interstitial lung diseases.5-" Age - vest's) Puck years of smoking Albums >i * 24 Cryptogenic fibrosing tifveafais . w =18 59(56 to 64) 26 (19 to 35) 57 (51 to 63) 29 (20 to 38) HWBUI0008883 Mo JoraJ. bUit.Ki'juj' iKntu/f.', fiitJj Table 2 Mean 1 95" ': confidence interval results of lung ' function tests expressed as percentage ofpredicted values* in patients with asbestosis and cryptogenicfibrosing alveolitis Cryptogenic . fibrqwtg Asbestosis alveolitis H - 74 n 18 FEV, FVC FEV./FVC Total lung capacity Residual volume Tteo Alveolar volume Kco 76 (67 to 85) 80(71 to 88) 94 (85 to 103) 89(81 to .97)* 99(90 to 108)*' 63(55 to 71)** .84 (77 to 92) 78(70 to 87)** 82(72 to 93) 91 (77 to 102) 100(9! to )09) 72(66 to 76) 76(67 to 85) 38 (3010 46) 77 (70 to 84) 54 (44 to 63) *p < 0*002, *-p < 0 001. FEV, e forced expiratory volume m one second. FVC = forced vital capacity, Tlco s carbon monoxide transfer factor, fCco Tlco.divided by alveolar volume. a profusion grade greater than 1/0 on the. International Labour Office scale" were seen in' the chest radiograph., in patients who had had.substantial exposure .to asbestos. In.II patients in. whom b.rdnchbajyedlar. Savagie was performed asbestos!bodies."were detected in I bronchoalveolar lavage 'fluid- Cryptogenic fibrosing alveolitis wa'sdiagnqsed bn the basis of open lung biopsy iri'[2 patients and on clinical and plain radiographic evidence of interstitial" I lung disease hi the other .six. None of the. 1 patients. with- cryptogenic fibrosing alveolitis.. (I had been exposed to"jisbescos, had. any symp- / toms' or signs. suggesting .connective'.tissue ; disease or malignancy, had positive test results ' for.avian precipitinsy or,had'received any drug known to induce lung.fibrosis. r* . .. HIGH RESOLUTION COMPETED TOMOGRAPHY All.scans were carried out with an.Gtscini 2002 scanner with a scan, time of fi-5 s. We 'took 3 mm sections, 10 mm apart, from the lung apices to .the bases in full inspiration at total lung, capacity 'using .a bone, algorithm reconstruction.21* Window , settings for lung .fields (mean, vyindow,setting" 1602 .Hounsfield units) and for soft tissue' for clear identification .of .'the...pleura (mean window setting'621 , Hounsfieid units) were obtained in all patients. Figure 1 Cryptogenic fibrosing alveolitis: distribution of Additional sections, were obtained in.the prone . shadows. Fibrosis is predominantlyposterior in lower position. ' ... sections (a), lateral in middle Sections fb)\and anterior in upper sections (c). This distribution was seen in /? (61%) patients ioiih cryptogenicfibrosing alveolitis and INTERPRETATION OF,SCANS . four f 17%) patiemstoiih asbestosis. High resolution computed . tomograms were assessed by two independent readers. Lung ' 'ft-::.- fields, were divided! ijStb. three equal thirds, confluent, ground glass, honeycombing), and measured from apex "to base. Readers' were any pleural abnormalities in each lung xone. asked, to identify "the presence of emphysema, Readers also noted the distribution of the opacities suggesting .fibrosis (linear, reticular, abnormal shadows present in the lung fields. Table 3 Distribution of thadotoing in the upper, middle, and lower thirds of lungfield in patients with cryptogenicfibrosing aheotiiis t CFA > and asbestosis Upper third Middle third Lower third Fibrosis Asbestosis CFA n = 24 n -- 18 p value 6 to <005 19 18 <0 05 23 18 NS Emphysema Asbestosis CFA n = 24 n = 18 p value n 13 NS 15 li NS 20 12 NS LUNG FUNCTION MEASUREMENTS Patients did respiratory function tests within three weeks of undergoing high resolution computed tomography. Spirometry was done with a dry cylinder spirometer, single breath carbon monoxide transfer factor was measured with an Auto-link transfer factor machine, and lung volumes were measured with a computcrised constant volume plethysmograph. Predicted values were calculated for age, sex- . HWBUI0008884 High resolution eomputed tomographic astcssmem of asbestosis and cryptogenicfibrosing alveolitis: a comparative study 647 Table 4 Types andfrequencies of opacities in asbettosis and cryptogenicfibrosing alveolitis - Type ofopacities Asbestosis Crescentic She reticular pattern with - small cysts {fig I) 4,24 Confluent or ground glass (fig 3) V24 Subpleural lines (figs 4 and 5) . 8>24 Thiels linear or band like densities in the lower zones merging with the pleura (fig 7) 18/24 Wedge shapctLor irregular densities closely related to the pleura (figs 8 and 9) $'24 Pleural plaques and diffuse pleural thickening 21 24 Rounded atelectasis (fig 10} .u 6.24 cryptogenic fibrosing alveolitis ^ . p value "i, -. *. tjflB . ;<o-ooo6 14/ i'a '. ' <0-00008 4i!8 ..-.-NS 2,;ia <00002 0/lfi < 0-007 *0)18 6/18 <0-00001 <003 and height1' and results were expressed as percentages of predicted values. Figure 3 uryptogemcfibrosing c shadowing in basal segments oflower lobes with irregular subpleural areas oflow attenuation, especially on right. Thts "ahrcolar'1 type ofchange is rarely seen in asbettosis. Asbeswtis: 'Stic shadows in ii.Pleural plaque "lateral aspect. STATISTICAL ANALYSIS Age',;pack years of smoking, and lung function anteriorly in the* upper zones (fig 1). Tftis measurements in patients with asbestosjs and cryptogenic fibrosing alveolitis were compared by the Mann-Whitney U-'tcsr. The frequencies ofdisease in each of the lung thilds:and type.of shadows seen in' the two conditions were compared by Fisher's exact test. or. the jr with the continuity (Yates) correction 'when the' former - test was in appropriate. Results were - 'considered sig nificant-when p was less thari'0'-05. ' distribution was seen in 11 (61 %) patients with cryptogenic fibrosing alveolitis but in only four (17%) with asbestosis (p < 0 003). We gained .a.qualitaiive impression that interstitial fibrosis -' and emphysema tended to be more distorting to lung architecture in* cryptogenic fibrosing alveolitis than; in asbestosis. Emphysema was not found in any ofthe non-smoking patients in either group. Table 4 summarises the types of opacities and their frequency of occurrence in asbestosis and cryptogenic fibrosing alveolitis. In 15 ofthe . 18 patients with cryptogenic fibrosing alveolitis Results.-,.- . -there were areas-of reticular or reticulonodular There Were no differences between the patients shadowing (fig 1). A fine honeycomb or cystic with- asbestosis. and cryptogenic fibrosing pattern with no or minimum pleural disease alvcoliiisun -age or pack years of smoking occurred in four of the 24 patients with asbes- (table 1).-There.were no significant differences tosis-(fig 2). Areas of confluent and sometimes rbdaamhltbuhefeloiivvfgnoesTteteiwhgh:ipdcadloo-eoietexubgewlxreidharldtiieneoidinlsr-.'ure3mdvbt-htptzossyhhoesoth-learur;ianoangenmtalewvnrhsosteoseisebhnuof,fewetueptlhseaaptarsettonrssopwf^tfbd;soeaa-opeiiiVnsrlrcsrs;occatttgFlooruscolrruirsEie'brnnc'dm:iyis'Vudghu(pr.eTit'[ph;,tti'jrLoi{oiioao(dqn(gCtnnpKrda*eoasaolFbpcre).lcilafoiVieicotiFtp)tahCii2pyejaini'b),afr,wntdi.dirbcebtoecssirntuasrToietewritwsssblsie-tcinohfatriirhonnngeelil--;'*.''..;.;spgp3afM|cie/uabaQ)rl.yyoo^rrtrtbveairDuoisefo7pumlntsiunupsltd^etieanctsgniipdtrdsnwi*eVaie-e4atnti'epsoad.tigehthpt'slnl(javnacnaslbdetyswcruasyyosilbif-tt:p)liap.hhci,ttart;wr"larieo'esa;etpaaiug,nceitsaosrhrcsaebttnrpnthlaeseo.aieccdsrctflntei'iirfoeen'i,ynlb,sibennnptiroscitse.tcps.yots.hsa,cwgws'ihwnneetuaidergnetrberhen8iracpctedlicvrlcae'siytsensueeuepfbogirelebrtaielnsoanirrstttogliitoisconisenaaa(sinfnnnbil1isliggddyec4a. . cryptogenic fibrosing alveolitis the opacification tended to be [post posteriorly in the narrower in asbestosis (fig 4) than in cryp togenic fibrosirig alveolitis (fig 5). Subpleural lower zones,'laferallytm-the rniddle zones, and '( - .-r-.'T-. - *%>.: Figure 4 , Astsestbsis: harrow subpleural eurvi linear tines parallel to 'pltuirafsurface on both sides. HWBUI0008885 648 Jarad, Strickland, Pearson, Rubens. Rudd Figure 5 Cryptogenic fibrosing alveolitis.- on the . right irregular, dense - crescenticsubpleural Una . vijible'cphere fibrosis is v-;; ;m>stjc1>{re; on the left . :ircfi>u/orii*6p/e('af lint it visible. The line is less well defin'fd thdn'.thdt. normally : seenfit asbestosis;'- 'Figure 6 Asbestosis ;(al subpleural curvilinear lines in lupine position, in 63 year old former logger; (b) these lines disappear in prone position. This may - represent early stage asbestosis,in which fibrosis is shown by summatian effect ofvascular shadowing. lines were die only pulmonary abnormalities seen in three patients with asbestosis but were always associated with other types ofinterstitial opacities in cryptogenic fibrosing alveolitis. Two patients with asbestosis had discrete subpleural lines in the lower zones posteriorly which disappeared in the prone position (fig 6). Both patients had fine end inspiratory crackles on'auscultation and the plain radiograph was. interpreted as showing interstitial fibrosis. ' Thick linear'opacities perpendicular to the pleura were seen in the lower zones in 18patients' with a'Sbestosis but in only two .with' ' cryptogenic fibrosing alveolitis (fig 7).. Wedge shapedor curvilinear intrapulmonary opacities (figs:8 and 9)'were seen in eight patients with asbestosis biit were not identified in any patient with cryptogenic fibrosing alveolitis. These opacities were-usually close to the pleura and merged with it, although in two patients they were wholly within the lung parenchyma (fig 9). Circumscribed pleural plaques and areas of more diffuse pleural thickening were seen in 19 patients with asbestosis (fig 10), although in some the pleural thickening was minor in thickness and extent. Two further patients with asbestosis had pleural plaques alone, and three had no detectable pleural disease. Areas of rounded atelectasis due to pleural infolding (Blesovsky syndrome, figs 8 and 10) were seen in six patients with asbestosis and in none with cryptogenic fibrosing .alveolitis. No definite pleural thickening was seen "in cryptogenic fibrosing alveolitis, but multiple small peaks of density arising from the visceral pleura on both lateral and mediastinal surfaces were often present (fig 1). . Discussion The distribution and type of radiographic shadows in asbestosis and cryptogenic fibrosing alveolitis have not been compared sys tematically. before, probably because the presence- of pleural disease in asbestosis has been used as the prime differentiating radiogra phic finding. Pleural plaques are not invariably present in asbestosis, however, and in their absence these two conditions may be indistin- guishableby chest radiography. , Our study suggests that features visible on high resolution- computed tomograms aid differentiation between asbestosis and cryptogenic fibrosing alveolitis. Pulmonary fibrosis affecting the upper and middle thirds of the lungs was-'more common in cryptogenic fibrosing alveolitis than in asbestosis, in which fibrosis waS'often localised to the lower lobes. In cryptogenic fibrosing alveolitis a characteristic pattemiofopacities in the posterior areas of the Sower zones, the lateral areas of the middle zones, and the anterior areas of the upper zones - was commonly seen; the posterior and lateral -aspects.of the upper zones appeared relatively normal. We`a!so found that when asbestosis -affected the' anterior segments of the upper zones the abnormality was usually less severe than that'- seen in cryptogenic fibrosing .alveolitis. :.. -. Confluent' or ground glass opacities were S' '/ 4 m. V"--. ' i: V . :4i irS: 0?>t? 35- Vf-xbi:;-: '-'Y'ji ; C ..'Cfit Fi rite hii iifi tin vtlt ex. M hit ; '-r ' 7.`Asbeitpsis:coarse subpleural reiicular patient m right lung mfichmerges with thickened posterior and diaphragmatic pleura.** HWBUI0008886 tdd of 19 in ;<u ng en ith ite lie of *th en tic S" le as aly ir 1- id td r) ;h n ic le ie :s il .y is -T *e g > High resolution computed tomographic assessment ofasbestosis and cryptogenicfibrosing alveolitis: a comparative study 649 Figure 8 Asbestosis: on the left tong thick irregular linear densities lie perpendicular to'and merge Knth pleural surface and are associated aiih, soft reticular density. On the right there is an. irregular opacity attracting, vestcls and bronchi. Appearances on both sides may represent infolded lung in varying stages of evolution. CJI' ci- radiographic evidence of asbestosis in smokers compared with non-smokers.lJ"" In asbestosis the commonest features were coarse linear opacities, often adjacent to pleural thickening. This pattern, which was seen rarely in cryptogenic fibrosing alveolitis, is believed to be. due to interlobular and intralobular fibrosis.1* A fine regular cystic honeycomb pattern, as is often seen in cryptogenic fibrosing alveolitis,1 occurred in only a few patients with asbestosis. Ventilatory capacity was slightly, although not significantly, lower in the asbestosis group more common in our patients with cryptogenic than the cryptogenic fibrosing alveolitis group, fibrosing'alveolitis than in those with asbestosis " but the residual volume and total lung capacity and were commonly surrounded by subpleural were higher, perhaps reflecting- asbestos or paramediastinal radiolucency, or both. induced narrowing of the small airway.11"*1 Histological studies have shown that the The carbon'monoxide gas transfer and co opacities arc due to mild thickening of the efficient were more impaired in patients with alveolar wall and interlobular area by- oedema cryptogenic fibrosing alveolitis, perhaps reflect ot fibrosis.11 The subpleural ttansradiency. is., ing the mote widespread distribution of the probably due to air being trapped around interstitial fibrosis. Pleural thickening may have sheets of lung-fibrosis.10 " contributed to relative preservation of the Kco Subpleural curvilinear lines in patients with value in some patients with asbestosis. asbestosis were discrete, and.in three patients ' The question arises whether the more wide these were the only interstitial abnormalities. spread distribution ofopacities in patients with In cryptogenic fibrosing alveolitis, the sub cryptogenic fibrosing alveolitis than in those pleural lines were less discrete and were always with asbestosis reflects more advah'ced'tiisease associated with other interstitial opacities. In in the former group. This is unlikely to be the . three patients with asbestosis discrete, sub- .case. Fibrosis of-.upper zones in cryptogenic pleural lines were detected posteriorly in the -fibrosing alveolitis ahd the type ofopacity were supine position but were pot seen in ,the.prn>ne not confined to, those with more severely position since all three patients had fine mid to impaired lung function but were seen at an late'i'tispiratory crackles and a chest radiograph early. stage in some patients with mildly .appeared consistent with interstitial fibrosis. impaired lung function. We presume that these reversible lines are.-an We conclude that, the features seen on high early sign of asbestosis/pqssibly representing resolution computed tomography which favour areas of fibrosis highlighted by gravity induced a diagnosis of cryptogenic fibrosing alveolitis vascular shadows. ,, include confluent (ground glass) shadows, Emphysema, cysts in a fibrotte area, and reticulonodular. an$i cystic shadows extending subpleural cysts may be increased in size by to the upper thirds of the lung field, and a fibrosis exerting trac.tioq,16 These features;-were characteristic pattern of posterior lower zone, 'fo'md^mote often in patients w(ith cryptogenic, lateral middle zone, and anterior upper zone fibrosing alveolitis than in those wjlh asbestopis, opacities. Features, that favour a diagnosis of ' especially in areas .of severe .fibrosis, .Ftfcrosis asbestosis include, pleural plaques ot.diffuse arid cystic shadows were nqtfound in the 'tipper p.leural thickening, thick band like opacities in and.middle zones in the three non-smokers the lower zones which extend to merge with the with cryptogenic fibrosing alyeplitis and theone. pleura, and. .isolated narrow subpleural non-smoker with asbestosis. Smoking may cuiyilinear fines. induce.or exacerbate the cystic disease and may also exacerbate the interstitial fibrosis. This suggestion,is consistent with previous findings pf increased frequency and severity of chest-.- Figure#' Aibestotit': on the right thick pleural based lines penetrate deep illto Itingfields Oh ike left a thich idd'rvilinedr1 line is ' attached to pleura and esttnds.into lungfield, . firming an arch within Itntg field. Figure tO Asbestosis: posterior pleural based opacities in both lower zone's probably represent infolded pleura and lung parenchyma tpseudotumours or Btezovsky syndrome I. HWBUI0008887 i\ j, ,,-t,. KtixiJ i ZcrhiHjni EA. N^tdkh DP. Sniik KP. Khuuri ST. 13 M,*lhieM*n JK, Msyi* JR. Suplo- (..A. Mvltvr Nt.. fiutims. Sicg^tmun SS. Cbtftpuicd toff*fcraph> *f the pu!nu>ury parcnehvnra, \\. Inlcniilial dive-fee. J 7V/.ro.* intents? 19*5:1:54-64. . Jitru>cinKllrauvc1un^Ui>vu^`: Aornp.*ri?**n`J Uiugiu^tii. iKCurjcs of `CT* unJ che't rudtintrjphv. Rjf,d>v\ . M;Pl;l)l-ft.;.Vi . . 3 S'lricfclind B, Strickland NH, Tbc vahie of high Uchniikm, narrow section ci'mptHcd-iomjfgraphy in rihrosing alveolitis, dinjtfdiof l98fc3fc*R9a&; .. 3 Bergin Cj, Muller XL. CT of isurrsmibi lung disease: a I }' Internationa! r.ittviir Orhee. fnicrn>ttt>`uA rt*stpc%itu* t>t rpdifpr^ph/ f /pntu*tti\*wn'>h Cknetj. |I.O. |^i. * yOccupational >afci\ anJ health sene'. No 22; rev 80 . H Strickland B- Brennan J. DoniMrp PM. Computed U>mo* diagnostic appw*dts. AmJ f?arffr/i9S7;i48;8-l5. graphv. in diffuse lung disease:. Improving the image. 4 Staples CA Muller NL, Veda] S. Abhtrbd'.R. CKmwD. . Ctimcat rudtotLyty lV8o;37; J.15-8- Miller RR. UsuM yjatcrstiiuii^octimonia^cDrrcUtion of - 15 Cores 'JK. ftbn-tuvt: j-v//ww .W Jppfkrn*>t m Cr with dime?!,' funaional? aihd radiolugic findings. 'medicine. 4ch cd^Oxfiird: Blackwell Scientific 1979:2*1-7. RatHdezv 1 W;j62rJ77-3i. *' V* -1* Id .yfigginv J. Strickland* B. Turner*VTu/wtek M- Combined 5 Muller NL, Miller .RR. State of the art: computed turnip - cryptogenic fibroving alvcnUti^um) emphysema:the value graphyofchronic diffused infiltrative lung disease, part I. of highVcsoluintn cumpurcil tomograph* in assessment. Am Rev RespirPi, 1990,142:1206-15. Resptr Mid iw^4>l6S-. '. 6 Hansel! DM, Kerr fH.'1he rplcofhighresolution computed 17 Weirs !X>-`Cigarette- smoking, asbestos. siHi pulmonan tomography in the diagnueis odinRUrativc Hung distovc. fibroiiiki^m Ret Retpir f>o`j97l;104:22!-7. Thorax I99(;46i77-fW. ' " r*''v' 18 VTeiv*. W. Ihevdas PA. Plvurupufrtuuum disuse among 7 Nakau H* KifnotoT, NafcayamaT.Kido .MM. Miyauki N\ Narada S. Diffuse peripheral lung disease: Evaluatkm by highresolution computed tiMnuprephv. R%hiudogy 19*5; . . 157:181-5. . ' .. asbertm workers irs relation to smtfctnp und type oi exposure^.f (hvitpAfrd 1978:20:34 lw Lilts R. ^cliVbtf IJ. I.efman V, SviJman H. Gclh hK. Avbvsiosts*. interstitial pulmonary t>btx>is and ptcuru! 8 Staples C^rGamso Gt Ray CS, VTebb VI*R. High revolution fibrt>si in a et'KonofasbcMos insulation workers: iTtfiucmx1 computed tomography 2nd lung function in asbestos of cigarette smoking..-! J t*td Met! lU8n:10:-l59-7tt. workers with normal chest radiograph. An* Rev Retpir Dip 20 Ktlbum KH('brilicanim ol data i<n the clioV*giCa1 role ol |989j839sl502-S. , . .... cigarette smokinn m pulnn'nars' fibrosis. ,4 X itnf AieJ 9 Aberle DR, Qamsu G, Ray CS, Feuerslcin EM. Asbexov- lK4;3:42J-2.. - related pleural and parcnchvmul fibrusis: detection bv 21 Begin R. C!amin A. tlvrihiaumc Y. tkiileau R, Pehmuin 2i. high-resolution CT. Raditfay .|488:166:729-M. Masse SC Airwuy (unction in lifelong nonsiru4;ing olJ |0 Yoshimura H, Hatakeyama M, Otsuji H. Maeda M, Ohishi asbestos workers. ,*li J A l*J l8 3:75:6 U-8. H, Uchida H,, tr, i?i. Pulmonary asbestosis: CT study of 22 Cohen BM. Adasc/ik A.C!then EM. Small airw*av\ change' ' subpleural curvilinear shadow*. Work in progress. Radiology 1986;! S&653-&. in workers espi>sed (t asbestos. Rcipiraiuw I*i84;45: 29^02, . ' - II Akira M* Yamamoto S. Yukoyama K. Kua N, Morinagj 2' VYright jL .Oturg A. Severe dllfu'e small airwuys * K-, Higaihjhan `I*, a at. Asbestos!*: high-fc*oluiii>n C'r* abnormaliiics in Itwg term asbestos miners. RrJ fnJ Alcd pathologic Cm relation. Radtohny i9<Hhl76:lK*94. 1985:42:556-9, ` Adventitia My only private patient ! f: y-**/-*`.*.. .w-. ; Foolishly I never, did private practice.' Fool- would have to have'a biopsy. The posh GP said ishly because'ifyo'u doti't-'do private'practice he would'arrange It. 1 assumed that this was the you are never going to sce-'E(izabcth 'Schwarz-' usuafthirig in'priyatc practice. He sent her to a koff as a patient,'(br for lhar-'matter`Madonna, urologistl'A 'wcek'or two later die answer came and the money must come in handy-Jtho'ugh back. It'was Follicular carcinoma of die thyroid, ' whenTstarted a cprisultahVs salary was a'living which apparently, is well known to occur in wage. ' . -' ' teenage girls. It wisn't well known to me. It ' Almost 30 years ago a posh GP rang me up to was the first I had heard of it and the last. So I say that he was sending'me-the 14 year old rang the posh GP and told him the girl should daughter of an American film producer--this be sent to Jac' .Piercy, die surgeon superinten- oh' the advice oF'an American' professor of dent of'New Knd Hospital in Hampstead. New paediatrics I had met in'N'ew'York. The girl - End was die name of a famous thyroid clinic had been diagnosed in New York as having originally started by London County Council.. ' tuberailous'glands'^of the riltfk and I'wa's 'to' It had had several great men on its staff-- continue her:treatment'with'-iisohia2id alone; I- among them Cecil joll, who wrote a massive didh'tlike die .sound of that'.' ' -': ' r' '* surgical textbook' on the thyroid; Geoffrey : 'i found' a rather sulky'girt'-'with bilateral' Keynes (the brother of Maynard, the econ cervical- gland enlargement.-The glands were '- omist), who was the world authority . on quite large, up to about an inch in diameter, not' `William Blake, and also Raymond Greene (the , . ,.{ender^|trinj.aad mobile'. Not at'all' like tuber- brother of Graham, the writer), who had been culous'glandsfc'l^ltatfis ntoFC'the'girl's mother an Everest climber. Jack Piercy was the greatest told me that`th`c g!r!jhad 'started menstruating of the lot. Two days'later the posh GP rang me and thatiduring tfiepycle the glands changed in to say that Sir Ronald Bodlcy Scott, physician size (Jm.te'considerably; tpat.didn't sound like to the Quqen, had said that yve couldn't do tub^pculQSis either.''j;.' better. I w&.yejy chuffed. - , -v^6';f%and;;by doing'a tuberculin test (the Jack Picrcjf:tolti me in his letter that'he had .' Nw^Ork-diagriosis had been purely clinical-- treated 17 sirriilar.pitierits by total'thyroidec " poinytstigadeSs had been done). It was a Hcaf tomy and block dissection of neck and that they *OV testV"tl\e'diily;pnc available in the chest clinic (a had all survived; girl underwent a success shop near.Okford (Circus) and itjs-a vcry.good . ful block dissection o.f the thyroid. Many'years test: it requires nofskill, it is 'virtually.,painless," 1 later l heard thatfsii'ewas well (taking thyroxinc and, conveniently^i^can be readat sMveekvThe as replacement therapy, of course). response ..wast ric'gative.; So it 'Wasn't fuber-- I sent.the^film producer a bill for 25, which 'Culosis'' (atypi<ifc?hyi:obacteria as' a cause of he'patd by returr?btit.with no word of thanks. cervical adcriitis^had hardly been heard of in I thought, "i wfij'never be as lucky as that . Britain at that.time). again so Ldi better-not see any more privati . I rang the .posh GP and. told him that the girl patients,''.and f rfever did. :r-/ PETER D B DAv1 '? S' i .i HWBUI0008888