Document N2d70roa36nZNnOOr0w3qLO2V

Comp^jj. and coa- ^P'^mosi ?n. leases, I 1 I LeeSider, MD Elizabeth A. Holland, MD Thomas M. Davis, Jr., MD David W. Cugell, MD oel IP, tj. of roentastases to 77> 144:903. [ -ocnogra. * Acta Radi^j Changes on Radiographs of Wives of Workers Exposed to Asbestos1 Xoth JA. tases in p*. - tissue aaj. .ans comr tomoJ Clin Logothrtj diagnostic 1983: ev TR, FalThe prob- uJes in chilotherapg. Benign s with cm44. . manRM/ les of the i Surg 1984; 3etv January and March 1986, 1' s of insulation workers ex posed to asbestos were screened by neans of chest radiography, pulmo nary function testing, and a detailed juestionnaire. The final study jroup included 93 women over 40 ; tears of age. Eighteen of these 19.4%) demonstrated pleural | changes consistent with asbestos ex 1 posure including pleural plaque | >38.9 ' pleu: iiaphragm plaque (27.8%), alcification (16.6%), and I diffuse pleural thickening (5.5%). In f statistical correlation between the groups with normal and abnormal radiographs, the only factor that proved significant was the year of first exposure (the duration of the latent period). Finally, radiographs of the husbands were compared for 17 of the 18 wives with radiographic abnc lities. Fourteen of the hus band, 2%) demonstrated more se vere radiographic changes than their wives. 'ndex terms: Asbestosis. 66.773 "eura. diseases, 66 / 73 *idiologv 1987; 164:723-726 * - /' e Departments of Radiology (LS . 4 D.) and Pulmonary Medicine 7 .orrhwestern Memorial Hospital, V havilion, Superior St. and Fairbanks Ct., ^'"80 1L 60611. From the 1986 RSNA annual '""ting Received December 23. 1986: revision ,Rested February 24. 1987, revision received Oct, -- Jccepted April 22. Address reprint Juts to L.S. sh\A. 1987 xposure to asbestos fibers has E long been recognized as a cause of radiographic and functional ab normalities of the chest. The radio graphic changes range from limited pleura] plaque formation to complex parenchymal fibrosis and malignan cy, and they have been noted for all types of asbestos exposure, including mining, milling, and insulation. Less attention has been given to the household contacts of these asbestos workers, a group with only limited or secondary exposure. Although this at-risk population was originally de scribed in 1960 and 1965, few investi gations have centered on it (1, 2). Both of these initial studies con cerned the presence of mesothelioma in first environmental contacts and later household contacts. We recently screened 117 wives of pipe toverers and asbestos removers for radio graphic, functional, and symptomatic abnormalities. ty (FVC) (percent predicted) and forced expiratory volume (FHVi) (percent pre dicted) were chosen as indicators of func tional status, as set forth by Environmen tal Protection Agencv guidelines. Forced expiratory flow (FEF) (73-25) was also ob tained as a more sensitive indicator of small airwav disease. An additional questionnaire was subse quently presented to the wives that par ticipated in the screening program. Spe cific questions concerned length and amount of cigarette smoking, breathing problems, past diagnoses of heart or pul monary disease, and known chest radio graphic abnormalities. Additional ques tions pertained to asbestos-exposed husbands, fathers, brothers, or sons, in cluding year of first exposure, years liv ing in the same house, date of retirement, other medical problems, and previous employment. All information obtained from the survev was submitted for statis tical analysis by an outside statistician who had no prior knowledge ot expected results. RESULTS MATERIALS AND METHODS From Jaiiuai v to March ok 19S6, 194 in sulation workers exposed to asbestos and 117 of the - wives were screened in a vol untary program at Northwestern Memo rial Hospital in Chicago. The screening program was offered through the local pipe coverers' union and was available to current and retired workers and their wives A posteroanterior chest radiograph was obtained for each patient bv means of standard techniques (140 kV). Film quali ty was monitored throughout the pro gram to assure good-quality radiographs. The chest radiograph was rated by a certi fied "B" reader and graded according to the 1980 International Labor Organiza tion (ILO) classification system. The read er had no knowledge of the patient's length of exposure to asbestos, age, or fa milial exposure history. A second B read er reviewed some of the radiographs. The screening program also included pulmonary function testing monitored and administered bv the pulmonary medicine department. Forced vital capaci None of the 24 women under 40 years of age demonstrated radio graphic abnormalities, and each of them had been exposed for less than 8 years. We therefore chose to ex clude this group. Of the 93 women remaining, 18 (19.4%) had radio graphic abnormalities consistent with asbestos exposure, as defined by the IT O classification. The radio graphic findings are presented in Ta ble 1. Most of the abnormalities were limited to circumscribed plaque for mation of width A or B and extent 1 or 2 along the lateral aspect of the chest wall or face on plaque extent 1 or 2 (88.9%) (Fig. 1). Plaques on the diaphragm were seen in six cases (33.3%), and in two cases (11.1%) these were the only evidence of as bestos exposure. Calcification of the chest wall or diaphragm plaques was seen in three cases (16.7%) (Fig. 2). Diffuse pieural thickening was present in only one case (5.5%). nber 723 Table 1 Abnormal Radiographic Findings Width Extent Finding A R c 1 2 3 Total No. of Cases* Circumscribed pleural thickening Right chest wail s30 920 Right face on 152 Leri tiiesi wail Lett face on 8 4 0 11 1 0 430 Diffuse pleural thickening Right chest wall 000 000 Lett chest wall 100 010 Pleurai calcification Right 1 00 Lett 200 11/18 (61.1) 8/18 (44.41 12/18(66.7) 7/18 (38.9) 0/18(0) 1/18(5.5) 1/18(5.5) 2/18(11.1) Mote. -- A. B, C and I. 2. 3 refer to the iLO classification system. Five subjects (27.8%) had plaque on the nghr side ot the diaphragm, six (33.3%) on the left. * Percentages in parentheses. Table 2 Pulmonary Function Test Results Parameter Normal Radiographs (n = 75) Abnormal Radiographs (n - 18) FEVi (% predicted) FVC (% predicted) FEF(75-25) (% predicted) 99.8 15.4 101.7 14.0 95.5 29.7 90.7 14.0 92.0 13.2 89.4 31.8 Note.--Values indicate means with standard deviations (SD). P <.028 <.011 <456 Those whose fathers or brothers*^ asbestos workers also reported siZ? lar exposure. None were asbesto*> workers themselves. Jr; Many of the women were not**!: posed continually to asbestos their husbands had changed job**, retired. Only the year of initial sure was statistically significant!?! 18 women with abnormal radio. Jj- graphs had a mean year of initial*, posure of 1952, versus 1958 forth*7| with normal radiographs (P < Qjn; The differences in total years of eF* posure (P < .72), number of contacts (P < .89), and age (P < were not statistically significantTQ* women with normal radiograph**"*" showed a statistically greater ing history than those with plaqaj formation (P < .024). *" Finally, the radiographs of 17 the 18 women with positive fini were compared with those of husbands. (One of the husband* of heart disease 1 year before th*'^ study.) Fourteen of the husbandsw pleural involvement more severe** than that of their wives. Six of men also had concurrent pare; mal abnormalities consistent bestos exposure. Three husbi normal radiographs, and their all demonstrated only mild graphic abnormalities, with wall plaques of extent 1 (n = 2) (n = 1) and width A. There was no evidence of parenchy mal opacities or thoracic malignancy. The pulmonary' function tests re vealed no significant "functional" impairment in either the group with normal or the group with abnormal radiographs, although there were sta tistical differences for the measured parameters (Table 2). Data from the questionnaires are presented in Tables 3-8. Virtually ev ery woman questioned described her exposure as primarily from shaking and washing her husband's clothes. DISCUSSION The presence of radiograpl normalities in household coni asbestos workers has received ing attention since the first reL In 1976, a study of the household g contacts of workers in an asbestoi,, factory manufacturing insulation* terials found a 35% prevalence Ot* small parenchymal opacities andj| pleural plaques consistent wjUtjf* bestos exposure (3). A second JWgJp of 60 wives ot Los Angeles slupJ*L workers showed a lower overall prevalence of similar radiogi*P abnormalities (11.3%) (4)groups of investigators post that the exposure to asbestos < curred via asbestos dust in tjl clothes and hair of the workei*| Pleural plaque formation Is most common manifestation tos-related changes in gardless of the type posure. Eventually, or deg at least oone-fl of asbestos-exposed WOI^efti show some radiographic a ties, with pleural plaque to being by far the most common mothers ivjj. orted simj. table 3 Year of Initial Exposure asbestos i Normal Abnormal CX- 'sts Decays lobsor rutlal exp^ hicant. TTj, Ivledi sieuid-0 Radiographs Radiographs (n = 75) (it - 18) P 1958 10.46 1926-1958 1958 1952 6.89 1936-1963 1953 <.037 ... ... <.049 radio- - r initial cx. 58 for the 75 ,P < 037). ears of ex-*? jf family ? MP < .282) Table 4 So. of Subjects with Normal and Abnormal Radiographs, according to Decade of Initial Exposure ificant. 'graphs ater smok- Decent. Normal Radiographs (n * 75) Abnormal Radiographs (rr * 18) ;h plaque r? . 1? 5 ot 17 of `' ve finding* e of their sbands died ore the 1020-1929 1930-1939 1940-1949 '050-1959 1960-1969 1970-1979 1980-1989 I 3 10 35 18 5 3 0 1 7 9 1 0 0 isbands had i severe ^ ix of these"" parenchy-1* ent within .s bands had `heir --ive* th chest ^ "e ra raphs of patients with lim ed or c.ousehoid exposure seem to :iiow the same pattern as those of ccupationallv exposed workers, but *-.th lower prevalence. Our study nowed exclusively pleural changes a this population. Other reports of i = 2) or 2 ` .* it* V eusehold exposure agree that pleuii changes are the most common ab. 'ormaiitv. { Pare Trial abnormalities such as (trail: alar opacities are less con- aphic ab- contacts of* tentiy reported in household con dos (6, 7). None of the women in ved grow- tur program had such abnormalities. t reports. ' isehold isbestos 1 previous studies, the peak inci. -r:iee of parenchymal opacities has 177; (3. 6). As in our survey, ulation ma* "one ot the women in these studies ence of es and with as>nd study | "ad had direct exposure to asbestos. ' * :he study of Los Angeles shipyard ! 'orke e radiographs of 485 `ome. re analyzed (4). The 1976 shipyard . ^Jdv included 676 household con verail ^graphic I Jh$ of workers who handled asbes; ^directly or performed brake re 3oth stulated ' 'Jlr work, drvwall construction, or | '"'lPyard work (3, 6). The lack of pa- os oc- 1 ^rhymal opacities in our patients the work rkers (3,4). a is the in of asb<*" chest, re- - ' "av reflect the smaller patient popu- aPon or a different type of exposure Sinn pioe coverers. Even so, paren'\vnia mges appear to be a signif^nth consistent indicator of ^eeffects of asbestos exposure than ^ presence of pleural plaque, espe- rs will . >' bnonnali* ^ v with limited household expo- urination mon (5). the factors in our survey, the '^erice of pleural plaque appears to Table 5 Total Duration of Exposure (yr) Normal Radiographs (x - 75) Mean SD Range Median 27.76 10.01 1.0-52.0 29.0U Table 6 Age of Subjects (yr) Normal Radiographs (n - 75) Mean SD Range Median 54.48 8.93 41.0-82.0 54.00 Table 7 Number of Asbestos Workers in Household No. of Subjects No. of Workers Normal Radiographs (n = 75) Abnormal Radiographs (n - 18) 1 2 3+ Mean* 34 (45.3) 19(25.3) 22 (29.3) 1.96 6 (33.3) 8 (44.4) 4(22.2) 2.00 Note.--Workers included husbands, fathers, brothers, and sons. Percentages in parentheses. P < .890. be most dependent on the interval since the household contact's first ex posure. In addition, the latency peri od before radiographic abnormalities appears to be longer than with occu pational exposure (6). In our study, the mean latency period for women was 32.8 years, compared with 23.8 years for the workers. The intensity of exposure and total number of years exposed appear to be less im portant. The functional abnormalities in our study are somewhat difficult to interpret. The women with pleural plaque formation did show consis tently and statistically lower mean values for FEV! (P < '028) and FVC (P < .011) than those with normal ra diographs (Table 2). However, both mean values remained within the normal range. In addition, there was no statistical difference between the two groups in complaints of dyspnea on exertion. However, the lower val ues in the women with radiographic abnormalities may be important, as* the women with normal radiographs had a mean pack-year smoking histo- Abnormal Radiographs (n - 18) 32.28 6.57 23.0-48.0 50.50 p <.72 <.081 Abnormal Radiographs (x = 18) 56.94 7.46 42.0-68.0 59 00 P <.282 <.180 Table 8 Cigarette Smoking No. of Subjects Smoking History Normal Radiographs (x " 75) Abnormal Radiographs (x *= 18) Never smoked Past smoker Current smoker Mean packyears' 34 (45.3) 24 (32.0) 17 (22.7) 36.66 6 (33.3) 10(55.6) 2(11.1) 18.37 Note.--Percentages in parentheses. * P < .024. rv of 36 years, versus 18.4 years for the group with abnormal radio graphs. A previous study of pulmo nary function data in household con tacts in the Los Angeles harbor area, which used sensitive measurements including vital capacity and flow rates, thoracic gas volume, and sin gle-breath diffusing capacity for carbon monoxide, documented a sig nificant functional impairment when this group was compared with a con trol group in Michigan matched for smoking history (8). In that study, the pulmonary function of exposed women with visible signs of asbestos exposure on chest radiographs (pleu ral and parenchymal) was not differ ent from that of exposed women with normal radiographs. Our data, although not corrected for smoking history, further suggest that func tional abnormalities in persons with indirect asbestos exposure may ap pear only after a certain latency peri od since first exposure. One finding remains difficult to explain. Three women had more se vere radiographic abnormalities than mber 1f vo| u,T>e 164 Number 3 Radiology 725 their husbands. However, each ot these women gave a family history of at least one household contact in ad dition to her husband (a brother, a fa ther, and a father and son). These ad ditional contacts did not participate in our study and may have contribut ed significantlv to the household ex posure of these three women. The significance of pleural disease as a sign of limited or household as bestos exposure is important to rec ognize. The widespread use of asbes tos did not start until the mid-1940s. Since there appears to be a long la tency period with this limited expo sure, often greater than 30 years, the full extent of disease risk is not yet known. Although we did not find any such cases, it has been shown that household contacts have an in creased risk of mesothelioma (9, 10). In addition, studies with longer fol low-ups should soon be available to show whether these levels of asbes tos exposure are sufficient to cause disabling disease other than meso thelioma (6). Although the data on the risks of household exposure to asbestos are far from complete, chest radiography is clearly a valuable tool. It is impor tant for radiologists and clinicians to be aware of the significance of pleu ral plaque in women without other radiographic abnormalities. References 1. Wagner JC, Sleggs CA. Hammond EC. Diffuse pleural mesothelioma and asbes tos exposure In the North Western Cape province. Br J Ind Med 1960; 17:260-271. 2. Newhouse ML, Thompson H. Mesotheli oma of pleura and peritoneum following exposure to asbestos in the London area. Br*J Ind Med 1963; 22:261-269. 3. Anderson HAR, Lilis R, Daum SM, Selikoff IJ. Household contact asbestos neo plastic risk. Ann NY Acad Sci 1976; 271: 311. 4. Kilburn KH. Lilis R. Anderson HA. et al. Asbestos disease in family contacts of shipyard workers. Am J Public Health 198S; 75:615 617. Daiuuen P. Hinz I. Dabbert AF. Pleura- plaques. Asbestose. und Asbestexpositio^ erne epidemiologische Studie aus dem Hamburger Raum. Pneumonotogie 1975. 143:23-42. ' 6. Anderson HA. Lilis R. Daum SM, Selikojj IJ. Asbestosis among household contact* of asbestos factory workers. Ann NY Acaj Sci 1979; 330:387-399. Epler GR. Fitzgerald MX, Gaensler EA. Carrington CB. Asbestos-related disease from household exposure. Respiration 1980,39:229-240. 8. Kilburn KH, Warshaw R. Thornton JC. Pulmonary functional impairment and symptoms in women in the Los Angeles harbor area. Am J Med 1985; 79:23-28. 9. Barrs YIM. Artvinli M. Sahin AA. Envi ronmental mesothelioma in Turkey. Ann NY Acad Set 1979: 330:423-432. ' 10. Vlanna NJ, Paian AK. Non-occupationaJ exposure to asbestos and malignant meso theliomas in females. Lancet 1978; 1:1061 1063. 4: \iC0r -he n p` -evie -cans to Ttjl 0 rroba . isthe | u pei j a ith -;ort r \ { not : i twee, patie embo :robc :3 pa jnda ilso [ Vvhil scan emb pertc mav othei Jrv p Index tjdif ir ! 726 Radiology September 1987