Document v1DLOZkq69v61ZELxKLMQVQjb

.SC ES C. Banlldd L. Serological Evaluation of two vean' ;ir Dis 1979: 60: 176-183. accy B. Assessment of the rculosis. Thorax 1977: 32; Miettinen A. Haahtela T. ination test as a diagnostic iences in Finland. Finnish :tion 1978: Yearbook 7: <. Ahmad F S. .Allen B \\\ rological test for tubcrcu.383-1384. :a! test lor tuberculosis. J >-853. s. Serological diagnosis of 2 m---clinical experi* .3.). < devaluation BrJDis Chest 1 EurJ Respir Dis .1980 61, 315-319 j i PLAINTIFF'S i exhibit \54-2fi 1 Pleural plaques: Correlation of autopsy findings to radiographic findings and occupational history CUXNAR HiLLERDAL & ANDERS LlXDGREN Departments of Lung Medicine and Pathology, University Hospital. Uppsala. Sweden Abstract: An investigation was made to correlate autopsy findings of pleural plaques (PP) with the occupational history and lindings of such plaques at X-ray before death. A good correlation was found between occupation and occurrence of PPat autopsy. Using strict criteria. 12.5% of all PP observed at autopsy, including small ones, were visible at X-ray. Almost half (3 of 8} of the widespread changes found at autopsy were seen on the X-rays. With more liberal roentgenological criteria 11 of the 24 cases were noted, but there were also 15 false positives. Plar/ues pleuraies: Correlation entre leut presence a 1'autopsie Us anomalies rndiographiques at 1`anamncse pro/essionnclle. Resume: L'investigation a cherche a correler la mise en evidence de plaques pleuraies a 1'aucopsie avec 1`anamncse professionnelle et ('observation radiologique de ces mcmes plaques avant la mort. On a trouve une bonne correlation entre la profession et I'existence de plaques pleuraies a 1'autopsie. En utilisam des critercs stricts. 12.5% seulement de tomes les plaques pleuraies observers a 1'autopsie. v compris les petites. etaiem visibles aux rayons X. Presque la moitie 3 sur 8'. des modifications diffuses decouvertes a I'autop'ieetait visible aux rayons X. Si 1'onadopte des critcres radiologiqties plus larges, on decouvre des anomalies dans 11 eas sur 24. mais il y a egalemem 15 faux positil's. Air words: asbestos - correlation X-ray and autopsy - occupation - pleural plaques. Submitted in original lorm 1979-05-27 Pleural changes are a common finding on X-rays of the lungs. They are mostly late results of pleural trauma. Some are nor mally occurring soft tissue shadows, and some are the result of exposure to asbestos. These latter changes, "pleural plaques" (PP). may be hyaline or calcilied and are often characteristic. With the use of strict roentgenological criteria for PP/fable l),a good eonrlulioit between exposure to as bestos ;ititl roentgenological oli-er\ati<uts ol TABLE 1. The roentgenological criteriaJar definite phiual plai/ties used in this study 1. Bilateral changes 2. Typical changes, i. e. uneven, situated mainlv in the Hanks and the diaphragm. Il oiiiy wen in tlic Hanks, at least 5 mm thick on a normal-sized chest X-i a\. Diaphrngmai plaques, if the univ tlmling. not accepted unless bilateral!) calctlii d. 3. (ileai eoslinhaphiagwal \inn\e\ 4. I`iiigie\\i"ti in ii 5`uai imitul il \-ravs ate avail.ildc. All ritrti.t utti-l lie 11 l!tilt'd CN<cpl No. I. il no e.lt ltd \ - t a \ - ate .tv at la Me . tilth), t ;.;u ::tl lion It .-U'. > (l.'.aO l> M>;;n MuiA-euani. ('.I'cnli.iecr r / l i= i \ 1 tv l 4 :ilt C I ill .I.I.K I ).\l A UMU.KIA I'P was fomid in a previous.'! inly ^7). 1 o test those criteria ami lo see how main Pi* may he missed. it wits decided to compare X-ray findings before death with findings at autopsy, where I'P arc easily identifiable. PATIENTS AND METHODS All patients above 40 years of age from the County of Uppsala upon whom autopsy was performed between 1 October 197(7 and 31 March 1077 were investigated for PP. PP were delined as shining white, ir regular elevations of the parietal pleura with well-defined borders, as described by many authors (10, M). An attempt was made to determine the occupations of the patients from the case reports or other available means, including obituary notices in the local newspapers. X-rays of the lungs from the different hospitals or miniature Xrays from the general health survey were collected. Only films of good technical quality taken within 7 years before death were included. If the terminal disease had led to roemgenologicalchanges.forexampie pulmonary congestion or pleural exudate, an earlier X-ray was used ifavailable within a 7-year limit, if not, the X-ray was disre garded. The X-rays were scrutinized for pleural changes and were divided into those which fuiniled the criteria for PP (Tabic 1) definite cases), those with changes that could be early PP but did not fulfill the criteria (questionable cases), and those with no pleural changes or changes typical for pleural fat. extrathoracic muscles, or past pleurisy, X-ravs showing obliteration ofone or both costodiaphragmal sinuses, tenting of the diaphragm, and other changes strongly suggesting late results ofpleuritisor infection were classified in the last category. The X-rays were classified without any know ledge of the autopsy results or of the occupation of the patients. Is l..s I' J.T.S 11 otnt H- Must <>l i lie women were housewives. .\uto|>'*v was performed on 21 1 women. 189 of whom hud an acceptable X-rav. At autopsy one case with small I'P was found but none of the X-rays showed anv PP. .!/<. There were 22G male autopsies. The occupations were determined in 198 cases, and were divided into those known to be associated with possible use of asbestos (plumbers, electricians, and workers in the building trade, automobile workshops and factories known to use asbestos) and those known probably not to be. At autopsy. 10 cases with widespread pleural changes typi cal of PP. and 17 with changes of lesser degree, were found. A comparison between the autopsy findings and the occupational histories was.made (Table 2). Of 61 cases with known possible exposure to asbestos. 18 (29.5%) showed PP at autopsy, while in 137 persons with occupations in which asbestos is unlikely to be used, only five PP (3.6 %) were found. X-rays were available in 202 cases. In three of the positive autopsy cases no X-rays wereavailable. Three out of eight "widespread" PP were found on X-ray with "definite" criteria, and none out of 16 "small" PP. Thus three out of 24 (12.5%; TABLE 2. Occupation* and pleural plaques ai autopsy (men only) Total Typical PP at autopsy Per cent w ith PP Persons in occupation* known to give [>ossihlc exposure to aslx'stos 61 18 29.5 Persons in occupations where asi>cstos is unlikely to he used 137 5 3.6 Unknown occupation 28 4 14.3 Total 226 27 11.9 table / k/,- Autopsy vigils <>l picuml pliiqufN were found (Tal positives. If"que nosed as PP, 11 but in addition t When the autop X-rays of the po scrutinized. In < bilateral, slight 1 the diaphragm i !c At autopsy, tht present investic somewhere belt the literature ;2 place and time 4). The radiolog ii I and 2% amon i > TABLE 4. Frequency Il Authc i \ Robi: t 45) I ii Ger; Tirr. Dor. af Hiu &5 (' I'l.KUUAl. I'l.At.HXS 317 f.Vlil.L 3. Finding <"J ph null i at iiuti'p'Y iiml <il A-uiy ' Wi ll nillyi Definite X-rn\ >ts;n> ol )>le oral |il.it|iies Qitf'iiunalile None ,ig> of pleural plaiiuf' idc'jiread Moderate small None Total J4 1 0 4 12 0 15 163 3 23 176 Total 8 1ft 178 202 were found (Table 3). There were no false positives. If "questionable'' cases were diag nosed as PP, 11 of the 24 cases were found, but in addition there were 15 false positives. When the autopsy results were known, the X-rays of the positives autopsies were again scrutinized. In one case it was found that bilateral, slight but definite calcifications of the diaphragm had been ov erlooked. DISCUSSION At autopsy, the frequency of PP in the present investigation was 12%, a figure somewhere between the extremes given in the literature (2.7-49%), depending on the place and time of the investigation (Table 4). The radiological frequency was between 1 and 2% among males above 50, which is similar to the figures obtained in earlier investigations on the same area (7). The roentgenological diagnosis of hya line PP can be a problem. In a multicentre study in Britain (1), no correlation between exposure to asbestos and pleural changes was found. The most probable explanation is that no clear definition of PP was used. Apart from remnants of earlier pleuritis, intrathoracic fat deposits (18) and in some cases intrathoracic muscles (12) may lead to a false diagnosis. As in the present study, other authors have found that many asbestos-related changes seen at autopsy cannot be seen on X-ray (9,16). Even ifchest roentgenography is an unreliable method of diagnosing PP, some comfort may be found in the fact that widespread changes presumably indicate TABLE 4. Frequency of PP at autopsy (men only). Selected reports Author Population Place Robinson (15) Rural Florida Per cent 2.7 Gerlach & Timmel (5) Doniach et al. .'2} Hagerstrand Si Seifert ''10': Urban Urban Urban Halle London Malmo 24 30 49 Comment Only PPs with diameter >5 mm i :;ik (. im.i.t.Ki> u. ,,\ a. i.].mh;ki.\ lieiivirr expo.suiv to asbestos and therefore probably are more important to Jlnci. Asbestos is possibly licit (lie onh cause ol I'l\ but it is generally agreed that it is bv iar tlic most common, and PP (if propcrlv defined) can be considered to be a very specific indicator of exposure to this sub stance (7). This is further confirmed by the good correlation between ``asbestos occu pations'* and PP found in this study. Even slight exposure to asbestos probably in creases the risk of bronchial carcinoma in smokers (13, 19). The time from first ex posure to asbestos to development of roent genologically typical PP is about 30 years (7) and the latency time in asbestos-related bronchial cancer is about the same "6. 8, 11). Possibly therefore a risk group could be identified by detecting PP roentgenologicallv. This has been corroborated by Fletcher (4) and Edge (3), who found that the risk of bronchial carcinoma in dockyard workers in England was more than twice as high in those with PP than in those with similar exposure but without PP. There is also a higher frequency of PP than expected among patients with bronchial carcinoma (8, 17). CONCLUSION Failure to detect roentgenological changes does not exclude the possibility that signifi cant pleural changes resulting from expo sure to asbestos may be present. With strict roentgenological criteria, between half and one third of widespread PP will be found, and "very few false-positive cases will be diagnosed. With wider limits for what shall be diagnosed at X-ray as "probable asbestos changes" or "small PP", more cases of true PP will be diagnosed, but there will also be a considerable number of cases which at autopsy show no sign of PP. Even with such liberal criteria, a few widespread PP and quite a few moderate to small ones will be missed. REFERENCES 1. British Thoracic and Tuberculosis Association/ MRC Pneumoconiosis Unit. A survey of pleural thickening: its relation to asbestos exposure and previous pleurai disease. Environ Res 1972; 5. !-12-515. 2. Doniach I, Sweitenhnm K V. Hathorn M K. S Prevalence of asbestos bodies in a necropsy series in East London: association with disease, occupation and domiciliary address. Br J Ind Med 1975: 32; 16-30. ' ' 3. Edge J R. .Asbestos related disease in Barrow-inFurness. Environ Res 1976: 11: 244-247. 4. Fletcher D E. A mortality study of shipyard workers with pleura! plaques. Br J Ind Med 1972: 29: 142-145. 5. Gerlaeh H. Timmel H. Hyaline pleuraplaques im Obduktionsgm. Zemralbl. Allg Pathol: 1972:115: 517-521. 6. Hammond E C. SclikofT I J. ChurgJ. Neoplasia among insulation workers in the Untied States with special reference to intra-abdominal neopla sia. .Ann New York .Acad Sci 1965: 132: 519-525. 7. Hillerdal G. Pleura! plaques in a health survey material. Frequency, development and exposure to asbestos. Scand J Respir Dis 1978: 59: 257-263. 8. Hillerdal G, Nou E. Occupation and bronchial carcinoma. Scand J Respir Dis 1979: 60: 76-82. 9. Honrihane D'Ob. Lcssof L. Richardson P C. Hyaline and calcified pleural plaques as an index of exposure to asbestos. A study ofradiological and pathological features of 100 cases with a considera tion ofcpidcmiology. Br.Med.J 1966:1:1069-1074. 10. Hiigerstrand I, Seifert B. Asbestos bodies and pleural plaques in human lungs at necropsy. Acta Pathol Microbiol Scand. Sect A 1973:81:457-460. 11. Jacob G. Anspach M. Pulmonary neoplasia among Dresden asbestos workers. .Ann New York Acad Sci 1965: 132: 53G-548. 12. Knutsson F. Zur Kenntnisder normafen Rontgen ologic der Pleura Parietaiis. Acta Radioi. 1932: 13: 638-677. 13 Martischnig K M. Newell D J. Barnsley \V C. Cowan \V K. Feinmann E L. Oliver E. Unsus pected exposure to asbestos and bronchogenic carcinoma. Br MedJ 1977: 1: 746-749. |4. Mi umiiii] I. in a Finiu-h Mil loluul N . j5. Robinson J ) 'deio'is in ad 93: 118-122. 16. Sluis-Crcmcr radiological c proved at nut 1968: 608-6K ]7. Ton L. Her Thoincoiomk Elude prelim: Fr Mai Respi \ pi.i.I'kai. pi.aum.n .'.I1.) u ;"'d 11 niit'> " ill be i ! j ]-} Men i nun 1.. A-be'in- in k I if' and pleural plaques m ,i Finnish series ul auiop't rases. .Vta I'ailml Mi. lul'iol Stand I9nt>: Suppl. If!!. Ip Knliii)M>n J J. Pleural plaques and splenic capMilar sclerosis in adult male autopsies. An h Pathol 1972; 18. Vi.\ V A. Extrapleural costal I.it. Radiology 1974: 1 12: 3(i:>-*>()5. 19. Wamoek M L. Clun g AM. Association ofasbcsios and bronchogenic caiinoma inti population with low asbestos exposure, Clancer 1975: 35; 123b- PA I 18-122. 12-12. 16. Sluis-Crcmcr G K. Wagner j C. A pathologieal- lo>if Av'Wj;il/on/ >um'\ ofpicui'al -tos expo-tire ;md -o Rc> 1972: j. radiological correlation in 108 cases of asbestosis proved at autopsy. Proc hit Congr Occup Health l`tri8: (i08-('IO. 17. Toty L. Hertzog P. Pcrsonne C. Bnkduch H. Thoracotomies et plaques plettrales lihrohyalines. Atkl ivss: Gtmnar Hillerdal Departtnent of Lung Medicine I'niversity Hospital Haifmni M K S. : necrops\ >erie> in Ltnde preliminaire a propos dc 125 maiadcs. Rev Fr Mai Respir Suppl. 2 1975: d: 93-%. S-750 H Uppsala Sweden ica-'C. occupation, :id Med 1975; 32- ase in Barrow-in- :udv of shipvard rj Ind Med 1972: pieuraplaques Pathoi:'l972: 115: nurgj. Neoplasia the `"d States 'eopla9-525. .. . survey aeni and exposure 1978: 59: 257-263. ion and bronchial . 1979: 60: 76-82. Richardson P C. laques as an index ofradiological and > with a considera* 966:1: 1069-107-1. >estos bodies and at necropsy. Acta 1973:81: 457-dbO. y neoplasia among sew York Acad Sc; ormalen Rontgen* .eta Radiol. 1932: J. Barnsiev W C. Oliver . UnsU'tnd bronchogenic M6-7d9. I