Conventional digital chest radiography computed tomography in occupational lung diseases
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Conventional & Digital Chest Radiography & Computed Tomography in Occupational Lung Diseases. John E. Parker, M.D. Pulmonary & Critical Care Medicine West Virginia University Morgantown, WV USA 11 th Annual Congress Turkish Thoracic Society 2008 24 Nisan 2008. Presenter Disclosures.

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Conventional digital chest radiography computed tomography in occupational lung diseases

Conventional & Digital Chest Radiography & Computed Tomography in Occupational Lung Diseases

John E. Parker, M.D.

Pulmonary & Critical Care Medicine

West Virginia University

Morgantown, WV USA

11th Annual Congress

Turkish Thoracic Society 2008

24 Nisan 2008


Presenter disclosures
Presenter Disclosures

John E. Parker, M.D.

“No relationships to disclose”

The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:


Thanks for the privilege
Thanks for the privilege

  • Present and attend the 11th TTS in Antalya

  • Meet colleagues for professional scientific interactions and renewing, making, and maintaining personal friendships

  • The knowledge that a forest is being grown because of the Turk Toraks Dernegi


Goals of presentation imaging
Goals of Presentation- Imaging

  • Review the advantages and limitations of chest radiographic imaging for occupational respiratory disorders

  • Review the utility of computed tomography in the study and evaluation of dust related lung diseases

  • Look at some images of silica- and asbestos- related diseases on both CXR and HRCT

  • Review the ILO guidelines used for grading or scoring pneumoconiosis & introduce an HRCT scoring system

  • Make a pitch for the wide acceptance of digital radiography

  • Look at some wildlife photos and paintings


Roles for chest radiography in clinical medicine
Roles for Chest Radiography in Clinical Medicine

  • CXR is an important and classic tool for evaluating pulmonary disease – both for occupational and for non- occupational respiratory diseases

  • Useful in clinical care, assisting in both the diagnosis of disease & for the evaluation of response to therapeutic interventions

  • Especially helpful in the diagnosis of infectious, neoplastic, and interstitial lung diseases


Chest radiography in dust exposed workers
Chest Radiography in Dust Exposed Workers

  • Chest radiography has been useful tool in screening and surveillance of dust exposed workers

  • Major role in establishing dose or exposure response relationships, what is safe?

  • Although a helpful tool, improvement is possible

  • Documents failures of dust control


Diego Rivera: El vendedor de floresDust diseases impose a heavy burden on workers, their families, and on societies all over the world



Limitations of chest radiographic imaging
Limitations of Chest Radiographic Imaging helpful in some diseases

  • Imperfect tool, not diagnostic gold standard

  • Airway disorders not well evaluated by imaging

  • Functional impairment not well evaluated or assessed

  • Imaging cannot provide certainty about the etiology of observed findings due to limited lung response patterns – but rather images generate differential diagnostic considerations


2002 revision of the ilo guidelines for radiology of the pneumoconiosis
2002 Revision of the ILO Guidelines for Radiology of the Pneumoconiosis

  • Introduces new written guidelines describing profusion, size, shape, location of small opacities

  • Introduces more 2 letter symbols for other findings

  • Includes clarifications of ambiguities of the 1980 ILO guidelines especially for pleural abnormalities

  • Introduces new sectional standard radiographs – an optional 14 film standard set

  • Correction of pleural standard film labeling & provides an example of diffuse thickening



What about a role for computed tomography
What About A Role for Computed Tomography look at

  • Becoming more widely available

  • Provides images with exquisite detail of pulmonary parenchyma and other structures

  • HRCT and CT has excellent anatomical correlation with pathological findings

  • Not currently a universally accepted “ILO system” for HRCT or CT


Hrct and ct advantages
HRCT and CT Advantages look at

  • 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 or cancer

  • In some cases may clarify presence or absence of abnormalities on low profusion Posterior-Anterior Chest films


Limitations of hrct and ct
Limitations of HRCT and CT look at

  • 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 always distinguish occupational from non-occupational etiology of findings


Hrct classification standardization project
HRCT Classification Standardization Project look at

  • Multinational effort--Japan, US, Germany, Finland, France, Belgium, Brasil, and UK

  • Similar, but distinct from the ILO chest radiographic classification system

  • Standardizes imaging parameters

  • Introduces comparison or reference films

  • Features a standardized reading sheet


Ct classification of occupational and environmental respiratory diseases r0 irr0

Jack Parker: look at

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




Ct classification of occupational and environmental respiratory diseases r0 irr03
CT-Classification of Occupational and Environmental Respiratory Diseases: R0/Irr0

Calcified plaques









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


Botero familia
Botero: Respiratory Diseases: Familia


Extra pleural fat
Extra Pleural Fat Respiratory Diseases:


Ct classification of occupational respiratory diseases fp extrapleural fat
CT-Classification of Occupational Respiratory Diseases: Respiratory Diseases: FP-Extrapleural fat




Ct classification of occupational respiratory diseases honeycombing grades 1 3
CT-Classification of Occupational Respiratory Diseases: Honeycombing grades 1-3

HC Grade 3

HC Grade 2

HC Grade 1



Limitations of hrct and ct1
Limitations of HRCT and CT Rounded Atelectasis

  • Cost for scanners and operation prohibitive for some nations and some settings

  • Radiation dose concerns

  • Not recommended for screening, but is recommended for individual patient care

  • May not be as useful for silica related diseases as for asbestos related diseases


Limitations of hrct and ct2
Limitations of HRCT and CT Rounded Atelectasis

  • HRCT is not recommended for large screening projects, but can be important for individual patient care

  • Not the magic solution for drawing the line between disease and no disease or health

  • HRCT still has the same challenge as the chest radiograph to separate low level profusion of disease at the “0/1 vs. 1/0” boundary

  • HRCT cannot always distinguish occupational from non- occupational etiology of findings


Frida kahlo las dos fridas
Frida Kahlo: Rounded AtelectasisLas dos Fridas


Roles for hrct i
Roles for HRCT - I Rounded Atelectasis

  • HRCT is a useful supplement but not a replacement for chest radiography

  • HRCT is helpful in difficult cases where CXR is equivocal for pneumoconiosis

  • HRCT is useful when lung function is discordant with the radiograph


Roles for hrct ii
Roles for HRCT - II Rounded Atelectasis

  • HRCT is helpful when pleural shadows obscure the parenchyma --especially anterior or posterior, face on shadows

  • HRCT is useful to clarify presence or absence of irregular shadows

  • HRCT is helpful to identify emphysema, and other diseases such as cancer or infection

  • HRCT is helpful to clarify pleural shadows, that may not be well visualized on the “2-dimensional” chest radiograph


Helical ct scanning for early lung cancer detection not currently recommended in clinical practice
Helical CT Scanning for Rounded AtelectasisEarly Lung Cancer DetectionNot Currently Recommended in Clinical Practice

  • Proposes to improve cancer detection at early stage

  • High risk asymptomatic populations are screened with non-contrast helical or spiral CT

  • Computerized volume reconstruction of nodules

  • Downside is many benign lesions are identified

  • Small nodules trigger invasive investigations with trans-thoracic FNA or frequent follow up scans (benign or malignant)


Positron emission tomography with ct overlay
Positron Emission Tomography with CT Overlay Rounded Atelectasis

  • PET scan lights up metabolically active tissues

  • Can then overlay CT scan abnormality

  • Positive in lung cancer, lymphoma, sarcoidosis

  • Also PET images are positive in the lesions of progressive massive fibrosis


Summary what is in ready and what is still needed
Summary—What is in ready and what is still needed? Rounded Atelectasis

  • 2000 Revision of ILO Guidelines – are published

  • More global training activities for the ILO Classification System around the international community - including train the trainer programs

  • Formal acceptance by the ILO and other governing bodies of digital radiography along with traditional film screen radiography for dust exposed worker evaluation

  • HRCT classification standardization efforts

  • Publish research findings for the utility or non-utility of CT screening for lung cancer in high risk populations


The future in imaging
The Future in Imaging? Rounded Atelectasis

  • Take advantage of digital systems for image acquisition & transfer

  • Improve training and quality assurance using computer and digital technologies

  • Further improvements in CT scanning and harmonization of classification systems

  • Advance PET scanning or other technologies to identify inflammation


P picasso el viejo guitarrista the old guitarist may life be good to you and yours
P. Picasso: Rounded AtelectasisEl viejo guitarrista {the old guitarist} [May life be good to you and yours]


Quantitative lung imaging
Quantitative lung imaging Rounded Atelectasis

(Courtesy D. Lynch)


Advantages of ct
Advantages of CT Rounded Atelectasis

  • Potential for computer-based image analysis

  • Quantification

  • Characterization


Quantitative lung imaging Rounded Atelectasis


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