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

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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


Conventional digital chest radiography computed tomography in occupational lung diseases

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


Occupational respiratory disease spectrum chest imaging only helpful in some diseases

Occupational Respiratory Disease Spectrum Chest imaging only helpful in some diseases


Limitations of chest radiographic imaging

Limitations of Chest Radiographic Imaging

  • 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 other imaging techniques do we have to take a good hard look at the lungs and pleura

What other imaging techniques do we have to take a good hard look at the lungs and pleura


What about a role for computed tomography

What About A Role for Computed Tomography

  • 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

  • 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

  • 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

  • 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:

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


Ct classification of occupational and environmental respiratory diseases r0 irr01

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


Ct classification of occupational and environmental respiratory diseases r0 irr02

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 rgr2q

CT-Classification of Occupational and Environmental Respiratory Diseases: RGr2Q


Ct classification of occupational and environmental respiratory diseases rgr2q1

CT-Classification of Occupational and Environmental Respiratory Diseases: RGr2Q


Ct classification of occupational respiratory diseases ax or coalescence

CT-Classification of Occupational Respiratory Diseases: AX or coalescence


Ct classification of occupational respiratory diseases large opacity b size

CT-Classification of Occupational Respiratory Diseases: Large opacity B size


Ct classification of occupational and environmental respiratory diseases irrgr1

CT-Classification of Occupational and Environmental Respiratory Diseases: IrrGr1


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 irrgr21

CT-Classification of Occupational and Environmental Respiratory Diseases: IrrGr2


Conventional digital chest radiography computed tomography in occupational lung diseases

CT-Classification of Occupational and Environmental Respiratory Diseases: Pleura - parietal type, width b


Conventional digital chest radiography computed tomography in occupational lung diseases

CT-Classification of Occupational and Environmental Respiratory Diseases: Pleura - parietal and visceral type, width c


Botero familia

Botero: Familia


Extra pleural fat

Extra Pleural Fat


Ct classification of occupational respiratory diseases fp extrapleural fat

CT-Classification of Occupational Respiratory Diseases: FP-Extrapleural fat


Ct classification of occupational and environmental respiratory dis cancer

CT-Classification of Occupational and Environmental Respiratory Dis: CANCER


Ct classification of occupational respiratory diseases emphysema grade 3

CT-Classification of Occupational Respiratory Diseases: Emphysema Grade 3


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


Ct classification of occupational respiratory diseases rounded atelectasis

CT-Classification of Occupational Respiratory Diseases: Rounded Atelectasis


Limitations of hrct and ct1

Limitations of HRCT and CT

  • 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

  • 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: Las dos Fridas


Roles for hrct i

Roles for HRCT - I

  • 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

  • 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 Early 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

  • 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?

  • 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?

  • 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:El viejo guitarrista {the old guitarist} [May life be good to you and yours]


Quantitative lung imaging

Quantitative lung imaging

(Courtesy D. Lynch)


Advantages of ct

Advantages of CT

  • Potential for computer-based image analysis

  • Quantification

  • Characterization


Conventional digital chest radiography computed tomography in occupational lung diseases

Quantitative lung imaging


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