neumocon|os|s

Dav|d W. kamp, M.D.

D|sc|osures
1. CranLs: vA MerlL Award
nlP-8C1LS020337

2. AssoclaLe LdlLor: 1ranslauonal 8esearch

3. Speaker: 8oehrlnger-lngelhelm
CSk
neumocon|os|s: Objecnves
S|||cos|s ] Coa| Workers' neumocon|os|s
Asbestos-Induced Lung D|seases
|eura (eus|ons & p|aques)
Lung (asbestos|s & rounded ate|ectas|s)
Ma||gnanc|es (Mesothe||oma ] Lung CA)
Cther neumocon|oses
8ery|||os|s
nard Meta| Lung D|sease
Acknowledgement: Dr. David Cugell
neumocon|os|s
neumoconlosls ls a 19
Lh
cenLury Creek Lerm
(poeomo - lung, kools - dusL) LhaL descrlbes lung
dlseases assoclaLed wlLh mlneral dusL exposure.
1he parucular Lerm lmplles Lhe puLauve dusL or
worker aL rlsk
Slllcosls - slllca AsbesLosls - asbesLos
8erylllosls - berylllum SLanosls - un
Coal Workers' neumoconlosls [CW]
Pard MeLal Lung ulsease - cobalL usually
"Doc - now do you know I have
pneumocon|os|s?"
Lno|ogy of Intersnna| Lung D|sease
keyno|ds, chest 1998, 113:192 (17 years, 2 centers)
P
E
R
C
E
N
T

(
%
)

Wh|ch statement about s|||cos|s |s
|ncorrect ?
A. Plgh rlsk occupauons lnclude mlnlng, sLonecumng
and foundry work.
8. lavors Lhe upper lobe
C. 1yplcally asympLomauc
u. 1he acceleraLed form of slllcosls ls characLerlzed by
alveolar proLelnosls
L. CavlLaung leslons should suggesL 18
S|||cos|s
A chronlc lung dlsease due Lo lnhalauon of
crysLalllne slllca (usually quarLz)
CharacLerlzed by progresslve parenchymal nodules
and pulmonary brosls.
Slllca or slllcon dloxlde ls Lhe mosL abundanL mlneral
ln Lhe earLh's crusL
Cccupauons: Mlnlng, quarrylng, sLonework,
foundrles, abraslve / sandblasung, ceramlc (pouery,
oven brlcks), denlm [ean sandblasung *
S|||cos|s
pidemio/oqy
1he mosL prevalenL chronlc occupauonal lung dlsease
worldwlde
8lsk ls dlrecLly proporuonal Lo parucle concenLrauon,
durauon of exposure, and slllca conLenL of dlerenL rock
Lypes (~100: sandsLone / lnL Lo < 10: shale)
uSA Workers: 1983: 2.3 mllllon aL rlsk" slllcosls
2006 > 1 mllllon
ueaLhs: 1,133 per year ln 1970
> 123 per year ln 2006
CSPA-LL: <100 g/m
3
x 8h
Leung et al Lancet 2012; 379:2008-2018 (Review)
1
2
3
1 - Acellular hyalinized collagen
2 - Layered collagen
3 - Thick capsule
Phase Contrast Microscopy
Birefringent Crystals (Silica)
Injury (silica, coal, asbestos)
Epithelial cells
athogenes|s of M|nera| Dust
u|monary 1ox|c|ty
Mitochondria
ROS / RNS
DNA damage
Macrophages
SiIica / CWP
NoduIes
Fibrotic Response
Epithelial cells
Collagen
Myofibroblast
Apoptosis
Treg: TGF-!, PDGF, etc
Teff: IL-1#, IL-4, IFN$, etc
Other: TNF%, Gremlin, etc
Pathogenesis of Mineral Dust
Pulmonary Toxicity
Chron|c S|||cos|s
c/inico/-Potho/oqic leotures
MosL common form
Low-level exposure (< 100 g/cm
3
) > 20 y
revalence: 0.4 - 11
ChesL x-8ay
Small (1-3 mm) nodules
SymmeLrlcal bllaLeral upper lobes
Calcled nodules - 10-20
Pllar Ln wlLh eggshell calclcauon
S|||cos|s - qq 5he// co/cifconon
Progressive Massive Pulmonary Fibrosis (PMF)
Remember to
exclude TB
Chron|c S|||cos|s
c/inico/ leotures {cont)
l1: Cen normal early -> LaLer:
lung volumes
ulco
Alrways obsLrucuon => 2nd ux (eg. CCu)
ux: PlsLory & chesL x-ray (8arely 8x)
rognosls: no ln morbldlLy &
morLallLy unless progresslve masslve
pulmonary brosls (Ml) develops
Conglomerate Silicosis
S|||ca (n = 220), Coa| (n = S11) and Asbestos (n = 277)
Workers: cxk & 5ymptoms
Wang & Chr|snan| l Occup Med 2000, 42:1076
Dyspnea Cough
% %
Chest X-Ray Stage
S|||ca, Coa| and Asbestos Workers:
Pl1 v. cxk
Wang & Chr|snan| l Occup Med 2000, 42:1076
FVC (% pd)
Dlco (% pd)
Chest X-Ray Stage
Acute ] Acce|erated S|||cos|s
c/inico/-Potho/oqic leotures
ACu1L:
Several mo / yrs of hlgh level exposure Lo quarLz
aLhology: Alveolar proLelnosls, poorly formed nodules,
lnLersuual lnlLraLes
Cx8 / P8C1: Alveolar pauern / crazy pavlng"
l1: 8esLrlcLed volumes / low ulco
ACCLLL8A1Lu:
3 - 13 yrs of moderaLe level exposure Lo quarLz
numerous nodules w. varlable lnLersuual lnlLraLes
Cen progresses Lo resplraLory fallure
l1: 8esLrlcLed volumes / low ulco
Acute S|||cos|s:
4/veo/or Proteinosis
Crazy Paving - alveolar proteinosis
1he r|sk for tubercu|os|s |s greatest |n
wh|ch group of workers ?
A. Welders
8. lpeuers
C. Saw Sharpeners
u. 8rlcklayers
L. loundry Workers

SILICCSIS: Monoqement
Avoldance: nlCSP LL 30 g/m
3

CSPA LL 100 g/m
3

Cx8 survelllance * / no esLabllshed 8x
Lung LransplanL - anecdoLal reporLs
MycobacLerlal lnfecuons:
Slllca lmpalrs AM funcuon
Cnly pneumoconlosls wlLh 18 rlsk
SuspecL ln all slllcosls pLs wlLh Ml or lung cavlLy
Sub-opumal prophylacuc (lnP 6-12 mo) and 8x (8 mo)
* Leung et al. Lancet 2012; 379:2008-2018 (Review).

S|||cos|s
Lunq concer kisk controversy
Slllca exposure lncreased lung cancer rlsk ln 9
of 11 sLudles, only 1 / 9 show a dose-
dependenL eecL aer correcung for
confounders (Lobacco, asbesLos, eLc)
> 40 sLudles show pauenLs wlLh slllcosls have a
2-4-fold lncreased rlsk of dylng from lung
cancer
Weill and McDonald Thorax 1996; 51:97
Pelucchi et al Ann Oncol 2006; 17:1039

Coa| Workers' neumocon|os|s
Wh|ch statement about Coa| Workers'
neumocon|os|s |s |ncorrect ?
A. underground mlners have Lhe greaLesL rlsk.
8. CenLrllobular emphysema oen seen
C. rogresslve masslve brosls occurs
u. Cen are sympLomauc
L. 1he chesL x-ray pauern ls slmllar Lo slllcosls
Chronlc exposure Lo coal
dusL, graphlLe and oLher
forms of carbon.
CW (black nodules) vs.
slllcosls (whlLe nodules)
Carbon ls less brogenlc
Lhan quarLz (Mlxed dusL).
MSPA -LL 2 mg/m
3

nlCSP -LL 1 mg/m
3

Coa| Workers' neumocon|os|s
'8|ack Lung' or 'Antraco-S|||cos|s'
eLsonk eL al. Am I kesplt ctlt cote MeJ 2013, 187:1178-87 (8LvlLW)
NICSn Coa| Workers' Ckk
Surve|||ance rogram
Black Lung Is Increasing !
http://www.npr.org/2012/07/09/155978300/as-mine-protections-fail-black-lung-cases-surge (accessed 7-10-12)
Coal Workers Health Surveillance Program; NIOSH; NPR (July 2012)
Percent of evaluated miners with PMF (by years of mining; 1970-2009 in 5 yr groups)
Percent of evaluated miners with any stage of black lung (by yrs of mining; 2000-2009)
underground mlners - greaLesL rlsk
1930s - 1960s morLallLy raLe ln coal
mlners due Lo CW
1960-70s - uusL conLrol Lhe
prevalence & morLallLy of CW.
> 100,000 uSA coal mlners
CW prevalence: 1970s: 20 - 33
2006: 6 - 10
CW -> Ml: < 0.3 (lncreaslng !)
Ml ls dlrecLly proporuonal Lo Lhe levels
of quarLz ln Lhe coal belng mlned.
Coa| Workers' neumocon|os|s
pidemio/oqy
0.5 - 3.0 m
2 - 10 m
Coa| Workers' neumocon|os|s
Potho/oqy
ln conLrasL Lo slllcosls, CW
presenLs wlLh:
greaLer dusL burden
black lung nodules (random)
black lymph nodes
cenLrllobular emphysema
Coal-laden AM
Ml occurs - even now
Wv: 138 pLs 2000-09
Wade eL al cbest 2011, 139:1438
Coa| Workers' neumocon|os|s
c/inico/ Monifestonons
usually asympLomauc
Lung Lxam -> normal
Advanced dlsease -> cough,
SC8, Cor pulm.
ChesL x-8ay
Same as slllcosls
Caplan's Syndrome
large conglomeraLe masses
LhaL cavlLaLe
8heumaLold arLhrlus
Coa| Workers' neumocon|os|s
Proqnosis
l1 A (CW < Slllcosls)
8esLrlcLed volumes
8educed ulco
Mlxed 8esLrlcuve /
CbsLrucuve defecLs
Ml - severe mlxed
resLrlcuon & obsLrucuon
Lung CA rlsk: no *
+ Slllcosls (noL CW)
no esLabllshed 8x

Progressive Massive Fibrosis
* Am J Ind Med 2008; 51:231
Wh|ch statement about asbestos-|nduced
pu|monary tox|c|ty |s |ncorrect ?
A. lerruglnous bodles are only seen wlLh asbesLos
exposure.
8. 1he dlagnosls of asbesLosls does noL requlre ussue.
C. CharacLerlzed by a long laLency perlod beLween
exposure and dlsease
u. Can presenL wlLh brosls or cancer
L. ulrecLly proporuonal Lo Lhe magnlLude and
durauon of asbesLos exposure
Asbestos
6reek-derived term for inexnnquishob/e or
unquenchob/e
naLurally occurrlng slllcaLe bers
ldeal for consLrucuon
AsbesLos Lxposure:
Mloloq ooJ mlllloq
loJosttlol oppllcouoos
Lexules
cemenL
shlpbulldlng
brake llnlng, frlcuon maLerlal
laggers, plpe cuuers
Noo-occopouoool exposote

Mossman & Churg AJRCCM 1998
ASBESTOS FIBER TYPES
* MosL brogenlc and carclnogenlc
CrocldollLe * AmoslLe
Chrysotile (serpentine) Anthrocite
Asbestos 8od|es
(lerruqinous 8odies)
Length: 20 - 200 m
W|dth: 2 - 6 m
Coated w mucopo|ysacchar|des and
|ron (redox acnve)
I|ber burden - '1|p of the Iceberg'
kano of coated (asbestos bod|es) ] uncoated hbers - 30
Asbestos
pidemio/oqy
1927 Cooke - 'asbesLosls'
1930s AsbesLos-assoclaLed Lung CA
1960s AsbesLos-mesoLhelloma llnk esLabllshed
1970s uramauc decllne ln asbesLos use
1940-79: ~ 27 mllllon workers ln Lhe uSA exposed
300,000 workers sull occupauonally exposed
Long laLency (13-40 yrs) from exposure Lo dlsease
2030: AsbesLos deaLhs ln Lhe uSA may > 200,000.
Legal sysLem lnundaLed by asbesLos-relaLed class-acuon
lawsulLs and 68,000 clalms ln 2000.

A|| mesothe||oma |eura| mesothe||oma
er|tonea| mesothe||oma
Asbestos|s
Lin et al Lancet 2007; 369:844
Asbestos-re|ated d|seases d|rect|y corre|ate w|th asbestos
consumpnon g|oba||y (1960-1969)
Is there a safe thresho|d |eve| of
asbestos exposure?
CSPA - LL for bers > 3 m long wlLh 3:1
aspecL rauo ls 0.1 bers/cm
3
for 8 h
lrench reLrospecuve populauon sLudy of rlsk
from 3 years of exposure Lo CSPA - LL -> 4-
fold lncrease rlsk of pleural mesoLhelloma
lwaLsubo eL al Am I plJemlol 1998, 148:133
Mapp|ng the r|sk of mesothe||oma due to
ne|ghborhood asbestos exposure
kurumatan| and kamaga| AIkCCM 2008, 178:624
- Amagasakl, !apan
(crocldollLe /
chrysoule planL)
- 73 cases of
mesoLhelloma
- uose-relaLed ln
proxlmlLy Lo planL ~
2200 m down-wlnd

Mapp|ng the r|sk of mesothe||oma due to
ne|ghborhood asbestos exposure
kurumatan| and kamaga| AIkCCM 2008, 178:624
- Amagasakl, !apan
(crocldollLe /
chrysoule planL)
- 73 cases of
mesoLhelloma
- uose-relaLed ln
proxlmlLy Lo planL ~
2200 m down-wlnd

Llbby, M1 (vermlcullLe mlne 1920-1990)
ConLamlnaLed wlLh up Lo 26 amphlboles
leural abnl: W8 Crace worker 31, resldenL 7
MesoLhelloma - 31 resldenLs
8esldenLs: 40- Lo 80-fold lncrease rlsk of asbesLosls and
mesoLhelloma Lhan uSA ave
2009: LA ubllc PealLh Lmergency (1
sL
ln Px)
rlce keq 1ox lbotm 2007, WhlLehouse eL al Am I loJ MeJ 2008
hup://www.epa.gov/reglon8/superfund/llbby/phe.hLml
Asbestos
Pothophysio/oqy
Amphlbole hypoLhesls: Amphlboles, especlally crocldollLe,
are more brogenlc and carclnogenlc Lhan chrysoule
uose response: ?ears of exposure, lnLenslLy, uusL conLrol
(masks)
LaLency perlod: 10-40 yrs Lyplcally
< 3 yrs aer lnlual asbesLos exposure unllkely due Lo asbesLos
Ceneuc SuscepublllLy (noL fully undersLood)
Anu-oxldanL defenses (le / free radlcals)
lnammaLory / lmmune response (1nl / 1Cl)
Cene olymorphlsms (CS1M1, SCu2, 1A1, x8CC1/3)
p33
kamp 1tooslouoool kes 2009, 133:143 Llu eL al Aooo kev lotbol Mecb us 2013, 8:161-87
8en|gn Asbestos |eura| Lus|ons
(8AL)
LaLency perlod: LarllesL manlfesLauon
1yplcally > 20yrs (8ange: < 1 yr [rare] Lo > 40 yrs)
lnvolves vlsceral and parleLal pleura
Lxudauve euslon, unllaLeral, le-slded
8arely ferruglnous bodles are found
Cen asympLomauc
MusL exclude mallgnancy - oen vla vA1S
varlable cllnlcal course: resoluuon (rare), blunLed
CA (mosL common), rounded aLelecLasls, dluse
pleural Lhlckenlng, mesoLhelloma (?)
Wh|ch of the fo||ow|ng |s the |ncorrect
statement about asbestos-|nduced p|eura|
p|aques ?
A. 8arely occurs unul 20 yrs aer lnlual exposure.
8. MosL oen are bllaLeral.
C. 1yplcally lnvolve Lhe parleLal pleura
u. Mlnlmally alLers l1s
L. ls a well esLabllshed rlsk facLor for mesoLhelloma
and bronchogenlc carclnoma
ulscreLe collagenous
maLerlal along parleLal
pleura of Lhe mld-
lower rlbs and
dlaphragm
LaLency > 20 years
revalence - varles
wlLh lnLenslLy of
exposure
Cccupauonal: 20-60
non-Cccupauonal: 2-6
Asbestos-Induced |eura| |aques
Pleural
Plaques
& calcifi-
cations
PLEURAL PLAQUES
WITH CALCIFICATION
ON CHEST WALL &
DIAPHRAGM
CT w. seIect HRCT cuts better denes the
extent of disease and DDx (asbestosis,
CA, fat, muscIe [SA or EO])
now Does Asbestos Cause |eura| |aques?
Dona|dson k et a| Pornc/e ond liber 1oxico/oqy 2010, 7:S
Stomata
Long I|ber ketennon |n the ar|eta| |eura
Dona|dson k et a| Pornc/e ond liber 1oxico/oqy 2010, 7:S
ar|eta| |eura
Lymph
ChanneI
Stomata
roteases
kCS
M|togens
Irustrated
hagocytos|s
Conrms asbesLos
exposure and llule else
8arely aecLs l1s
no rm evldence of
lncreased lung CA rlsk
0/10 sLudles show dlrecL
relauonshlp w and CA
1997: lnLernauonal
LxperLs laques lnsumclenL
Lo llnk lung CA Lo asbesLos
Asbestos-Induced |eura| |aques:
5iqnifconce
Weiss Chest 1993;
Henderson et aI Scan J Work Environ HeaIth 1997
InvoIves visceraI &
parietaI pIeura with
bIunted CPA
Can aIter PFTs
UniIateraI or biIateraI
ROUNDED ATELECTASIS
PIeuraI brosis entraps Iung => Major DDx is Lung CA (FNA/VATS?)
'Comet taiI' sign - entrapped BV bundIe
Wh|ch of the fo||ow|ng |s the correct
statement about ma||gnant
mesothe||oma ?
A. LaLency perlod ls Lyplcally less Lhan 20 years.
8. AsbesLos ls Lhe only known cause.
C. 1here ls a synerglsuc lnLeracuon beLween asbesLos
and Lobacco smoke on Lhe lncldence of
mesoLhelloma.
u. ls an uncommon Lumor wlLh posslbly an lncreaslng
lncldence
L. A slngle paLhognomonlc LesL can esLabllsh Lhe
dlagnosls
Ma||gnant Mesothe||oma
pidemio/oqy
8are Lumor caused by all forms of asbesLos
AsbesLos exposure documenLed ln 30-83 (81, vlrus,
chronlc pl)
no synergy wlLh Lobacco smoke (unllke lung CA)
LaLency perlod > 30 years
lncldence peaked ln uSA ?
CuC - esumaLed peak ln 2010 (MMwk 2009, 38:393)
SLL8 daLa - MM peak ln 2004 (rlce & Ware Am I plJemlol 2004, 139:107)
~ 8 of deaLhs ln asbesLos workers exposed Lo
greaLer Lhan CSPA-LL (0.1 bers / cm
3
x 8h)
8ouun eL al ot kesplt I 1998, 12:972, 8oblnson eL al NIM 2003, 333:1391
eLo eL al Aoo Occop nyq 1983, 29:303,
leura
Llderly (30 - 70 y/o)
Male (3:1)
lnsldlous (3 mo - 2 yrs)
nonsp. ComplalnLs
(fever, wL loss, swLs)
uyspnea (30-70)
nonpl chesL paln (60)
Cough (30)
l. euslon (80-93)
erlLoneum
Abdomlnal aln (40)
Abdm. ulsLenslon (37)
WelghL Loss (3)
8owel CbsLrucuon (4)
Abdm. Mass (2)
AsclLes (1)
Ma||gnant Mesothe||oma
c/inico/ Monifestonons
8lbak eL al 8tlt I loJost MeJ
1988, 43:182
8ounn et a| ur kespir l 1998, 12:972
Mesothe||oma - C1 Chest
MLSC1nLLICMA
Ma||gnant Mesothe||oma
uioqnosis
no slngle paLhognomonlc lmmunohlsLochemlcal
marker or ulLrasLrucLural feaLure
SLrong cllnlcal susplclon, approprlaLe exposure Px, laLency
ulagnosuc LesLs:
leural uld cyLology (23-33),
Closed pleural 8x (21-77),
vA1S >90
lmmunohlsLochemlcal markers:
MesoLhelloma: (+) vlmenun and Calreunln / (-) AS and CLA
AdenoCA: (-) vlmenun and Calreunln / (+) AS and CLA
ulLrasLrucLure of MM: mlcrovllll / desmosomes

Mossman eL al coocet lovest 1996, 14:464 ass eL al NIM 2003, 333:1364 8oblnson and Lake
NIM 2003, 333:1391 ass eL al Aoo 1bot 5otq 2008, 83:263
Mesothe||oma Serum 8|omarkers ?
Meerbeek & n|||erda| et a| 4lkccM 2008, Luo et a| kespir Med 2010,
no||evoet et a|. l 1horoc Onc 2011, kosar|o et al c/in Pu/m Med 2012, 19:282
Var|ab|es SMk MI Csteoponnn
Screen|ng n|gh I n|gh I n|gh I
Sens|nv|ty 73 34 47
Mon|tor kx es es es
rognos|s es es es
DDx MM]8D oss|b|y oss|b|y oss|b|y
Conc|us|on: No usefu| screen|ng test yet, too many
fa|se pos|nve and neganve tests
Ma||gnant Mesothe||oma
Monoqement
lavorable prognosuc slgns:
< 3 LoLal body wL loss - Cood performance sLaLus
1umor conned Lo Lhe lpsllaL. pleura - laLeleLs < 400,000
LplLhellod hlsLology (noL sarcoma) - Age < 60
Medlan Survlval: 6-18 mo
3 year survlval: < 3
1reaLmenL rarely curauve (ldeally proLocol based)
Clsplaunum: 88 17-23, medlan survlval 9 mo
Clsplaunum + emeLrexed: 88 41, medlan survlval 12 mo
Mulu-modallLy (Chemo / x81 / Surgery - exLrapleural pneumonecLomy) -
Medlan survlval 22 mo, 3 yr survlval 14, MorbldlLy: 30
8ec: Cnly done ln cllnlcal Lralls ls speclallzed cenLers

Voge|zang et a| l c/in Onco/ 2003, LkS 1ask Iorce kl 2010, 3S:479
Wh|ch of the fo||ow|ng |s the not requ|red
to make a conhdent d|agnos|s of
asbestos|s ?
A. PlsLory of asbesLos exposure wlLh an approprlaLe
laLency perlod.
8. l1s showlng resLrlcuve physlology and a reduced
ulco
C. Clubblng
u. 8lbasllar crackles
L. lrregular opaclues on Lhe chesL x-ray
Asbestos|s - D|agnos|s
415 2004 consensus 5totement
8ellable exposure hlsLory - Lyplcally heavy occupauonal
exposure (8AL > 1 A8 / ml)
An approprlaLe laLency perlod - Lyplcally > 20 yrs
ChesL x-ray abnl: lLC > 1/1 (1986) > 1/0 (2004)
leural plaques presenL ln 80-90 (unllke ll)
P8C1 ndlngs slmllar Lo ll buL wlLh plaques
l1s wlLh lung volumes and ulco below normal
Lnd-lnsplraLory blbasllar crackles (slmllar Lo ll)
uoes noL requlre ussue (blopsy)
2010 updaLe: >2 A8/cm
2
or lung asbesLosls (LM / LM)
4kku 1986 134:363 4lkccM 2004, 170:691 4rch Potho/ Lob Med 2010, 134:462
Asbestos|s nkC1 hnd|ngs s|m||ar to II but
w|th p|eura| p|aques
Unlike IPF, asbestosis is
slowly progressive
Lung CA k|sk:
II ~10
1urner-Warw|ck 1horox 1980
Asbestos|s
Do|| 8r l lndust Med 19SS,
nughs & We|| 8r l lnd Med 1991


Controversy: Asbestos|s |s requ|red for the
deve|opment of asbestos-assoc|ated |ung cancer.

Weiss Chest 1999; 115:536
- AsbesLos ls a carclnogen
- Synergy beLween asbesLos
and Lobacco smoke
Coal: 1o provlde experL-based consensus for Lhe dx
of asbesLos-relaLed lung dlsease
ACC & Workman's Compensauon 8oard developed
32 sLaLemenLs / 34 'experLs'
Consensus on 23 sLaLemenLs
no Consensus on 9 sLaLemenLs
2009; 135:1619
Consensus Statements Show|ng
Agreement
Px of asbesLos exposure of sumclenL durauon, dose and
laLency ls Lhe llkely cause of lLu ln absence of oLher causes
ldenucauon of asbesLos bers ln lung speclmens ls lnLegral
Lo Lhe hlsLologlcal dlagnosls of asbesLosls
Workers wlLh slgnlcanL asbesLos exposure buL w/o
asbesLosls are aL lncreased rlsk for lung cancer
Workers wlLh pleural abnormallues are noL aL lncreased rlsk
for lung cancer v. workers w/o pleural changes
AsbesLos exposure does noL lead Lo CCu

8anks et a| chest 2009, 13S:1619
Statements W|thout Lxpert ane|
Agreement
1he exLenL of asbesLos exposure correlaLes wlLh Lhe
presence and exLenL of pleural abnormallues
A reasonable scheme can be develop Lo apporuon
Lhe lndlvldual aurlbuLablllLy of smoklng ln an
asbesLos worker LhaL smokes
8AL can accuraLely esLabllsh lung ber burden
ChesL C1 scans should be used Lo screen populauons
aL rlsk for asbesLos-relaLed lung dlseases.
Wh|ch of the fo||ow|ng |s the |ncorrect
statement about 8ery|||os|s ?
A. Can occur ln workers of uorescenL llghL and
nuclear reacLor lndusLrles.
8. AcuLely presenLs as a dlrecL lrrlLanL.
C. Chronlc berylllum exposure resulLs ln a sarcoldosls-
llke plcLure.
u. 8erylllum workers can become sensluzed as
assessed by a lymphocyLe Lransformauon LesL
L. 1he lymphocyLe Lransformauon LesL ls dlagnosuc of
berylllosls
8ery|||os|s
Newman et a| 4lkccM 200S, 171:S4 Sawyer et a| 8iometo/s 2011, 24:1-17
ldeal meLal for heaL shlelds, x-ray Lubes, uorescenL
llghL xLures, nuclear reacLors
AcuLe 8erylllum ulsease: Lracheobronchlus
+/- lnlLraLes and hypoxemla
Chronlc 8erylllosls: ldenucal Lo Sarcold
Cllnlcally, radlographlcally (8PA / med Ln) and
paLhologlcally (non-caseaung granulomas)
LymphocyLe Lransformauon LesL - ldenues sensluzed
workers (~16-30) whlle only 3-31 develop ds (1-9 y)
ux: Lxposure Px, Cx8, 8erylllum-L11, 1lssue
8x: Avold furLher berylllum exposure, sLerolds
nard Meta| Lung D|sease
Agent n|stopatho|ogy Cccupanon
A|um|num ILD ] sarco|d-||ke A| m|ner
8ery|||um Sarco|d-||ke ILD M|ner, e|ect
Cadm|um Acute pneum, ILD 8auery]8raz|ers ds
Coba|t G|ant ce|| ILD*, 1oo| cuuers
A|rways Cbstrucnon Denta| dr|||s
Iron Dust macu|e, ILD Iron m|ner,
'S|deros|s' Iron we|der
* Nearly pathognomonic for hard metal lung disease from Cobalt
Cobalt-Associated Diseases:
1. Airways obstruction
2. Acute interstitial pneumonitis
(HP-like)
3. Chronic giant cell interstitial
pneumonitis
Giant Cell Interstitial Pneumonitis
I|ock Worker's Lung D|sease
kre|ss 2013, 143:1S29 1urcoue et a|. 2013, 143:1642
lLu (lymphocyuc bronchlollus / perlbronchlollus)
seen ln workers exposed Lo ock nylon bers (e.g.
velveL-llke fabrlcs, fuzzy greeung cards, auLo glove
boxes)
Case reporLs 1970-1990s -> nlCSP 1998 Workshop
rogresslve uCL, cough, resLrlcLed l1s, low ulco
P8C1: erlpheral / basal ground glass changes
CuLcome: (1) compleLe resoluuon, (2) sLable,
(3) progresslve decllne- deaLh (low ulco lnc rlsk), ?CA
???
Pneumoconiosis
I hope the doc
remembers
to take a careful
occupational Hx !!