AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Background

Asbestos is a naturally occurring, fibrous silicate that was widely used in the past for commercial applications because of its heat-resistance properties. Asbestos exists in several forms. The 2 primary groups of asbestos are made up of amphibole and serpentine fibers. Amphibole fibers, which are characteristically straight, rigid, and needlelike, can be subdivided into commercial amphiboles (crocidolite, blue asbestos, and amosite [brown asbestos]) and noncommercial amphiboles (actinolite, anthophyllite, and tremolite). Chrysotile (white asbestos) is the only form of serpentine asbestos that is used commercially, and it accounts for more than 90% of asbestos used in the United States.¹

For the most part, asbestos exposure has been industrial or occupational; such exposure primarily affects workers involved in mining or processing asbestos or those involved in the use of asbestos in the shipbuilding, construction, and textile- and insulation-manufacturing industries.^{2, 3} Chrysotile is mined in Canada, and tremolite and anthophyllite are mined in Finland and North America. Crocidolite and amosite are mined in South Africa and Australia. About 2-6 million people in the United States are estimated to have had significant levels of exposure.^{3, 4}

High exposures ceased in the United States in the late 1970s, and later in the United Kingdom, because of governmental legislation passed after the adverse effects became recognized. However, because the latency period between an initial exposure and the development of most asbestos-related disease is 20 years or longer, asbestos-related disease remains an important public health issue.^{5, 6}

The spectrum of asbestos-related thoracic diseases includes benign pleural effusion, pleural plaques, diffuse pleural thickening, rounded atelectasis, asbestosis, mesothelioma, and lung cancer.⁷

Asbestosis is defined as diffuse lung fibrosis due to the inhalation of asbestos fibers, and it is one of the major causes of occupationally related lung damage. Mesothelioma is a malignant pleural or peritoneal tumor that rarely occurs in patients who have not been exposed to asbestos.^{8, 9, 10, 11, 12, 13}

The diagnostic approach to asbestos-related intrathoracic disease is different from that of other diffuse lung diseases because of the medicolegal implications.¹⁴ The likelihood of asbestos-related disease should be determined, and other possible causes should be eliminated. An assessment of the extent of disease is used to calculate compensation. Therefore, imaging plays a pivotal role in the diagnosis and management of asbestos-related disease.

See also the following related eMedicine topics:
Asbestosis [Pulmonology]
Asbestosis [Radiology]
Mesothelioma
Mesothelioma, Malignant
Peritoneal Cancer

See also the following related Medscape topic:
Resource Center Lung Cancer

Pathophysiology

Physical properties of asbestos fibers

Evidence regarding the relative importance of the different physical properties of the asbestos types in causing disease is conflicting.^{15, 16} Certainly, fine fibers are more pathogenic than are thick fibers. Fibers of 5 µm or more in diameter tend to become deposited in larger airways, from which they are effectively cleared through mucociliary action. In comparison, fibers that are more slender tend to be deposited in small airways or airspaces, from which only a proportion of them are cleared.

The effect of fiber length is less certain, but straight fibers that are approximately 5-20 µm long, such as crocidolite fibers, are not cleared as effectively as others are, and they can cause intense inflammation and fibrogenic changes within the interstitium. Conversely, chrysotile fibers are flexible, they usually do not fragment, and they are longer than 100 µm; therefore, they tend to be deposited in major airways, from which they are cleared to a large extent.

Despite differences in their physical properties, all types of asbestos fibers are fibrogenic. However, crocidolite is the most carcinogenic.

Pathogenesis

The pleurae are more sensitive than pulmonary parenchyma to the effects of the fibers. Thus, pleural plaques develop after low, intermittent exposure, whereas asbestosis is associated with cumulative, high-level, long-term, continuous exposure in association with a definite dose-effect relationship. Nonmanual workers in industries involving asbestos, inhabitants of areas immediately surrounding asbestos mills, and families of asbestos workers have an increased incidence of mesothelioma. However, even with significant industrial exposure, asbestosis is unusual.

Pleural plaques are the most common manifestation of asbestos exposure, occurring after a latent period of approximately 20-40 years. A history of exposure can be elicited in more than 80% of patients. Histologically, pleural plaques consist of acellular collagen bundles that form a basket-weave pattern, which almost exclusively involves the parietal pleura. The plaques may contain chrysotile asbestos fibers.

The precise pathogenesis of pleural plaques remains undetermined. That they are caused by the mechanical effect of asbestos fibers piercing the visceral pleura (the scratching theory) was assumed. Currently, however, the fibers are believed to be transported to the parietal pleura via lymphatic channels, where they incite an inflammatory response. Plaques slowly grow over time, even after cessation of exposure, but they are not considered premalignant.

Calcification occurs later, often 30-40 years following exposure. Pleural plaques tend to occur in isolation without any other manifestations of asbestos-related disease; however, the converse is not true. Asbestosis is rarely seen in the absence of plaques.

Diffuse pleural thickening is less specific for asbestos exposure than is the presence of pleural plaques, since thickening also may be seen following tuberculous (TB) pleuritis, hemothorax, and empyema. Usually, the latent period is approximately 15 years. The pathogenesis is unclear, but it is believed to be due to inflammation and fibrosis of the visceral pleural lymphatics, and it has been considered to be an extension of parenchymal fibrosis. Histologically, the appearances are similar, although in diffuse pleural thickening, fusion of the visceral and parietal layers and asbestos bodies (which are absent in pleural plaques) is profuse. Development of diffuse pleural thickening has a similar time line as plaque formation.

Benign, asbestos-related pleural effusions are often the earliest manifestation of asbestos-related disease, typically occurring within 10 years after exposure. The effusions are exudative. Occasionally, they are hemorrhagic, but otherwise, their features are nonspecific. Effusions tend to be self-limiting, with a duration of a few months, but they can be chronic or recurrent. Diffuse pleural thickening not uncommonly develops following resolution of the effusion.^{17, 18, 19}

Fibers not cleared by mucociliary action are believed to be transported into the interstitium, where they form aggregates, usually at the level of the respiratory bronchiole. Research results suggest that the fibers stimulate the release of a collagenase inhibitor–like protein that locally disturbs the balance of collagen turnover, resulting in fibrogenic changes within the interstitium.

Asbestosis is usually seen when levels reach 10 million asbestos fibers per gram of pulmonary tissue. Asbestosis characteristically occurs following a latent period of 15-20 years, with a progression of disease even after exposure has ceased. Fibrosis first arises in and around the respiratory bronchioles, predominating in the subpleural portions of the lung in the lower lobes. This progresses to involve the alveolar walls, eventually causing honeycombing in a minority of patients.

Folded lung (also termed round atelectasis, pulmonary pseudotumor, or Blesovsky syndrome) specifically refers to an area of atelectatic lung adjacent to pleural thickening, with characteristic in-drawing of bronchi and vessels. Blesovsky first reported folded lung in 1966. Although folded lung is strongly associated with asbestos exposure, it may also be seen as a consequence of any inflammatory or infective organizing pleural exudate.

The presence of the effusion has been postulated to cause passive atelectasis, with infolding of the lung resulting in invagination of the adjacent pleura. This process causes tethering, which prevents reexpansion of the lung upon resolution of the effusion and which causes round atelectasis. A more accepted alternative explanation is that an insult to the pleura leads to localized inflammation and fibrosis, which results in volume loss and buckling of the underlying lung. Interestingly, the changes have been shown to resolve after decortication. The lingula is the most common site, followed by the middle and then the lower lobes, although lesions may be multiple and bilateral.

Malignant pleural mesothelioma is a rare neoplasm, accounting for less than 5% of pleural malignancies. Malignant pleural mesothelioma is strongly associated with asbestos exposure, particularly crocidolite exposure; however, the association does not appear to be dose-related, because significant numbers of cases occur after trivial environmental or household exposure. No relevant history of any asbestos exposure is found in 20% of patients. The disease is frequently seen in the absence of any other manifestations of asbestos exposure and usually develops after a long latent period of 35-40 years.

Mesothelioma is 80% pleural and 20% peritoneal in origin. Pleural effusions are not a precursor of mesothelioma, but they often antedate development of malignancy. A confident diagnosis is often difficult to make and usually requires ultrastructural analysis and histochemical and immunohistochemical tests. Histologically, 3 forms of malignant mesothelioma are recognized: epithelial, mixed, and sarcomatous (also known as mesenchymal). These must be differentiated from mesothelial hyperplasia and metastatic adenocarcinoma. The most common histologic subtype is epithelial, accounting for 50% of cases.

Bronchogenic carcinoma is estimated to develop in 20-25% of heavily exposed asbestos workers. Smoking has a cumulative effect, further increasing the risk of lung cancer to a factor of 90 versus a factor of 5 in exposed nonsmokers. Often, asbestos-related interstitial disease is associated; however, no correlation exists between the severity of asbestosis and the development of lung cancer. Furthermore, lung cancer has been reported in individuals without interstitial lung disease who have been exposed to asbestos. A latency period of 25-35 years is usual. Histologically, the predominant subtype is broncho-alveolar cell carcinoma, but adenocarcinoma and squamous cell carcinoma also occur.

Associations between asbestos exposure and other cancers—including carcinomas of the larynx, esophagus, stomach, and colon, as well as a variety of lymphoid malignancies—have been reported anecdotally.

See also the following related eMedicine topics:
Atelectasis
Atelectasis, Lobar
Atelectasis, Pulmonary

Frequency

United States

The number of individuals affected by asbestos-related disease is slowly increasing. However, whether this is secondary to a true increase in incidence or due to increased recognition is debated.

The prevalence of benign pleural plaques in the non–asbestos-exposed general population is extremely low. The prevalence in environmentally exposed general populations in industrial societies is approximately 0.5-8%. Frequencies in exposed individuals are 3-58%, depending on occupation. The development of plaques depends on the length of exposure or the amount of time that has passed since the first exposure, as opposed to being dependent on a threshold dose, which is the case for asbestosis. The prevalence of pleural plaques is 10% in exposed individuals 20 years after exposure, rising to 50% after 40 years.

The prevalence of diffuse pleural thickening is not known, although it is reported to occur with frequency equal to that of pleural plaques. Thickening is a common concomitant finding to asbestosis, with a reported associated incidence of 10%.

The frequency of benign, asbestos-related pleural effusions in exposed individuals is reported to be 3-7%. However, this number may be an underestimate, because most patients are asymptomatic; therefore, effusions are subclinical and undetected. The incidence rises with increasing levels of asbestos exposure.

Asbestosis is reported to develop in 49-52% of adults with industrial asbestos exposure, after a latency period of 40-45 years.

Approximately 2000-3000 cases of malignant mesothelioma, or 7-13 cases per million general population, are diagnosed annually in the United States.

Epidemiologic studies predicted a decline in incidence in the United States after the year 2000, with a peak incidence in the United Kingdom in 2020. The prediction is probably applicable to benign pleural plaques also, because the latency period is similar. Lung cancer develops in as many as 25% of asbestos workers. In asbestos-exposed nonsmokers, the incidence of lung cancer is 5 times that of the general population. In exposed individuals, smoking further increases the risk of bronchogenic carcinoma by 80-90 fold.

International

The incidence of asbestos-related lung and pleural disease in the remainder of the industrialized world remains similar to that of the United States. In the United Kingdom, asbestos use was highest in the 1970s, later than in the United States; therefore, the peak incidence of disease lags as well. Legislation regarding asbestos varies from country to country, and although crocidolite is rarely used internationally, other forms of asbestos remain in use.

Mortality/Morbidity

After the onset of symptoms, severe asbestosis may lead to respiratory failure and death over 12-24 years. Respiratory failure may be accelerated by the development of Caplan syndrome; pulmonary hypertension; or malignancy, including lung cancer or mesothelioma.

No treatment for asbestosis is effective. The primary strategy is prevention, through the worldwide elimination of asbestos use and the replacement of asbestos with safe synthetic products.

Mesothelioma tends to appear late and is usually associated with an extremely poor prognosis. The median survival is 10 months or less, and most patients die within 2 years.²⁰

See also the following related Medscape topics:
CME Advances in the Systemic Therapy of Malignant Pleural Mesothelioma
CME/CE Interstitial Lung Disease and Pulmonary Hypertension

Race

No race predilection exists for asbestos-related disease.

Sex

Mesothelioma has a male-to-female ratio of approximately 4:1. Asbestos-related disease in women is uncommon and is usually confined to spouses of industrial workers, as well as to secretarial and domestic staff working in asbestos industries.

Age

A minimum latency period of 8-10 years is required for an asbestos-related pleural effusion to develop; this is usually the earliest manifestation of asbestos-related disease. Similarly, a latency period of more than 20 years is required for the development of asbestosis. As a result, most patients with asbestos-related disease are older than 40 years.

Mesothelioma usually is seen after a longer latency period, with most patients in the sixth-to-eighth decades of life.

Clinical Details

• Pleural plaques are not reported to cause symptoms.
• Diffuse pleural thickening may be associated with symptoms and signs comparable to those arising from other causes of fibrothorax, such as dyspnea. The restriction of lung function rarely may be severe enough to warrant decortication of the lung.
• The clinical picture in benign, asbestos-related pleural effusion varies from asymptomatic patients to patients with an acute episode of pleuritic chest pain and pyrexia.
• Asbestosis may cause an insidious onset of progressive dyspnea in addition to a dry cough. Clinical findings of basal inspiratory crackles associated with reduction in vital capacity and diffusion capacity are also seen.
• Asbestosis is usually diagnosed on the basis of certain clinical, functional, and radiographic findings outlined by the American Thoracic Society (ATS).²¹ However, these guidelines have not been updated since the routine clinical use of high-resolution computed tomography (HRCT) scanning began in the early 1990s.^{22, 23} Findings based on the ATS criteria include the following:
• • Reliable history of nontrivial asbestos exposure
  • Appropriate interval between exposure and detection (usually >10 y)
  • Abnormal chest radiographic findings
  • Restrictive lung disease as indicated by pulmonary function test results
  • Abnormal diffusing capacity
  • Bilateral crackles at the lung bases that are not cleared by coughing
• Clinical symptoms in malignant mesothelioma are frequently present 6-8 months prior to diagnosis. Symptoms include localized chest wall pain and weight loss. Cough and dyspnea may also be present.

The international staging system for malignant mesothelioma is as follows:

• Tumor
• • T1a - Tumor limited to ipsilateral parietal pleura
  • T1b - Additional scattered foci of visceral pleural involvement
  • T2 - T1 plus involvement of diaphragmatic muscle and/or confluent visceral tumor (including fissures) or direct extension to the pulmonary parenchyma
  • T3 - Locally advanced (but potentially resectable) tumor encasing the lung with at least 1 of the following features:
  • • Involvement of endothoracic fascia
    • Extension into mediastinal fat
    • Solitary focus of chest wall invasion
    • Nontransmural involvement of pericardium
  • T4 - Locally advanced, unresectable tumor encasing the lung, with at least 1 of the following features:
  • • Multifocal or diffuse chest wall involvement
    • Transdiaphragmatic peritoneal spread
    • Direct extension to contralateral pleura
    • Involvement of vital mediastinal structures
    • Direct extension to the spine
    • Transpericardial disease, with or without pericardial effusion or myocardial involvement
• Node
• • N0 - No regional nodal metastases
  • N1 - Ipsilateral bronchopulmonary or hilar nodal enlargement
  • N2 - Ipsilateral mediastinal (including internal mammary) or subcarinal nodal enlargement
  • N3 - Contralateral mediastinal, contralateral internal mammary, or supraclavicular nodal enlargement
• Metastasis
• • M0 - No distant metastases
  • M1 - Distant metastases present
• Staging
• • Stage Ia - T1a, N0, M0
  • Stage Ib - T1b, N0, M0
  • Stage II - T2, N0, M0
  • Stage III - Any T3, M0; any N1, M0; any N2, M0
  • Stage IV - Any T4, any N3, any M1

Preferred Examination

HRCT scanning is playing an increasingly important role in the diagnosis of diffuse interstitial lung disease. However, chest radiography remains the initial modality for the detection and characterization of pleural and parenchymal disease. Ultrasonography has a role in characterizing pleural effusions and guiding pleural aspiration and biopsy. Nuclear medicine study has a limited role in the investigation of asbestos-related intrathoracic disease. Gallium-67 (⁶⁷Ga) citrate testing has been used to differentiate benign from malignant, asbestos-related pleural disease and to give a quantitative index of inflammatory activity.²⁴

Limitations of Techniques

The limitations of chest radiography in the diagnosis and evaluation of asbestos-related disease are well recognized. The quality of the radiograph and the size, shape, position, and degree of calcification determine whether the radiologist can detect pleural plaques on the image. While the identification of bilateral, scattered, calcified, costal, and diaphragmatic pleural plaques is virtually diagnostic of asbestos exposure, studies have shown an 11% false-positive rate with chest radiographs. In particular, extrapleural fat mimics pleural thickening and is a significant cause of false-positive readings. Conversely, a high false-negative rate has also been reported.

Computed tomography (CT) scans have long been known to be more sensitive and specific than chest radiographs for the diagnosis of asbestos-related pleural disease.^{25, 26}

Radiographic-pathologic studies have shown that chest radiographic findings are normal in as many as 20% of patients with asbestosis. HRCT scanning is more sensitive and specific than other studies, particularly when images are obtained with the patient in the prone position, which allows differentiation of mild parenchymal changes from dependent density (increased attenuation of the posterior, usually basal, lung, which is gravity induced and secondary to nonaeration of dependent alveoli).²⁷

Nuclear medicine studies have been used in small series, but their exact role remains unclear.

DIFFERENTIALS

Section 3 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Other Problems to Be Considered

Causes of diffuse pleural thickening

Benign, asbestos-related, diffuse pleural thickening
Postexudative effusion (eg, parapneumonic effusion, connective tissue disease)
Hemothorax
Mesothelioma

Causes of nodular pleural thickening

Malignant mesothelioma
Metastatic adenocarcinoma

Causes of basal subpleural fibrosis

Asbestosis
Usual interstitial pneumonia
Connective tissue disease
Drug-related fibrosis

Causes of a solitary pulmonary mass

Folded lung
Malignancy (eg, bronchogenic carcinoma, metastasis, and lymphoma)
Benign neoplasm (eg, hamartoma and adenoma)
Vascular (eg, arteriovenous malformation, pulmonary infarction, hematoma)
Infection (eg, tuberculosis, round pneumonia, fungal infection)

RADIOGRAPH

Section 4 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

• Benign pleural plaques
• • Benign pleural plaques may be seen in profile or en face. In profile, plaques appear as focal, smooth opacities, usually less than 1 cm thick, paralleling the chest wall. Appearances en face are of a more ill-defined opacity with irregular margins.
  • Plaques may occur as isolated abnormalities or in association with lung parenchymal involvement.
  • Most pleural plaques are multiple, bilateral, and often symmetric and are located in the midportion of the chest wall between the seventh and tenth ribs, following rib contours, or adjacent to the aponeurotic portion of the diaphragm and vertebral column.
  • Visceral pleura, lung apices, and costophrenic angles are typically spared.
• Pleural calcification
• • On chest radiographs, the prevalence of calcification in pleural plaques is reported to be 10-15%.
  • In profile, calcified plaques appear as opaque lines that lie parallel to the chest wall, mediastinum, pericardium, and diaphragm.
  • Viewed en face, calcified plaques are seen as irregular, heterogeneous densities, the so-called holly leaf.
  • The presence of bilateral, superior diaphragmatic surface calcifications with clear costophrenic angles is virtually pathognomonic for asbestos-related pleural disease.
• Diffuse pleural thickening
• • Asbestos-related, diffuse pleural thickening is defined as a smooth, uninterrupted pleural opacity extending over at least one quarter of the chest wall, with or without obliteration of the costophrenic angles.
  • Pleural thickening may be difficult to diagnose using conventional chest radiographs, and differentiation between diffuse thickening and focal pleural plaques may be problematic. However, diffuse pleural thickening due to asbestos exposure rarely calcifies, tends to involve the costophrenic angles (unlike plaques), tends to be ill defined rather than sharply marginated, and is more extensive than focal plaques.
  • Involvement of interlobar fissures is not uncommon.
  • Diffuse pleural thickening is associated more often with radiographically detectable asbestosis than are pleural plaques.
• Benign, asbestos-related pleural effusions
• • Benign, asbestos-related effusions have the same radiographic appearance as effusions due to other etiologies; the diagnosis usually is one of exclusion.
  • Effusions are usually small, they may be unilateral or bilateral, and they tend to resolve spontaneously over 3-4 months, although as many as 30% recur.
  • Some effusions are associated with pleural plaques.
  • Effusions tend to resolve over a period ranging from 1 month to 1 year, with residual blunting of the costophrenic angles due to pleural thickening in 50% of patients.
• Asbestosis
• • Asbestosis is defined as interstitial pulmonary fibrosis secondary to the presence of intrapulmonary asbestos bodies or asbestos fibers. The fibrosis is usually most severe in the subpleural lower zones.
  • Chest radiographic findings include fine reticular opacities and septal lines that progress towards a coarser linear pattern of honeycombing.
  • With advanced disease, the heart border and diaphragmatic contours become ill defined, the so-called shaggy heart.
• Round atelectasis
• • Round atelectasis appears as a well-defined, rounded, focal, subpleural soft-tissue mass of 2-7 cm in diameter that abuts an area of pleural thickening.
  • Most atelectases are located in the posterolateral or posteromedial parts of the lower lobes.
  • Occasionally, bilateral masses are seen.
  • Mild volume loss may be associated.
  • Appearances usually remain stable over time, but occasionally, masses may increase or decrease in size.
• Bronchogenic carcinoma associated with asbestos exposure
• • Appearances are those of non–asbestos-related lung cancer.
  • The most common radiographic finding is a pulmonary mass with associated mediastinal lymphadenopathy.
  • Lung cancer in asbestos-related disease tends to occur at the lung bases but can arise in any location if also associated with smoking.
• Malignant mesothelioma
  • Mesothelioma typically appears as irregular, nodular, diffuse pleural thickening, occasionally associated with a pleural effusion.
  • Less commonly, an isolated effusion or pleural mass is seen.
  • The tumor progresses to encase the entire hemithorax, encasing the lung.
  • The mediastinum usually is fixed or shifted toward the side of the tumor.
  • Evidence of other asbestos-related disease, such as plaques, is seen in only approximately 20-25% of patients.
  • Patients rarely may present with spontaneous pneumothorax.

Degree of Confidence

The presence of bilateral, calcified pleural plaques can be considered diagnostic of asbestos exposure.

Unfortunately, the value of chest radiography is limited. Reviewing a series of 200 radiographs, Epstein and colleagues found that images in 18% of the patients showed small opacities.²⁸ This finding was consistent with pneumoconiosis, according to the International Labour Office (ILO) classification. Of these patients, 61% had no known occupational exposure to asbestos. Furthermore, as many as 20% of patients with histologically proven asbestos-related lung disease have normal chest radiographic findings, and 80% of patients with radiographic findings of mild disease have histologic results of moderate or severe fibrosis.

The extent of malignant mesothelioma frequently is underestimated with chest radiography.

False Positives/Negatives

False-positive, false-negative, and interobserver variability rates are relatively high when chest radiographs are evaluated for pleural plaques. Prominent subpleural fat or normal rib companion shadows may mimic focal or diffuse pleural thickening, leading to false-positive diagnoses in as many as 20% of patients.

Plaques may be difficult to differentiate from diffuse pleural thickening radiographically. However, plaques usually spare the costophrenic angles and apices and rarely extend over more than 4 rib interspaces, while diffuse pleural thickening rarely calcifies and is usually more irregular and ill defined.

Extensive pleural calcification usually suggests other etiologies, such as talc exposure, hemothorax, empyema, and therapeutic pneumothorax. However, bilateral diaphragmatic calcification with costophrenic angle sparing is considered pathognomonic for asbestos-related disease.

The differential diagnosis of predominantly basal subpleural fibrosis includes idiopathic pulmonary fibrosis (cryptogenic fibrosing alveolitis or usual interstitial pneumonitis), drug reactions, and connective tissue diseases.

The most important differential diagnosis of round atelectasis is bronchogenic carcinoma. Biopsy may be necessary. Round atelectasis is not specific for asbestos exposure and may be preceded by pulmonary infarction, Dressler syndrome, heart failure, and nonspecific pleural effusions.

No definite evidence links benign, asbestos-related pleural effusion to the development of malignant mesothelioma; however, malignant mesothelioma is an important differential diagnosis for benign, asbestos-related effusion. Specific criteria for the diagnosis of a benign, asbestos-related effusion include (1) a history of asbestos exposure, (2) the elimination of other etiologies of an effusion, and (3) the absence of malignancy for 3 years after the onset of the effusion. Although benign, asbestos-related effusion and mesothelioma are related to asbestos exposure, effusion tends to occur earlier than mesothelioma, with an onset approximately 10 years after exposure versus approximately 20-40 years.

CT SCAN

Section 5 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

CT scanning has been established as the criterion standard in the evaluation of pleural disease. Developments in HRCT scanning have made it an invaluable tool in the assessment of asbestosis.²⁹ Scanning the patient in the prone and supine positions increases sensitivity and specificity.²⁷

• Focal pleural plaques
• • Plaques appear as discrete, well-defined areas of localized pleural thickening.
  • Plaques are usually multiple, bilateral, and located adjacent to rigid structures, such as the ribs, midportion of the chest, aponeurotic portion of the diaphragm, mediastinum, and paravertebral regions.
  • Lung apices and costophrenic angles typically are spared.
  • Rarely, the visceral pleura within fissures is involved, or plaques may be pedunculated.
  • CT scanning is reported to be 50% more sensitive for the detection of pleural calcification than chest radiography.
  • Pleural plaques occur in isolation in 48% patients and in association with parenchymal disease in 41%.
  • Plaques remain stable over time.
  • Occasionally, pleural plaques are associated with short lines in the adjacent parenchyma. These hairy plaques (so called because of their fuzzy appearance) are of undetermined significance, although they should be distinguished from the more generalized fibrosis of asbestosis.
• Diffuse pleural thickening
• • Diffuse pleural thickening is defined as an uninterrupted sheet at least 5 cm wide, 8-10 cm long craniocaudally, and 3 mm thick.
  • Proliferation of extrapleural fat is a frequent finding; this presumably occurs as a response to pleural retraction.
  • Disease may be bilateral and tends to involve the posterolateral surfaces of the lower thorax.
  • Differentiation of diffuse pleural thickening from discrete pleural plaques is important because the former may be associated with significant reduction in pulmonary function.
• Benign, asbestos-related pleural effusion¹⁹
• • Effusions may be unilateral or bilateral and are usually small.
  • Benign, asbestos-related effusions greater than 500 mL are uncommon.
  • Effusions are associated with subsequent development of diffuse pleural thickening in just over 50% of patients, and an association with subsequent development of round atelectasis also exists.
  • CT scanning is useful to help exclude an underlying cause or associated pleural mass.
• Rounded atelectasis
• • As on chest radiographs, round atelectasis appears as a well-defined, rounded or wedge-shaped mass forming an acute angle with the adjacent pleura, which is always thickened. The mass usually is separated from the diaphragm by interposed lung.
  • Additional features identifiable on CT scans may include crowding of air bronchograms and the presence of a comet-tail sign, or hurricane sign, which is a curvilinear bronchovascular bundle leading into the mass.³⁰
  • Volume loss, focal emphysema, and calcification may be seen.
  • Because a round atelectasis represents a collapsed lung, it enhances significantly after the intravenous administration of contrast material, usually with a minimum attenuation increase of 200%. Enhancement is usually uniform.
  • Pleuroparenchymal fibrous bands may be seen radiating from thickened pleura. These crows' feet are believed to represent contiguous, thickened interlobular septa.
• Asbestosis
• • The earliest abnormal HRCT scan finding in patients with asbestosis is subpleural micronodularity, which represents early, mild peribronchial and centrilobular fibrosis.
  • As the disease progresses, intralobular and interlobular septal thickening are seen, eventually resulting in architectural distortion, traction bronchiectasis, and honeycombing.
  • Ground-glass attenuation (increased lung attenuation without obscuration of the underlying pulmonary architecture) is a relatively unusual feature of asbestosis. When present, it may represent edema or fine intralobular fibrosis.
  • Ancillary findings of curvilinear subpleural lines and parenchymal bands, which are linear opacities 2-5 cm long extending from or paralleling the pleural surface, may be seen. These are characteristic (occurring in 60-80% of patients with asbestosis), although not specific (occurring in 10-20% of patients with non–asbestos-related diseases). The lines and bands represent contiguous, thickened interlobular septa, which are areas of subsegmental atelectasis or fibrosis along bronchovascular bundles.
  • Mild mediastinal lymphadenopathy, believed to represent a form of reactive hyperplasia, is found frequently in patients with uncomplicated asbestosis.
• Malignant mesothelioma
  • CT scan findings include irregular, nodular pleural thickening (92%), which may involve the interlobar fissures (86%), pleural effusion (74%), loss of volume (42%), pleural calcification (20%), and chest wall invasion (18%).
  • Pleural thickening is typically nodular and is usually greater than 1 cm thick, circumferentially involving the parietal and visceral costal and mediastinal pleura.
  • Tumor often spreads to involve the underlying lung, causing thickening of interlobular septa and parenchymal nodules.
  • Chest wall and mediastinal invasion spreading to the contralateral hemithorax and through the diaphragm may be identified.
  • Mediastinal lymphadenopathy occurs, although distant metastases, including hematogenous spread to the contralateral lung, are uncommon.
  • Rarely, malignant mesotheliomas may present as localized masses.

Degree of Confidence

Compared with chest radiographs, CT scans are more sensitive and specific for the detection of diffuse pleural thickening.^{25, 26} Furthermore, interobserver agreement in assessing pleural disease is greater with CT scanning than with chest radiography.

The positive predictive value of chest radiographic findings for the diagnosis of pleural disease in asbestos-exposed individuals is reported to be 79%, compared with 100% for HRCT scan findings.

HRCT scans can depict subtle parenchymal abnormalities in approximately 33% of patients with asbestos-related disease in cases with no chest radiographic evidence of interstitial disease and isolated borderline diminished lung capacity. However, no HRCT scan finding is specific for asbestosis. Thus, while HRCT scanning is more sensitive than chest radiography for the diagnosis of asbestos-related disease, its specificity has been questioned.

The diagnosis is based on a combination of features, including bilateral pulmonary fibrosis and bilateral pleural plaques or diffuse pleural thickening in an individual with an appropriate history of exposure. The specificity of the diagnosis increases with the number of features identified; however, while asbestosis rarely occurs in the absence of plaques, plaques are not invariably present.

A small study correlating HRCT scan features and histopathologic findings revealed the presence of interstitial lines (84%), parenchymal bands (76%), architectural distortion (56%), subpleural lines (44%), and honeycombing (32%) in patients with proven asbestos-related lung disease. The specificity increased from 60% in patients in whom 1 feature was identified, to 80% with 2 features and 100% with 3 or more features.

In addition, HRCT scanning is valuable in excluding disease in individuals with equivocal chest radiographic findings. CT scanning is of value in differentiating benign disease from malignant pleural disease. The presence of a contiguous sheet or pleural rind, pleural nodularity, and thickening greater than 1 cm, as well as the involvement of mediastinal pleura, is regarded as suggestive of malignancy. However, case reports also report a variant of asbestos-related, diffuse pleural thickening that appears nodular and that is radiologically indistinguishable from mesothelioma. In equivocal cases, biopsy is recommended.

False Positives/Negatives

Normal extrapleural fat can be seen on HRCT scans internal to the ribs, particularly posterolaterally from the fourth-to-eighth ribs extending into the costophrenic angles. Fat can be several millimeters thick. Fat may be difficult to distinguish from pleural plaques or thickening, particularly when extended window settings are used, but it is more easily recognizable on soft-tissue window settings because of very low attenuation.

The transversus thoracis and subcostalis muscles, segments of intercostal veins, visceral pleural thickening, and confluent subpleural nodules (pseudoplaques) mimic pleural thickening. The transversus thoracis and subcostalis muscles usually are smooth, of uniform thickness, and bilaterally symmetrical. The subcostalis muscle is present only in a minority of individuals and is seen as 1- to 2-mm–thick lines internal to 1 or more lower ribs. The transversus thoracis muscle is almost always visible internal to the costochondral junctions anterior to the heart and adjacent to the sternum.

Intercostal vessels are seen commonly in the paravertebral regions and may cause spurious appearances of focal pleural thickening. Intercostal vessels can occasionally be traced to the azygos or hemi-azygos veins; this observation allows the correct interpretation of the findings. Moreover, extrapleural fat should be visible between the vessel and the pleura. When the images are read on the lung window setting, intercostal segments do not indent adjacent lung, while pleural plaques invariably indent. Furthermore, pleural plaques usually are visible over several contiguous intercostal segments and may contain calcification.

Bilateral, calcified pleural plaques are usually considered asbestos related, although rare causes, such as radiation exposure, hyperparathyroidism, pulmonary infarction, and pancreatitis, have been reported. Unilateral pleural calcification rarely is related to asbestos exposure and should prompt consideration of old tuberculosis, empyema, or hemothorax. Unilateral, noncalcified pleural plaques also are rare in asbestos-related disease.

Coal miner's pneumoconiosis, silicoses, and sarcoidosis occasionally can give rise to confluent subpleural nodules (pseudoplaques) that may mimic pleural plaques; however, these are associated with pulmonary nodules rather than with pulmonary fibrosis.³¹ Interstitial fibrosis seen in asbestosis is indistinguishable from idiopathic pulmonary fibrosis at radiographic, HRCT scan, and pathologic examination; the only distinguishing feature is the presence of asbestos bodies.

In most patients, CT scan appearances of round atelectasis are sufficiently characteristic to obviate intervention; however, differentiating benign, fibrotic masses from bronchial carcinoma is essential, and some patients require close follow-up monitoring or biopsy. Although bronchial neoplasms can opacify to some degree after the intravenous administration of contrast material, uniform enhancement has not been reported as a feature of lung cancer. On radiographs, malignant mesothelioma cannot be reliably distinguished from pleural metastases resulting from an adenocarcinoma. Focal mesothelioma may be mistaken for a benign, fibrous tumor.

MRI

Section 6 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

The role of magnetic resonance imaging (MRI) in the diagnosis of interstitial lung disease has not been established, and no consistent pattern of signal intensity has been described for round atelectasis.³² However, MRI has a complementary role in the evaluation of pleural effusions and mesothelioma.

Mesothelioma typically shows high signal intensity on T1-weighted images and moderately high signal intensity on T2-weighted images.

Degree of Confidence

MRI and CT scanning have been shown to be similar in terms of their accuracy in the diagnosis of malignant mesothelioma, although MRI is superior to CT scanning in depicting isolated foci of chest wall and diaphragmatic invasion. However, this difference has not been shown to confer any benefit in terms of overall staging.

MRI provides a certain advantage because the thorax can be directly imaged in various planes. The normal pleural space cannot be depicted by using current MRI techniques. T2-weighted sequences may offer tissue-specific information concerning pleural effusions and chest wall invasion by malignant processes because of increased tumor-to-muscle contrast.

ULTRASOUND

Section 7 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

Ultrasonography is useful in characterizing pleural effusions and evaluating pleural thickening or masses. Ultrasonography also facilitates image-guided pleural intervention.

Ultrasonography has also been used to help evaluate round atelectasis. It has been shown to reliably demonstrate the mass and adjacent pleural thickening. The presence of a highly echogenic line within the mass, which represents invaginated fibrotic pleura, is described as a useful ancillary finding, one seen in 86% of patients.

NUCLEAR MEDICINE

Section 8 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

Lung uptake of ⁶⁷Ga has been used to create a quantitative index of inflammatory activity in patients with asbestosis.²⁴ Combined with evidence of serum markers indicating inflammation-associated pulmonary collagen formation, these findings may provide a clinically useful algorithmic approach permitting an early diagnosis of asbestosis. Single photon-emission computed tomography (SPECT) improves the sensitivity for detecting the presence and extent of interstitial occupational lung disease.

⁶⁷Ga study has also been used to differentiate malignant from benign, asbestos-related pleural disease. Although studies in 86% of patients with asbestos-related mesothelioma show radionuclide uptake, only 19% of patients with benign asbestos effusions have positive findings.

Positron emission tomography (PET) scanning with [fluorine 18]-fluoro-2-deoxy-D-glucose has been suggested to aid in the differentiation of round atelectasis from bronchogenic carcinoma. To date, limited studies have shown round atelectasis to be metabolically inactive.

Degree of Confidence

Although experience is limited, the combination of HRCT scanning, ⁶⁷Ga scanning, and inflammatory serum marker testing may allow for an earlier diagnosis of asbestosis.

False Positives/Negatives

Mesothelioma unrelated to asbestos exposure is also known to give rise to positive findings on ⁶⁷Ga scans.

INTERVENTION

Section 9 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

No treatment for asbestosis is effective. The primary strategy is prevention, through the worldwide elimination of asbestos use and the replacement of asbestos with safe synthetic products.

Image-guided pleural thoracentesis or pleural biopsy is occasionally required for the further evaluation of pleural effusions and masses.^{33, 34}

Symptomatic patients with malignant pleural effusions may initially be treated by means of therapeutic aspiration or drainage; however, effusions tend to recur and often require pleurodesis. Pleurectomy is considered only if the prognosis is otherwise good. Percutaneous biopsy is occasionally required to differentiate round atelectasis from bronchogenic carcinoma. Asbestos bodies have been identified in fine-needle aspirates from round atelectasis.^{35, 36, 37}

There exists a theoretical risk of seeding tumor cells along the needle track after biopsy of suggested malignant mesothelioma. Some centers advocate prophylactic radiation therapy at the biopsy site, which should be marked with India ink immediately after the procedure.

Aziz and colleagues reported on a center's 10-year experience with the management of malignant pleural mesothelioma (MPM).³⁸ They reviewed 302 patients with MPM (between 1989 and 1998) and concluded that complete surgical resection by extrapleural pneumonectomy is an important initial step in the management of selected patients with MPM. The authors also noted that systemic, post-operative chemotherapy improved survival in surgically treated patients in their study.

Medical/Legal Pitfalls

• Imaging is frequently required as part of the assessment of occupationally exposed individuals to calculate compensation. The ILO classification of asbestos-related pleural disease is based on chest radiographic findings obtained in the postero-anterior projection.
• For certain claims, patients must be shown to have a prescribed disease that was acquired as a result of employment in a prescribed occupation. In the United Kingdom, compensation is awarded for asbestosis, malignant mesothelioma, bronchogenic carcinoma in the presence of asbestosis, and bilateral, diffuse pleural thickening.

See also the Medscape article Medical Malpractice and Legal Issues.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

Media file 1:  Case 1. Postero-anterior (PA) chest radiograph in a 58-year-old man with a history of occupational exposure to asbestos shows right diaphragmatic pleural plaque calcifications, linear calcification along the left pericardium, and bilateral pleural plaques along upper ribs.
	View Full Size Image
Media type:  X-RAY

Media file 2:  Case 1. Contrast-enhanced computed tomography (CT) scan of the chest at the level of the pulmonary artery bifurcation shows calcified pleural plaques along the posterior, lateral, and anterior pleural surfaces.
	View Full Size Image
Media type:  CT

Media file 3:  Case 2. An asymptomatic man (>50 y) was noted to have a mass in the left lower lobe after an exposure to asbestos. High-resolution computed tomography (HRCT) scan demonstrates a round mass at a site of pleural thickening, with a comet-tail bronchovascular bundle. This is an appearance of a folded lung (round atelectasis). The soft-tissue window showed parenchymal enhancement.
	View Full Size Image
Media type:  CT

Media file 4:  Case 3. A 55-year-old former asbestos worker has been complaining of shortness of breath. High-resolution computed tomography (HRCT) scan obtained at the lung bases shows prominent interstitial septal lines, subpleural cysts, and pleural plaques. This has the appearance of asbestosis.
	View Full Size Image
Media type:  CT

Media file 5:  Case 4. A 67-year-old man with a history of occupational exposure to asbestos for decades began experiencing a nagging, left-sided chest pain. Postero-anterior (PA) chest radiograph shows a left pleural effusion and peripheral, left-sided nodules.
	View Full Size Image
Media type:  X-RAY

Media file 6:  Case 4. The pulmonary window setting of this chest computed tomography (CT) scan shows an irregular, nodular pleural surface, not lung parenchymal nodules. Nodularity is also present along the fissure.
	View Full Size Image
Media type:  CT

Media file 7:  Case 4. The soft-tissue window setting of this chest computed tomography (CT) scan shows the envelope-like mass along the pleural surface surrounding the lung. This was a mesothelioma.
	View Full Size Image
Media type:  CT

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Ultrasound
• Nuclear Medicine
• Intervention
• Multimedia
• References

1. Pierce JS, McKinley MA, Paustenbach DJ, et al. An evaluation of reported no-effect chrysotile asbestos exposures for lung cancer and mesothelioma. Crit Rev Toxicol. 2008;38(3):191-214. [Medline].
2. Aguilar-Madrid G, Juárez-Pérez CA, Markowitz S, et al. Globalization and the transfer of hazardous industry: asbestos in Mexico, 1979-2000. Int J Occup Environ Health. Jul-Sep 2003;9(3):272-9. [Medline].
3. Morse T, Grey M, Storey E. Occupational disease in Connecticut, 2000. Conn Med. Dec 2002;66(12):723-30. [Medline].
4. Ribak J, Ribak G. Human health effects associated with the commercial use of grunerite asbestos (amosite): Paterson, NJ; Tyler, TX; Uxbridge, UK. Regul Toxicol Pharmacol. Oct 11 2007 [Epub ahead of print];[Medline].
5. Bolton C, Richards A, Ebden P. Asbestos-related disease. Hosp Med. Mar 2002;63(3):148-51. [Medline].
6. Roggli VL, Vollmer RT. Twenty-five years of fiber analysis: what have we learned?. Hum Pathol. Mar 2008;39(3):307-15. [Medline].
7. al Jarad N. Asbestos-related disease. J R Coll Physicians Lond. Nov-Dec 1999;33(6):532-6. [Medline].
8. Attanoos RL, Gibbs AR. ''Pseudomesotheliomatous'' carcinomas of the pleura: a 10-year analysis of cases from the Environmental Lung Disease Research Group, Cardiff. Histopathology. Nov 2003;43(5):444-52. [Medline].
9. Bard M, Debrosse D, Caliandro R. [Current insights in malignant pleural mesothelioma]. Bull Cancer. Jan 2002;89(1):67-74. [Medline].
10. Girling DJ, Muers MF, Qian W. Multicenter randomized controlled trial of the management of unresectable malignant mesothelioma proposed by the British Thoracic Society and the British Medical Research Council. Semin Oncol. Feb 2002;29(1):97-101. [Medline].
11. Puntoni R, Filiberti R, Cerrano PG. Implementation of a molecular epidemiology approach to human pleural malignant mesothelioma. Mutat Res. Nov 2003;544(2-3):385-96. [Medline].
12. van Haarst JM, Baas P, Manegold Ch. Multicentre phase II study of gemcitabine and cisplatin in malignant pleural mesothelioma. Br J Cancer. Feb 1 2002;86(3):342-5. [Medline].
13. Yilmaz UM, Utkaner G, Yalniz E, et al. Computed tomographic findings of environmental asbestos-related malignant pleural mesothelioma. Respirology. Mar 1998;3(1):33-8. [Medline].
14. Guidotti TL. Apportionment in asbestos-related disease for purposes of compensation. Ind Health. Oct 2002;40(4):295-311. [Medline].
15. Dodson RF, Atkinson MA, Levin JL. Asbestos fiber length as related to potential pathogenicity: a critical review. Am J Ind Med. Sep 2003;44(3):291-7. [Medline].
16. Stayner LT, Kuempel E, Gilbert S, et al. An epidemiologic study of the role of chrysotile asbestos fiber dimensions in determining respiratory disease risk in exposed workers. Occup Environ Med. Dec 20 2007 [Epub ahead of print];[Medline].
17. Chapman SJ, Cookson WO, Musk AW. Benign asbestos pleural diseases. Curr Opin Pulm Med. Jul 2003;9(4):266-71. [Medline].
18. Peacock C, Copley SJ, Hansell DM. Asbestos-related benign pleural disease. Clin Radiol. Jun 2000;55(6):422-32. [Medline].
19. Staples CA. Computed tomography in the evaluation of benign asbestos-related disorders. Radiol Clin North Am. Nov 1992;30(6):1191-207. [Medline].
20. Metintas M, Ak G, Parspour S, et al. Local recurrence of tumor at sites of intervention in malignant pleural mesothelioma. Lung Cancer. Feb 25 2008 [Epub ahead of print];[Medline].
21. McLoud TC. Conventional radiography in the diagnosis of asbestos-related disease. Radiol Clin North Am. Nov 1992;30(6):1177-89. [Medline].
22. Aberle DR. High-resolution computed tomography of asbestos-related diseases. Semin Roentgenol. Apr 1991;26(2):118-31. [Medline].
23. Huuskonen O, Kivisaari L, Zitting K. High resolution computed tomography classification of lung fibrosis for patients with asbestos-related disease. Scand J Work Environ Health. 2001;27:106-12. [Medline].
24. Cordasco EM, O''Donnell J, MacIntyre W, et al. Multiplane gallium tomography in assessment of occupational chest diseases. Am J Ind Med. 1990;17(3):285-97. [Medline].
25. Tiitola M, Kivisaari L, Huuskonen MS. Computed tomography screening for lung cancer in asbestos-exposed workers. Lung Cancer. Jan 2002;35(1):17-22. [Medline].
26. Tiitola M, Kivisaari L, Zitting A. Computed tomography of asbestos-related pleural abnormalities. Int Arch Occup Environ Health. Apr 2002;75(4):224-8. [Medline].
27. Murray KA, Gamsu G, Webb WR, et al. High-resolution computed tomography sampling for detection of asbestos-related lung disease. Acad Radiol. Feb 1995;2(2):111-5. [Medline].
28. Epstein DM, Miller WT, Bresnitz EA, et al. Application of ILO classification to a population without industrial exposure: findings to be differentiated from pneumoconiosis. AJR Am J Roentgenol. Jan 1984;142(1):53-8. [Medline]. [Full Text].
29. Majurin ML, Varpula M, Kurki T, et al. High-resolution CT of the lung in asbestos-exposed subjects. Comparison of low-dose and high-dose HRCT. Acta Radiol. Sep 1994;35(5):473-7. [Medline].
30. Roach HD, Davies GJ, Attanoos R. Asbestos: when the dust settles--an imaging review of asbestos-related disease. Radiographics. Oct 2002;22 Spec No:S167-84. [Medline]. [Full Text].
31. Gamsu G. Computed tomography and high-resolution computed tomography of pneumoconioses. J Occup Med. Jul 1991;33(7):794-6. [Medline].
32. Jarad NA, Underwood SR, Rudd RM. Asbestos-related pericardial thickening detected by magnetic resonance imaging. Respir Med. May 1993;87(4):309-12. [Medline].
33. Lerman Y, Ribak J, Selikoff IJ. Hazards of lung biopsy in asbestos workers. Br J Ind Med. Mar 1986;43(3):165-9. [Medline].
34. Tukiainen P, Taskinen E, Korhola O, et al. TruCutR needle biopsy in asbestosis and silicosis: correlation of histological changes with radiographic changes and pulmonary function in 41 patients. Br J Ind Med. Nov 1978;35(4):292-304. [Medline].
35. Leiman G. Asbestos bodies in fine needle aspirates of lung masses. Markers of underlying pathology. Acta Cytol. Mar-Apr 1991;35(2):171-4. [Medline].
36. Miller WT Jr, Gupta PK, Grippi MA, et al. Rounded atelectasis: diagnosis by fine-needle aspiration cytology. Diagn Cytopathol. 1992;8(6):617-20. [Medline].
37. Roggli VL, Johnston WW, Kaminsky DB. Asbestos bodies in fine needle aspirates of the lung. Acta Cytol. Jul-Aug 1984;28(4):493-8. [Medline].
38. Aziz T, Jilaihawi A, Prakash D. The management of malignant pleural mesothelioma; single centre experience in 10 years. Eur J Cardiothorac Surg. Aug 2002;22(2):298-305. [Medline].
39. Boutin C, Cargnino P, Viallat J. [Thoracoscopy in chronic pleural effusion (author's transl)]. Poumon Coeur. 1979;35(1):23-9. [Medline].
40. Dujic Z, Tocilj J, Saric M. Early detection of interstitial lung disease in asbestos exposed non- smoking workers by mid-expiratory flow rate and high resolution computed tomography. Br J Ind Med. Oct 1991;48(10):663-4. [Medline].
41. Hu H, Beckett L, Kelsey K, Christiani D. The left-sided predominance of asbestos-related pleural disease. Am Rev Respir Dis. Oct 1993;148(4 Pt 1):981-4. [Medline].
42. Neri S, Boraschi P, Antonelli A, et al. Pulmonary function, smoking habits, and high resolution computed tomography (HRCT) early abnormalities of lung and pleural fibrosis in shipyard workers exposed to asbestos. Am J Ind Med. Nov 1996;30(5):588-95. [Medline].
43. Ohnishi K. [Interferon-alpha therapy in chronic myelogenous leukemia]. Rinsho Ketsueki. Apr 2000;41(4):275-9. [Medline].
44. Turton CW. Pleural effusions. Br J Hosp Med. Mar 1980;23(3):239-40, 244, 246-7 passim. [Medline].
45. Whitman GJ, Niklason LT, Pandit M. Dual-energy digital subtraction chest radiography: technical considerations. Curr Probl Diagn Radiol. Mar-Apr 2002;31(2):48-62. [Medline].

Article Last Updated: Mar 25, 2008