AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Nuclear Medicine
• Intervention
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Nuclear Medicine
• Intervention
• Multimedia
• References

Background

Asbestos is the generic term used for the group of fibrous mineral silicates of magnesium and iron whose chemical and physical properties make it ideal for a variety of commercial and industrial uses. Asbestos is derived from the Greek word meaning inextinguishable. Its natural resistance to heat and fire, tensile strength, flexibility, and insulating properties have led to its use in more than 3000 applications, including floor tiles, boiler and pipe insulation, roofing, and brake lining.

Asbestos is classified into 2 groups based on its physical properties: the serpentines, which tend to be wavy and long, and the amphiboles, which are straight and rodlike. The most important member of the serpentines is chrysotile, which makes up more than 90% of the asbestos used in the United States. The amphibole group includes crocidolite, amosite, and tremolite, which is often found as a contaminant of chrysotile ore.

The use of asbestos can be traced through history as far back as the Stone Age when it was mixed in with earthenware pots for strength. Though the versatility of asbestos has been known since ancient times, its use did not become widespread until the Industrial Revolution in the late 19th century when mass quantities were needed for booming textile and insulation factories. Asbestos production increased during the next century until its peak in the 1970s. Despite the well-documented health risks from exposure, asbestos remains widely used, particularly in developing countries.

Three major diseases are associated with asbestos exposure: asbestosis, lung cancer, and mesothelioma. Pleural plaques are the most common manifestation of exposure. This article focuses on asbestosis, which specifically refers to the bilateral diffuse interstitial fibrosis of the lungs caused by inhalation of asbestos fibers.

The first documented case of an asbestos-related death occurred in 1906 when the autopsy of an asbestos worker revealed lung fibrosis. In 1918, insurance companies began refusing to insure asbestos workers because of increasing incidence of illnesses. The term "asbestosis" was first used in 1927 by Cooke, who reported that asbestos could cause pulmonary fibrosis. A few years later, an association between asbestos exposure and lung cancer was suggested. In 1955, epidemiologic data revealed that lung cancer was a specific health risk in asbestos workers.

Asbestos exposure is divided into 3 main categories. Primary exposure occurs in miners and millers. Secondary exposure, which is the largest and clinically most significant group, includes occupations involved in the industrial and commercial use of asbestos (eg, manufacturing plants, construction). The third category is nonoccupational (environmental or para-occupational) exposure to contaminated air. Nonoccupational exposure (eg, schools, offices) does not appear to pose significant health risks. The frequent finding of asbestos bodies in the lungs of city dwellers at autopsy, as high as 60% in New York City, suggests that environmental exposure is widespread. Asbestos fibers can remain airborne for many hours even in still conditions.

Pathophysiology

Studies show that the risk of developing asbestosis and the severity of disease increase with higher exposures. However, the exact roles of fiber dose, type, and size in the pathogenic pathway remain unclear. Although a dose-dependent relationship exists with all asbestos-related disease, asbestosis is associated with the highest fiber burdens. Most asbestos workers have no histologic evidence of fibrosis, suggesting that individual variations in susceptibility may be the most important factor in disease development. Another important factor worth mentioning is cigarette smoke, which contributes to the development of cancers and according to some investigators may enhance development of asbestosis.

Pathogenesis of pulmonary asbestos-related diseases begins with the inhalation of fine asbestos fibers. The larger fibers are trapped in the nose and upper airway, which are then cleared by mucociliary transport, but those with diameters of 0.5-5 micrometers are deposited at airway bifurcations, respiratory bronchioles, and alveoli. There they cause direct injury to epithelial cells and alveolar macrophages, which attempt to engulf the fibers. Some of the fibers enter the interstitium by direct penetration across the epithelium or macrophage transport. The damaged macrophages become activated, releasing tissue-damaging reactive oxygen species and various cytokines, including tumor necrosis factor, interleukin-1, and arachidonic acid metabolites, which initiate alveolitis. Damaged epithelial cells also release inflammatory cytokines.

Alveolitis is the inflammation caused by monocyte recruitment and macrophage accumulation in both the airspace and interstitium, although lymphocytes and neutrophils also are involved. If the asbestos burden is relatively small, most fibers may be cleared and tissue reaction is limited. If fiber retention is high, the resulting alveolitis is likely to be more intense, which may cause greater tissue reaction and injury. In this latter setting, progressive fibrosis can ensue.

The inflammatory phase described above is followed by the fibrosis phase, which is mediated by the various cytokines released by damaged type I pneumocytes and macrophages. Profibrosis cytokines such as fibronectin, fibroblast growth factor, platelet-derived growth factor, and insulinlike growth factor stimulate recruitment and proliferation of fibroblasts and type II pneumocytes. Initially, proliferation occurs locally at the site of asbestos deposition, but over time, the fibers may migrate to distal sites causing further tissue damage and inflammation. The result is collagen biosynthesis, which eventually leads to fibrosis.

The size and type of asbestos fiber are important determinants in pathogenesis. Longer fibers are less likely to be phagocytized and cleared by defense mechanisms, resulting in greater potential for alveolitis and subsequent fibrosis. The type of fiber also appears to influence pathogenesis. Amosite and crocidolite (amphiboles), which have greater biopersistence than chrysotile, appear to have higher fibrogenic potential. The half-life of chrysotile is on the order of months, whereas that of the amphiboles is in decades. Because of fiber bio-persistence, progression of disease can occur without ongoing exposure.

The progression of asbestosis may be enhanced by cigarette smoke according to some investigators. The mechanisms are unclear but appear to be related to clearance inhibition and increased pneumocyte fiber uptake leading to overall increased retention of asbestos fibers, particularly the shorter-length fibers.

A latency period of at least 15-20 years is generally required for the clinical manifestations of asbestosis to appear after initial exposure. Studies have demonstrated that the latency period is inversely proportional to exposure level. Early epidemiologic studies from the 1930s reported a latency period of approximately 5 years whereas more recent values are in the range of 13-20 years. This trend of increasing latency is likely related to decreasing exposures from stricter workplace regulations initiated in the 1970s.

Frequency

United States

In 1978, the National Institutes of Health reported that 8-11 million people have had occupational exposure to asbestos since the early 1940s. Because of a long latency period, long-term follow-up is difficult. The disease frequency calculations also are complicated by the dose-response relationship that exists for asbestosis. The prevalence of asbestosis appears to correlate with length of exposure. This was well demonstrated in one study that looked at the chest radiographs of asbestos workers. Asbestosis was detected in 10% of workers employed for 10-19 years, in 73% employed 20-29 years, and in 92% employed for more than 40 years. In another Finnish study, asbestosis was found in 22% of people who had worked in the construction industry for 10 years or in the shipyards for 1 year, reflecting the higher exposures in the ship industry.

Mortality/Morbidity

Calculating the death rate from asbestosis is confounded by deaths from asbestos-related malignancies, mainly lung cancer and mesothelioma. The asbestosis mortality rate in the United States increased from 0.49 per million persons in 1970 to 3.06 in 1990. However, because of decreasing asbestos use and stricter work regulations since the 1970s, the asbestosis mortality rate was expected to peak in the mid-1990s and then decline, although updated statistics are not available. Recent reports reveal that clinical asbestosis is decreasing in frequency and severity but that asbestos-related lung cancer deaths are becoming increasingly common.

The US National Center for Health Statistics reports the number of asbestosis deaths from 1968-1992 in US residents aged 15 years and older as follows:

• From 1968-1978 - 1359 total deaths
• From 1979-1990 - 6856 total deaths
• In 1991 - 946 total deaths
• In 1992 - 959 total deaths

Race

The US National Center for Health Statistics reports the race-based number of asbestosis deaths in 1992 in US residents aged 15 years and older as follows:

• Whites - 898 deaths (93.6%)
• Blacks - 57 (5.9%)
• Others - 4 (0.4%)

Sex

Older white males account most asbestosis deaths, which likely reflects the workforce demographics in the asbestos occupations several decades ago when its use was most prevalent. The US National Center for Health Statistics reports the sex-based number of asbestosis deaths in 1992 in US residents aged 15 years and older as follows:

• Males - 923 (96.2%)
• Females - 36 (3.8%)

Age

The US National Center for Health Statistics reports the age-based number of asbestosis deaths in 1992 in US residents aged 15 years and older as follows:

• Aged 15-34 years - 0 (0%)
• Aged 35-44 years - 3 (0.3%)
• Aged 45-54 years - 13 (1.4%)
• Aged 55-64 years - 124 (12.9%)
• Aged 65-74 years - 371 (38.7%)
• Aged 75-84 years - 355 (37%)
• Aged >85 years - 93 (9.7%)
• Mean age (range) - 73.5 years (38-100 y)

Anatomy

The gross pathologic picture of asbestosis ranges from mild coarsening of the lung parenchyma to honeycombing. Distribution is bilateral with fibrosis most prominent in the subpleural zones, particularly in the lower lobes. Microscopically, the appearance ranges from a mild increase in interstitial collagen to complete distortion of lung architecture by thick fibrosis and cystic spaces. The earliest histologic findings of asbestosis are discrete areas of fibrosis in the walls of proximal respiratory bronchioles. As the disease progresses, the more distal bronchiolar and alveolar interstitium become involved. With time, greater portions of the lung are affected in a centrifugal fashion.

The microscopic diagnosis of asbestosis requires the presence of diffuse interstitial fibrosis and asbestos bodies. Inhaled asbestos exists either as uncoated fibers or asbestos bodies, which are fibers that have been phagocytized and coated with a protein-iron matrix. Uncoated fibers are visible only under electron microscopy whereas asbestos bodies are readily detected with conventional light microscopy. The presence of more than one asbestos body has long been considered necessary for the pathologic diagnosis of asbestosis.

However, asbestos bodies comprise only a small fraction of the total asbestos burden in the lung, and a patient with heavy exposure may not have any detectable asbestos bodies. Therefore, the presence of asbestos bodies should be considered a marker of exposure but their absence should not exclude it. Pathologically, the lung fibrosis seen in asbestosis cannot be distinguished from that of other interstitial diseases except for the presence of asbestos bodies. In addition, unlike other pneumoconioses, lymphadenopathy and progressive massive fibrosis tend not to occur.

Clinical Details

Clinical onset of symptoms in patients with asbestosis generally occurs approximately 20 years after initial exposure. The signs and symptoms associated with asbestosis are for the most part nonspecific and can resemble those found in other restrictive interstitial lung diseases.

The most prominent symptom, and usually the earliest, is the insidious onset of dyspnea on exertion. This is often progressive, despite discontinued asbestos exposure. Other common symptoms include a persistent dry or productive cough, chest tightness and/or pain, and wheezing.

On physical examination, the most common finding is bibasilar crackles, typically at end-inspiration, which are heard in approximately 60% of patients with radiographic evidence of asbestosis. Finger clubbing is observed in approximately 30-40% of patients and tends to be associated with more severe or advanced disease. With time, patients may develop signs of cor pulmonale. The clinician also should be vigilant for the signs of asbestos-related malignancies, such as cancers of the lung, pleura, larynx, and even stomach and pancreas.

The pulmonary function examination generally reveals a restrictive pattern with decreased vital capacity, total lung capacity, diffusion capacity, and arterial hypoxemia. A mild obstructive pattern also can be seen in asbestosis as a result of bronchiolar fibrosis and narrowing.

The diagnosis of asbestosis requires documentation of pulmonary fibrosis with an exposure history of sufficient duration, intensity, and latency. Pulmonary fibrosis is usually first detected on chest radiograph, but high-resolution CT (HRCT) can confirm the diagnosis in equivocal instances. Lung biopsy is seldom warranted unless another potentially reversible cause of interstitial lung disease is strongly suggested. A less invasive means of establishing exposure is bronchoalveolar lavage, which can detect the presence of asbestos bodies. Ancillary diagnostic clues may be gained from clinical history and physical examination, including pulmonary function tests. Note that many patients with radiographic asbestosis do not manifest clinical symptoms. In addition, the chest radiograph is normal in 10-20% of patients with histologic evidence of fibrosis. Once the diagnosis has been established, asbestosis may remain static or progress but rarely regresses.

In patients with severe disease, respiratory impairment can lead to death. With increased resistance to pulmonary blood flow from fibrosis and reactive vasoconstriction secondary to alveolar hypoxia, pulmonary hypertension and cor pulmonale may develop.

Currently, no effective treatment exists for asbestosis. Steroids and colchicine, which have been used to treat patients with idiopathic pulmonary fibrosis, have shown no benefit for asbestosis. The respiratory failure associated with advanced disease may be managed with home oxygen. All patients with asbestosis should obtain a pneumococcal vaccine, an annual influenza vaccine, and prompt treatment of respiratory infections. Smoking cessation should be strongly stressed. Smoking may be associated with a higher prevalence of asbestosis and has been shown to increase the asbestos-related lung cancer mortality rate by a factor of more than 50. Long-term medical surveillance is recommended for all person with significant asbestos exposure.

Considerable controversy exists concerning the topic of asbestosis and lung cancer. The risk of lung cancer increases with heavy asbestos exposure, and asbestosis is an indicator of high exposure; however, a significant number of lung cancers develop in the absence of radiologic asbestosis. As a result, most current opinion holds that lung cancer risk should be based on clinical and occupational histories and not the presence of asbestosis. Whether the presence of lung fibrosis contributes an added risk is uncertain and is the topic of further research.

Preferred Examination

Chest radiography is the traditional modality used to perform the initial diagnostic evaluation of asbestosis.

"B" readings (standardized forms from the International Labour Organization, filled out by certified "B" readers to assess lung parenchymal and pleural abnormalities related to pneumoconiosis) often are performed on chest radiographs. These readings have little or no clinical utility.

HRCT is more sensitive than conventional radiography in the detection of early or mild fibrosis, particularly in the subpleural zones. HRCT and SRCT (standard resolution CT) are both indicated in patients suspected of having asbestosis. HRCT can define and detect alveolitis and fibrosis earlier than SRCT. SRCT is essential in detecting lung cancer earlier than chest radiography. HRCT is excellent in defining lung parenchymal detail whereas SRCT images the entire lung, making it more likely to detect a malignancy.

Limitations of Techniques

The chest radiograph is normal in 10-20% of patients with histologic evidence of asbestosis. The classic radiographic appearance of asbestosis in nonspecific but ancillary findings, such as pleural plaques or diffuse pleural thickening, strongly suggests asbestos exposure as the cause.

Individual HRCT findings are nonspecific, but the likelihood that the fibrosis is the result of asbestos exposure increases with the number of characteristic abnormalities observed and the presence of asbestos-related abnormalities such as pleural disease.

DIFFERENTIALS

Section 3 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Nuclear Medicine
• Intervention
• Multimedia
• References

Other Problems to be Considered

Rheumatoid disease
Dermatomyositis
Drug exposures
Chronic aspiration with fibrosis

RADIOGRAPH

Section 4 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

The characteristic finding in asbestosis is the presence of small irregular opacities, usually in the mid and lower lung zones. According to the 1980 International Labor Organization classification, "small irregular opacities" describe irregular linear shadows that develop in the lung parenchyma and obscure normal bronchovascular markings. The progression of disease is divided into 3 stages.

In the first stage, a fine reticular pattern may be seen, usually at the lung bases, in association with a ground-glass appearance, which may represent a combination of alveolitis and interstitial fibrosis.

The second stage is characterized by progression of the small irregular opacities into a prominent interstitial pattern. During this stage, a combination of parenchymal and pleural abnormalities may partially obscure the heart border (shaggy heart sign) and diaphragm.

In the last stage, progression of the coarse interstitial pattern and honeycombing to the upper lung zones occurs, along with further obscuration of the heart and diaphragm.

Degree of Confidence

The radiographic findings described above are rather nonspecific, which may lead to a high false-positive rate, but the presence of pleural abnormalities and a compatible clinical history would increase the specificity of the diagnosis of asbestosis. Estimates of the sensitivity of chest radiography in the detection of asbestos-related interstitial fibrosis vary widely from 40-90%. Conventional radiographs are relatively insensitive in the detection of early asbestosis and tend to underestimate the severity of disease.

CT SCAN

Section 5 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

Common HRCT findings in early asbestosis are intralobular small rounded or branching opacities, thickened interlobular septa, subpleural curvilinear lines, and parenchymal bands. The interlobular septal lines typically represent fibrosis. With progression of disease, honeycombing is seen. Similar to the radiographic appearance, the findings described above predominantly involve the subpleural regions of the lower lung zones. As most of the abnormalities seen in mild asbestosis may be confined to the posterior basal lung zones, the CT study should include images with the patient in the prone position to differentiate normal dependent parenchymal opacity from mild subpleural fibrosis.

The earliest lesions observed on HRCT indicating fibrosis are believed to be subpleural intralobular rounded or branching opacities, which correspond to peribronchiolar fibrosis, the earliest microscopic finding. Theoretically, prior to fibrosis, a ground glass appearance involving the air spaces may indicate alveolitis.

Subpleural lines, which also are present early on, are curvilinear opacities observed parallel to and within 1 cm of the pleura. They are usually 5-10 cm long and likely represent a combination of peribronchiolar fibrosis and atelectasis.

Parenchymal bands are thick linear 2-5 cm long opacities that course through the lung and contact the pleural surface. These correspond to fibrosis along a bronchovascular sheath or interlobular septa with architectural distortion.

Honeycombing is characterized by thick-walled multiple cystic spaces smaller than 1 cm in diameter.

Degree of Confidence

With its ability to show lung abnormalities not appreciated on conventional radiographs, CT is considerably more sensitive than conventional radiography for detecting asbestosis, especially for early or mild disease. In particular, the advent of HRCT has further improved sensitivity.

As with radiography, CT findings in asbestosis are nonspecific, and the identification of a single abnormality is not diagnostic. One study assessing the accuracy of HRCT in asbestos-exposed individuals demonstrated 100% specificity when at least 3 of the abnormalities described above were present on the scans. However, the exceptionally high specificity came at the expense of a decreased sensitivity (56% when 3 findings were present). The converse holds true as well: diagnosis based on one or two abnormalities increases sensitivity but decreases specificity.

MRI

Section 6 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

Currently, the role of MR imaging in the diagnosis of asbestosis is limited but a recent study has shown MR to be more sensitive than chest radiography in detecting subclinical asbestosis.

NUCLEAR MEDICINE

Section 7 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

Before HRCT gained popularity, gallium Ga 67 scans were often helpful in diagnosing asbestosis in patients with appropriate clinical presentations but normal or equivocal chest radiographs. Gallium-67 scans are usually positive in patients with asbestosis and may even provide a measure of inflammatory activity because the isotope is believed to be engulfed by alveolar macrophages.

INTERVENTION

Section 8 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Nuclear Medicine
• Intervention
• Multimedia
• References

Medical/Legal Pitfalls

• Patients who are diagnosed with asbestos-related disease should be made aware of their legal rights. This includes entitlement to appropriate medical treatment and/or monetary payment from a workers' compensation system. However, a compensation claim must be made within a set time period, which starts from the time of diagnosis (eg, 2 y in New York). As a result, it is important that the physician ensures patients understand the legal implications associated with the diagnosis.
• Currently, asbestosis is a reportable occupational disease in approximately half of the states in the United States. Laws and regulations have been set forth to limit worker exposure and protect the public. Any reports of asbestos exposure should be promptly investigated by occupational health authorities. Most importantly, any effort to reduce exposure and risk of disease must involve proper training and education of workers and employers.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Nuclear Medicine
• Intervention
• Multimedia
• References

Media file 1:  Asbestosis. Posteroanterior chest radiograph reveals a few reticulonodular opacities at the lung bases consistent with mild asbestosis.
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Media type:  X-RAY

Media file 2:  Asbestosis. Posteroanterior chest radiograph in a 54-year-old man with asbestosis demonstrates coarse linear opacities at the bases more prominent on the left, obscuring the cardiac borders and diaphragm (shaggy heart border sign).
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Media type:  X-RAY

Media file 3:  Asbestosis. Asbestosis and asbestos-related pleural disease in a 70-year-old man (Images 3-6). Posteroanterior chest radiograph reveals prominent linear opacities at both bases with obscuration of the cardiac borders and diaphragm. The thick linear band at the right lateral base likely represents the subpleural curvilinear opacities observed on high-resolution CT.
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Media type:  X-RAY

Media file 4:  Asbestosis. High-resolution CT scan through the mid lung zone demonstrates a parenchymal band on the left (arrow).
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Media type:  CT

Media file 5:  Asbestosis. High-resolution CT scan more inferiorly reveals subpleural curvilinear opacities bilaterally (white arrows) and thickened interstitial lines (black arrows).
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Media type:  CT

Media file 6:  Asbestosis. High-resolution CT scan through the lower lung zone nicely demonstrates thickened septal lines (white arrows) and small rounded subpleural intralobular opacities (black arrow). Also note the calcified diaphragmatic pleural plaque on the left.
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Media type:  CT

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Nuclear Medicine
• Intervention
• Multimedia
• References

• Akira M, Yamamoto S, Yokoyama K. Asbestosis: high-resolution CT-pathologic correlation. Radiology. Aug 1990;176(2):389-94. [Medline].
• Becklake MR, Cowie RL. Environmental and occupational disorders. Textbook of Respiratory Medicine, 3rd edition. 2000;1830-37.
• Bekkelund SI, Aasebo U, Pierre-Jerome C. Magnetic resonance imaging of the thorax in the evaluation of asbestosis. Eur Respir J. Jan 1998;11(1):194-7. [Medline].
• Billings CG, Howard P. Asbestos exposure, lung cancer and asbestosis. Monaldi Arch Chest Dis. Apr 2000;55(2):151-6. [Medline].
• Fraser RS, Muller NL, Colman N. Inhalation of inorganic dust (pneumoconioses). Fraser and Pare's Diagnosis of Diseases of the Chest, 4th edition. 1999;2386-2484.
• Fujimura N. Pathology and pathophysiology of pneumoconiosis. Curr Opin Pulm Med. Mar 2000;6(2):140-4. [Medline].
• Gamsu G, Salmon CJ, Warnock ML. CT quantification of interstitial fibrosis in patients with asbestosis: a comparison of two methods. AJR Am J Roentgenol. Jan 1995;164(1):63-8. [Medline].
• Kamp DW, Weitzman SA. The molecular basis of asbestos induced lung injury. Thorax. Jul 1999;54(7):638-52. [Medline].
• Levin SM, Kann PE, Lax MB. Medical examination for asbestos-related disease. Am J Ind Med. Jan 2000;37(1):6-22. [Medline].
• McLoud TC. Conventional radiography in the diagnosis of asbestos-related disease. Radiol Clin North Am. Nov 1992;30(6):1177-89. [Medline].
• Mossman BT, Churg A. Mechanisms in the pathogenesis of asbestosis and silicosis. Am J Respir Crit Care Med. May 1998;157(5 Pt 1):1666-80. [Medline].
• Rom WN. Asbestos-related lung disease. Fishman's Pulmonary Diseases and Disorders, 3rd edition. 1998;879-887.
• Staples CA. Computed tomography in the evaluation of benign asbestos-related disorders. Radiol Clin North Am. Nov 1992;30(6):1191-207. [Medline].
• Wagner GR. Asbestosis and silicosis. Lancet. May 3 1997;349(9061):1311-5. [Medline].
• Wagner GR, Attfield MD, Kennedy RD. The NIOSH B Reader Certification Program an Update Report. JOM. 1992;34:879-884.

Article Last Updated: Aug 11, 2004