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Pleural Thickening on Screening Chest X-Rays Saito et al. Respiratory Research (2019) 20:138 https://doi.org/10.1186/s12931-019-1116-9 RESEARCH Open Access Pleural thickening on screening chest X-rays: a single institutional study Akira Saito1,2* , Yukichika Hakamata2, Yukiko Yamada2, Mitsuhiro Sunohara1,2, Megumi Tarui1,2, Yoko Murano2, Akihisa Mitani1,2, Kimie Tanaka2, Takahide Nagase1 and Shintaro Yanagimoto2 Abstract Although pleural thickening is a common finding on routine chest X-rays, its radiological and clinical features remain poorly characterized. Our investigation of 28,727 chest X-rays obtained from annual health examinations confirmed that pleural thickening was the most common abnormal radiological finding. In most cases (92.2%), pleural thickening involved the apex of the lung, particularly on the right side; thus, it was defined as a pulmonary apical cap. Pleural thickening was more common in males than in females and in current smokers or ex-smokers than in never smokers. The prevalence increased with age, ranging from 1.8% in teenagers to 9.8% in adults aged 60 years and older. Moreover, pleural thickening was clearly associated with greater height and lower body weight and body mass index, suggesting that a tall, thin body shape may predispose to pleural thickening. These observations allowed us to speculate about the causative mechanisms of pleural thickening that are attributable to disproportionate perfusion, ventilation, or mechanical forces in the lungs. Keywords: Chest X-ray, Screening, Pleural thickening, Pulmonary apical cap, Body mass index Background Pleural thickening may be a manifestation of several Pleural thickening is a common finding on routine chest X- pulmonary diseases, including mycobacterial infection, rays. It typically involves the apex of the lung, which is lung cancer, and idiopathic interstitial pneumonia. Of called ‘pulmonary apical cap’. On chest X-rays, the apical particular note, pleuroparenchymal fibroelastosis is in- cap is an irregular density located at the extreme apex and creasingly recognized as a rare form of idiopathic inter- is less than 5 mm in width [1]. In the early twentieth cen- stitial pneumonia characterized by pleural and subjacent tury, a pulmonary apical cap was thought to be a tubercular parenchymal fibrosis predominantly in the upper lobes, lesion; however, detailed pathological studies conducted in which may mimic an apical cap. Therefore, clinicians the 1970s found no evidence of tuberculosis [2–4]. The ap- must rule out these pathological conditions when evalu- ical cap is a fibroelastic scar involving the visceral pleura ating pleural thickening found on a chest X-ray. More- and lung parenchyma at the apex and is occasionally ob- over, it is necessary to characterize the radiological and served in healthy and asymptomatic individuals [5]. clinical features of pleural thickening or an apical cap In 1974, Renner et al. [3] identified unilateral or bilat- that is not disease-related in and of itself. eral apical cap shadows in 22.1% (n = 57) of 258 routine We reviewed 28,727 chest X-rays obtained from an- chest X-rays. This was a pioneering radiological study; nual health examinations performed between April 2017 however, the sample size was small. Surprisingly, no sub- and March 2018 in a large population. We confirmed sequent studies have investigated the prevalence of an that pleural thickening, typically located at the apex of apical cap on chest X-ray examination [3, 6] or its asso- the lung, was the most common abnormal finding. Fur- ciation with various subject characteristics. thermore, we investigated the prevalence and laterality of pleural thickening and its association with subject characteristics, including sex, age, smoking status, * Correspondence: [email protected] 1Department of Respiratory Medicine, Graduate School of Medicine, The height, body weight, and body mass index (BMI). Our University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan findings suggest that individuals with taller and thinner 2Division for Health Service Promotion, The University of Tokyo, 7-3-1 Hongo, body shapes may be prone to pleural thickening. Given Bunkyo-ku, Tokyo 113-0033, Japan © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Saito et al. Respiratory Research (2019) 20:138 Page 2 of 7 these findings, we speculate that an apical cap may be that was identified in 911 individuals. A representative the result of disproportionate perfusion, ventilation, or X-ray image of pleural thickening is shown in Fig. 1. The mechanical forces in the lungs. prevalence of pleural thickening was 3.2% (n = 911/28, 727) in our sample. Methods Study population Pleural thickening was found predominantly at the apex We conducted a cross-sectional analysis of chest X-rays of the right lung obtained from the annual health examinations of 28,727 The apex of the lung was the most frequently affected employees and students at the University of Tokyo area (Additional file 1: Table S2). Pleural thickening between April 2017 and March 2018. The chest X-rays involving the apical area of either lung was defined as were assessed independently by two physicians. Abnormal an apical cap, which accounted for 92.2% (n =836/ findings were referred to board-certified pulmonologists 907) of the cases (Fig. 2a). More than half of the (M.S., M.T., Y.M., A.M., and A.S.) for further evaluation cases were bilateral and 35.7% involved thickening on using available clinical information and previous X-ray the right side only. Together, the bilateral and right- images. sided cases comprised nearly 90% of the 907 cases (Fig. 2b). These findings indicate that the pleural Pleural thickening assessment thickening and apical cap cases overlapped, and that Four areas of the lung (apical, upper, middle, and pleural thickening occurred predominantly in the lower portions) were examined bilaterally for the right lung (Fig. 2). presence of pleural thickening. Pleural thickening that involved the apex of either lung was defined as an Pleural thickening was more common in males and apical cap. increased with age Pleural thickening was more common in males (3.4%) than Statistical analyses in females (2.7%; p < 0.01) (Additional file 1:TableS3),and Between-group comparisons were made using two-tailed the incidence increased with age, ranging from 1.8% in Student’s t-tests, and the chi-square test was used to as- teenagers (17–19 years) to 9.8% in adults aged 60–83 years sess the associations of pleural thickening with sex and (Additional file 1: Table S4). It is worth noting that pleural smoking status. The binary logistic regression model was thickening occurred in individuals as young as 18 years, used to evaluate the effects of sex, age, smoking status, and the prevalence increased markedly after the age of 40 and BMI on pleural thickening. All statistical tests were years (Fig. 3). performed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA). Pleural thickening was more common in current and ex- smokers than in never smokers Results We further investigated whether smoking history was We investigated the prevalence and distribution of associated with pleural thickening. Information about pleural thickening and its association with subject char- smoking status was available for 25,291 individuals acteristics, including sex, age, smoking status, height, (16,043 males and 9248 females). The smoking rates body weight, and BMI. of those with and without pleural thickening were 6.3 and 4.7%, respectively. The percentages of individuals Pleural thickening is the most common abnormal finding with a smoking history (i.e., current smokers and ex- on screening chest X-rays smokers) with and without pleural thickening were Chest X-rays obtained from the annual health examina- 14.6 and 10.2%, respectively. The prevalence of tions of 28,727 individuals between April 2017 and pleural thickening was higher in current smokers March 2018 were independently reviewed by two physi- (4.4%) and ex-smokers (5.0%) than in never smokers cians. The study included 10,012 females and 18,715 (3.2%; p < 0.01) (Additional file 1:TableS5).More- males, and the mean (± standard deviation) age was over, these trends were confirmed when males and fe- 30.5 ± 12.1 (range, 17–83) years. Four areas of the lung males were analyzed separately. (apical, upper, middle, and lower portions) were exam- ined bilaterally for the presence of abnormal findings. Pleural thickening was associated with greater height and There could be more than one finding in a subset of in- lower body weight and BMI dividuals. In total, 4041 abnormal findings were ob- Next, we investigated the association between pleural served on the chest X-rays of 3113 individuals by at least thickening and body shape. Height, body weight, and BMI one physician (Additional file 1: Table S1). Pleural thick- were compared in individuals with and without pleural ening was the most common finding (35.2%; n = 1423) thickening (Fig. 4a). Males and females with pleural Saito et al. Respiratory Research (2019) 20:138 Page 3 of 7 A B Fig. 1 Representative chest X-ray image of pleural thickening. a. Chest X-ray image of a healthy 47-year-old male. The right apical cap appears as an irregular, wedge-shaped density. b. Enlarged image of the right apex. The white triangles indicate pleural thickening AB Fig.
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