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Occupational Lung Disease * 2 Disease 210 Thoraxc 1996;51:210-216 Occupational lung disease * 2 Series editor: P S Burge Thorax: first published as 10.1136/thx.51.2.210 on 1 February 1996. Downloaded from New developments in asbestos-related pleural disease Robin M Rudd Asbestos causes several types of benign pleural Moreover, chrysotile is the major fibre type disease, the best recognised of which is pleural found in the parietal pleura,67 rather than the plaque formation. Diffuse pleural thickening is needle-like amphiboles which would be more a more serious consequence of exposure to likely to penetrate the pleura in this way. It is asbestos and this often first appears as a sequel possible that fibres may pass via the lymphatic to benign pleural effusion associated with as- system from the lung, through the lymphatic bestos-induced pleurisy. circulation to the intercostal and diaphragmatic lymph vessels. From these vessels the fibres Pleural plaques could reach the parietal pleura and be de- posited, thereafter causing plaques to develop. Pleural are areas plaques discrete raised which This theory requires that fibres should travel may be situated on the parietal on pleura the against the normal flow of lymph, but this chest wall, diaphragm, pericardium, and me- appears to be possible as coal dust can be found diastinum. are They strongly associated with in intercostal lymphatics.8 exposure to asbestos although they are also Sebastien and using found in subjects from whom no history of colleagues, transmission electron exposure can be elicited. They occur after in- microscopy (TEM), studied the fibre halation of all types of asbestos although content of parietal pleural plaques and normal anthophyllite appears to be the most potent. parietal pleura and compared the results with Plaques occur with increased frequency in those in lung tissue from the same subjects populations living in areas where the soil is who had various conditions possibly related to http://thorax.bmj.com/ asbestos exposure.6 Asbestos fibres were found contaminated with asbestiform minerals - for example, in areas ofFinland, Bulgaria, Czecho- in the parietal pleura in 16 of 29 cases, whereas fibres were found in 27 of 29 lung tissue slovakia, and Greece - and in those living in proximity to asbestos mines or factories. samples. When a pleural sample was positive Plaques may occur after slight asbestos ex- for asbestos fibres almost all the fibres were posure but in occupationally exposed groups chrysotile and they were shorter than chrysotile the prevalence of plaques increases with in- fibres from the lung tissue. Significant quant- creasing dose of asbestos inhaled,' continues ities ofamphibole fibre were found in the pleura on October 2, 2021 by guest. Protected copyright. to increase more than 40 years after first ex- in only one ofthe 29 cases, whereas in lung tissue posure to asbestos,2 and is not affected by a mean of 56% (range 0-100%) of fibres were smoking.2 Pleural plaques are rarely seen in amphiboles. Churg and Vedal have recently persons under 40 years of age,3 which is con- reported, on the basis of multiple regression sistent with observations that they are not found analysis of data from TEM of lung tissue, that less than 10 years - and seldom less than 20 plaques are associated with fibres of higher years - after first exposure to asbestos.4 Pleural aspect ratio (length/width) than mesothelioma.9 calcification rarely occurs less than 20 years Necroscopic studies show that plaques of after first exposure to asbestos.5 minor extent are frequently not detected by The route by which asbestos fibres reach radiological examination.'0 Computed tomo- the parietal pleura is not known for certain. graphic scanning demonstrates the extent of Asbestos fibres deposited in the peripheral parts pleural plaques more accurately than does a ofthe lung tissue probably penetrate the visceral plain radiograph. Multiple plaques visually super- pleura to be carried in the pulmonary lymphatic imposed upon each other may be impossible system to the visceral pleural surface. It is to distinguish from diffuse pleural thickening theoretically possible that sharp fibres could on the plain radiograph, but computed tomo- penetrate the visceral pleura and pass directly graphic scanning allows differentiation." into the parietal pleura, there to cause tissue Pleural plaques do not usually cause enough damage which eventually results in the form- impairment of lung function to give rise to ation of a pleural plaque. This seems unlikely symptoms, although occasionally their extent London Chest because the formation of plaques is not pre- is sufficiently great for the plaques to fuse Hospital, ceded evidence of an to form sheets which can interfere with the Bonner Road, by inflammatory pleurisy London E2 9JX, UK and the visceral pleura immediately opposite a expansion of the lungs by making the chest R M Rudd parietal pleural plaque usually looks normal. wall stiff and resistant to movement. Plaques New developments in asbestos-related pleural disease 211 are frequently associated with evidence of lim- average of 26 years after first exposure to as- itation to airflow in the small airways'2-16 and bestos, but in four cases it was seen after an with a minor reduction in vital capacity.'718 interval of less than 10 years.26 Most asbestos workers are or have been Injection of crocidolite into the pleura of the smokers, and this probably contributes to the rabbit induces chemotactic activity resulting in Thorax: first published as 10.1136/thx.51.2.210 on 1 February 1996. Downloaded from airflow limitation. However, airflow limitation a polymorphonuclear effusion. The process is in small airways has been observed even in not dependent on complement activation but non-smokers,'3 and it is probably the functional is probably a result of a direct effect of the counterpart of asbestos airway disease. A study fibres on pleural tissue.27 The pathology is that of 36 long term chrysotile miners without as- of an acute exudative pleurisy. bestosis found evidence of severe diffuse small In humans pleural aspiration usually reveals airway abnormalities.'9 an exudate which is often bloodstained even in Pleural plaques have some prognostic sig- the absence of malignancy, and it is important nificance. Among persons found to have plaques to recognise that the finding of a bloodstained who have sustained substantial exposure to effusion in an asbestos worker does not ne- asbestos there is a risk that clinically obvious cessarily imply mesothelioma. Pleural biopsy asbestosis will develop in the future. Of 1 55 dock- samples show only non-specific pleural in- yard workers who were re-examined 10 years flammation and fibrosis. Asbestos bodies or after detection ofbenign pleural changes, 10-3% fibres are rarely evident by light microscopy had radiographic small parenchymal opacities although sparse fibres, usually chrysotile, may suggestive of asbestosis and 4-5% had both be seen in the pleura by electron microscopy. clinical and radiological signs ofasbestosis.20 The Pleural aspiration relieves breathlessness and attack rate was substantially higher than among anti-inflammatory analgesics relieve pain. men with no initial pleural abnormality. Spontaneous resolution of each episode is Pleural plaques are not themselves pre- usual, but the condition may be recurrent with cursors of malignant change but, in so far as increasing diffuse pleural thickening after each they reflect exposure to asbestos, they may be episode.26 Occasionally mesothelioma emerges associated with an increased risk of asbestos- some years after what at first seemed to be a related malignancy. In most cases of both benign effusion.27 pleural and peritoneal mesothelioma radio- logical evidence of benign pleural disease is Diffuse pleural thickening also present and is likely to have antedated the Diffuse pleural thickening is a type of pleural development of mesothelioma.2' The relation fibrosis which extends continuously over a vari- between pleural plaques and lung cancer is not able proportion of the thoracic cavity. There entirely clear. A study of shipyard workers in are frequently adhesions between the parietal the UK found a significant excess of deaths and visceral pleurae. Diffuse pleural thickening from both lung cancer and mesothelioma in is a less common manifestation of exposure to those with plaques compared with unexposed asbestos than pleural plaque formation. The http://thorax.bmj.com/ controls matched for age and sex.22 However, incidence increases with increasing time after this study was potentially flawed by selection first exposure.28 Its occurrence is dose related28 bias. A recent review of evidence from several although less clearly so than asbestosis or the studies concluded that studies which supported malignant diseases.2930 an increased risk of lung cancer in those with A wide range of fibre counts is observed in plaques were the most subject to selection bias.23 association with the condition.3' Among 12 It was concluded that there is no convincing cases with diffuse pleural fibrosis studied by evidence that the presence of pleural plaques is Gibbs et al32 the mean total asbestos fibre count on October 2, 2021 by guest. Protected copyright. predictive of an increased risk of lung cancer. was 89 million fibres/g dried lung (calculated However, each ofthe studies available for review from data in tables 2 and 3 in the paper, was unsatisfactory in one or more respects; they averaging counts from central and subpleural concerned populations with unknown or low regions). This may be compared with mean level exposure to asbestos and/or a low incidence total fibre counts of 42, 59, 343, and 2550 of asbestos-related lung cancer, control for the million/g dried lung (including, respectively, effects of smoking was often unsatisfactory, lat- 34%, 24%, 18%, and 7% non-asbestos fibres) ency was often ignored, and follow up was often in cases of histologically defined minimal, incomplete.
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