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3.2 ILO Classification ILO Classifi cation 93 3.2 ILO Classification Vinicius C. S. Antao and John E. Parker CONTENTS dust diseases. It is not designed to define patho- logical entities, and it does not take into account 3.2.1 Introduction 93 working capacity or compensation for disability 3.2.2 The 2000 Revision 93 Jacobsen 3.2.2.1 Parenchymal Abnormalities 94 ( 1991). The initial version of the Classifi- 3.2.2.2 Pleural Abnormalities 94 cation was issued in 1930, with subsequent revisions 3.2.2.3 Symbols and Comments 94 published in 1950, 1958, 1968, 1971, 1980, and 2000. 3.2.2.4 The Quad Set 95 The first editions were focused on silicosis. In 1958, 3.2.3 Proficiency in the Use of the ILO Classification 95 a single category was included to cover all types 3.2.4 Correlation with Other Tests 95 3.2.5 Assessment of Disease Progression 96 and profusions of linear markings. In the 1960s, the 3.2.6 Limitations of the Classification 96 International Union Against Cancer (UICC) evolved 3.2.6.1 Reader Variability 96 a parallel system for linear (now called irregular) 3.2.6.2 Insensitivity of Radiographs to Pneumoconiosis 96 opacities, mainly spurred by asbestos exposure. 3.2.6.3 Lack of Specificity to Pneumoconiotic Lesions 97 In 1968, the UICC and ILO systems were merged 3.2.6.4 Importance of Film Quality 97 for all dust-induced pneumoconioses, with the ILO 3.2.6.5 Additional Limitations of the Classification 97 Henry ILO 3.2.7 Other Classifications 97 embracing the UICC ideas ( 2002; 2002; 3.2.8 Future Trends in Digital Radiography and Shipley 1992). Computed Imaging 97 References 98 3.2.2 The 2000 Revision 3.2.1 Introduction The 2000 revision of the Classification comprises a set of 22 standard radiographs (Complete Set) and The International Labour Office (ILO) International the text guidelines for its use (ILO 2002). For this Classification of Radiographs of Pneumoconioses is issue, 20 of the radiographs are made from digitized an instrument intended to “standardize classifica- copies of the full-size standards distributed with the tion methods and facilitate international compari- 1980 version of the Classification. A further compos- sons of data on pneumoconiosis, epidemiological ite film shows three different profusions of u/u size investigations and research reports” (ILO 2002). The opacities plus an example of subcategory 0/0. A new scope and purpose of the Classification are clearly film is provided to exemplify pleural abnormalities. stated in its guidelines: to describe and system- It is recommended that standard reading sheets be atically record radiographic abnormalities seen on used to record the classification. Because technical postero-anterior chest radiographs due to inhaled quality of the radiograph is essential to the interpre- tation, the reader must record a judgment regarding quality, using the following categories: (1) good; (2) V. C. S. Antao, MD, PhD acceptable, with minor defects; (3) acceptable, with Division of Respiratory Disease Studies -National Institute for considerable defects; and (4) unacceptable for clas- Occupational Safety and Health, CDC, 1095 Willowdale Rd - sification purposes. Comments must be made about MS 2800, Morgantown, WV 26505, USA technical defects, if quality is not grade 1 (ILO 2002). J. E. Parker, MD Professor and Chief, Pulmonary and Critical Care Medicine, The reporting system combines semi-quantitative West Virginia University, HSC 4075A-9166, Morgantown, WV and descriptive portions. The reader is required to 26506-9166, USA record characteristics of the parenchyma or pleura 94 V. C. S. Antao and J. E. Parker that are consistent with pneumoconiosis, as well as Table 3.2.1. International Classifi cation of Radiographs of to note, under symbols and comments, other find- Pneumoconioses: categories and subcategories for profusion ings that are more likely to be due to other disease of small opacities Shipley processes ( 1992). Categories0123 Subcategories 0/- 0/0 0/1 1/0 1/1 1/2 2/1 2/2 2/3 3/2 3/3 3/+ 3.2.2.1 Parenchymal Abnormalities 3.2.2.2 Pleural Abnormalities There were no significant changes from the 1980 version of the Classification in the way parenchymal Pleural abnormalities described by the Classification changes are reported. Small opacities are defined as include pleural plaques (localized pleural thicken- parenchymal opacities less than 10 mm in size. They ing), costophrenic angle obliteration, and diffuse are described according to their shape (rounded pleural thickening. Pleural plaques are classified on or irregular), size, profusion level, and location. each hemithorax, according to their location (chest Rounded opacities are labeled p, q, r, according to wall – in profile or face on, diaphragm, or other site), their size (p, <1.5 mm; q, 1.5–3 mm; and r, 3–10 mm). presence of calcification, and combined extent (1=up Irregular opacities are identified by the letters s, t, to 1/4; 2=1/4 to 1/2; and 3=more than 1/2 of lateral and u, and categorized according to their width (s, chest wall). For the 2000 version of the Classification, <1.5 mm; t, 1.5–3 mm; and u, 3–10 mm). Two let- the recording of width is optional, and a minimum ters are used to record shape and size, and both width of 3 mm is required for an in-profile plaque to rounded and irregular opacities may be described be considered as present. If recorded, the width is cat- in the same film. For example, if the reader consid- egorized as a (3–5 mm); b (5–10 mm); or c (>10 mm). ers that virtually all lesions are irregular, with a It is no longer necessary to measure the extent of width up to 1.5 mm, the film is coded s/s. A clas- calcification in this new version. Costophrenic angle sification r/s would mean that the predominant obliteration is registered as either present or absent, type of opacity is rounded, 3–10 mm (r), but there for each hemithorax, and the lower limit for its clas- are also a significant number of irregular opaci- sification is defined by comparison with the standard ties, up to 1.5 mm (s). The concentration of small radiograph illustrating subcategory 1/1 t/t. Diffuse opacities in affected zones of the lung is referred to pleural thickening is recorded only if costophrenic as profusion. The profusion level is derived from angle obliteration is present. It is classified in the comparisons with the standard films, which depict same manner as pleural plaques (ILO 2002). four categories: 0, 1, 2, and 3, for the increasing profusion. Category 0 indicates the absence of small opacities or that there are fewer opacities than cat- 3.2.2.3 egory 1. The classification includes 12 subcategories Symbols and Comments (Table 3.2.1). The first number denotes the category that the film resembles the most. If the appearance Important features seen on the radiograph that have of the film closely matches the standard, the number not been registered previously are coded with the is repeated (i.e., 2/2), but if another category is seri- use of symbols. It is important to note that some ously considered (e.g., category 3), that is recorded of the symbols imply interpretations, rather than as the second number, and the final classification just descriptions, but are not definite diagnoses of should be 2/3. For the location of affected zones, the specific findings. The 2000 Classification provides radiograph is divided into six zones: upper, middle, 29 symbols, an addition of 7 from the 1980 version. and lower on each side. Large opacities are defined The new symbols are: aa (atherosclerotic aorta); at as opacities having the longest dimension exceed- (significant apical pleural thickening); cg (calci- ing 10 mm. They are coded as A (longest dimension fied non-pneumoconiotic nodules (granulomas) or between 10 mm and 50 mm); B (greater than 50 mm nodes); me (mesothelioma); pa (plate atelectasis); but less than the area of the right upper zone); and pb (parenchymal bands); and ra (rounded atelecta- C (greater than the area of the right upper zone). If sis). If the symbol od (other disease or significant there is more than one large opacity, the sum of the abnormality) is used or other relevant information greatest dimensions of the large opacities is used for is necessary, the reader should provide further clari- the categorization (ILO 2002). fication in the comments section (ILO 2002). ILO Classifi cation 95 3.2.2.4 sifications during the first years of NIOSH’s Coal The Quad Set Workers’ X-Ray Surveillance Program (Attfield and Wagner 1992). The first examinations began One of the main innovations of the 2000 version of in 1974, but the program only went into full opera- the Classification was the introduction of a set of tion in 1978. The program certifies two categories 14 standard radiographs that are compatible with of readers. The A readers are considered those who the Complete Set. The Quad Set includes 9 of the have applied for certification after attending a 2- original films (category 0/0 example 1; category day course on the Classification or have submit- 0/0 example 2; category 1/1 q/q; category 1/1 t/t; ted to NIOSH six sample chest radiographs that category 2/2 q/q; category 2/2 t/t; category 3/3 q/q; are regarded as properly classified by a panel of B category 3/3 t/t; and the composite that shows pleu- readers. A B reader is a physician who has been ral abnormalities).
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