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Weekly Chest CasesImaging Conference Cases

Case No : 11

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  • Age/Sex 64 / M
  • Case Title He presented with epigastric pain and vomiting for two days. Endoscopic biopsy revealed early gastric cancer. He had an occupational history of construction worker for 20 years but had no subjective chest symptoms. Supplier: Mi-Young Kim, M.D., Sejong
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Chest PA

Diagnosis With Brief Discussion

Definitive Diagnosis
Radiologic diagnosis
1. lung asbestosis
2. pleural plaque and calcification
3. mass, lingular division
lung cancer
fibrotic mass
malignant mesothelioma

Open lung biopsy at 4 sites
1. Mass like opacity in the lingular division - dense fibrous tissue with focal inflammation
(benign fibrotic mass)
2. Lung parenchyma in lingular division- multifocal interstitial fibrosis
3. Diaphragmatic pleural plaque
4. Lateral pleural plaque
: collagen bundle
Past History
He presented with epigastric pain and vomiting for two days. Endoscopic biopsy revealed early gastric cancer. He had an occupational history of construction worker for 20 years but had no subjective chest symptoms.
Discussion
In the most reported series of asbestos-related disease, roentgenographic changes in the pleura are far more striking than those in the lung. Four types of roentgenographic abnormality can be identified in the pleura: plaques, diffuse thickening, thickening of the interlobar fissure, and effusion. Pleural plaques may be smooth or nodular in outline and can measure up to 1cm in thickness. They are most often interrupted multiple and usually occur on the posterolateral chest wall. Pleural plaques and thickening are usually bilateral and fairly symmetric. Diffuse pleural thickening is a generalized, an acceptable definition: a smooth, non-interrupted pleural density extending over at least one-fourth of the chest wall, with or without costophrenic angle obliteration. A history of exposure to asbestos is obtained from 50 to 85 per cent of subjects in most series of patients with malignant mesothelioma. Four types of roentgenographic abnormality can be identified in the lung: asbestosis, the asbestosis body, round atelectasis, and pulmonary carcinoma. The roentgenographic changes of asbestosis occur in two forms, small and large opacities. The former can be round (a nodular pattern) or irregular (a reticular pattern). The characteristic findings of HRCT include (1) short linear opacities radiating from the subpleural parenchyma to the pleura (thickened interlobular septa); (2) nontapering linear opacities 2 to 5cm in length extending to the pleura, usually to areas of pleural thickening ("parenchymal bands" caused by fibrous tissue in the bronchovascular sheath); (3) small cystlike spaces up to 1 cm in diameter with discrete walls (honeycombing); and (4) nondependent curvilinear lines parallel to the pleura (subpleural curvilinear shadows). Although these findings are characteristic of asbestosis, they may be indistinguishable form those of idiopathic pulmonary fibrosis. Large opacities measure 1cm or more in diameter and are an uncommon manifestation of asbestosis. They may be well or ill defined, solitary or multiple, and vary from one to several centimeters in diameter. They are typically nonsegmental in distribution. Unlikely the large opacities of silicosis or CWP, the massive fibrosis of asbestosis does not appear to "migrate" toward the center of the lung, tends not to show upper lobe predominance, and has not been known to undergo roentgenographically demonstrable cavitation. In on study shows to consist pathologically of foci of fibrosis with or without a concentric lamellated appearance.
Reference
1. Fraser RS, Pare JAP, Fraser RG, Pare PD. Synopsis of diseases of the chest. 2nd ed. Philadelphia : Saunders, 1994:719-728, 886-891
Keywords
Lung, Metabolic and storage lung disesae, Occupational lung disease,
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