Study Syllabus for Classification of Radiographs of Pneumoconioses

Radiograph Classification

Subset 2

Radiograph #23

Answer Key #23

This case demonstrates pleural plaques and pleural effusion without small parenchymal opacities. In many instances, pleural abnormalities are the first radiographic evidence of asbestos exposure. Detailed analysis is as follows:

The technical quality of the radiograph is classified as 3 because of overexposure of the lungs, and “Overexposed (dark)” is checked. Other technical deficiencies include improper position (because the scapulae overlap the lungs) and exclusion of the left costophrenic angle, which is included on a second image. Artifacts, perhaps monitors, are also present.

There are no parenchymal abnormalities consistent with a pneumoconiosis, so “NO” is checked in Section 2A.

There are extensive pleural abnormalities bilaterally involving the chest wall and both costophrenic angles. Section 3A is therefore checked “YES.”

There are in-profile and face-on pleural plaques on the left lateral chest wall, so in 3B, “In profile” and “face on” are marked L for Site. Pleural calcifications are visualized in these plagues, so in profile and face on are marked L under Calcification as well. The left chest wall plaques are classified as follows: on the left, the maximum width of the plaque (the distance from the medial surface of the adjacent rib to the most medial and sharpest margin of the circumscribed plaque) measures more than 10 mm (width c). The combined length is between one-fourth and one-half of the projection of the lateral chest wall, classified as extent 2. (The face-on component produces a less sharply defined border overlying the third through fifth ribs anteriorly.) There is no right face-on or in-profile plaque, so O is marked under extent and width for the right side.

The right and left costophrenic angles are blunted either by thickened pleura or effusion. The left is seen on the second lower image of the chest, so Section 3C is checked R and L. Diffuse pleural thickening usually extends into and obliterates the entire costophrenic angle. This is the case on the right, however the left CP angle blunting is not continuous with the left chest wall in profile or face on process. Therefore this is not classified under diffuse pleural thickening. On the right the diffuse pleural thickening is seen both in profile and face on, and the findings are recorded in 3D as R for “Chest wall, Site.” There is no in-profile or face-on diffuse pleural thickening on the left. There is calcification of the diffuse pleural thickening on the right seen face on, so R is marked under Calcification for face-on plaque but not for in-profile plaque. The length does exceed one-fourth of the lateral chest wall but less than half, so it is classified as extent 2, whereas the width is greater than 10 mm and is therefore classified c. There is no left diffuse pleural thickening, so O is marked under extent and width for diffuse pleural thickening on the left side.

Section 4A is checked “YES” to indicate that other abnormalities are present. These are indicated as follows: a pleural effusion may be present, so ef is checked; there may possibly be a mesothelioma on the right, so me is appropriately checked. (however, a mesothelioma usually produces an extensive pleural effusion and pleural nodularity, so the diagnosis is not likely in this case.) Notation should be made under 4C of the post-surgical changes of cardiac surgery and sternal wires. Since me was considered, the worker’s personal physician should be notified.