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Asbestos-Related Pleural Disease

by Lee S. Newman, MD, MA

Pleural disease, a hallmark of asbestos exposure, includes formation of pleural plaques, calcification, thickening, rounded atelectasis, adhesions, effusion, and mesothelioma. Diagnosis is based on history and chest x-ray or CT findings. Treatment is supportive.

Asbestos is a family of naturally occurring silicates whose heat-resistant and structural properties made it useful for inclusion in construction and shipbuilding materials, automobile brakes, and some textiles. Chrysotile (a serpentine fiber), crocidolite, and amosite (amphibole, or straight fibers) are the 3 main types of asbestos that cause disease.

Asbestos can cause pleural disease other than mesothelioma (see Mesothelioma). Such pleural disease causes effusion but few symptoms. All pleural changes are diagnosed by chest x-ray or CT, though chest CT is more sensitive than chest x-ray for detecting pleural disorders. Treatment is rarely needed.

Discrete plaques, which occur in up to 60% of workers exposed to asbestos, typically affect the parietal pleura between the 5th and 9th ribs bilaterally and adjacent to the diaphragm. Plaque calcification is common and can lead to misdiagnosis of severe pulmonary disease when radiographically superimposed on lung fields. CT can distinguish pleural from parenchymal disease in this setting. Fat stripes may be mistaken for pleural plaques on chest x-ray. CT can distinguish pleural disease from fat.

Diffuse thickening affects visceral as well as parietal pleurae. It may be an extension of pulmonary fibrosis from parenchyma to the pleurae or a nonspecific reaction to pleural effusion. With or without calcification, pleural thickening can cause a restrictive defect.

Rounded atelectasis is a benign manifestation of pleural thickening in which invagination of pleura into the parenchyma can entrap lung tissue, causing atelectasis. On chest x-ray and CT, it typically appears as a curvilinear, scar-like mass, often in the lower lung zones, and can be confused with a pulmonary cancer.

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