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T H E OCCURRENCE O F P L E U R A L CALCIFICATION

AMONG ASBESTOS INSULATION WORKERS*


Irving J. Selikoff
S e c t i o n on Enuironniental Health, D e p a r t m w t of Medicine
The M o u n t Sinai Hospital, N e i York,
~
'L'. Y .
The earliest reports of pulmonary asbestosis - clinical, anatomical,
radiological - made no mention of pleural calcification. We can now appreciate that this absence of comment was not based upon inattention or
incompleteness of observation. Rather, the asbestosis seen by Cooke, Wood,
Haddow, Stewart, Simson, Lynch, Ellman, Pancoast, Pendergrass, Merewether, was in some respects not the same asbestosis seen today. A result
of exposure under much more unfavorable conditions, the pulmonary fibrosis became extensive and disabling more rapidly, bringing patients to
medical attention a f t e r shorter exposures. Fewer individuals were able to
work for many decades in asbestos trades. Another factor which led to
thinning out of the ranks was t h e large number of women among asbestos
textile workers, who left work f o r home and were lost to industrial survey.'
Since there were, in addition, many fewer employees in these trades to start
with, the number reaching a 20-year-from-onset-of-exposure point of observation was small indeed. As we shall see from data presented here, calcification is usually not seen until this point is reached. Our predecessors, who
made so many important contributions to the problem of asbestosis, could
not have made this one. I t was not there for them to observe.

H i s t oricn 1 Revie 10
The first cases of asbestosis could not, as noted, have had pleural calcification. Montague Murray's patient had a 14-year history of asbestos work
in 1900,' and there is no record of medical examinations made of the deaths
in a n asbestos textile factory reported by Auribault in 1906; these workpeople, in any case, died in many instances a f t e r only five years of exposure.''
Cooke's patient, reported in 1924' and 1927: (reports which did much to
stimulate interest in this problem and provided the name for the pneumoconiosis) ;-' died after 20 years of asbestos textile work. Postmortem examination showed the pleurae to be thickened but calcification was not
mentioned.
Early in the 1930's, a number of references can be found to observations
which may now be interpreted a s perhaps having been due to pleural calcification. Sparks" wrote of ". . . some small calcereous deposits . . . seen
scattered in the lower zones of approximately t h e same size as the calcify*This study was supported by the Health Research Council of the City of
New York.

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Annals New York Academy of Sciences

ing tubercles, but they have a slightly lesser density and are irregular in
outline, but made no mention of specific pleural changes. D ~ n n e l l y too,
,~
observed calcification, but interpreted it a s being in the parenchyma.
Gloyne remarked on horn-like changes, but i t is not clear whether this
referred to burnished thickened pleura o r to calcification. There is no
mistaking t h e description of Lynch and Smith, on t h e other hand. They
speak of the pleura being thickened and collagenous and partly calcareous.
However, the impact of this observation was muffled by the main import
of their case report, which detailed the first case of asbestos lung cancer.
Similarly, there was no special note made of the observation by Vigliani
of pleural calcification, in his description of two autopsies with asbestosis
(1940) .lo
Pleural calcification was not mentioned in the several roentgenographic
studies of pulmonary asbestosis made in these decades. This was t h e case
in t h e first evaluation of X-ray changes among asbestos workers, made by
Pancoast and his colleagues in 1918 and in subsequent studies, including the pioneer descriptions of Wood.I5
this
Clinical studies also failed to call attention to this complication
and
was true even in the extensive surveys made by Merewether (1933) ?
by Dreessen and colleagues (1938) .?Ii The absence of clinical reference to
pleural calcification was mirrored by a similar hiatus in pathological studies, as in the early careful anatomical descriptions of the disease by Gloyne
and the later communication of Lynch and Cannon.y7
The virtual absence of reports of pleural calcification with asbestosis
conformed with the experience of the infrequency of this finding in general,
as attested by several early collected series,-: in which the relatively few
cases were usually secondary to empyema (particularly tuberculous ) ,
trauma and hemothorax. There were scattered instances of idiopathic
calcification, but since occupational histories were not available in these
cases, this source was not considered.
The question of occupational dusts causing pleural calcification became
much more important, however, with the striking report of Siegal and his
colleagues:-: of t h e finding of numerous instances of such calcification
during X-ray studies of talc miners and millers in northern New York State.
These observations a r e of particular interest to us, since these men were
exposed to tremolite, a variety of asbestos ; the pathology of the disease:,:
resembled that of classical asbestosis, including the finding of talc bodies,
which a r e not distinguishable from asbestos bodies.:
I n retrospect, t h e pleural calcification seen among tremolite talc workers
may perhaps be considered a variety of asbestotic calcification. However,
this judgment has as a background the development of knowledge concerning the occurrence of pleural calcification in asbestosis and the clarification
of the varied nature of talc, some talcs containing over 80 per cent of

Selikoff : Pleural Calcification


tremolite and others having traces or none. I This clarity of retrospective
vision was less evident at the time of the report of A. R. Smith in 1952,
when she found roentgenographic evidence of pleural calcification in 14
of 221 tremolite talc workers (6.3 per c e n t ) , but in none of 261 asbestos
workers: The observation of isolated cases of calcification among bakelite
insulation and calcimine workers was ascribed to the fact t h a t both talc
and mica are used in their manufacture. As late as 1955, studies of both
pathological and roentgenological findings in asbestosis failed to call attention to pleural calcification:*-
In 1955, interest was attracted to the occurrence of pleural calcification
in asbestosis by the inclusion of this entity in a list of roentgenological complications of asbestosis observed by Jacob and Bohlig in their study of 343
Dresden asbestos workers. They found such calcification in approximately
five per cent of their cases. No data was reported concerning the duration
of exposure of the employees studied. A valuable investigation was published the next year by Frost, Georg and Maller, describing 11 cases of
calcification among 31 asbestos workers with more than 20 years of work
experience.44 Fehre reported seven cases of pleural calcification among 35
employees in a factory making a composition material (Steinholz) which
contained talc (but which also was made with asbestos during the period
in which the men were exposed). Since then, additional examples have
been recorded, i and t h e use of pleural calcification a s a marker to discover cases of asbestosis has been brilliantly demonstrated. Parenthetically, such differential diagnostic use has been very valuable in our hands
and pleural calcification is often a reliable and accurate index of previous
asbestos exposure. Appreciation of such diagnostic reliability will make
f o r increased accuracy in the radiological determination of t h e presence
or absence of asbestosis, a problem which has been but incompletely resolved without the use of this sign.?

Present Investigation
This review of pertinent reported literature demonstrates t h a t pleural
calcification was not observed in association with asbestosis until scattered
examples were seen in the 1930s. I n the past decade, many more cases have
been reported, with much wider appreciation of the important association
of the two conditions. Above, t h e hypotliesis was proposed that this sequence of events i s t h e r(3siilt of t h e limited e x t e n t of t h e nsbestos i n d u s t r y
b e f o r e 1910, i t s expansion 1910-1930 and later, a i d t h e concomitant necess i t y for t h e lapse o f a considerable t i m e - u s u a l l y m o r e t h a n 20 y e a r s b e t w e e n h u m a n exposure t o asbestos and the radiological appearance of
pleural calcification. I f this hypothesis i s c o r w c t , t h e n pleural calcification
should be seen ioitli increasing f r e q u e n c y in t h e f u t u r e .

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Annals New York Academy of Sciences

With regard to the expansion of the asbestos industry, it may be noted


that asbestos production began on a commercial scale in 1876 (Italy) 1878 (Canada) .5s From then to the end of 1909, the total world production
was less than 700,000 tons: From 1910 to 1929, world production was
seven times that amount (4,123,780 tons) .54
Our studies in this investigation were designed to provide data concerning the second factor - lapsed time from onset of exposure - and also to
demonstrate the incidence of pleural calcification at least in one type of
asbestos work, in order to clarify its applicability as a diagnostic radiological sign.

Materials and Methods


Our study has been concerned with 1,258 current members of the International Association of Heat and Frost Insulators and Asbestos Workers
in the New York-New Jersey Metropolitan area. Details of the procedures
utilized in this investigation have been recorded.55 Briefly, these men represented all living members of the insulation workers union in this area
who had been on the unions rolls Dec. 31, 1942 or who had joined at any
time between January 1, 1943 to December 31, 1962. On January 1, 1963,
1,086 were active working members, 63 were retired (primarily because
of age), 34 were not working because of illness and 75 had withdrawn from
the insulation union, to take other work. One thousand one hundred seventeen of the 1,258 members were examined, including 984 of the working
members, 50 of those retired, 28 of the ill and 55 of those otherwise employed. TABLE1 details these data. TABLE2 contains an analysis of the men
TABLE1
ASBESTOS
WORKERS
UNIONN.Y. - N.J. 1943-1962. 632 MEMBERSDECEMBER
JANUARY
1, 1943 TO DECEMBER
31, 1962.
31, 1942. 890 ADMITTED
DURING
SURVEY 1963-1964
STATUS OF MEN EXAMINED

Status January 1, 1964 (1,522 members)

status
Retired

No.

Examined

% Examined

Withdrawn
Working

63
34
75
1,086

50
28
55
984

79.3
82.4
76.4
90.6

Total

1,258

1,117

89.9

Ill

Selikoff : Pleural Calcification

355

TABLE2
EXAMINATION
OF ASBESTOS
I N S U L A T I O N W O R K E R S : ANALYSIS
BY
WORKEXPOSURE
I

Onset of exposure

Total

Examined

No.

50+ (yrs.)
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4

36
41
64
92
126
18
66
186
225
184
220

O N S E T OF

1,258

28
39
54
83
111
16
61
174
205
154
192

1,117

according to lapsed time from onset of employment (and industrial exposure). I t will be seen t h a t a majority of men in each elapsed-time category
was examined.
The presence or absence of pleural calcification was determined roentgenographically. In each case, a standard posteroanterior film was taken,
using a 200 MA, four-valve apparatus with a 2 mm. rotating anode focal
spot. Generally, 10 MAS was used with kilovoltages varying from 60-80
KV, depending on thickness of chest. No grid was used. In addition, a
second, somewhat more penetrating film was taken in t h e posteroanterior
projection in each case, to better demonstrate pleural calcification, especially in those instances in which pleural fibrosis coexisted or when the
calcification was located in such areas as the posterior diaphragmatic sulcus, behind the heart, in the mediastinal pleura, etc.
In each case, films in both anterior oblique positions were also taken,
again with the object of better demonstrating pleural calcification. Some
cases of such calcification will be missed if routine oblique films a r e not
taken. We have been able to demonstrate pleural calcification with t h i s
technique when i t was obscured in the posteroanterior film by r i b markings,
cardiac shadow, diaphragm, mediastinum, etc. The pleural location of the
calcified plaques can often be best demonstrated by t h i s position since in
the posteroanterior film, the plaques may appear broadside-on, with a n
irregular indeterminate outline, yet a r e seen tangentially in t h e oblique
film as clearly pleural in location.
The observations made in this investigation a r e based upon the use of
the above X-ray techniques. I t would be anticipated that a smaller number

Annals New York Academy of Sciences

356

of instances of calcification would be found in a survey which failed to


utilize both higher kilovoltage and oblique-position techniques. Additional
roentgenological techniques may be used to f u r t h e r refine the diagnostic
search and would perhaps slightly increase the survey yield, but we have
no data on routine use of these techniques, which include tomography, the
lateral position and t h e use of the Bucky diaphragm, although we have used
each of these with good results in selected cases elsewhere.

Incidence of Calcification
Roentgenological evidence of pleural calcification is common among the
asbestos insulation workers. Pleural calcification was found in 150 of the
1,117 men examined. There is no other condition now known in which
such a n incidence of pleural calcification has been reported. Nevertheless,
these figures have limited meaning without relation t o the work experience
TABLE3
PLEURALCALCIFICATION
AMONG ASBESTOSINSULATION
WORKERS
I

Onset of
exposure (Yrs.)

No.

40+
30-39
20-29
10-19
0-9

121
194
77
379
346

Totals

1,117

Normal

Calcification

42.1
65.4
89.6
98.9
100.0

57.9
34.5
10.4
1.1
0.0

Extent of
calcification (grade)
1

37
46
5
0

20
15
0
0
0

13
6
0
0
0

96

35

19

of the men examined. Such an analysis is contained in TABLE 3, detailing


the incidence of pleural calcification in relation to the lapsed period from
onset of exposure among the men examined. I t will be seen that among
these men, all with the same type of exposure to asbestos, calcification was
relatively uncommon in less than 20 years from onset of exposure. Thus,
we found no instance of pleural calcification among 346 men whose exposure began less than 10 years from the date of their examination and in only
five cases of 379 whose exposure had begun from 10 to 19 years prior to
their examination. On the other hand, among men whose work experience
had begun more than 20 years before, calcification was common. E i g h t of
77 with 20 to 29 years from onset of exposure showed calcification, while
67 of 194 whose exposure had begun 30 to 39 years before and 70 of 121
with 40 years or more from onset of exposure showed calcification.
Not only did the incidence of calcification increase following the 20-yearsfrom-first-exposure-point, but the extent of calcification similarly became

Selikoff : Pleural Calcification

357

greater. Thus, in the 13 cases found in the group of men with less than
30 years from onset of exposure, the extent of calcification was limited in
each. On the other hand, among the 70 men with calcification in t h e 40year-and-over group, almost half had extensive calcification (Grade I1
or 111).
It is difficult to separate the effect of actual years of work exposure
from lapsed time from first exposure, since in many instances the two
figures coincide, among the men examined. To properly study this question, i t would be necessary to observe a significant number of men whose
work exposure had ceased many years before but had remained under
observation. Nevertheless, analysis of the work experience of the group
studied here provides some data which would suggest that both factors lapsed time since first exposure and total years of exposure-are of importance, with the latter of somewhat greater consequence. Thus, we have
analyzed the findings obtained during the examination of 331 men whose
exposure began more than 25 years prior to their examination. We divided
this group in two, the first containing 54 men who had less than 25 years
of exposure during their period of employment and the second consisting
of 277 men whose total period of work exposure approximated the lapsed
TABLE4
PLEURAL CALCIFICATION AMONG ASBESTOS
I N S U L A T I O N WORKERS :
EXAMINATION
OF 331 MEN W H O S E ExPost'itE BEGAN
A T LEAST25 Y E A R S
BEFORE SURVEY

1
~~

Years of Exposure

0-24

f:

EicYEiYon
Grade 1
Grade 2
Grade 3

25-50+

Total

1 !i 1 i ;i
;t

time from onset of exposure. As can be seen in TABLE 4, of t h e 54 men


whose total exposure tended to be measurably less than the period during
which this exposure occurred, only 11 had pleural calcification, and each of
these 11 was minimal in extent. On the other hand, of those men whose
total exposure tended to coincide with the period in which i t occurred, there
were 127 instances of calcification among the 277 examined. Not only was
the incidence of calcification larger in this group, but the extent of t h e
calcification was also greater, approximately two-fifths having extensive

Annals New York Academy of Sciences

358

TABLE5
PLEURAL
CALCIFICATION*
AMONG ASBESTOS
INSULATIONWORKERS
:
EXAMINATION
OF 839 MEN WITH 0-24 YEARS WORK EXPOSURE;
ANALYSISBY YEARS SINCE ONSET OF EXPOSURE

Exposure
(Yrs.)

Onset of exposure (yrs.)

I 40-50+ I 30-39

20-24
15-19
10- 14
5-9
0-4

20-29

15-19

5/31
2/35
1/4

3/123
1/39

0/1

0/7

0/1

3/17
4/13
0/3
1/2
0/1

2/3
0/0
0/2
0/1

o/o

I 8/36 I 8 / 7 2

2/6

10-14

5-9

Total

0-4

0/5

1/161
0/41
0/3

0/135
0/19

0/192

10/5 1
9/17 1
3/209
1/18?
0/221

4/174

1/205

0/154

0/192

23/839

10/42

12/246

1/551

calcification. These data would suggest that the total amount of exposure
is of considerable importance.
We have also analyzed, in TABLE 5, the findings in 839 men with less
than 25 years of work exposure according to the duration of years during
which this limited exposure occurred. There were 23 instances of calcification (all limited in extent) among these 839 men with 0-24 years work
exposure. Twenty-two of the 23 occurred in the group in which exposure
began a t least 15 years before. There were only 13 instances of pleural
calcification among men whose total work exposure was less than 20 years.
Of these, all except one had begun their exposure at least 15 years before.
Looked a t another way, there were 725 men whose work exposure began
TABLE6
ROENTGENOGRAPHIC
EVIDENCE
OF PLEURAL
ABNORMALITY
AMONG

Years from
onset
of exposure
40+
30-39
20-29
10- 19
0-9

1,117 ASBESTOSINStfL.4TlON WORKERS

Number
examined

I I

12 1
194
77
37 9
346

28
96
47
340
342

Ny&

Abnormal pleura
Fibrosis
65
62
25
36
4

Calcification
70
67
8
5
0

Selikoff : Pleural Calcification

Grade of
pleural
fibrosis

359

Grade of pleural calcification


??J

No.
0

171
61
15
0

45
25
18
3

17

2
3

240
99
43
10

11
4
3

7
2
6
4

Totals

392

247

91'

35

19

0
1

Calc.
28.8
38.3
65.1
100.0

less than 20 years from the date of their examination. Only five had
evidence of calcification (TABLE 3 ) . On the other hand, there were 22 men
whose total work experience was less than 20 years, but had begun t h a t
work experience a t least 30 years before. Five had calcification.
Relation to parenc/ry,mal and pleirial fibrosis. It is evident from TABLE
6 and TABLE 7 that pleural calcification may be roentgenographically associated with pleural fibrosis, but not in all cases. The data in TABLE 6
suggest that pleural fibrosis appears earlier t h a n does calcification. Among
802 men X-rayed, a t a point less than 30 years from onset of exposure,
there were 13 instances of calcification and 65 of pleural fibrosis.
On the other hand, fibrosis and calcification of the pleura do not necessarily coincide roentgenographically in each case. I t may be t h a t pathogenetically calcification appears on a background of pleural fibrosis ; studies
in this regard would be valuable. Nevertheless, we have seen numerous
instances of pleural calcification in the absence of roentgenographically
demonstrable fibrosis. As can be seen in TABLE 7, among 392 men with a t
least 20 years from onset of exposure, there were 240 who had no roentgenographic evidence of pleural fibrosis. Yet, 69 (28.8 per cent) showed some
calcification, 24 having extensive calcification. However, all 10 of those
with very extensive pleural fibrosis also had pleural calcification, usually
extensive. I t was evident that as pleural fibrosis visibly increased, t h e
tendency to coincident calcification simultaneously increased.
Analyzing the 392 men with at least 20 years from onset of exposure
(TABLE 8 ) , of 292 with minimal or no parenchymal fibrosis seen on X-ray,
there were 98 with calcification. Among the 100 men with extensive parenchymal fibrosis, there were 47 with pleural calcification. Miiller'G has
also commented upon the greater incidence of pleural calcification in individuals with extensive pulmonary asbestosis fibrosis, finding six per cent

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Annals New York Academy of Sciences


TABLE8

CORRELATION OF PLElJRAL CALCIFICATION WITH PARENCHYMAL FIBROSIS


IN
392 ASBESTOSINSULATIONWORKERS
WITH AT LEAST20 YEARSFROM ONSET
OF EXPOSITRE

Grade of
parenchymal
fibrosis

Grade of pleural calcification


%
J.

No.

Calc.

0
1
2
3

56
236
7a
22

52
142
38
15

4
58
23
6

0
24
11
0

0
12
6
1

Totals

392

247

91

35

19

7.1
39.8
51.3
31.8

calcification in Grade I asbestosis and 38 per cent in Grade I11 asbestosis.


Such comparisons have little meaning, however, without reference to duration of exposure and lapsed time from onset of exposure, since Grade I
asbestosis following relatively short periods of exposure, as can be seen
from our data above, could be anticipated to have a much lower incidence
of calcification than the same grade of asbestosis following a long period
of exposure. I t is worthy of note t h a t extensive pulmonary asbestosis may
exist without calcification (53 of 100 men in TABLE 8 ) . I n contrast, we
found four instances of calcification (albeit minimal) among 56 asbestos
insulation workers in this group who had no evidence of parenchymal
fibrosis.
Bilateral calcification. I n approximately half the cases (TABLE 9 ) t h e
pleural calcification was bilateral. In 49 cases, it was present only in the
left hemithorax and in 28 in the right alone. When bilateral, i t was often
bilaterally symmetrical or at least equal in extent on both sides. However,
in 28 cases one or the other side was dominant. Just as t h e left side was
more frequently involved in unilateral cases (49 as compared to 28 in the
right hemithorax), in the asymmetrical bilateral cases, the left hemithorax
had calcification of greater extent in 18.
It will be noted in TABLE 9 t h a t the more extensive calcification tended
to be bilateral. Forty-eight of the 54 instances of extensive calcification
were bilateral, whereas only 25 of the 96 instances of limited calcification
had evident bilateral calcification.
Localization and appearance. Although the main burden of this communication is concerned with the incidence of pleural calcification among
asbestos insulation workers, i t may be of some value to briefly outline the
roentgenographic appearances. There was no portion of the pleura found
immune to this complication. While diaphragmatic pleura was a very com-

Selikoff : Pleural Calcificatioii

361

TABLE9
LOCATION OF PLEURAL CALCIFICATION I N 150 INSTANCES OF SIJCH
CALCIFICATION AMONG ASBESTOS
INSULATION WORKERS

Location

I
1

Grade of calcification
1

Total

Left
Right
Bilateral*

45
26
25

4
2
29

0
0
19

49
28
73

Totals

96

35

19

150

mon site, the costal areas were frequently found to be involved as were the
various portions of t h e mediastinal pleura. Here, t h e pericardial surface
was not infrequently involved, particularly along the left cardiac border.
The right cardiac border was much less frequently seen to have calcification although the superimposition of vertebrdl and heavy vascular markings make any statement with regard to the relative frequency of pericardial calcifications on either side hazardous. Calcifications along the
pleura covering the aortic knob were seen; in such instances, differentiation
from calcified aortic plaques sometimes was difficult. The frequency of
anterior mediastinal pleural calcifications was low but, again, technical
factors such as superimposition of sternal shadows may have been responsible. Calcification in this latter site when seen on lateral films is often
extensive, an observation which correlates well with t h e known pathways
of lymphatic drainage from the parietal pleura.:7 While i t is t r u e that the
lower portions of the hemithoraces bear the brunt of t h e calcification, the
upper lung fields a r e by no means spared. The thick, shell-like calcifications
associated with tuberculous empyema a r e not seen, although tangential
oblique views may sometimes give this appearance. On the other hand, the
extensive calcifications a r e often racemic and lace-like on the costal pleura.
They a r e denser and more burnished on the diaphragm, where they often
follow the contours of the diaphragm on the posteroanterior projection.
Occasionally, small buttons a r e seen, with a radiolucent center. Sometimes the calcification is so extensive as to virtually obscure the pulmonary
parenchyma. On other occasions, it may involve the pleura of a n interlobar
fissure and in such cases may outline either the greater or lesser interlobar
fissures. On tomographic studies, we have found small linear areas of
calcification within thick areas of pleural fibrosis, the latter in the form
of pleural scallops. Our experience with serial observations of pleural calcification are too limited to more than suggest that calcification does not

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Annals New York Academy of Sciences

appear, in extensive cases, simultaneously in all areas, since we have observed extension of existing areas as well as increasing density of calcification of existing, faint areas.

Discussion
Evidence now available indicates that t h e pleural calcifications seen with
asbestosis involves the parietal pleura. Nevertheless, such evidence is not
yet extensive and our observation of admittedly infrequent calcification in
the interlobar fissure suggest that the visceral pleura may occasionally be
involved a s well. This would coincide with the known fact t h a t while t h e
parietal pleura is most heavily involved by fibrosis in cases of pulmonary
asbestosis, t h e visceral pleura may also be found to be thickened. I n our
cases, radiographic studies a r e consistent with those of others in demonstrating that, by and large, t h e calcification seen is in the parietal pleura.
Thus, tangential views showed little or no soft tissue between the calcification and the chest wall and cine-radiographic studies showed that the lung
moved independently of the costal pleural calcifications, whereas t h e latter
moved synchronously with the ribs and chest wall. Kiviluoto demonstrated
the parietal location of the calcification by diagnostic pneumothorax.
The diagnostic importance of the presence of bilateral pleural calcifications has been emphasized by Jacob and Bohlig and Kiviluoto. Mulleri
stated that calcification in asbestosis is almost always bilateral. Our finding of bilateral calcification in almost half our cases is in line with these
previously reported studies.
However, analysis of our data provides a f u r t h e r dimension to t h e diagnostic importance of pleural calcification insofar as asbestos exposure is
concerned. While bilateral calcification continues i t s status of being almost
pathognomonic of pneumoconiosis (primarily asbestosis, but occasional
instances consequent upon exposure to other dusts as well), unilateral calcification of the types seen in our study should similarly raise t h e very
strong suspicion of previous asbestos exposure 20 or more years before.
This is particularly true when previous traumatic or infectious disease
has not been known, when the calcification is evidently in the parietal
pleura, especially when basal or mediastinal in location, and if associated
with evidence of parenchymal and/or pleural fibrosis. In studies elsewhere,
we have frequently found a calcified fleck on the diaphragm to be valuable
in introducing o r establishing t h e diagnosis of asbestosis. It is sometimes
not appreciated how infrequent even unilateral pleural calcification is,
especially in the absence of obvious residuals of traumatic or infectious
pleural disease.
M The importance of the finding of 72 instances of unilateral calcification, in addition to 73 bilateral calcifications, among the
392 men with more than 20 years since onset of exposure is evident and
emphasizes t h e diagnostic value of this finding.
2H-30a

Seiikoff : Pleural Calcification

363

I t is difficult to relate o u r findings i n t h i s g r o u p of men w i t h t h e results


of other studies insofar as incidence is concerned. S m i t h " found n o instances of calcification a m o n g 261 asbestos workers b u t t h e w o r k experience
of t h e men studied is not given. If t h e g r o u p studied by h e r had had s h o r t
work experience, t h e findings woultl not he unexpected. Jacob a n d Bohlig
found a n incidence of five p e r cent a m o n g t h e i r cases" b u t correlations
with d u r a t i o n of exposure were not recorded. It is possible t h a t t h e d u r a tion of exposure in m a n y of t h e i r cases was s h o r t since t h e Dresden asbestos
i n d u s t r y had suffered severely d u r i n g t h e a i r r a i d s of t h e last w a r a n d much
of its work force was dispersed. T h u s , of t h e asbestos workers under observation by Jacob a n d Bohlig in 1955, very few were observed whose
exposure had begun more t h a n 15 y e a r s before..," I n Kiviluoto's series of
environmental cases" onset of exposure could not, of course, he determined
nor could t h e initial cohort of those exposed be known, t o allow a n e s t i m a t e
of incidence of calcification a m o n g those exposed. In t h e s t u d y of F r o s t
r t u/.,'' although a n a t t e m p t W:IS made t o X-ray each of t h e 34 men who had
been a t work f o r 20 y e a r s or more, no detailed information is given concerning t h e original cohort with which these m e n were associated, except
t o note t h a t t h e Copenhagen Union had had a b o u t 100 members d u r i n g t h e
1930's; 31 were available f o r t h e survey reported.
Comparison w i t h reported findings of calcification a m o n g asbestos insulation workers a r e particularly difficult because of t h e paucity df s u c h
reports. Fleischer and colleagues'"' conducted a n X-ray survey of a l a r g e
group of asbestos insulation workers a n d made no mention of finding a n y
calcification a m o n g them. However, 948 of t h e 1,074 men X-rayed had
worked f o r less t h a n five years a n d only 51 men had worked f o r more t h a n
10 years. Parenthetically, it may well have been t h e findings consequent
upon such relatively s h o r t periods of exposure t h a t led t h e m t o conclude
t h a t "asbestos pipe covering of naval vessels is a relatively s a f e operation."
T h e difficulties associated with t h e s t u d y of F r o s t a n d colleagues" have
already been mentioned. S i m i l a r potential selective effect is present in t h e
report of Bjure, Soderholm a n d Widimsky, since t h e men examined w e r e
all volunteers a n d no d a t a is given concerning t h e cohort f r o m which t h e y
were selected.'" F o u r of t h e e i g h t men examined were found t o have pleural
calcification. I n t h e history of work exposure, no information is given
concerning t h e relation of total exposure t o lapsed t i m e f r o m onset of
exposure.
Among o u r cases, w e found very f e w whose calcification appeared in
less t h a n 'LO y e a r s f r o m onset of exposure. T h e r e were f o u r cases found
whose work exposure had begun less t h a n 20 y e a r s prior t o t h e d a t e of
examination a n d only one of 555 men examined whose exposure began less
t h a n 16 y e a r s ( 1 2 y e a r s ) before examination. T h i s is not to say t h a t calcification cannot appear in periods s h o r t e r t h a n 10 years. Elsewhere, w e

364

Annals New York Academy of Sciences

have seen a small area of calcification on t h e pericardial pleura in a n oil


burner repair worker, exposed to frequent use of asbestos cements, examined seven years a f t e r beginning work in this trade. Enticknap and
Smither"' reported a man who died at the age of 78 whose exposure began
in 1942 and whose chest X-rays from 1948 onwards showed extensive
pleural calcification bilaterally. As noted, no mention is made in the paper
of distinction between lapsed time from onset of exposure
by Bjure et d.'"
and total exposure, so that i t is difficult t o evaluate the appearance of
pleural calcification in one man in their group who i s reported to have had
seven years of exposure.
The observations among t h e group of men studied by us indicates t h a t
at least among workmen exposed t o asbestos in the course of insulation
work, under the conditions which have obtained in the United States among
union insulation workers in the past 50 years, pleural calcification is very
uncommon in less than 20 years from onset of exposure.

Summary
1. Roentgenographic study of 1,117 asbestos insulation workers showed
pleural calcification to be a common finding. Altogether, 150 instances of
such calcification were present.
2 . Data i s presented which demonstrates t h a t pleural calcification among
workmen exposed to asbestos in this trade rarely occurs in less than 20
years from onset of exposure. Pleural calcification was found in 5 of 725
asbestos insulation workers with less than 20 years from onset of exposure
but in 145 of 392 men examined more than 20 years from beginning work
with asbestos. Similarly, the extent of calcification also increased with
duration of exposure.
3. Available data suggests that both total amount of exposure as well
as lapsed time from onset of exposure are of importance. In this group
of men, t h e earliest case seen was in a man examined 12 years from onset
of exposure. Elsewhere, somewhat shorter periods from onset of exposure
have been noted, but such cases a r e rare.
4. Approximately half the case:; were bilateral. In unilateral cases, involvement of the left hemithorax predominated. Extensive calcification was
usually bilateral.
5. Bilateral pleural calcification is almost pathognomonic of pleural
disease associated with pneumoconiosis. Asbestos is by f a r the most common industrial dust involved and bilateral pleural calcification in the
absence of evidence of traumatic or infectious pleural disease can usually
be considered to be due to asbestos exposure.
6. In half the cases, the calcification found was unilateral. The appearance and location of such calcification is described and no portion of t h e
pleura was found to be immune. The diagnostic importance of such uni-

Selikoff : Pleural Calcification

365

lateral calcification i s stressed since even unilateral calcification i s uncommon in the general population a n d when i t occurs, a t r a u m a t i c o r
infectious history can generally be obtained. W h e n t h e calcification i s
idiopathic, i t should strongly s u g g e s t asbestosis and the presence of unilateral pleural calcification is almost as strongly diagnostic of asbestosis
as i s bilateral calcification.
7. T h e pleural calcification is primarily f o u n d i n the parietal pleura,
more heavily in t h e lower portions of t h e chest. Data concerning correlations w i t h pleural fibrosis a n d asbestotic parenchymal fibrosis i s given.
Pleural calcification not infrequently is present in t h e absence of visible
pleural fibrosis a n d occasionally may b e p r e s e n t in t h e absence of radiologically visible parenchymal fibrosis.
8. In addition t o s t a n d a r d posteroanterior films, i t h a s been found advantageous t o use t w o additional simple techniques ; a second posteroa n t e r i o r film t a k e n w i t h a slightly more p e n e t r a t i n g technique a n d t h e
use of oblique projections.
9. A t t h e present time, i t i s likely t h a t asbestos exposure i s the m o s t
common cause of pleural calcification. T h e finding of such calcification as
described h e r e generally indicates asbestos exposure m o r e t h a n 20 y e a r s
before.

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