Thorax 1986;41:531-537

Central lymph node changes and progressive massivefibrosis in coalworkersRME SEAL, A COCKCROFT, I KUNG, JC WAGNER

From the Pathology Department and Medical Research Council Pneumoconiosis Unit, Llandough Hospital,Penarth, South Glamorgan

ABSTRACT Lungs from 123 coalworkers coming to necropsy were examined to determine theassociation between dust related changes in the central lymph nodes and progressive massive fibrosisand secondary foci in the lung parenchyma. Increasingly extensive changes of the central nodes werescored macroscopically, the highest scores indicating erosion through the walls of adjacent bronchior branches of the pulmonary artery or both. In 88 cases (mainly with extensive changes)microscopic assessment was also made. Increasingly extensive changes of central nodes were asso-ciated with the presence of progressive massive fibrosis in the lungs (p < 0.001) and the presenceof secondary foci in lungs without progressive massive fibrosis (p < 0-03). Microscopic assessmentsagreed fairly well with macroscopic assessments, but tended to be assigned lower scores.A hypothesis for the pathogenesis of progressive massive fibrosis is proposed whereby dust,accumulating in central lymph nodes, leads eventually to spread through the capsule and ruptureinto bronchi or pulmonary vessels, thereby sending dust laden activated cells back into the lungs toproduce progressive massive fibrosis. These preliminary results are consistent with the hypothesisbut more detailed studies are required.

The pathogenesis of progressive massive fibrosis incoalworkers' pneumoconiosis remains ill understood.The disease is more likely to occur in coalworkers whohave had a heavy total dust exposure' and is associ-ated with high levels of dust in the lungs at necropsy.2The stimulus for formation of progressive massivefibrosis in particular men is unknown, though proba-bly various factors play a part. The theory that pul-monary tuberculous infection is the main cause3 nowhas to be abandoned.4 Quartz may be a factor incertain types of progressive massive fibrosis and thereis an association between the rheumatoid diathesisand the 'Caplan' type of progressive massive fibrosis.5But in many cases no obvious precipitating factor ispresent and it is not clear why progressive massivefibrosis occurs. The lymph nodes in coalworkers'pneumoconiosis have received little attention andthere have been no studies of the relationship between

Address for reprint requests: Dr A Cockcroft, Department ofMedicine, Charing Cross and Westminster Medical School, LondonW6 8RF.

Accepted 24 November 1985

lymph node changes and the range of parenchymalchanges.On many occasions we have noted heavily dusted

lymph nodes breaching their capsules so that theircontents extend through into pulmonary vessels orbronchi, or both, in cases where there is progressivemassive fibrosis in areas of the lung served by thevessels or bronchi concerned. By analogy with caseouslymph nodes in primary tuberculosis, when ruptureinto bronchi is associated with a hypersensitivitypneumonitis of the distal lung (so called epi-tuberculosis), the changes in central structures incoalworkers' lungs may well have a vital role in thechain of events leading to progressive massive fibrosis.Wells6 reported that the pneumoconiotic processcould affect and cause ulceration of the wall of largeand medium sized pulmonary arterioles but did notdiscuss the possible significance of this in the patho-genesis of progressive massive fibrosis.The opportunity to investigate the association

between central node dust changes and progressivemassive fibrosis arose during a survey of postmortemlung pathology in a group of South Walescoalworkers.7 8 We were able to examine the centralnodes and compare the findings with features in thelung parenchyma.

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Seal, Cockeroft, Kung, Wagner

Fig 1 Diagrammatic illustrationof increasing dust changes incentral lymph nodes and thescoring system used to denote thegrades of dust changes. The gradeis given in the bottom left corner ofeach part of the figure. LN-lymph node; B-lumen ofbronchus; CP-cartilage plate;PA-lumen of branch ofpulmonary artery. See text (under"Changes in nodes in pneu-moconiosis") for full description ofchanges.

Methods

We studied fixed inflated lungs from 123 consecutivepostmortem examinations on coalworkers in Mid andSouth Glamorgan. They were forwarded from theCardiff Pneumoconiosis Medical Panel before thepanel's own routine examination. For a short periodlungs of all coalworkers received by the panel weresent, but thereafter only the lungs of men who hadspent at least 10 years underground. The lungs in thestudy were all those collected during about a year.The lungs were sliced in a sagittal plane to include

both upper and lower lobes. Parenchymal features

were studied on this single cut surface. Dust foci weredivided into two types: soft, peribronchiolar primarydust foci, which are the basic lesions of coalworkers'pneumoconiosis; and larger, palpable secondary dustfoci. The secondary foci were classified as either stel-late or circumscribed and the number ofeach type wasnoted. Progressive massive fibrosis was defined as anydust lesion more than 2 cm in diameter. The totaldiameter of all progressive massive fibrosis lesions onthe cut surface of the lung was noted.The hilum of the lung was examined macro-

scopically in every case to assess the state of the lymphnodes and their relationship to other central struc-

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Central lymph node changes and progressive massive fibrosis in coalworkers

Table 1 Central node changes in relation to the presence ofsecondary dust foci and progressive massive fibrosis inthe lungs

Grade of central node changes

0 1 2 3 4

Progressive massivefibrosis in lungsNone 5 23 10 13 25<5cm diameter 5 14> 5cm diameter 28Stellate secondary foci*None 5 21 8 13 121-9 1 2 12>10 ICircumscribed secondary foci*None 5 23 10 12 201-9 1 3>10 I

*In lungs without progressive massive fibrosis. In a few lungs both types of secondary foci were present.

tures. Macroscopic dust changes in the nodes weredescribed according to the scoring system illustratedin figure 1. Grade 4 in figure I was additionallydivided into 4b (bronchus breached), 4p (branch ofpulmonary artery breached), and 4bp (bothbreached). Where there was variation in the degree oflymph node changes in an individual, the score wasassigned to the most heavily affected nodes. In caseswhere the nodes macroscopically were heavily ladenwith dust, and in a few cases apparently little affected,sections were taken and prepared for histologicalexamination. Bronchi and vessels were examined on alimited number of slices and were not opened along

their length to look for dust on the inner surface.Microscopic assessments were made by IK, who is

a general pathologist and was not otherwise con-cerned in the study and who was unaware of thefindings in the lung parenchyma. He used the samescoring system as in figure 1. Sections of central nodeswere examined in 88 cases; nine of these were dis-carded as unsatisfactory for assessment, leaving 79assessments for comparison with macroscopicfindings.The significance of associations between scores for

different pathological features was tested with theMantel extension of the Mantel-Haenszel x2 test.9

iz<;}$;> ./+/M ;4 8* Fig 2 Lymph node with two8b,¢tJ'i*'t)t * e; _*%,e foci ofnecrosis in the medulla,,' *; > ,'.,' " .the one on the right also,*^wsj, E > z^, -e,showingfibroblasticz*<+rt*s;;: z .4 : vproliferation. (Haematoxyline an,deosin-)

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534 Seal, Cockcroft, Kung, Wagner

Fig 3 Lymph node showing normal lymphoidfollicles on the right, adjacent to thelumen of a bronchus, with the capsule intact. On the top left the infiltrative process hasbreached the capsule and extended towards but not affected a pulmonary artery. Notethe rectangular distortion of the node outline. (Haematoxylin and eosin.)

4..

Fig4 Changes in a bronchus adjacent to a lymph node. Cartilage plates are seen at thetop left and bottom right, with extension of collagen and dust laden macrophages from thenode (bottom left) towards the lumen of the bronchus on the right. (Haematoxylin andeosin.)

Central lymph node changes and progressive massive fibrosis in coalworkers

Fig 5 Collagenous and macrophage encroachment on anarterial wall. The material from the node forms part of thevessel wall (centre). (Haematoxylin and eosin.)

Results

MACROSCOPIC ASSESSMENT OF CENTRAL NODESIn 69% of the lungs the central nodes were thought tohave breached their capsules at some point (grade 3 or4) and in 54% there was dust penetration of a bron-chus, a pulmonary vessel, or both (variants of grade4). Dust was more common in bronchi than in pul-monary vessels and pulmonary vessels alone wererarely affected. Macroscopic appearances of affectednodes are shown in figure 6. Figure 7, from a papermounted section of a whole lung, shows node andparenchymal changes.

There was an association between central nodechanges and progressive massive fibrosis in the lung(table 1). In all lungs where progressive massive

Fig6 Macroscopic specimen of a node lesion affectingboth a bronchus and a vessel. The node is irregular in shapeand has extended beyond its capsule between cartilageplates of a bronchus (bottom centre) and into the wall of abranch of the pulmonary artery (top left). Note the blackintimal surface of the artery.

fibrosis more than 5 cm in diameter was present thecentral nodes were graded 4. Even smaller areas ofprogressive massive fibrosis were confined to lungswith nodes having dust changes of grade 3 or more.The association between increasing central nodechanges and the presence of progressive massivefibrosis in the lungs was significant at the 0.1% level(X2 = 37.22)-see table 1.The associations between increasing score for

changes in the central nodes and the presence of sec-ondary dust foci were examined in lungs withoutprogressive massive fibrosis. The association with stel-late foci was significant at the 0.1% level (X2 = 10.67)and the association with circumscribed secondary fociat the 3% level (X2 = 5.70)-see table 1. In four lungscontaining stellate secondary foci the nodes weregraded 1 or 2, but all lungs with circumscribed second-ary foci had grade 3 or 4 central nodes.

MICROSCOPIC FEATURES OF CENTRAL NODESChanges in nodes in pneumoconiosisThe following description is a reconstructed sequenceof events that seem to us likely, on the basis of anexamination of many lungs. Naturally, there has notbeen any longitudinal study in individuals. The fac-tors that enhance or inhibit the process are unknown.Figure I is a diagramatic illustration of this sequenceof increasing changes in nodes, with gradings thatwere used for both macroscopic and microscopicassessments of the nodes in this study.The earliest change, seen in young miners with only

simple pneumoconiosis, is packing of the medulla ofthe node with macrophages laden with coal dust, thedust particles having arrived from the pulmonaryparenchyma. In nodes heavily laden with dust twoevents seem to occur: the appearance of small focalareas of necrosis of the macrophages and the appear-ance of fibroblasts with deposition of collagen (fig 2).Necrosis and fibrosis continue until the node is moreor less completely replaced; either process may pre-dominate. The next stage in hilar node lesions is whenthe necrosis and fibrosis within the node breaches thecapsule. The necrotic collagenous area extends, pre-ceded by a mantel of dust laden macrophages (fig 3).As the available "space" between the node and nearbybronchi and vessels is filled the node appears enlargedand irregularly shaped in cross section. Finally, themigrating macrophages, followed by the necrotic andsclerotic material may extend between the carti-lagenous plates of the walls of large central bronchiand erode the epithelial surface (see fig 4). The ciliatedrespiratory epithelium may become replaced bycuboidal epithelium and there is loss of submucosalstructures. The pulmonary arteries may also beinvaded, with areas in their walls where all muscularand elastic tissues have disappeared and where many

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Fig 7 Paper mounted section of a whole lung showingprogressive massive fibrosis and secondary foci in a segmentof lung with heavily dust laden central nodes, but withthe remainder of the lung showing only mild simplepneumoconiosis.

dust laden macrophages can be seen on the intimalsurface (see fig 5). Often both bronchi and vessels arebreached in the same lung (fig 6).

Microscopic assessment of nodes in the studyThere was quite good agreement between macro-

scopic and microscopic assessments (table 2). Thirtysix cases were assigned lower scores microscopicallythan macroscopically, whereas only six cases hadhigher microscopic scores. Of 40 cases scored as 4bp

Seal, Cockcroft, Kung, Wagner

macroscopically, 19 were scored as 4b and 7 as 3microscopically.

Discussion

A hypothesis for the pathogenesis of secondary dustfoci and progressive massive fibrosis in coalworkers'pneumoconiosis could be framed as follows. Dust,initially accumulating in primary foci around terminalbronchioles, is removed continuously by macro-phages to intersegmental and hilar lymph nodes,where it accumulates. Dust induced reactions in thesenodes lead eventually to rupture of the capsule. Thisis frequently accompanied by rupture into a bronchus,a branch of the pulmonary artery, or both, spreadingdust laden activated cells back into a lung segment.There they produce secondary foci and progressivemassive fibrosis.

This study provides initial support for this hypoth-esis in that lungs with progressive massive fibrosis andsecondary dust foci had central nodes heavily ladenwith dust. The association between large areas ofprogressive massive fibrosis and lesions of the centralnodes could arise as a result of direct extension of thelesions into the nodes, but this is not likely to be thecase with the smaller lesions of progressive massivefibrosis or secondary dust foci. Other possible expla-nations for the association between lesions of centralnodes and progressive massive fibrosis would includeimpairment of bronchial clearance by the nodes orfailure of the nodes to function in lymphatic clearancefrom the lung.Nodes heavily laden with dust were present in many

lungs without progressive massive fibrosis or second-ary foci, but progressive massive fibrosis was notfound without grade 3 or 4 changes of the nodes. Thisimplies that the central node changes precede the sec-ondary foci and progressive massive fibrosis in thelung parenchyma. There was no evidence in this smallstudy that the men with heavily dust laden nodes, inthe absence of progressive massive fibrosis or second-ary foci, differed in age at death from men with lessaffected nodes, or from men with heavily dust laden

Table 2 Comparison ofmacroscopic and microscopic assessments of dust involvement of central nodes

Grade* on microscopic assessment

1 2 3 4b 4p 4bp

Grade* on 1 2 2macroscopic 2 1 1 1assessment 3 2 10 1

4b 5 10 14p 2 14bp 7 19 14

See under "Methods" for definitions of grades 4b, 4p and 4bp. The ordering of these grades in the table is not intended to imply thatthey represent increasing changes of the nodes.

Central lymph node changes and progressive massive fibrosis in coalworkers

nodes and progressive massive fibrosis. Among menwithout progressive massive fibrosis or secondaryfoci, length of underground exposure tended to belonger in those having nodes more heavily laden withdust (X2 = 2.8, p < 0.10). The dust load itselfdoes notseem to be the only factor in formation of progressivemassive fibrosis. Occasionally an area of fibrosis isfound in an otherwise lightly dusted lung but with thenodes to the segment containing the fibrotic lesionshowing considerable dust changes. An example ofthis is shown in figure 7. The case in this figure was notpart of the main study.

Unfortunately, in this study it was not possible tomake macroscopic assessments of the central nodes inignorance of the parenchymal findings, although thenodes were always assessed before a formal assess-ment of the parenchyma. The agreement with micro-scopic findings (made without knowledge ofany otherfindings) tends to validate the macroscopic findings.The tendency for lower microscopic assessmentscould be due either to overassessment macro-scopically or to the difficulties of including the rele-vant pathological changes in the sections withoutincluding a large number of blocks. In nine cases noartery was present on the sections examined.The results of this preliminary study are consistent

with a "central" hypothesis for the pathogenesis ofprogressive massive fibrosis in which, in some illunderstood way, immunological reactions in the cen-tral nodes play a part. There is evidence thatprogressive massive fibrosis lesions themselves con-tain immunologically active material.'01' Furtherwork on the associations between central nodechanges and lesions in the lung parenchyma is nowplanned, as well as more detailed studies of theaffected nodes.

We thank the mortuary technicians of LlandoughHospital for their cooperation, MrW Sullivan and hisstaff for the preparation of pathological material, DrJP Lyons for arranging for lungs to be sent from thePneumoconiosis Medical Panel, and Mr D Llewellynfor photography.

References

1 Jacobsen M, Rae S, Walton WH, Rogan JM. Therelation between pneumoconiosis and dust exposure inBritish coalmines. In: Walton WH, ed. Inhaled particlesIII. Old Woking: Unwin Bros, 1971:903-17.

2 King EJ, Maguire BA, Nagelschmidt G. Further studiesof dust in the lungs of coal miners. Br J Ind Med1956;13:9-23.

3 Mann KJ. A radiological study of the relationshipbetween tuberculosis and pneumokoniosis in coalminers. Thorax 1951;6:43-55.

4 Cochrane AL. The attack rate of progressive massivefibrosis. Br J Ind Med 1962;19:52-64.

5 Caplan A. Certain unusual radiological appearances inthe chest of coal miners suffering from rheumatoidarthritis. Thorax 1953;8:29-37.

6 Wells AL. Pulmonary vascular changes in coalworkers'pneumoconiosis. J Pathol Bacteriol 1954;68:573-87.

7 Cockcroft A, Seal RME, Wagner JC, Lyons JP, Ryder R,Andersson N. Post-mortem study of emphysema incoalworkers and non-coalworkers. Lancet 1982;ii:600-3.

8 Cockcroft A. The importance ofirregular opacities on thechest radiograph of coalworkers. MD thesis, LondonUniversity, 1985.

9 Mantel N. Chi-square tests with one degree of freedom:extensions of the Mantel-Haenszel procedure. J AmStatist Ass 1963;58:690-700.

10 Wagner JC, McCormick JN. Immunological investiga-tions of coalworkers' pneumoconiosis. J R CollPhysicians Lond 1967;2:49-56.

11 Wagner JC, Wusterman FS, Edwards JH, Hill RJ.Composition of massive lesions in coalworkers. Thorax1975;30:382-8.

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