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Smoking Cessation
Cigarette smoking accelerates lung function decline and increases mortality in silicosis 115 and, combined with silica exposure, raises lung cancer risk. 108 Vaping risks are unknown. All patients should be advised to quit smoking and provided with appropriate support to do so.
Lung Transplantation
Referrals for lung transplantation in patients with silicosis are rising worldwide, reflecting the growing epidemic of AS silicosis. 116, 117 Historically, silicosis accounted for only 0.2 % of US lung transplants between 1991 and 2018, 118 but recent case series highlight a rapid increase in referrals. In Israel, 25 patients were referred between 1997 and 2010, an incidence 14 times higher than expected globally. 18 In California, statewide surveillance since 2019 has identified at least 109 referrals and 52 lung transplants for AS silicosis. 119 Early single-center reports suggested worse survival for silicosis compared to idiopathic pulmonary fibrosis( IPF), 120 but subsequent studies from Israel, China, Brazil, and the United States demonstrate that outcomes are similar, with no significant differences in post-transplant survival or chronic lung allograft dysfunction( CLAD) rates. 117, 121 – 124 Additionally, a NIOSH study reported longer median survival in silicosis( 7.8 years) than in IPF( 5.1 years). 118
A recent experience at the University of California, San Diego, underscores the US contribution to this evolving picture. 117 Between 2019 and 2023, their team transplanted seven younger Latino men, all countertop workers with severe AS silicosis and profoundly reduced lung function. Despite longer ischemic times, perioperative complication rates were not increased, and one-year outcomes— including survival, rejection, and pulmonary function— were equivalent to those of patients transplanted for other interstitial lung diseases. 117 Together with international data, this experience illustrates that lung transplantation is a viable treatment option for end-stage silicosis, but also a stark indicator of the failure of primary prevention in this industry and the lack of effective treatments to prevent progression of disease.
Clinical Trials and Emerging Therapies
Whole lung lavage( WLL) may be of benefit to patients with silicoproteinosis( acute silicosis) or ground-glass changes; however, there have only been small series showing symptomatic and radiologic improvements with little effect on lung function or survival. 125 – 127 A small series found improvement in groundglass infiltrates, but less effect on established fibrosis. 126, 127 Considering the invasive nature, unproven benefit, and risk associated with WLL, careful patient selection is critical, and further studies are warranted.
Silica-induced lung injury arises from the cytotoxic effects of particles, oxidative stress, dysregulated autophagy, and chronic inflammation. 128 Evidence for immunosuppressive therapy is limited: Positron Emission Tomography( PET)/ CT imaging demonstrates inflammation in PMF regions, and small studies report improvements with prednisolone in some subgroups. 129 These findings suggest potential benefit but do not justify routine corticosteroid use; further trials are needed. Experimental therapies in models include NLRP3 inhibition, cytokine blockade, and modulation of autophagy, 128 though none have reached clinical trials.
Antifibrotics such as pirfenidone and nintedanib are established in other fibrosing lung diseases. 130 A trial of nintedanib in pneumoconiosis is ongoing, 131 but evidence in silicosis is needed. While nintedanib is approved by the US Food and Drug Administration for progressive pulmonary fibrosis of any etiology, clinical trials leading to approval lacked participants with silicosis, underscoring the need for further investigation. 132
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Actions to Address the Epidemic Current Situation and Regional Responses to AS Silicosis