The pathology of coal workers’ pneumoconiosis (CWP) and its most severe form—progressive massive fibrosis (PMF)—in US coal miners has changed in recent years. Severe disease is occurring in younger miners and has been linked to an increase in silica dust exposure.


To update the description of the pathologic features of CWP in contemporary miners compared to historical miners.


This study is a retrospective expert classification of lung tissue from 85 historical and contemporary coal miners with PMF. Significant pathologic features were scored by using a standardized instrument with consensus achieved for major findings, including newly defined categories of PMF as coal-type, mixed-type, and silica-type.


Pathologic features associated with silica dust exposure, including silica-type PMF, mineral dust alveolar proteinosis (MDAP), and immature (early stage) silicotic nodules were increased in contemporary miners. Detailed descriptions of the pathology of contemporary CWP with illustrative figures are provided.


Silica-related pathologies are more common in contemporary miners. Severe forms of CWP can be detected by subtyping PMF lesions (if present) or by identification of mature and immature silicotic nodules, coal mine dust–related alveolar proteinosis, and severe inflammation in coal miners’ lungs. Silica-type PMF cases showed significantly higher levels of MDAP than either mixed- or coal-type PMF (P < .001). High profusion of birefringent silica/silicate particles was observed more frequently in cases with immature (early stage) silicotic nodules (P = .04). Severe inflammation was also significantly increased in contemporary miners (P = .03). Our findings underscore the urgent need to revise current exposure limits and monitoring of respirable crystalline silica in US coal mines.

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Green and Cohen are co-senior authors.

Competing Interests

Go provides medicolegal opinions in workers’ compensation cases. Cohen performs independent medical reviews for subjects with occupational lung disease. Cool performs pathology slide reviews for black lung cases. The other authors have no relevant financial interest in the products or companies described in this article.

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