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  • 1. EUROPEAN TRAINING CHARTER FOR CLINICAL RADIOLOGYEuropean Association of Radiology DETAILED CURRICULUM FOR THE INITIAL STRUCTURED COMMON PROGRAMME Radiology Section ofthe Union of European Medical Specialists DETAILED CURRICULUM FOR SUBSPECIALTY TRAINING European Association of Radiology www.ear-online.org
  • 2. EAR EXECUTIVE BUREAU TABLE OF CONTENTSProf.Dr. N. Gourtsoyiannis Preface 1PRESIDENT European Training CharterProf.Dr. I.W. McCall for Clinical Radiology 2 - 10VICE-PRESIDENTProf. Dr. G. Frija Detailed Curriculum for theSECRETARY-GENERAL Initial Structured Common Programme 11 - 44Prof. Dr. L. Bonomo Breast Radiology 11-12TREASURER Cardiac Radiology 12-14 Chest Radiology 15-21Prof.Dr. P.A. Grenier Gastrointestinal and Abdominal Radiology 22-28EDUCATION Head and Neck Radiology 28-30Dr. B. Silberman Interventional Radiology 31-33PROFESSIONAL ORGANISATION Musculoskeletal Radiology 34-36Prof.Dr. G.P. Krestin Neuroradiology 37RESEARCH Paediatric Radiology 38-41Prof. Dr. J.I. Bilbao Urogenital Radiology 42-44SUBSPECIALTIESProf. Dr. A. Palkó Detailed Curriculum for Subspecialty Training 45 - 84NATIONAL MEMBERS Breast Radiology 46-48Prof.Dr. A.L. Baert Cardiac Radiology 49-51EUROPEAN RADIOLOGY Chest Radiology 52-54Prof. Dr. A. Chiesa Gastrointestinal and Abdominal Radiology 54-59ECR CHAIRMAN Head and Neck Radiology 60-64 Interventional Radiology 64-67 Musculoskeletal Radiology 67-71 Neuroradiology 71-76 Paediatric Radiology 76-79 Urogenital Radiology 79-84Vienna, November 2005Coordination: Isabella Grabensteiner, EAR Office, ViennaGraphics: ECR graphic_link / a department of ECREAR OFFICENeutorgasse 9/2a / AT-1010 Vienna, AustriaTel +43 1 533 40 64 - 33 / Fax +43 1 535 70 37office@ear-online.orgwww.ear-online.org© all rights reserved by theEUROPEAN ASSOCIATION OF RADIOLOGY (EAR)
  • 3. Preface Preface The European Association of Radiology (EAR) elaborated skills. However, it is essential for this group to have a in conjunction with the Union of European Medical broad understanding of radiology and the wide variety of Specialists (UEMS) Radiology Section a revised charter imaging modalities that they will use prior to subspeciali- for training which replaces the previous 2003 charter. This sation particularly as many diseases are not restricted to new version is a response to the rapid expansion of the one organ system. Those radiologists providing therapy role and diversity of radiology in recent years. The charter and particularly interventional radiologists will also require is designed to provide increased flexibility for trainees in sufficient clinical time to become competent in patient the latter part of training to enable them to pursue a management. greater variety of training opportunities within the overall defined training period. Two detailed curricula have also been produced which provide a in-depth check list for radiology trainers and The charter reiterates that the training period for radiology trainees to ensure that the appropriate areas of knowl- is five years which recognises the vast amount of knowl- edge and competence have been addressed and ob- edge and skills required to deliver a general radiology tained. The first curriculum covers the initial structured service. This knowledge includes cell function, physiology, training programme. The second provides guidance for anatomy and physics as well as a wide understanding of those wishing to spend their career working predominant- all disease manifestations, natural history and treatment. ly in one organ-based subspecialty area. The subspecial- Competence in undertaking and interpreting a wide range ty curricula also highlight the importance of the of imaging modalities and disease manifestations also specialised scientific literature to this group. The general takes a considerable time which cannot be condensed radiologist undertaking training in areas of special interest into shorter training periods. in the latter part of their training may also wish to use the subspecialty curricula for guidance albeit recognising that The charter recognises that most radiologists work in a they would not be required to fulfil all aspects of them. group providing a general service to a broad range of clin- ical specialists. However, the increased complexity of The detailed curricula for both the initial structured train- modern medicine and the impact of multi-disciplinary ing programme and the subspecialties have been devel- meetings requires a deeper knowledge of disease oped by the Subspecialty Societies of EAR. This has processes in many circumstances. Therefore, the charter involved an immense amount of time and patience and emphasises the need for general radiologists in their final the EAR Executive Bureau is extremely grateful to all two years of training to develop a more focussed and those in the Subspecialty Societies who have contributed deeper knowledge of at least two areas in order to en- to the process. EAR believes that the charter and the de- hance the service provided by the group of general radiol- tailed curricula will provide a valuable template for training ogists. radiologists and will enhance the quality of care for pa- tients throughout Europe. EAR hopes that the documents Finally, the charter recognises that for more specialised will also be helpful for National Societies in their discus- services a greater degree of specialisation by radiologists sions with governments to ensure a high-quality, five-year is required and that training in the latter years must be fo- training programme in every European country. cussed in order to obtain the necessary knowledge and Professor N. Gourtsoyiannis Professor I.W. McCall EAR President EAR Vice-President Professor P.A. Grenier EAR Education Committee Chairmanwww.ear-online.org 1
  • 4. European Training Charter for Clinical Radiology European Training Charter for Clinical Radiology Introduction: Radiology is a medical specialty involving 1.4 Clinical radiology all aspects of medical imaging which provide information An expert knowledge of current clinical radiology. about the anatomy, pathology, histopathology and func- This knowledge should include: tion of disease states. It also involves interventional tech- a. Organ- or system-based specialties, e.g. car- niques for diagnosis and minimally invasive therapy diac, chest, dental, oto-rhino-laryngology, involving image-guided systems. The duration of training gastrointestinal, genito-urinary, mammogra- is five years. phy, musculoskeletal, neuro, obstetric and vascular radiology, including the application Contents: of conventional x-rays, angiography, comput- 1. Core of knowledge ed tomography, magnetic resonance imag- 2. Training programmes ing, ultrasound and, where applicable, 3. Training facilities nuclear medicine. b. Age-based specialties, i.e. paediatric radiolo- Article 1 gy. c. Common interventional procedures, e.g. CORE OF KNOWLEDGE guided biopsy and drainage procedures. d. Dealing with emergency cases. 1.1 Basic sciences a. Radiation physics; 1.5 Administration and management b. Radiobiology; A knowledge of the principles of administration c. The physical basis of image formation includ- and management applied to a clinical depart- ing conventional x-ray, computed tomogra- ment with multi-disciplinary staff and high-cost phy, nuclear medicine, magnetic resonance equipment. imaging and ultrasound; d. Quality control; 1.6 Research e. Radiation protection; A knowledge of basic elements of scientific f. Anatomy, physiology, biochemistry and tech- methods and evidence base, including statistics niques related to radiological procedures; necessary for critical assessment and under- g. Cell biology, DNA, RNA, and cell activity; standing of published papers and the promotion h. Pharmacology and the application of contrast of personal research. media; i. Basic understanding of computer science, 1.7 Medico-legal image post processing, image archiving and An understanding of the medico-legal implica- image communication and teleradiology. tions of radiological practice. An understanding of uncertainty and error in radiology together 1.2 Pathological sciences with the methodology of learning from mistakes. A knowledge of pathology and pathophysiology as related to diagnostic and interventional radiol- Article 2 ogy. TRAINING PROGRAMMES 1.3 Current clinical practice A basic knowledge of current clinical practice as 2.1 The specialty of radiology involves all aspects of related to clinical radiology. Competence in pro- medical imaging, which provide information ducing a radiological report and in communica- about morphology, function and cell activity and tion with clinicians and patients. those aspects of interventional radiology or mini- mally invasive therapy (MIT), which fall under the remit of the department of radiology.2 www.ear-online.org
  • 5. European Training Charter for Clinical Radiology 2.2 Clinical experience. Radiologists are clinicians from department to department, but the time bal- and require a good clinical background in other ance should reflect the importance of the system disciplines. This is usually achieved through clini- to the core of radiological practice. cal experience and training prior to entering radi- ology, but may also require additional clinical 2.8 The training programme in years one to three experience during radiology training which should not impact negatively on the achievement 2.8.1 Early in this three-year period, trainees should of the full radiological training curriculum. The acquire the necessary knowledge of the basic fully trained radiologist should be capable of sciences, i.e. the physical basis of image forma- working independently when solving the majority tion in all imaging modalities, picture archiving of common clinical problems. In particular those computer systems (PACS), radiology and hospi- undertaking interventional procedures may re- tal information systems, quality control, radiation quire sufficient clinical knowledge to accept direct protection, radiation physics, radiation biology, referrals and to manage cases as out-patients anatomy, physiology, cell biology and molecular and in-patients. structure, biochemistry and techniques related to radiological procedures, the pharmacology and 2.3 A general radiologist should be conversant with application of contrast media and a basic under- all aspects of the core of knowledge for general standing of computer science as outlined in the radiology to ensure an understanding of those ra- core of knowledge for general radiology. diological skills required in a general or commu- nity hospital or in a general radiological practice. 2.8.2 The radiology training should ensure the under- standing and implementation of the process of 2.4 Radiological training should be based on clinical justification and optimisation as laid down in systems and not on modalities such as CT, MRI Euratom directive 97 / 43. and US. Understanding of the value and use of these modalities and training in the practice of 2.8.3 A detailed knowledge of normal imaging anatomy the techniques should be gained during the re- should be gained in the early stages of training. spective system-based module. 2.8.4 Modular rotations in clinical areas of radiology 2.5 The duration of training in radiology is five years; should be system-based involving the use of all the content of the first three years is a structured relevant modalities within the module and formu- common programme for radiological anatomy, lated into an integrated programme to cover all disease manifestations and core radiological aspects of radiology. The distribution of time will skills. The fourth and fifth year are structured reflect the complexity and relevance to general more flexibly to develop sufficient competence to clinical practice, but as a guideline the musculo- function autonomously as a general radiologist skeletal system, thorax and cardio-vascular sys- and to facilitate subspecialty training. The fourth tems, gastrointestinal system including and fifth years of training for those preparing to parenchymal organs, central nervous systems in- provide a general radiology service will include cluding head and neck and paediatrics are likely gaining additional experience in all organ sys- to require similar time balance. The remaining tems, but trainees should also develop at least areas being balanced as required. two special areas of interest. 2.8.5 Trainees should participate in clinical radiology 2.6 Radiologists in training should be available on a examinations and activities and the extent and full-time basis for the five years of training. complexity should gradually increase during the Arrangements may vary for those undertaking first year in line with experience. It is important flexible training, but the total time of training will that trainees participate in all sections of the de- be equivalent to a full-time trainee. It is recog- partment of radiology to gain experience in all nised that the starting date for radiological train- techniques so that they understand the function ing programmes will vary throughout Europe. and role and learn how to use the technology in practice of the following imaging methods: 2.7 The precise structure of the system-based mod- - Conventional radiology including film pro- ules may vary a little from country to country and cessing and archiving,www.ear-online.org 3
  • 6. European Training Charter for Clinical Radiology - Fluoroscopy, Musculoskeletal - Ultrasound, - Computed tomography, Core knowledge - Magnetic resonance imaging, - Musculoskeletal anatomy, normal skeletal - Radionuclide imaging where possible. All ra- variants which mimic disease and common diology trainees should have a knowledge of congenital dysplasias techniques available and diagnostic features - Clinical knowledge of medical, surgical and of the studies. pathology related to musculoskeletal system - Trauma involving skeleton and soft tissue and 2.8.6 The first three years of the five-year training pro- the value of different imaging modalities gramme should include the following elements: - Degenerative disorders and their clinical rele- - Chest diseases vance - Central nervous system - Manifestations of musculoskeletal infection, - Musculoskeletal system inflammation and metabolic diseases includ- - Gastrointestinal system including the hepato- ing osteoporosis and bone densitometry biliary system - Recognition and management of tumours - Urogenital system - Paediatrics Core skills - Cardiac diseases - Reporting plain radiographs, radionuclide in- - Head and neck, maxillo-facial and dental vestigations, CT and MR of common muscu- radiology loskeletal disorders - Obstetrics and gynaecology - Performing and reporting Ultrasound exami- - Breast diseases nations of muscle, tendons and ligaments - Endocrine system where appropriate - Vascular and lymphatic system - Managing and reporting radiographs, CT and - Oncology MR of musculoskeletal trauma - Emergency department radiology - Observing image guided biopsies and - Basic interventional techniques drainages in the musculoskeletal system - Observing minimally invasive therapeutic pro- 2.8.6 The trainee should be involved in the radiological cedures of the musculoskeletal system examination and diagnosis of patients presenting in the emergency department and be able to ap- Thorax propriately evaluate patients who are severely or critically ill. It is not anticipated that a trainee Core knowledge would enter into an emergency on-call rotation - Anatomy of the respiratory system, heart and entailing clinical responsibility until the end of the vessels, mediastinum and chest wall on radi- first year of training. ographs, CT and MR. - Recognise and state significance of generic 2.8.7 Trainee radiologists at the end of three years signs on chest radiographs should be fully conversant with the basic aspects - Features on radiographs and CT and differen- of the common trunk for general radiology. This tial diagnosis of atelectasis, diffuse infiltrative will be achieved by a mixture of didactic and and alveolar lung disease, airways and ob- practical training. structive lung disease - Recognise solitary and multiple pulmonary 2.8.8 In the common trunk, the trainees in radiology nodules, benign and malignant neoplasms, should develop a knowledge of the radiological hyperlucencies and their potential aetiology signs and techniques in line with the following - Thoracic diseases in immuno-compromised outline targets. All trainees should undertake patients and congenital lung disease basic interventional procedures during this peri- - Disorders of the pulmonary vascular system od. The trainees should be closely supervised by and great vessels including the diagnostic a fully qualified radiologist. Some detailed curric- role of radiographs, radionuclides, CT and ula for the use of trainers and trainees are pre- MR in diagnosis sented on pages 11-44.4 www.ear-online.org
  • 7. European Training Charter for Clinical Radiology - Abnormalities of the chest wall mediastinum trasound of the gastrointestinal system, ab- and pleura and including the post operative dominal viscera and their vessels chest and trauma - Managing and reporting CT of the abdomen - Understanding and where possible and ap- Core skills propriate observation and experience of - Managing and reporting radiographs, chest transrectal, transvaginal and endoscopic ul- radiographs, V/Q scans, high- resolution CT trasound including CT pulmonary angiography - Performing US and CT guided drainage and - Drainage of pleural space collections under biopsy image guidance and observation of image - Experience of the manifestations of abdomi- guided biopsies of lesions within the thorax nal disease on MRI - Understanding and, where appropriate, expe- Gastrointestinal rience of radionuclide investigations of the GI tract and abdominal organs Core knowledge - Observation of angiography and vascular in- - Anatomy of the abdomen including internal terventional techniques viscera, abdominal organs, omentum, mesentery and peritoneum on radiographs, Neuroradiology barium and other contrast studies, CT, US and MR Core knowledge - Recognise features of abdominal trauma and - Knowledge of the normal anatomy and nor- acute conditions including perforation, haem- mal variants of the brain, spinal cord and orrhage, inflammation, infection, obstruction, nerve roots ischaemia and infarction on radiographs, ul- - Understanding the rationale for selecting cer- trasound and CT tain imaging modalities, and the use of con- - Imaging features and differential diagnosis of trast enhancement, in diagnosing diseases of primary and secondary tumours of the solid the central nervous system organs, oesophagus, stomach, small bowel, - Imaging features on CT and MR and differen- colon and rectum tial diagnosis of stroke, haemorrhage, and - Imaging features of the stage and extent of other vascular lesions of the brain and spinal tumours including features which indicate un- cord and of the application of CT and MR an- resectability and knowledge of the role of en- giography doscopy and endoscopic US - Diagnosis of skull and spinal trauma and its - Radiological manifestations of inflammatory neurological sequelae bowel diseases, malabsorption syndromes - Imaging features and differential diagnosis of and infection white matter disease, inflammation and de- - Recognition of motility disorders, hernias and generation diverticula - Diagnosis of benign and malignant tumours - Radiological manifestation of vascular lesions of the brain, spinal cord and cranial nerves including varices, ischaemia, infarction, - Understanding the role of nuclear medicine haemorrhage and vascular malformations including PET in neurological disorders - Understanding of the applications of angiog- raphy, vascular interventional techniques, Core skills stenting and porto-systemic decompression - Reporting radiographs of the skull and spine procedures - Managing and reporting cranial and spinal CT and MR Core skills - Observation of cerebral angiography - Performance of plain film reporting - Observation of carotid ultrasound including - Performing and reporting contrast examina- Doppler tions of the pharynx, oesophagus, stomach, - Observation of interventional procedures small and large bowel - Performing and reporting trans-abdominal ul-www.ear-online.org 5
  • 8. European Training Charter for Clinical Radiology Urogenital - Radiological and echocardiographic features and causes of cardiac enlargement including Core knowledge (See also obstetrics and gynaecology.) acquired valvular disease - Knowledge of the normal anatomy of the kid- - Diagnosis of ischaemic heart disease includ- neys, ureters, bladder and urethra including ing radionuclide imaging and coronary an- normal variants giography - Knowledge of the normal anatomy of the - Diagnostic features of vasculitis, atheroma, retroperitoneum, female pelvis and male gen- thrombosis and aneurysmal dilatation of ar- ital tract teries and veins - Understanding of renal function, the diagno- - Radiological and ultrasound diagnosis of sis of renal parenchymal diseases including pericardial disease infection and renovascular disease including management of renal failure Core skills - Imaging features and appropriate investiga- - Reporting radiographs relevant to cardio-vas- tion of calculus disease cular disease. - Investigation and features of urinary tract ob- - Femoral artery and venous puncture tech- struction and reflux including radionuclide niques, and the introduction of guidewires studies and catheters into the arterial and venous - Imaging features and differential diagnosis of system tumours of the kidney and urinary tract - Performing and reporting aortography and - Imaging features and investigation of renal lower limb angiography transplants - Performing ultrasound of arteries and veins - Imaging features and differential diagnosis of - Managing and reporting CT and MR of the the retroperitoneum, prostate and testis vascular system including image manipula- tion Core skills - Reporting radiographs of the urinary tract Paediatric - Performing and reporting intravenous urograms, retrograde pyelo-ureterography, Core knowledge loopogram, nephrostograms, ascending ure- - Normal paediatric anatomy and normal vari- thrograms and micturating cysto-urethro- ants with particular relevance to normal matu- grams ration and growth - Performing and reporting transabdominal ul- - Disease entities specific to the paediatric age trasound imaging of the urinary tract and group and their clinical and radiological mani- testis festations using all modalities - Managing and reporting computed tomogra- - The value and indications for ultrasound, CT phy and MR imaging of the retroperitoneum, and MR in children urinary tract and pelvis - Disorders and imaging features of the - Observing nephrostomies, image guided neonate renal biopsies and angiography as applied to - Understanding the role of radionuclide imag- the urinary tract ing in paediatrics Cardiac, vascular and lymphatics Core skills - Reporting conventional radiographs in the in- Core knowledge vestigation of paediatric disorders - Normal anatomy of the heart and vessels in- - Performing and reporting ultrasound of the cluding lymphatic system as demonstrated by abdomen, head and musculoskeletal system radiographs, echocardiography and doppler, in the paediatric age group contrast enhanced CT and MR - Performing and reporting routine fluoroscopic - General principles and classification of con- contrast studies of the gastrointestinal sys- genital heart disease and the diagnostic fea- tem and urinary tract tures on conventional radiographs - Managing and reporting CT and MR exami- - Natural history and anatomic deformities nations causing central cyanosis6 www.ear-online.org
  • 9. European Training Charter for Clinical Radiology Head and neck Core skills - Mammography and ultrasound reporting of Core knowledge common breast diseases - Normal anatomy and congenital lesions of - Observation of interventions especially for the head and neck including paranasal sinus- biopsies and localisations es oral cavity, pharynx and larynx, inner ear, orbit, teeth and temporo-mandibular joint Gynaecology and obstetrics - Manifestations of diseases and the investiga- tion of the eye and orbit including trauma, for- Core knowledge eign bodies, inflammation and tumours - Normal anatomy of the female reproductive - Diagnosis of faciomaxillary trauma and tu- organs and physiological changes affecting mours and disorders of the teeth imaging - Diagnosis of lesions and abnormal function of - Changes in foetal anatomy during gestation the temporomandibular joint and the imaging appearances of foetal abnor- - Diagnosis of disorders of the thyroid, parathy- malities roid and salivary glands including hypo and - Imaging features of disorders of the ovaries, hyperactivity and tumours and awareness of uterus and vagina as demonstrated on ultra- the role of radionuclide imaging sound, CT and MR - Imaging features of trauma, inflammation, in- - Awareness of the applications of angiography fection and tumours of the paranasal sinuses, and vascular interventional techniques oral cavity, larynx and pharynx - Understanding the role of US and CT guided Core skills punctures of salivary glands, lymph nodes - Reporting radiographs performed for gynae- and thyroid cological disorders - Performing and reporting trans-abdominal Core skills and, where possible, endo-vaginal ultrasound - Reporting radiographs performed to show examinations in gynaecological disorders ENT/dental disease - Observing and, where possible, performing - Performing and reporting fluoroscopic exami- obstetric ultrasound nations including barium swallows, sialogra- - Managing and reporting CT and MR in gy- phy and dacrocystography naecological disorders - Performing and reporting ultrasound evalua- tion of the neck including thyroid, parathyroid Oncology and salivary glands - Managing and reporting CT and MR of neck, Core knowledge ear, nose, throat and skull base disorders - Familiarity with tumour staging nomenclature - Application of all imaging and interventional Breast techniques in staging and monitoring the re- sponse of tumours to therapy Core knowledge - Radiological manifestations of complications - Normal anatomy and pathology of the breast in tumour management relevant to clinical radiology - Understanding of the radiographic and ultra- Core skills sound techniques employed in screening and - Reporting radiographs performed to assess diagnostic mammography tumours - Diagnosis of both benign and malignant ab- - Performing and reporting ultrasound, CT, MR normalities in the breast and, where possible, radionuclide examina- - Understanding current practice in breast im- tions for staging and monitoring tumours aging, breast interventions and screening for breast cancer 2.8.9 Trainees should become familiar with clinical - Awareness of the role of other techniques for problems presenting in the emergency depart- breast imaging ment and be able to manage the appropriate im-www.ear-online.org 7
  • 10. European Training Charter for Clinical Radiology aging of cases in acutely ill or traumatised pa- during the fourth and fifth year. For those subspe- tients. cialties with a single year of subspecialty training continued training in general radiology during the 2.8.10 An assessment process should be instituted dur- balance of time will be undertaken. ing the clinical radiological training programme. This should be a structured process with written 2.9.4 A period of training in approved hospitals other assessments of the trainees by the trainers at the than those in which the trainee is based in either end of each rotation. The extent of assessment the same country or abroad may be required for a and appraisal will vary from country to country, variable period according to the national regula- but a regular dialogue between trainer and tions. trainee is desirable to monitor progress and to rectify any weaknesses that may be manifested. 2.9.5 Some subspecialty training may extend beyond Formal written / oral examination and / or a scien- the fifth year depending on national training tific thesis may be required in some countries arrangements relevant to their specialist pro- during or at the end of this period of training. It is gramme. recommended that a log-book (carnet de stage) of clinical radiological activities and periods of ro- 2.10 Course participation tation should be maintained during the training Attendance at outside-courses will depend on period. Such a log-book might include the num- the stage of training and the relevance of the ber of clinical examinations performed. courses to the trainees’ stage of training. At least two congress or course attendances It is recommended that personal guidance and should be mandatory over the period of the continuous assessment should be provided by a fourth and fifth year of training. nominated tutor. 2.11 Research 2.9 Fourth and fifth year of training A dedicated period of research should be per- missible as part of the overall training pro- 2.9.1 In the fourth and fifth year the rotations of the ra- gramme. This may be up to one year and may diologist in training should be organised to serve require approval by a national regulatory or the individual’s needs, dependent on the avail- European body, especially if any additional time ability within the training programme, which may is involved. Trainees should be encouraged to un- be in general radiology or in a subspeciality. dertake a research project during their training, even if they do not have a dedicated period of re- 2.9.2 General Radiology: General radiology training search. This is particularly valid for those under- in the fourth and fifth year is designed to enable taking subspecialty training. the trainee to acquire further experience, knowl- edge and skills in disorders present in general Article 3 hospitals and private practice in order to reach a level required to undertake autonomous practice. TRAINING FACILITIES This period of training should include an extend- ed period of time in at least two areas of special 3.1 Aims of training: Each training programme should interest to acquire more detailed knowledge and outline the educational goals and objectives of skills. This will enable the general radiologist to the programme with respect to knowledge, skills have areas where they may contribute to specific and other attributes of residents at each level of multidisciplinary meetings and consultations as training and for each major training assignment. part of a radiologists’ team within his / her future general radiology practice. 3.1.1 Training should aim at providing sufficient knowl- edge to enable the trainee on completion of the 2.9.3 Radiological Subspecialty: For those entering training period to be able to work independently a subspecialty, the total period of subspecialist as a qualified radiologist at radiological depart- training will vary according to the subspecialty, ments in hospitals, out-patient departments and but would normally be expected to be completed private practice.8 www.ear-online.org
  • 11. European Training Charter for Clinical Radiology 3.1.2 As previously indicated formal trainee appraisal 3.3.2 The number of radiological examinations per and assessment during the period of specialist year should be sufficient to enable a comprehen- training should be performed in order to verify sive experience of general radiology. that the appropriate training has been undertak- en and that the required standard has been 3.4 Standard of equipment achieved towards the award of the certificate of completion of specialist training (CCST) or other 3.4.1 Only departments with adequate imaging equip- national equivalent. ment and services should be approved. Assessments must include: 3.4.2 The equipment should fulfil radiological safety - Clinical competences standards and be in good technical condition. - Technical competences Technical efficiency, security, electric control, ra- - Attitude and character diation safety and control should be of adequate standard and fulfil agreed quality control criteria. 3.1.3 Health-care systems in individual European 3.4.3 Radioprotection should be organised and radia- countries differ for a variety of reasons, which in- tion monitored according to European standards. clude administration, management, equipment, budgeting and tradition. In spite of these differ- 3.4.4 Down-time of the equipment for repairs should be ences, recommendations for training facilities for minimal and not interfere with training. specialisation in general radiology can be de- fined. The practical implementation of these rec- 3.5 Availability of modalities ommendations must be left to the respective countries. 3.5.1 The modalities for adequate radiological training will depend on local availability. 3.2 Requirements for fully accredited training de- partments 3.5.2 The following are mandatory: a. Conventional radiography, 3.2.1 The status of a training department can be spec- b. Angiography, ified in the following ways: c. Ultrasonography, a. Quantity and distribution of radiological ex- d. Computed tomography, aminations, e. Interventional radiology, b. Standards of equipment, f. Magnetic resonance imaging (cooperation c. Availability of modalities, with other radiological training departments d. Staffing, may be necessary). e. Teaching programme of the radiological de- partment, 3.5.3 Access to nuclear medicine is desirable. f. Teaching materials, g. Research activity. 3.6 Staffing structure 3.3 Quantity and distribution of radiological ex- 3.6.1 The number of qualified radiologists with teach- aminations ing functions in the department should be suffi- cient to cover the needs of teaching, even at time 3.3.1 Patient material should be varied enough to en- of leave or in the event of other staff shortages. able the trainee to gain experience in all fields of clinical radiology. This requires a radiological de- 3.6.2 The expertise of the teaching staff should be di- partment situated in a large polyvalent hospital. versified and cover the main areas of activity. However, some attachments may be in small or specialist hospitals providing expert teaching in 3.6.3 Teaching staff should have training in teaching specific parts of the curriculum. All training de- methods. partments should have access to expert patholo- gy services.www.ear-online.org 9
  • 12. European Training Charter for Clinical Radiology 3.7 Teaching programme 3.10.2 There should be an active and ongoing research and audit programme at the training department 3.7.1 There must be an approved and structured con- and trainees should be encouraged to partici- tinuing teaching programme for general radiology pate. as well as the main subspecialty areas. 3.11 Partition of radiological training in university, 3.7.2 The teaching programme should also include teaching and non-university hospitals regular clinico-radiological meetings and other consultations with clinical departments at least 3.11.1 Part of the training may be at acknowledged and on a weekly basis. Participation in meetings to re- accredited non-university hospitals, or private view radiological errors should be undertaken. practices that have been appropriately accredit- ed, but some should be carried out at university 3.7.3 Radiological and clinico-radiological confer- departments. The non-university component ences, seminars and training courses outside the should provide training at least in general radiolo- hospital are recommended. gy, and may provide some sub-specialty training which would supplement that provided in the uni- versity departments. The composition of the pa- 3.8 Teaching facilities tient material needs to be taken into account in Appropriate demonstration equipment and rooms selecting all hospitals concerned with teaching. should be available in the department of radiolo- gy, sufficient to enable the teaching programme 3.11.2 All the university departments and training hospi- to be implemented. tals should be part of a coordinated national or federal training scheme. 3.9 Teaching material 3.11.3 It is of great importance that cooperation exists 3.9.1 There should be a selection of good and modern between central authorities (e.g. Ministry of text books as well as other audio-visual material Health, Ministry of Education, National in a general radiology department, completed by Professional Organisations, National Radio- text books in sub-specialties and modalities (e.g. logical Societies, National Health Insurance neuroradiology, paediatric radiology, ultrasonog- Funds etc.) and regional and local authorities, raphy, computed tomography, magnetic reso- teaching centres and local hospital administra- nance imaging, mammography). Adequate tions etc. textbooks in imaging physics and pertinent mate- rial concerning radiation protection should be available. 3.9.2 A selection of high-standard radiological journals should be available on a continuing basis. 3.9.3 There should be an active teaching film-video li- brary. 3.9.4 Computer technology for teaching, research pur- poses, image processing and communication is highly desirable. 3.10 Research and Audit 3.10.1 The importance of radiological research and audit for the training of radiologists should be em- phasised.10 www.ear-online.org
  • 13. Detailed Curriculum for the Initial Structured Common Programme Detailed Curriculum for the Initial Structured Common Programme This document details the knowledge-based curriculum Breast Radiology for resident training in radiology. It defines the required standards in terms of the core of knowledge that might be 1 - INTRODUCTION reasonably achieved within the first three years of the training programme. The document is presented in organ- The aim of this curriculum in breast imaging is to ensure based sections plus one section dedicated to paediatric that the trainee develops a core of knowledge in breast radiology and one to interventional radiology. disease that will form the basis for further training (if de- sired). It will also provide transferable skills that will equip The specialty of clinical radiology involves all aspects of the trainee for working as a specialist in any branch of ra- medical imaging, which provide information about mor- diology. phology, function and cell activity and those aspects of in- terventional radiology or minimally invasive therapy (MIT), Physics and radiation protection are covered in separate which fall under the remit of the department of radiology. A courses and are not covered in detail unless specific to general radiologist should be conversant with all aspects breast imaging. of the core of knowledge for general radiology to ensure an understanding of those radiological skills required in a 2 - CORE OF KNOWLEDGE general or community hospital or in a general radiological practice. 2.1. Breast anatomy and associated structures and how they change with age. It is important to remind the duration of training in radiolo- gy is 5 years; the content of the first 3 years is a structured 2.2. Breast pathology and clinical practice relevant to common programme for radiological anatomy, disease breast imaging. manifestations and core radiological skills. The fourth and fifth years are structured more flexibly to develop sufficient 2.3. Knowledge and understanding of the physics of competence to function autonomously as a general radi- image production, particularly how they affect ologist and to facilitate subspecialty training. General radi- image quality. ology training in the fourth and fifth years is designed to enable the trainee to acquire further experience, knowl- 2.4 Knowledge and understanding of the risk / benefit edge and skills in disorders present in general hospitals analysis associated with breast screening using and private practice in order to reach a level required to ionising radiation as compared with other tech- undertake autonomous practice. The fully trained radiolo- niques. gist should be capable of working independently when solving the majority of common clinical problems. 2.5. Understanding of the radiographic techniques employed in diagnostic mammography. 2.6. Understanding of the principles of current practice in breast imaging and breast cancer screening. 2.7. Awareness of the proper application of other im- aging techniques in this specific field, such as US, MRI, or radionuclide imaging. 2.8. Knowledge of the indications and contraindica- tions of FNA and core biopsy and their relative advantages and disadvantages.www.ear-online.org 11
  • 14. Detailed Curriculum for the Initial Structured Common Programme 2.9. Appearances of cancer and common benign dis- Cardiac Radiology ease on - Mammography 1 - INTRODUCTION - Ultrasound - Magnetic Resonance Imaging. Cardiac radiology is an important and rapidly developing field in radiology. The use of cardiac imaging has pro- 2.10. Knowledge and understanding of the principles gressed over the last decade to involve all modalities in di- of communication specifically related to the agnostic radiology. Interventional techniques in the heart breaking of bad news and consent. have also progressed, and whether or not a radiologist is involved in cardiac intervention it is important that there is 3 - TECHNICAL, COMMUNICATION AND DECISION- an understanding of the clinical and diagnostic implica- MAKING SKILLS tions of these techniques. The heart is not an isolated organ, and it is equally important that the relationship be- 3.1. To supervise technical staff to ensure appropriate tween the heart and the cardiovascular and cardiopul- images are obtained. monary systems are understood. 3.2. To understand when to utilise ultrasound and 2 - CORE OF KNOWLEDGE other imaging techniques; to produce a report on mammographic and ultrasound breast imaging 2.1. Basic knowledge with respect to common breast disease. The principle is to acquire: 3.3. To understand when it is appropriate to obtain as- sistance in interpreting and reporting breast im- 2.1.1. Basic clinical, pathological, and pathophysiologi- ages. cal knowledge in cardiovascular disease. 3.4. To be able to perform interventional breast proce- 2.1.2. An understanding of the principles and practice dures under ultrasound and X-ray control under of screening techniques and risk factors in car- supervision. diac disease. 3.5. To be able to communicate with patients explain- 2.1.3. Knowledge of: ing the nature of benign breast disease, giving - The indications, contraindications and poten- and observing ‘breaking bad news’. tial hazards (especially radiation hazards) of procedures and techniques relevant to car- 4 - CONFERENCES diovascular disease - Cardiovascular anatomy in clinical practice As part of the curriculum in breast imaging, the trainee relevant to clinical radiology should attend in-house teaching sessions for radiologists - Normal variants, which may mimic disease as well as multidisciplinary conferences with the rest of - Manifestations of cardiovascular disease in- the breast team where patient management is discussed. cluding trauma as demonstrated by conven- The MDT conference should be included to facilitate the tional radiography, CT, MRI, angiography, radiology residents’ understanding of the use of imaging radionuclide investigations and ultrasound and its role in the management of breast disease and to - Differential diagnosis relevant to clinical pres- allow direct radiological-pathological correlation. entation and imaging appearance of cardio- vascular disease - Calcium scoring - Relevant embryological, anatomical, patho- physiological, biochemical and clinical as- pects of cardiac disease 2.1.4. Knowledge and management of procedural com- plications in cardiac treatment and diagnosis.12 www.ear-online.org
  • 15. Detailed Curriculum for the Initial Structured Common Programme 2.1.5. An understanding of the various treatment 2.2.6. Congenital heart disease modalities for cardiac disease and their relation- - Neonatal heart disease ship to cardiac imaging. - Congenital disease in childhood - Grown-up congenital heart disease 2.2. Knowledge in clinical cardiac radiology 2.2.7. Major vessel disease The following manifestations of cardiovascular disease, - Thoracic aneurysm including trauma, have to be covered during the general - Marfan’s syndrome radiological training. This should include formal teaching - Takayasu’s disease and exposure to clinical case material. - Relationship between peripheral and cere- bro-vascular disease and cardiac disease 2.2.1. Coronary artery disease including acute coro- nary syndromes 2.2.8. Right heart disease - Myocardial ischaemia - Pulmonary embolism - Myocardial infarction - Right heart disease related to pulmonary dis- - Post myocardial infarction syndrome ease - Ventricular aneurysm - Coronary calcium 2.2.9. Acute cardiac and thoracic vascular trauma - Coronary disease in women and specific - Aortic dissection coronary disease patterns in different com- - Aortic rupture and fracture munities - Blunt trauma - Heart disease in the elderly 2.2.10. Arrhythmias 2.2.2. Valve disease - Diagnosis of disease causing or predisposing - Stenosis and incompetence of cardiac valves to arrhythmias - Endocarditis - Cardiac disease in endocrine conditions - Sub and supra-valvar disease - Cardiac psychological related illness, i.e. - Subvalvar apparatus disease manifestations of anxiety - Pacemakers 2.2.3. The pericardium - Defibrillators - Tamponade and restrictive disease - Ablation - Acute pericarditis - Tuberculous disease 2.2.11. Hypertension - Malignant pericardial disease - Hypertensive heart disease - Diseases causing hypertension 2.2.4. Cardiac tumours - Intracardiac tumours, i.e. myxomas, haeman- 2.2.12. Medical and invasive treatment giomas, and sarcomas - Abnormalities arising from cardiac therapy, - Secondary tumours i.e. amioderone treatment - Tumours invading the heart - Complications of cardiac catheterisation and coronary angioplasty 2.2.5. Cardiomyopathy - Appearance of stents and stent grafts - Acute myocarditis - Dilated cardiomyopathy 2.2.13. Post-operative cardiac disease and findings - Restrictive and obstructive cardiomyopathy - By-pass grafts - Cardiomyopathy related to systemic disease - Valve replacement - Infiltrative heart disease - Aortic replacement - Diabetic and renal cardiac disease - Ventricular surgery - Athlete’s heart - Pericardectomywww.ear-online.org 13
  • 16. Detailed Curriculum for the Initial Structured Common Programme 3 - TECHNICAL, COMMUNICATION AND DECISION- - Principles´ uses and limitations of nuclear MAKING SKILLS cardiac imaging - Principles of intravascular imaging At the end of his/her training, the resident should be able to discuss the appropriate imaging modality for the clinical 3.2. Stress testing problem with the referring clinician. He / she should be - Principles of exercise stress testing, uses and able to understand management and communications is- limitation sues in cardiac disease. - Methods of stress testing as applied to cardiac imaging 3.1. Modality-based skills - Patient management of stress testing for cardiac imaging 3.1.1. Plain film interpretation - Limitations, advantages and principles of 3.3. Communication and management skills chest X-ray diagnosis of adult and congenital - To be able to supervise technical staff to en- cardiac disease sure appropriate images are obtained - Ability to recognise cardiac conditions on PA, - To discuss significant or unexpected radiolog- AP, and lateral radiographs ical findings with referring clinicians and know - Ability to recognise cardiac post-operative when to contact a clinician findings on plain radiographs - To be able to recommend the most appropri- ate imaging modality, appropriate to patients´ 3.1.2. CT interpretation and patient management symptoms or pathology or request from the - CT anatomy of the heart, pulmonary arteries referring clinician and great vessels - To develop skills in forming protocols, moni- - Principles of multislice and ultrafast CT of the toring and interpreting cardiac studies, appro- heart including prospective and retrospective priate to the patient history and other clinical gating information - Interpretation of cardiac and pulmonary - To demonstrate the ability to effectively pres- pathology ent cardiac imaging in a conference setting - Contrast administration - To demonstrate the ability to provide a coher- - Decision-making on the basis of patients´ ent report symptoms and CT diagnosis 3.1.3. MRI interpretation and patient management - MRI anatomy of the heart, great vessels, pulmonary and peripheral vascular system - Principles of image sequencing and specialised gating - Interpretation of cardiovascular and pulmonary pathology - Understanding of cardiac physiology related to MRI, including flow sequencing and specialised tagging techniques - Use of MRI contrast - Uses limitations and hazards of MRI cardiac imaging 3.1.4. Cardiac imaging by other modalities - Principles´ uses and limitations of cardiac an- giography catheterisation and pressure measurement - Principles´ uses and interpretation of stress and non-stress echocardiography, including trans-oesophageal echocardiography14 www.ear-online.org
  • 17. Detailed Curriculum for the Initial Structured Common Programme Chest Radiology - Aortopulmonary window - Both hemidiaphragms 1 – INTRODUCTION 2.1.3. Identify the following structures on chest Physics, radiography and contrast media are generally CT and / or chest MRI: covered in separate courses and are therefore not includ- - All pulmonary lobes and segments ed in this document, but physics and radiography topics - A secondary pulmonary lobule specific to thoracic imaging should be covered either in - Fissures – major, minor, azygos and common the thoracic rotation or included in the physics / radiogra- accessory fissures phy courses, particularly: - Extrapleural fat - Positioning / views of chest radiographs for - Inferior pulmonary ligaments adults, newborns, infants and children - Airway – trachea, carina, main bronchi, lobar - Mean exposure doses at skin entrance, kVp, bronchi, and segmental bronchi antiscatter techniques - Heart – left ventricle, right ventricle, left atri- - Principles of digital imaging and image process- um, left atrial appendage, right atrium, right ing pertinent to chest radiology atrial appendage - Pericardium – including superior pericardial 2 – CORE OF KNOWLEDGE recesses - Pulmonary arteries – main, right, left, interlo- 2.1. Normal anatomy bar, segmental - Aorta – sinuses of Valsalva, ascending, arch, 2-1.1 To be able to: and descending aorta - List the lobar and segmental bronchi - Arteries – brachiocephalic (innominate), com- - Describe the relationships of the hilar vessels mon carotid, subclavian, axillary, vertebral, in- and bronchi ternal mammary arteries - Define a secondary pulmonary lobule and its - Veins – pulmonary, superior vena cava, inferi- component parts or vena cava, brachiocephalic, subclavian, in- - Use the correct terminology for describing the ternal jugular, external jugular, azygos, site of mediastinal and hilar lymph nodes hemiazygos, left superior intercostal, internal mammary 2.1.2. Identify the following structures on posteroanteri- - Esophagus or (PA) and lateral chest radiographs: - Thymus - Right upper, middle and lower lobes; left - Normal mediastinal and hilar lymph nodes upper and lower lobes; and lingula - Azygoesophageal recess - Fissures – major, minor, superior accessory, - Inferior pulmonary ligaments inferior accessory, and azygos - Airway – trachea, carina, main bronchi, pos- 2.2. Generic signs on chest radiographs terior wall of intermediate bronchus, and lobar bronchi To be able to recognise and state the significance of the - Heart – position of the two atria, two following chest radiographic signs: ventricles, left atrial appendage, and the 2.2.1 Silhouette sign - loss of the contour of the heart location of the four cardiac valves or diaphragm indicating adjacent pathology (e.g. - Pulmonary arteries – main, right, left, and atelectasis of the right middle lobe obscures the interlobar right heart border). - Aorta – ascending, arch and descending 2.2.2. Air bronchogram - indicates airless alveoli and, aorta therefore, a parenchymal process as distin- - Arteries – brachiocephalic (innominate), guished from a pleural or mediastinal process. carotid, and subclavian arteries 2.2.3. Air crescent sign - indicates solid material in a - Veins – superior and inferior vena cava, azy- lung cavity, often due to a fungus ball, or crescen- gos, left superior intercostal ("aortic nipple"), tic cavitation in invasive fungal infection. and left brachiocephalic (innominate) veins 2.2.4. Cervicothoracic sign - a mediastinal opacity that - The components of the thoracic skeleton projects above the clavicles, situated posterior to - Mediastinal stripes and interfaces the plane of the trachea, while an opacitywww.ear-online.org 15
  • 18. Detailed Curriculum for the Initial Structured Common Programme projecting at or below the clavicles is situated an- 2.4. Differential diagnosis of diffuse infiltrative teriorly. lung disease 2.2.5. Tapered margins - a lesion in the chest wall, me- diastinum or pleura may have smooth tapered To be able to develop a differential diagnostic list for the fol- borders and obtuse angles with the chest wall or lowing patterns taking account of the anatomical and imag- mediastinum, while parenchymal lesions usually ing distribution of the signs and the clinical information: form acute angles. 2.2.6. Gloved finger sign - indicates bronchial impaction, 2.4.1. On chest radiographs (according to whether the e.g. in allergic bronchopulmonary aspergillosis, or pattern is upper, mid or lower zone predominant; other chronic obstructive processes. or shows central or peripheral predominance): 2.2.7. Golden S sign - indicates lobar collapse with a - Air space shadowing central mass, suggesting an obstructing bron- - Ground glass opacity chogenic carcinoma in an adult. - Nodular pattern 2.2.8. Deep sulcus sign on a supine radiograph - indi- - Reticular pattern cates pneumothorax. - Cystic pattern - Widespread septal lines 2.3. Features of diffuse infiltrative lung disease on chest radiographs and chest CT 2.4.2. On HRCT (according to whether the pattern is upper, mid or lower zone predominant; or shows 2.3.1. To recognise the effects of various pathological perihilar or subpleural predominance; or shows processes on the component parts of the sec- centrilobular, bronchocentric, lymphatic or peri- ondary pulmonary lobule as seen on HRCT. lymphatic, or random distributions) 2.3.2. To list and be able to identify the following pat- - Septal thickening / nodularity terns: air space shadowing, ground glass opacity - Ground glass opacity (and understand its pathophysiology), reticular - Reticular pattern pattern, honeycombing, nodular pattern, bronchi- - Honeycombing olar opacities ("tree-in-bud"), air trapping, cysts - Nodular pattern and mosaic attenuation pattern. - Air space consolidation 2.3.3. To identify septal lines (thickened interlobular - Tree-in-bud pattern septa) and explain the possible causes. - Mosaic attenuation pattern 2.3.4. To make a specific diagnosis of interstitial lung - Cyst and cyst-like pattern disease (ILD) when HRCT appearances are characteristic or findings are present (e.g. dilated 2.5. Alveolar lung diseases and atelectasis esophagus and ILD in scleroderma, enlarged heart and a pacemaker or defibrillator in a pa- - To recognise segmental and lobar consolida- tient with prior sternotomy and ILD suggesting tion amiodarone drug toxicity). - To list four common causes of segmental 2.3.5. To recognise the spectrum of changes of heart consolidation failure on chest radiographs, notably: pleural effu- - To recognise partial or complete atelectasis sions, vascular redistribution on erect chest radi- of single or combined lobes on chest radi- ographs, and the features of interstitial and ographs and list the likely causes alveolar edema, including septal lines and thick- - To recognise complete collapse of the right or ening of fissures. left lung on a chest radiograph and list appro- 2.3.6. To define the terms "asbestos-related pleural priate causes for the collapse disease" and "asbestosis"; identify the imaging - To distinguish lung collapse from massive findings. pleural effusion on a frontal chest radiograph 2.3.7. To recognise progressive massive fibrosis / con- - To list five of the most common causes of glomerate masses secondary to silicosis or coal adult (acute) respiratory distress syndrome worker’s pneumoconiosis on radiography and - To name four predisposing causes of or asso- chest CT. ciations with organising pneumonia - To recognise the halo sign and suggest a di- agnosis of invasive aspergillosis in an im- munosuppressed patient16 www.ear-online.org
  • 19. Detailed Curriculum for the Initial Structured Common Programme 2.6. Airways and obstructive lung disease - To state the complications of percutaneous lung biopsy and their frequency - To recognise the signs of bronchiectasis on - To state the indications for chest tube place- chest radiographs and chest CT ment as a treatment for pneumothorax relat- - To name four common causes of bronchiectasis ed to percutaneous lung biopsy - To recognise the HRCT signs of obliterative and exudative small airways disease (tree-in- 2.9. Benign and malignant neoplasms of the lung bud, air trapping, mosaic pattern, and associ- ated bronchiectasis) - To name the four major histologic types of - To recognise the typical appearance of cystic bronchogenic carcinoma, and state the differ- fibrosis on chest radiographs and chest CT ence in treatment between non-small cell and - To list the causes of wheeze that may be de- small cell lung cancer tected on chest radiographs - To describe the TNM classification for staging - To recognise tracheal and bronchial stenosis non-small cell lung cancer, including the com- on chest CT and name the most common ponents of each stage (I, II, III, IV, and sub- causes stages) and the definition of each component - To define centrilobular, paraseptal and (T1-4, N0-3, M0-1) panacinar emphysema - To state up to which stage a non-small cell - To recognise the signs of panacinar emphy- lung cancer is generally regarded as surgical- sema on chest radiographs and CT ly resectable for cure - To recognise the signs of centrilobular em- - To state the staging of small cell lung cancer physema on HRCT - To name the four most common extrathoracic - To state the imaging findings used to identify metastatic sites for non-small cell lung cancer surgical candidates for giant bullectomy or and for small cell lung cancer lung volume reduction surgery - To recognise abnormal contralateral medi- astinal shift on a post-pneumonectomy chest 2.7. Unilateral hyperlucent lung / Hemithorax radiograph and state two possible aetiologies for the abnormal shift - To recognise a unilateral hyperlucent lung on - To describe the acute and chronic radi- chest radiographs or chest CT ographic and CT appearance of radiation in- - To give an appropriate differential diagnosis jury in the thorax (lung, pleura, pericardium) when a hyperlucent lung / hemithorax is seen and the temporal relationship to radiation on a chest radiograph, and indicate the signs therapy that allow a specific diagnosis - To state the roles of CT and MR in lung can- cer staging To state the role of positron emis- 2.8. Solitary and multiple pulmonary nodules sion tomography (PET) in lung cancer staging - To name the most common location and ap- - To state the definition of a solitary pulmonary pearance of adenoid cystic and carcinoid tu- nodule and a pulmonary mass mours - To name the four most common causes of a - To describe the appearances of hamartoma solitary pulmonary nodule, cavitary pul- of the lung on chest radiographs and CT monary nodules and multiple pulmonary nod- - To state the manifestations and the role of im- ules aging in thoracic lymphoma - To provide strategy for managing an inciden- - To describe the typical chest radiograph and tal or screening-detected solitary pulmonary chest CT appearances of Kaposi sarcoma nodule - To state the role of contrast-enhanced CT and positron emission tomography (PET) in the evaluation of a solitary pulmonary nodule - To describe the features that indicate benigni- ty of a solitary pulmonary nodule and their limitationswww.ear-online.org 17
  • 20. Detailed Curriculum for the Initial Structured Common Programme 2.10. Thoracic disease in immunocompetent, a chest radiograph and distinguish them from immunocompromised and post-transplant enlarged hilar lymph nodes patients - To name five of the most common causes of pulmonary artery hypertension - To name and recognise the radiographic - To recognise lobar and segmental pulmonary manifestations of pulmonary tuberculosis on emboli on CT angiography and chest MRI (in- a radiograph and CT cluding MR angiography). - To describe the types of pulmonary - To define the role of ventilation-perfusion Aspergillus disease, understand that they scintigraphy, CT pulmonary angiography form part of a continuum, and recognise (CTPA), MRI / MRA, and lower extremity ve- these entities on chest radiographs and CT nous studies in the evaluation of a patient - To name the major categories of disease- with suspected venous thromboembolic dis- causing chest radiographic or chest CT ab- ease, including the advantages and limita- normalities in the immunocompromised tions of each modality depending on patient patient presentation - To name two common infections and two - To recognise the vascular redistribution seen common neoplasms in patients with AIDS in raised pulmonary venous pressure and chest radiographic or chest CT abnor- malities 2.13. Pleura and diaphragm - To describe the chest radiographic and chest CT appearances of pneumocystis now called - To recognise the typical chest radiographic "jiroveci" pneumonia appearances of pleural effusion in erect, - To name the three most important aetiologies supine and lateral decubitus chest radio- of hilar and mediastinal adenopathy in pa- graphs and name four causes of a large uni- tients with AIDS lateral pleural effusion - To list the differential diagnoses for wide- - To recognise a pneumothorax on an upright spread consolidation in an immunocompro- and supine chest radiograph mised host - To recognise a pleural-based mass with bone - To describe the chest radiographic and CT destruction or infiltration of the chest wall on a findings of post-transplant lymphoproliferative radiograph or chest CT, and name four likely disorders causes - To describe the chest radiographic and CT - To recognise the various forms of pleural cal- findings of graft-versus-host-disease cification on a radiograph or chest CT and suggest the diagnosis of asbestos exposure 2.11. Congenital lung disease (bilateral involvement) or old TB, old empye- ma, or old haemothorax (unilateral involve- - To name and recognise the components of ment). the pulmonary venolobar syndrome (scimitar - To recognise unilateral elevation of one syndrome) on a frontal chest radiograph, hemidiaphragm on chest radiographs and list chest CT and chest MRI five causes (e.g. subdiaphragmatic abscess, - To list the signs of intralobar pulmonary se- diaphragm rupture, and phrenic nerve in- questration and cystic adenomatoid malfor- volvement with lung cancer, postcardiac sur- mation on chest radiographs and chest CT gery, eventration) - To explain the differences between intralobar - To recognise tension pneumothorax and extralobar pulmonary sequestration - To recognise diffuse pleural thickening and - To recognise bronchial atresia on a radi- list four causes ograph and chest CT, and state the most - To recognise the split pleura sign in empyema common lobes of the lungs in which it occurs - To state and recognise the chest radiographic and CT findings of malignant mesothelioma 2.12. Pulmonary vascular disease - To recognise enlarged pulmonary arteries on18 www.ear-online.org
  • 21. Detailed Curriculum for the Initial Structured Common Programme 2.14. Mediastinal and hilar disease - To state and recognise the findings of, and distinguish between each of the following on - To name the four most common causes of an chest CT and MR: anterior mediastinal mass and localise a - aortic aneurysm mass to the anterior mediastinum on chest - aortic dissection radiographs, chest CT and chest MRI - aortic intramural hematoma - To name the three most common causes of a - penetrating atherosclerotic ulcer middle mediastinal mass and localise a mass - ulcerated plaque in the middle mediastinum on chest radi- - ruptured aortic aneurysm ographs, chest CT and chest MRI - sinus of Valsalva aneurysm - To name the most common cause of a poste- - subclavian or brachiocephalic artery rior mediastinal mass and localise a mass in aneurysm the posterior mediastinum on chest radi- - aortic coarctation ographs, chest CT and chest MRI - aortic pseudocoarctation - To name two causes of a mass that straddles - cervical aortic arch the thoracic inlet and localise a mass to the - To state the significance of a right aortic arch thoracic inlet on chest radiographs, chest CT with mirror image branching versus an aber- and chest MRI rant subclavian artery - To identify normal vessels or vascular abnor- - To recognise the two standard types of right mality on chest CT and chest MRI that may aortic arch and a double aortic arch on chest mimic a solid mass radiographs, chest CT and chest MR - To recognise mediastinal and hilar lym- - To recognise an aberrant subclavian artery phadenopathy on chest radiographs, CT and on chest CT MRI - To recognise normal variants of aortic arch - To name four aetiologies of bilateral hilar branching, including the common origin of lymph node enlargement brachiocephalic and left common carotid ar- - To list the four most common aetiologies of teries ("bovine arch"), and separate origin of "egg-shell" calcified lymph nodes in the chest vertebral artery from arch - To name four causes of a mass arising in the To define the terms aneurysm and pseudoa- thymus neurysm - To list the imaging features and common as- - To state and identify the findings seen in ar- sociations of thymoma teritis of the aorta on chest CT and chest MR - To list three types of malignant germ cell tu- - To state the advantages and disadvantages mour of the mediastinum of CT, MRI / MRA and transoesophageal - To recognise the imaging signs of benign cys- echocardiography in the evaluation of the tho- tic teratoma racic aorta - To list five signs of intrathoracic thyroid masses - To recognise a cystic mass in the medi- 2.16. Chest Trauma astinum and suggest the possible diagnosis of a bronchogenic, pericardial, thymic or oe- - To identify a widened mediastinum on chest sophageal duplication cyst radiographs taken for trauma and state the - To state the mechanisms and list the signs of possible causes (including aortic / arterial in- pneumomediastinum jury, venous injury, fracture of sternum or spine) 2.15. Thoracic aorta and great vessels - To identify the indirect and direct signs of aor- tic injury on contrast-enhanced chest CT - To state the normal dimensions of the tho- scan racic aorta - To identify and state the significance of chron- - To describe the Stanford A and B classifica- ic traumatic pseudoaneurysm on chest radi- tion of aortic dissection and the implications ographs, CT or MRI of the classification for medical versus surgi- - To identify fractured ribs, clavicle, spine and cal management scapula on chest radiographs or chest CTwww.ear-online.org 19
  • 22. Detailed Curriculum for the Initial Structured Common Programme - To name three common causes of abnormal - coronary artery bypass graft surgery lung opacity following trauma on chest radio- - cardiac valve replacement graphs or CT - aortic graft - To identify an abnormally positioned di- - aortic stent aphragm or loss of definition of a diaphragm - transhiatal oesophagectomy on chest radiographs following trauma and be - lung transplant able to suggest the diagnosis of a ruptured di- - heart transplant aphragm - lung volume reduction surgery - To identify a pneumothorax and pneumome- diastinum following trauma on chest radio- 3 – TECHNICAL, COMMUNICATION AND DECISION- graphs MAKING SKILLS - To identify a cavitary lesion following trauma on chest radiographs or chest CT and sug- At the end of his / her training, the resident should be able gest the diagnosis of laceration with pneuma- to demonstrate the following: tocele formation, hematoma or abscess 3.1. Dictate intelligible and useful reports on chest ra- secondary to aspiration diographs, CT and MR imaging. These reports - To name the three most common causes of should contain a brief description of the imaging pneumomediastinum following trauma findings and their significance along with a short - To recognise and distinguish between pul- summary where necessary. monary contusion, laceration and aspiration 3.2. Supervise technical staff to ensure appropriate 2.17. Monitoring and support devices – "Tubes and images are obtained. lines" 3.3. Discuss significant or unexpected radiologic find- To be able to identify and state the preferred placement ings with referring clinicians and know when to of the following devices and lines; to be able to list the contact a clinician. complications associated with malposition of each of the following: 3.4. Describe patient positioning and indications for a - endotracheal tube PA, lateral, decubitus, and lordotic chest radi- - central venous catheter ograph. - Swan-Ganz catheter - nasogastric tube 3.5. Decide when it is appropriate to obtain help from - chest tube / drain supervisory faculty in interpreting radiographs. - intra-aortic balloon pump - pacemaker and pacemaker leads 3.6. Understand the clinical indications for obtaining - implantable cardiac defibrillator chest radiographs and when further views or a - left ventricular assistant device chest CT or MR may be necessary. - atrial septal defect closure device ("clamshell device") 3.7. Develop skills in protocolling, monitoring, and in- - pericardial drain terpreting chest CT scans, including HRCT, ap- - extracorporeal life support cannulae propriate to patient history and other clinical - intraoesophageal manometer, temperature information. probe or pH probe - tracheal or bronchial stent 3.8. Describe a chest CT protocol optimised for evalu- ating each of the following: 2.18. Postoperative Chest - thoracic aorta and great vessels - superior vena cava and brachiocephalic vein To identify normal post-operative findings and complications stenosis or obstruction of the following procedures on chest radiographs, CT and - suspected pulmonary embolism MRI: - tracheobronchial tree - wedge resection, lobectomy - suspected bronchiectasis pneumonectomy - suspected small airway disease20 www.ear-online.org
  • 23. Detailed Curriculum for the Initial Structured Common Programme - lung cancer staging mended that this latter type of conference be included to - oesophageal cancer staging facilitate the radiology residents’ understanding of the use - superior sulcus tumour of imaging and clinical circumstances, in which imaging is - suspected pulmonary metastases requested. - suspected pulmonary nodule on a radiograph - shortness of breath - Radiology resident-specific chest radiology - haemoptysis teaching conference - An appropriate proportion of radiology grand 3.9. Develop skills in protocolling, monitoring, and in- rounds devoted to chest radiology terpreting chest MR studies. - Pulmonary medicine conference - Intensive care unit conference 3.10. Demonstrate the ability to effectively present - Thoracic oncology conference chest imaging in a conference setting. - Thoracic surgery conference 3.11. Recommend the appropriate use of imaging 5 – TEACHING MATERIAL AND SUGGESTIONS FOR studies to referring clinicians. READING 3.12. Be able to perform the following imaging-guided Recommended study materials and mandatory confer- transthoracic interventions under appropriate ence attendance are an important component of training, supervision, and know the indications, contraindi- but since they vary between individual departments, a de- cations, and management of complications: tailed listing is not provided in this document. The follow- - paracentesis and drainage of pleural effu- ing short list of textbooks covering a wide range of topics sions should be available in departmental libraries: - percutaneous lung biopsy - paracentesis of mediastinal and pericardial Webb WR, Müller NL, Naidich DP: High-resolution CT of fluid collections the Lung, published by Lippincott Williams & Wilkins. - drainage of refractory lung abscess Hansell DM, Armstrong P, Lynch DA, McAdams HP: - arteriography of thoracic aorta and great ves- Imaging of Diseases of the Chest, published by Elsevier. sels Fraser RS, Müller NL, Colman N, Paré PD: Fraser & - venography of major intrathoracic systemic Paré’s Diagnosis of Diseases of the Chest, published by veins of bronchial arteries, anatomy, and im- Saunders. portant collaterals Colby TV, Lombard C, Yousem SA, Kitaichi M: Atlas of - pulmonary arteriography Pulmonary Surgical Pathology, published by Saunders. - principles of bronchial artery embolisation: McCloud TC: Thoracic Radiology: the Requisites, pub- indications, technique and complications lished by Mosby. - principles of intrathoracic vein recanalisation and stenting: indications, technique - principles of interventional procedures in the pulmonary circulation: - local thrombolysis - AVM embolisation 3.13. Correlate pathologic and clinical data with radi- ographic and chest CT and MRI findings. 4 – CONFERENCES The following list gives examples of the types of confer- ences that should be considered part of the chest curricu- lum. Some of these conferences may be run by the Radiology Department, others may be run by other de- partments or multidisciplinary programmes. It is recom-www.ear-online.org 21
  • 24. Detailed Curriculum for the Initial Structured Common Programme Gastrointestinal and - To be able to identify oesophageal perforation on plain films and contrast studies Abdominal Radiology - To be able to identify oesophageal cancer, di- verticulum, extrinsic compression, sub-mu- 1 – INTRODUCTION cosal masses, fistulae, sliding and para-oesophageal hiatus hernia, benign stric- Gastrointestinal and abdominal radiology include all as- tures, benign tumours, varices, different pects of medical imaging (diagnostic and interventional), forms of oesophagitis on a contrast examina- thus covering information relative to the anatomy, patho- tion of the oesophagus physiology and the various diseases that may affect the - To understand the significance of Barrett’s abdomen. Gastrointestinal and abdominal radiology in- oesophagus and the manifestations of this cludes various techniques (ultrasonography, duplex disease Doppler, conventional X-ray imaging, computed tomogra- - To be able to perform a motility assessment phy, magnetic resonance imaging, angiography and other barium study and understand the appearance interventional procedures) and various organs (pharynx, of common motility disorders oesophagus, stomach, duodenum, small bowel, colon, - To understand the use and be experienced in rectum, anus, pancreas, liver, biliary tract, spleen, peri- the technique of bolus studies, such as bread toneum, abdominal wall and pelvic floor). The aim of this or marshmallow, in the identification of caus- document is to describe a curriculum for training in gas- es of dysphagia trointestinal and abdominal radiology. - To know the basic surgical techniques in oe- sophageal surgery and to be able to identify 2 – CORE OF KNOWLEDGE post-surgical appearances on imaging exam- inations 2.1. Anatomy and physiology - To be able to identify a mega oesophagus, oesophageal diverticulum, hiatus hernia, oe- - To know the principal aspects of embryology sophageal varices, pneumo-mediastinum, of the oesophagus, stomach, duodenum, and oesophageal perforation on CT scan small bowel, appendix, colon, rectum, anus, - To be able to identify an oesophageal cancer pancreas, liver, biliary tract, and spleen on CT scan and to analyse the criteria for - To know the anatomy of the pharynx, oesoph- non-resectability and lymph node involve- agus, stomach, duodenum, small bowel, ap- ment pendix, colon, rectum, anus, pancreas, liver, - To understand the use of endoscopic ultra- biliary tract, spleen, mesentery, and peri- sound in the staging of oesophageal cancer toneum and the technique of endoscopic ultrasound - To know the anatomy of the pelvic floor and guided biopsy abdominal wall - To know the arterial supply and venous 2.3. Stomach and duodenum drainage, including important variants, of the various portions of the gastrointestinal tract - To be able to determine the most appropriate To know the possible variations of flow in the imaging examination and contrast use in sus- superior mesenteric artery and vein and the pected perforation of the stomach and post- portal and hepatic veins operative follow-up; to know the limitations - To know the lymphatic drainage of the of each examination for these specific relevant organs conditions - To understand the imaging features (on bari- 2.2. Oesophagus um and CT) of a variety of conditions such as benign and malignant tumours, infiltrative dis- - To be able to identify the abnormalities orders, e.g. linitis plastica, gastric ulcers and demonstrable on a video-fluoroscopy study of positional abnormalities including gastric the swallowing mechanism and their implica- volvulus tions in conjunction with swallowing thera- - To be able to perform a CT examination of the pists; to recognise pharyngeal pouch, webs stomach, using the most appropriate protocol and post-cricoid tumours according to the clinical problem22 www.ear-online.org
  • 25. Detailed Curriculum for the Initial Structured Common Programme - To be able to stage gastric carcinoma and density of the mesenteric fat, peritoneal ab- lymphoma on CT and MRI normality and malrotation - To be able to identify duplication cysts of the - To be able to determine the cause of small upper gastrointestinal tract on CT scan bowel obstruction on CT scan (adhesion, - To understand the appearance of gastro-duo- band, strangulation, intussusception, volvu- denal disease on ultrasound lus, internal and external hernias) and their - To understand rotational abnormalities of the complications; to be able to identify criteria for duodenum on barium studies and also the emergency surgery appearance of annular pancreas, sub-mucos- - To know the basic principles of MR imaging of al tumours, papillary tumours, inflammatory the small bowel disease including ulceration, as well as lym- phoid hyperplasia and gastric metaplasia 2.5. Colon and rectum 2.4. Small bowel - To be able to determine the optimal imaging examination to study the colon according to - To be able to determine the most appropriate the suspected disease (obstruction, volvulus, imaging examination in the following cases: diverticulitis, benign tumour, inflammatory small bowel obstruction, inflammatory dis- disease, cancer, lymphoma, carcinoid tu- ease, infiltrative disease, small bowel perfora- mour, stromal tumour, perforation, postopera- tion and ischaemia, cancer, lymphoma, tive evaluation) and to know the limitations of carcinoid tumour, and post-operative follow-up; each technique to know the limitations of each examination - To be able to identify rotational abnormalities for these specific cases of the colon on contrast studies and CT - To be able to identify lymphoid hyperplasia of - To be able to identify the normal appendix on the terminal ileum on small bowel series; to a CT scan and a sonographic examination; to be able to identify the most common mid gut know the various features of appendicitis on abnormalities (malrotation, internal hernia) CT scan and sonographic examination - To know the features of small bowel diseases - To know the different features of colon tu- on small bowel series, including stenosis, fold mours, diverticulitis, inflammatory diseases, abnormalities, nodules, ulcerations, thicken- colon ischaemia, radiation-induced colitis ing, marked angulation, extrinsic compres- - To be able to identify a megacolon, colonic di- sion, and fistula verticulosis, specific and non-specific colitis, - To be able to identify on a small bowel series colonic fistula, carcinoma, polyps and postop- the following diseases: adenocarcinoma, erative stenosis on an enema polyposis, stromal tumour, lymphoma, carci- - To be able to identify a colonic diverticulosis, noid tumour, Crohn’s disease, mesenteric is- diverticulitis, tumour stenosis, ileocolic intus- chaemia, haematoma, Whipple’s disease, susception, colonic fistula, paracolic abscess, amyloidosis, radiation-induced injury, malro- epiploic appenditis, intra-peritoneal fluid col- tation, Meckel’s diverticulum, coeliac disease, lection, colonic pneumatosis, and pneumo- diverticulosis, systemic sclerosis, chronic peritoneum on a CT scan pseudo-obstruction - To know the CT features of colon cancer on a - To be able to perform a CT examination of the CT scan; to be able to identify criteria for local small bowel and to know the main principles extent (enlarged lymph nodes, peritoneal car- of interpretation; to know the findings in the cinomatosis, hepatic metastases, and ob- various diseases of the small bowel, and es- struction) pecially to describe a halo sign and a target - To know the TNM classification of colon can- sign; to be able to identify a transitional zone cer and its prognostic value; to understand in case of small bowel obstruction; to be able the technique and value of both MRI and en- to identify a small bowel tumour (adenocarci- dosonography in the staging of rectal cancer noma, lymphoma, carcinoid tumour, stromal - To know the basic technique of interventional tumour); to be able to identify mural pneu- radiology in colon cancer, especially of matosis, vascular engorgement, increased colonic stent placement in case of colonic ob-www.ear-online.org 23
  • 26. Detailed Curriculum for the Initial Structured Common Programme struction; to know the indications and con- - To be able to identify the following peritoneal traindications of this technique diseases on CT: peritonitis, peritoneal carci- - To know the various diseases of the rectum nomatosis, peritoneal tuberculosis, mesen- and the anus and the most frequent operative teric lymphoma, mesenteric and greater techniques that may be used to treat them omental infarction - To know the anatomy of the rectum, peri-rec- tal tissues and of the anal sphincters 2.7. Vessels - To know the main functional diseases of the pelvic floor and their features on a defeacog- - To know the basic principles of duplex raphy examination; to know the potential role Doppler sonography and to be able to identify of sonography and MR imaging in the evalua- superior mesenteric artery stenosis or occlu- tion of functional diseases of the pelvic floor sion on duplex Doppler sonography; to be - To be able to identify a rectal cancer, tumour able to use Doppler to assess the patency of recurrence after surgery and a pelvic fistula and the direction of flow in the portal and he- on a CT scan and on a MR examination; to patic veins know the value of CT / PET; to know the crite- - To be able to identify small bowel infarct on a ria that may help in differentiating between CT scan postoperative fibrosis and tumour recurrence; - To be able to interpret an angiographic study to be able to select patients who may benefit of the mesenteric vessels and to identify oc- from percutaneous biopsy in case of suspect- clusion and stenosis of the superior mesen- ed tumour recurrence teric artery - To know the basic MR imaging technique that - To know the basic principles of balloon angio- is used to search for a pelvic / perianal fistula; plasty and stenting of the superior mesenteric to be able to identify fistulae on MR imaging artery for the treatment of stenosis of the su- - To know the basic MR imaging technique that perior mesenteric artery has to be used for MRI of rectal cancer - To know the TNM classification of rectal can- 2.8. Liver cer and its effect on treatment options - To be able to identify a rectal cancer and its - To be able to localise a focal liver lesion ac- relation to relevant surrounding structures cording to liver segmentation and major ves- sels anatomy (hepatic and portal vein, IVC) 2.6. Peritoneum and abdominal wall - To describe the appearance of typical biliary cyst on US, CT and MRI - To be able to identify the various types of ab- - To describe the appearance of Hydatid cysts dominal wall hernias (inguinal, umbilical, and to be able to classify into the five cate- parastomal, postoperative) on a CT scan; to gories be able to identify an abdominal wall hernia - To list the differences between amoebic ab- on a sonographic examination; to be able to scess and pyogenic abscess of the liver (ap- identify a hernial strangulation on a CT scan pearance, evolution, treatment, indication for and on a sonographic examination drainage) - To be able to identify a mesenteric tumour - To be able to describe the most common sur- and to determine its location on a CT scan gical procedures for hepatectomy - To know the features of a mesenteric cyst on - To know the appearance of liver haeman- a CT scan gioma on US, CT and MRI including typical - To know the normal features of the peri- cases and giant haemangioma; to be able to toneum on a sonographic and a CT scan ex- discuss the indications for CT or MRI as an amination; to know the various findings that adjunct to US can be seen in cases of peritoneal disease - To describe the usual appearance of Focal (nodules, thickening, fluid collection) Nodular Hyperplasia and Liver Cell Adenoma - To be able to identify an ascites on a sono- on US including Doppler US, CT and MRI; to graphic and a CT scan examination; to know be able to discuss the indications for CT or the features of loculated ascites MRI as an adjunct to US, as well as cases when biopsy is necessary24 www.ear-online.org
  • 27. Detailed Curriculum for the Initial Structured Common Programme - To know the appearance of fatty liver, homog- and to be able to perform tumour staging, enous and heterogeneous, on US, CT, and with regard to treatment options (resectability, MRI (including in- / out-of-phase imaging) indication for palliation) - To describe the natural history of hepatocellu- - To describe the appearance of ampullar car- lar carcinoma (HCC), major techniques and cinoma on US, CT, MRI, and endoscopic US indications for treatment (surgical resection, - To be able to describe the common appear- chemotherapy, chemoembolisation, percuta- ance of sclerosing cholangitis on US, CT, and neous ablation, liver transplantation) MRI, including MRCP; to know the natural - To describe the appearance of HCC on US history and possibility for associated cholan- (including Doppler), CT, and MRI; to be able giocarcinoma and indications for treatment; to to stage the lesion in order to discuss indica- be able to discuss indications for biliary tract tions for treatment opacification - To describe the usual appearance of liver - To describe the main techniques for surgery metastases on US (including Doppler), CT, of the bile duct and its common complications and MRI, sensitivity and specificity for each - To list the methods for interventional radiolo- Be able to discuss the indications for percuta- gy of the biliary tract and discuss the indica- neous biopsy tions and complications - To be able to discuss the indications for ad- - To attest participation in five procedures vanced methods (CTAP, MRI with liver specif- ic contrast) in liver metastases staging 2.10. Pancreas - To describe the most common morphologic changes associated with liver cirrhosis: - To know the natural history of chronic pancre- lobar atrophy or hypertrophy, regeneration atitis; to list the common causes nodules, fibrosis; to list the main causes for - To identify pancreatic calcifications on plain liver cirrhosis films, US, and CT - To be able to list rare tumours of the liver and - To know the clinico-biological (Ranson score, to find their radiological appearance using lit- APACHE II) and CT (Balthazar’s CT severity erature sources score) methods for the grading of acute pan- - To be able to describe the technique for per- creatitis cutaneous guided liver biopsy and its most - To describe the common appearance of common indications; to list the complication extra-pancreatic fluid collections and phleg- with a precise evaluation of the occurrence of mons in case of acute pancreatitis morbidity and mortality - To be able to detect a pancreatic pseudocyst and discuss advantages and limitations of dif- 2.9. Biliary tract ferent treatments (follow-up, interventional procedure, percutaneous or endoscopic, sur- - To know sensitivity and specificity of imaging gery) according to practical cases methods for the detection of gall bladder and - To describe the most common appearance common bile duct stones (nodular, infiltrating) on US, CT, MRI, and en- - To describe the common appearance of doscopic US of pancreatic adenocarcinoma acute cholecystitis on US (including Doppler), and be able to perform staging in order to CT, and MRI; to know the unusual features choose a treatment like gangrenous, emphysematous, and acal- - To be able to describe the usual appearance culous cholecystis of cystic tumours of the pancreas, mainly se- - To list the main causes for gallbladder wall rious and mucinous cystadenoma, intraductal thickening on US mucinous tumour, and rare cystic tumours; to - To describe the appearance of gallbladder be able to give initial indication for tumour cancer on US, CT, and MRI; to be able to dif- characterisation ferentiate cancer from subacute cholecystitis - To be able to describe the main techniques on US and CT for pancreatic surgery and their usual compli- - To describe the appearance of cholangiocar- cations cinoma of the liver hilum (Klatskin tumour)www.ear-online.org 25
  • 28. Detailed Curriculum for the Initial Structured Common Programme 3 – TECHNICAL, COMMUNICATION AND DECISION- mechanical obstruction and pseudo obstruc- MAKING SKILLS tion, toxic dilatation of the colon, gas in small and large bowel wall indicating ischaemia and 3.1. Patient information and examination conduct necrosis, pancreatic and biliary calcifications, and aerobilia on plain abdominal films - To be able to tailor the examination protocol to the clinical question 3.4.2. X-ray examination of the upper gastrointestinal - To be able to justify and explain the indication tract and the examination conduct to the patient - To be able to obtain fully informed consent - To know how to perform an X-ray examination - To be able to inform the patient of the results of the upper gastrointestinal tract and to de- of the examination and to be able to evaluate termine the most appropriate contrast the patient’s understanding material - To know how to perform both single and dou- 3.2. Reporting ble contrast studies as well as motility as- sessments; to understand the principles and - To be able to make a precise and concise de- limitations of these studies and their advan- scription of the imaging signs present tages and disadvantages compared to en- - To be able to answer the clinical problem and doscopy make a conclusion accordingly - To understand the technique and indications - To be able to suggest additional imaging ex- of video-fluoroscopy of the swallowing mech- aminations when needed, using appropriate anism in conjunction with speech therapy and justification ENT - To be able to maintain good working relation- - To know how to perform small bowel follow ships with referring clinicians through and enteroclysis, including catheter - To be able to code the findings of examina- placement beyond the ligament of Treitz; to tions appreciate the importance and degree of fill- ing and distension of small bowel loops 3.3. Imaging techniques - General requirements - To be able to interpret a small bowel series, to recognise normal findings and to be able to - To know the indications and contra-indica- recognise the various segments of the small tions of the various imaging examinations in bowel abdominal imaging - To be able to indicate to the referring physi- 3.4.3. X-ray examination of the lower gastrointestinal cian the most appropriate imaging examina- tract tion according to the clinical problem - To be able to determine the best contrast ma- - To be able to perform a double contrast bari- terial and its optimal use according to the im- um enema aging technique and the clinical problem - To be able to perform a single contrast enema - To be able to evaluate the quality of the imag- - To know how to catheterise a stoma for colon ing examinations in abdominal imaging opacification and how to perform pou- - To know the relative cost of the various imag- chograms and loopograms ing examinations in abdominal imaging - To understand the indication and technique to - To understand the radiation burden and risks be used in an instant enema of different investigations - To know the indications and contraindications for enema techniques and to be able to deter- 3.4. Imaging techniques - Specific requirements mine the optimal contrast material and tech- nique to be used in each clinical situation 3.4.1. Plain abdominal film - To be able to interpret an enema, to know the - To know the three basic indications for plain normal findings and recognise the anatomical abdominal film components of the rectum and colon - To be able to diagnose pneumoperitoneum,26 www.ear-online.org
  • 29. Detailed Curriculum for the Initial Structured Common Programme 3.4.4. Sonography be able to tailor the protocol to the specific organ to be studied; to be able to determine if - To be able to perform an ultrasound examina- intravenous administration of a contrast mate- tion of the liver, gall bladder biliary tree, pan- rial is needed; to determine the optimal proto- creas, and spleen col for the injection (rate of injection, dose, - To be able to perform a duplex Doppler study delay); to know the various phases (plain, ar- of the abdominal vessels; to know the normal terial-dominant, portal-dominant, late phase) findings of the duplex Doppler study of the and their respective values according to the hepatic artery, superior mesenteric artery, clinical problem portal vein, and hepatic veins - To know the various contrast materials that - To be able to perform a sonographic study of can be used for MR examination of the liver the gastrointestinal tract and to identify the and their individual uses various portions (stomach, duodenum, small - To be able to perform an MR examination of bowel, appendix, and colon) the biliary tree and the pancreatic duct; to - To recognise the retroperitoneal structures know the single shot fast spin echo technique and understand the application and limita- (SSFSE) and to be able to place the various tions of sonography in this area planes on the axial image - To understand the strengths and limitations of - To be able to perform an MR examination of endosonography, particularly in the oesopha- the gastrointestinal tract; to be aware of a po- gus, pancreas, rectum and anal canal tential of MR enteroclysis; to know the basic protocol for MR examination of the anorectum 3.4.5. Computed tomography 3.4.7. Interventional imaging - To be able to perform a CT examination of the abdomen and to tailor the protocol to the spe- - To know the basic techniques for percuta- cific organ or clinical situation to be studied; neous drainage of abdominal collections to be able to determine if intravenous admin- using CT and ultrasonography istration of a contrast material is needed; to - To know the basic rules of percutaneous determine the optimal protocol for the injec- biopsy of the liver (indications, contraindica- tion of contrast (rate of injection, dose, delay); tions) and other organs under sonographic to know the various phases (plain, arterial- and CT guidance dominant, portal-dominant, late phase) and - To know the basic principles for angiography their respective values according to the clini- of the abdominal arteries (including indica- cal problem tions, contraindications); to be able to identify - To be able to determine the best contrast ma- the hepatic artery and its main anatomical terial for imaging a specific gastrointestinal variants, the superior and inferior mesenteric segment according to the clinical problem artery, and the portal vein (water, air, fat, iodine or barium containing - To know the basic principles for selective em- contrast materials) bolisation of the abdominal arteries (including - To know the techniques for CT Colonography; indications, contra-indications) to be aware of the potential of CT enteroclysis - To know the technique of percutaneous gas- - To understand the technique and limited indi- trostomy under image guidance cation for CT Cholangiography - To know the techniques for percutaneous bil- - To have experience of the use of workstations iary intervention for multiplanar reconstructions (MPR) and 3D - To understand the technique for radiological reconstruction based around volume data guided stenting of the biliary system and gas- sets trointestinal system, using PTFE and expand- able metal stents 3.4.6. Magnetic resonance imaging - To be able to perform an MR examination of the liver, the biliary tract and the pancreas; towww.ear-online.org 27
  • 30. Detailed Curriculum for the Initial Structured Common Programme 3.4.8. Miscellaneous Head and Neck Radiology - To know the indications, strengths and limita- (Including Maxillo-Facial and tions of the other imaging techniques (includ- Dental Radiology) ing endoscopy, endosonography, nuclear medicine (including PET) in abdominal imag- 1 – INTRODUCTION ing) The head and neck imaging curriculum describes: 4 – CONFERENCES - The knowledge-based objectives for general head and neck radiology and maxillofacial As part of the curriculum in abdominal radiology, the and dental radiology trainee should attend in-house teaching sessions for radi- - The appropriate technical and communica- ologists as well as clinical conferences with colleagues tion skills from other specialties. The latter type of conference should be included to facilitate the radiology residents’ un- Physics, radiography and contrast media are generally derstanding of the use of imaging and clinical circum- covered in separate courses, and therefore are not includ- stances, in which imaging is requested. ed in this document, but physics and radiography topics specific to head and neck should be covered either in the The following list gives examples of the types of confer- head and neck rotation or included in the physics / radiog- ences that should be considered part of the curriculum: raphy courses, particularly: 1. Abdominal radiology resident-specific teaching - Positioning / views of radiographs for adults, conference newborns, infants and children 2. Internal medicine / gastroenterology conferences - Mean exposure doses at skin entrance, kVp, 3. Surgery / abdominal surgery conferences antiscatter techniques 4. Oncology conferences - Principles of digital image processing perti- 5. Pathology conferences nent to head and neck and maxillofacial dental radiology 5 – TEACHING MATERIAL AND SUGGESTIONS FOR READING 2 – CORE OF KNOWLEDGE The following English textbooks are recommended to an- 2.1. Normal anatomy swer all questions and address all objectives defined in the curriculum of abdominal radiology. One of these books - Temporal bone (title) serves as "bench book", i.e. it is valid for all training - Facial skeleton, skull base and cranial nerves programmes across Europe and aims at unification and - Orbit and visual pathways standardisation of Radiology training in Europe. It is very - Sinuses important that "bench books" be available in the radiology - Pharynx department and the library of each institution. - Oral cavity - Larynx - Gore RM, Levine MS. Textbook of - Neck Gastrointestinal Radiology (2nd Edition). WB - Mandible, teeth and temporomandibular Saunders, Philadelphia, 2000 joints - Eisenberg RL. Gastrointestinal Radiology – A - Salivary glands Pattern Approach (4th Edition). Lippincott, - Deep spaces of the face and neck Philadelphia, 2003 - Thoracic inlet and brachial plexus - Abdominal radiology book(s) in local lan- - Thyroid gland and parathyroid glands guage28 www.ear-online.org
  • 31. Detailed Curriculum for the Initial Structured Common Programme 2.2. Temporal bone 2.8. The larynx - To know pathologic conditions defining deaf- - To know and be able to recognise on CT and ness MRI the pathologic conditions of the larynx - To know and recognise on CT and MRI - Temporal bone inflammatory disease 2.9. The neck - Temporal bone fractures - Tumours of the temporal bone and cere- - To know and be able to recognise on US, CT bello-pontine angle and MRI - To know vascular tinnitus - Embryology and congenital cystic lesions - The clinical significance of lymph nodes, 2.3. The facial skeleton, skull base and cranial nerves metastatic, inflammatory, and infectious disease - To know and be able to recognise on CT and - Non-nodal masses of the neck MRI - To know and be able to recognise on US, CT, - Inflammatory conditions CT-angiography, MRI, MRI-angiography and - Tumours and tumour-like conditions conventional angiography vascular diseases - Trauma and resulting complications - Major pathologic conditions involving the 2.10. The mandible, teeth, and temporomandibular cranial nerves joints 2.4. Orbit and visual pathways - To know and be able to recognise on or- thopantomography, CT, MRI, and dental radi- - To know ographs pathologic conditions of the mandible - Orbital pathology - To get familiarity with dental implants and - Pathology of the visual apparatus dental CT programmes - To know pathologic conditions of the tem- 2.5. The sinuses poro-mandibular joint - To know and be able to recognise on CT 2.11. The salivary glands anatomical variations and congenital anom- alies of the paranasal sinuses - To know and be able to recognise on US, CT, - To know and be able to recognise on CT and MRI and MR-sialography inflammatory disor- MRI inflammatory conditions, tumours and tu- ders and tumours mour-like conditions - To know and be able to recognise on US, - To be familiar with common (Functional Doppler US, CT and MRI vascular malforma- Endoscopic Sinus Surgery) techniques tions - To know how to evaluate the paranasal sinus- - To know and be able to recognise on US, CT es after surgery and MRI periglandular lesions and recognis- ing these on US, CT, MRI 2.6. The pharynx 2.12. The deep spaces of the face and neck - To know and be able to recognise on US, CT and MRI the pathologic conditions of: - To know the anatomy of the deep cervical fas- - nasopharynx cia and of the most common pathologic con- - oropharynx ditions involving the different spaces of the - hypopharynx supra- and infrahyoid neck 2.7. The oral cavity 2.13. The thoracic inlet and the brachial plexus - To know and be able to recognise on US, CT, - To know and be able to recognise on CT and MRI and videofluoroscopy the pathologic MRI the most common pathologic conditions conditions of the oral cavity of the thoracic inlet and brachial plexuswww.ear-online.org 29
  • 32. Detailed Curriculum for the Initial Structured Common Programme 2.14. The thyroid gland and the parathyroid glands 3.3. At the end of his / her training the resident should be able to: - To know and be able to recognise on US, Doppler US, CT and MRI 3.3.1. Dictate intelligible and useful reports. - Congenital lesions The reports should contain a brief - Inflammatory lesions description of the imaging findings and - Benign thyroid masses their significance along with a short sum- - Malignancies of the thyroid gland mary where necessary. - Pathologic conditions of the parathyroid glands 3.3.2. Recommend the appropriate use of imag- - To be familiar with the most important findings ing studies to referring clinicians. of Tc-99m-scintigraphy in specific disease of the thyroid gland 3.3.3. Demonstrate the ability to present head - To be able to perform fine needle aspiration and neck examinations effectively in a biopsy in easy cases conference setting. 3 – TECHNICAL, COMMUNICATION AND DECISION- 3.3.4. Discuss significant and unexpected radio- MAKING SKILLS logic findings with referring clinicians and know when to contact a clinician. Diagnostic procedures: Skull radiography + special views: 50 Sinus radiography: 50 Head and neck CT (including Dental CT): 100 Head and neck MRI: 50 Ultrasound of head and neck: 50 3.1. At the end of the 4th year the resident should be able to carry out or supervise the following tech- niques to a level appropriate to practice in a gen- eral hospital. This competence should include the ability to evaluate and justify referrals for the pur- pose of protection of the patient. - Radiography of the skull, sinus, skull base, and facial bones including special views - Imaging of swallowing including dynamic functional studies - Orthopantomography (OPG) - Ultrasound of the neck, tongue, and salivary glands - Percutaneous biopsy, guided by ultrasound, CT and / or MRI in straightforward / techni- cally easy cases - Doppler ultrasound - CT of the face, skull base and neck - MRI of the face and neck - Angiography, including digital subtraction or CT angiography - Dental radiology, including the use of CT 3.2. The trainee should also have knowledge of or- thopantomography and experience of lymph node aspiration biopsies.30 www.ear-online.org
  • 33. Detailed Curriculum for the Initial Structured Common Programme Interventional Radiology - CTA protocols including contrast materials used and reconstruction techniques 1 – INTRODUCTION - Radiation doses for CTA and methods to re- duce these Interventional Radiology is a vibrant and dynamic special- - Advantages and disadvantages of CTA ver- ty in which, unfortunately, trainees have variable exposure sus other techniques to radiology during training. It is important that radiology trainees develop the basic skills in interventional radiolo- 2.1.3. MR Angiography (MRA) gy, irrespective of whether they specialise in intervention- The trainee should be familiar with: al radiology. Basic skills and a core programme of - MR physics and MRA techniques knowledge will allow the trainees to perform routine pro- - Advantages and disadvantages of different cedures using image guidance throughout their careers. contrast materials used for MRA This can only serve to strengthen the specialty of radiolo- - Differences between time of flight, phase con- gy as a whole. trast, and contrast-enhanced techniques per- taining to MRA The following is an attempt to develop a core programme - Advantages and disadvantages of MRA com- of knowledge for trainees in interventional radiology. It is pared to other techniques clear that there is some overlap with some other sections in the diagnostic radiology syllabus, but it is nevertheless 2.2. Diagnostic Angiography / Venography important to define a core programme for interventional radiology. 2.2.1. General The trainee should be familiar with: Length of training - The basic chemistry of the different iodinated In order for the trainee to achieve basic skills and core contrast materials used, and the advantages / knowledge in interventional radiology, four to six months disadvantages of each for angiography of dedicated time in interventional radiology will be re- - Mechanisms to minimise nephrotoxicity in quired during basic training. risk patients, such as patients with diabetes or renal impairment 2 – CORE OF KNOWLEDGE - Cortico-steroid prophylaxis - Treatment of both minor and major allergic re- It is expected that, at the end of residency, the trainee will actions to iodinated contrast materials have a thorough knowledge of the performance and inter- pretation of diagnostic vascular techniques and a basic 2.2.2. Arterial Puncture Technique understanding of common interventional procedures. The Trainee should have a thorough knowledge of: - Standard groin anatomy, including the posi- 2.1. Non-Invasive Vascular Imaging tion of the inguinal ligament and the femoral nerve, artery and vein 2.1.1. Doppler Ultrasound - The Seldinger technique of arterial and ve- The trainee should demonstrate a thorough un- nous puncture derstanding and be able to interpret the following: - Mechanisms for guidewire, sheath and - Duplex ultrasound, including both arterial and catheter insertions into the groin venous examinations - Mechanisms of puncture site haemostasis in- - Normal and abnormal Doppler waveforms cluding manual compression and common - Common Doppler examinations, such as closure devices carotid Doppler, hepatic and renal Doppler - Alternative sites of arterial puncture, such as studies and lower extremity venous duplex brachial, axillary and translumbar examinations 2.2.3. Diagnostic Angiography 2.1.2. CT Angiography The trainee should be familiar with: The trainee should have a thorough understand- - Guidewires, sheaths and catheters used for ing of: common diagnostic angiographic procedures - The basic physics of single slice helical CT - Digital subtraction angiographic techniques, and multi-detector CTwww.ear-online.org 31
  • 34. Detailed Curriculum for the Initial Structured Common Programme bolus chase techniques, road mapping, and - The technique of venous access in jugular pixel shift techniques and subclavian veins - Standard arterial and venous anatomy and - Results and complications variations in anatomy throughout the body - Peripheral vascular angiography 2.4.2. Venoplasty and Stenting - Mesenteric and renal angiography The trainee should be familiar with: - Abdominal aortography - Techniques of venoplasty and stenting - Thoracic aortography - Success rates and complications - Carotid, vertebral and subclavian angiography - Post-procedural care - Diagnosis of atherosclerotic disease, vasculi- tis, aneurysmal disease, thrombosis, em- 2.4.3. Caval Interruption bolism and other vascular pathology The trainee should be familiar with: - The complication rates for common diagnos- - Indications for caval filter placement tic procedures - Different filter types available, including re- - Post-procedural care regimens for standard trievable filters diagnostic vascular procedures - Success rates and complications - Post-procedural care 2.3. Vascular Intervention 2.5. Non-Vascular Intervention The trainee should be familiar with common vascular in- terventional procedures, such as: Trainees should have performed and have a thorough un- derstanding of basic non-vascular interventional tech- 2.3.1. Angioplasty niques, such as biopsy, abscess drainage, - Angioplasty balloon dynamics, mechanism of transhepaticholangiography and nephrostomy tech- action of angioplasty niques. - Indications for angioplasty - Complications and results in different 2.5.1. Biopsy anatomic areas The trainee should be familiar with: - Drugs used during angioplasty - Consent procedures - Intra-arterial pressure studies - Pre-procedure coagulation tests and correc- - Common angioplasty procedures, such as tion of abnormalities renal, iliac and femoral angioplasties - Differences in image modalities used for guid- - Groin closure techniques and post-procedur- ing biopsy, including CT and ultrasound al care - Needles used for biopsy procedures including fine gauge needles, large gauge needles and 2.3.2. Arterial / Venous Stenting trucut biopsy - Basic mechanisms for stent deployment and - Planning a safe access route to the lesion to materials used for stent construction be biopsied - Indications for stent placement versus angio- - Complication rates associated with individual plasty organ biopsy - Complications and results - Indications for fine needle biopsy versus large - Post-procedural care gauge or core biopsy - Post-procedural care for chest and abdominal 2.4. Venous Intervention biopsy - Algorithms for treatment of common compli- 2.4.1. Venous Access cations, such as pneumothorax and hemor- The trainee should be familiar with the various rhage forms of venous access including: - PICC lines, Hickman catheters, dialysis 2.5.2. Fluid Aspiration and Abscess Drainage. catheters and ports The trainee should be familiar with: - Indications for use of the above venous ac- - Commonly used chest tubes and abscess cess catheters drainage catheters32 www.ear-online.org
  • 35. Detailed Curriculum for the Initial Structured Common Programme - Indications for chest drainage, fluid aspira- 3 – TECHNICAL, COMMUNICATION AND DECISION- tion, and abscess drainage MAKING SKILLS - Imaging modalities used for guidance - Interpretation of gram stain results The goals of basic training in interventional radiology are - Methods of chest tube placement as follows: - Underwater seal drainage systems - The trainee should be able to interpret non-in- - Fibrinolytic agents used in patients with locu- vasive imaging studies to determine that the lated or complex empyemas requested procedure is appropriate - Planning a safe access route for abscess - To determine the appropriateness of patient drainage selection for a requested interventional pro- - Antibiotic regimens used before abscess cedure through a review of available history, drainage imaging, laboratory values, and proposed or - Trocar and Seldinger techniques for catheter expected outcomes of the procedure placement - To demonstrate an understanding of the his- - Situations where more than one catheter or tory or physical findings that would require larger catheters are required pre-procedure assistance from other special- - Various approaches to pelvic abscess ty disciplines, such as Cardiology, drainage Anaesthesia, Surgery or Internal Medicine - Post-procedural care including catheter care, - To obtain informed consent after discussion ward rounds and when to remove catheters of the procedure with the patient, including a discussion of risks, benefits, and alternative 2.5.3. Hepatobiliary Intervention therapeutic options The trainees should have knowledge of, and be - To be familiar with monitoring equipment able to perform basic hepatobiliary intervention, used during interventional radiology proce- such as, transhepaticholangiography and basic dures and be able to recognise abnormalities percutaneous biliary drainage (PBD). and physical signs or symptoms that need im- mediate attention during the procedure The trainee should be familiar with: - To demonstrate an understanding of and be - Pre-procedure workup, including antibiotic able to identify risk factors from the patient’s regimens, coagulation screening and intra- history, physical or laboratory examinations venous fluid replacement that indicate potential risk for bleeding, - Performance of transhepaticholangiography nephrotoxicity, cardiovascular problems, - One-stick needle systems for biliary drainage breathing abnormalities, or adverse drug in- - Catheters used for biliary decompression teractions during or after the procedure - Complications of biliary procedures - Knowledge of agents used for conscious se- - Aftercare, including knowledge of complica- dation and analgesia during interventional tions, catheter care, and ward rounds procedures, with ability to identify risk factors that may indicate potential risks for conscious 2.5.4. Genitourinary Intervention sedation The trainee should be familiar with: - Knowledge of radiation safety in the interven- - Indications for percutaneous nephrostomy tional radiology suite - Integration of ultrasound, CT and urographic - Knowledge of methods used to reduce acci- studies to plan an appropriate nephrostomy dental exposure to blood and body fluids in - Pre-procedural work-up including coagulation the interventional radiology suite screens and antibiotic regimens - Ultrasound / fluoroscopic guidance mecha- nism for percutaneous nephrostomy - Catheters used for percutaneous nephrostomy - Placement of percutaneous nephrostomy tubes - Complications of percutaneous nephrostomy - Aftercare, including catheter care and re- movalwww.ear-online.org 33
  • 36. Detailed Curriculum for the Initial Structured Common Programme Musculoskeletal - features in the adult skeleton - features in the immature skeleton* (including Radiology normal development) - articular (chondral & osteochondral) (includ- 1 – INTRODUCTION ing osteochondritis dissecans) - healing & complications Musculoskeletal imaging involves all aspects of medical - delayed union / non-union imaging which provide information about the anatomy, - avascular necrosis function, disease states and those aspects of interven- - reflex sympathetic dystrophy tional radiology or minimally invasive therapy appertaining - myositis ossificans to the musculoskeletal system. This will include imaging in - stress (fatigue & insufficiency) orthopaedics, trauma, rheumatology, metabolic and en- - avulsion docrine disease as well as aspects of paediatrics and on- - pathological cology. Imaging of the spine is included within both the - non-accidental injury* musculoskeletal and neuroradiological fields. It should be noted that elements of musculoskeletal imaging are part 2.1.2. Specific Bony / Joint Injuries of paediatric and emergency radiology and to a lesser ex- - skull & facial bone fractures tent of oncological imaging. - spinal fractures (including spondylolysis) - shoulder girdle 2 – CORE OF KNOWLEDGE - sternoclavicular & acromioclavicular dislo- cations - Basic clinical knowledge, that is medical, sur- - clavicular fractures gical and pathology as well as pathophysiolo- - scapular fractures gy related to the musculoskeletal system - shoulder dislocation / instability - Knowledge of current good clinical practice - upper limb - Knowledge of the indications, contraindications - humeral fractures and potential hazards (especially radiation - elbow fractures / dislocations hazards) of procedures and techniques rele- - proximal & distal forearm fractures / dislo- vant to musculoskeletal disease and trauma cations - Knowledge and management of procedural - wrist joint fractures / dislocations complications - hand fractures / dislocations - Knowledge of musculoskeletal anatomy in - pelvic fractures / dislocations (including asso- clinical practice relevant to clinical radiology ciated soft tissue injuries) - Knowledge of normal skeletal variants, which - lower limb may mimic disease - hip fractures / dislocations - Knowledge of the manifestations of muscu- - femoral fractures loskeletal disease and trauma (see list - tibial & fibular fractures (including ankle below), as demonstrated by conventional ra- joint) diography, CT, MRI, arthrography, radionu- - hindfoot fractures clide investigations, and ultrasound - tarso-metatarsal fractures / dislocations - Knowledge of differential diagnosis relevant - forefoot fractures / dislocations to clinical presentation and imaging appear- ance of musculoskeletal disease and trauma 2.1.3. Soft Tissues as listed below - shoulder - rotator cuff, glenoid labrum, biceps ten- The following manifestations of musculoskeletal disease don and trauma have to be covered during the general radio- - wrist logical training. This should include formal teaching and - triangular fibrocartilage complex exposure to clinical case material. - knee - menisci, cruciate ligaments, collateral lig- 2.1. Trauma (acute & chronic) aments - ankle 2.1.1. Fractures & Dislocations - principal tendons & ligaments - types and general classifications34 www.ear-online.org
  • 37. Detailed Curriculum for the Initial Structured Common Programme 2.2. Infections - lipoma - acute, subacute & chronic osteomyelitis - liposarcoma - spine - neural origin - appendicular skeleton - neurofibroma - post-traumatic osteomyelitis - schwannoma - tuberculosis - vascular origin - spine - haemangioma - appendicular skeleton - soft tissue sarcomas - rarer infections (e.g. leprosy, brucellosis – main manifestations only) 2.4. Haematological disorders - commoner parasites worldwide (e.g. echinoc- - haemoglobinopathies coccus) - sickle cell disease - soft tissue infections - thalassaemia - HIV-associated infections - myelofibrosis 2.3. Tumours & umour-like lesions 2.5. Metabolic, endocrine & toxic disorders - rickets* & osteomalacia 2.3.1. Bone - primary & secondary hyperparathyroidism - principles of tumour characterisation and (including chronic renal failure) staging - osteoporosis (including basic concepts of - bone-forming bone mineral density measurements) - osteoma & bone islands - fluorosis - osteoid osteoma & osteoblastoma - osteosarcoma (conventional and com- 2.6. Joints moner variants) - degenerative joint disease - cartilage-forming - spine (including intervertebral disc & facet - osteochondroma joints) - enchondroma - peripheral joints - chondroblastoma - inflammatory joint disease - chondromyxoid fibroma - rheumatoid arthritis - chondrosarcoma (central & peripheral) - juvenile rheumatoid arthritis* - fibrous origin - ankylosing spondylitis - fibrous cortical defect / non-ossifying fi- - psoriatic arthritis broma - enteropathic arthropathies - fibrous dysplasia - infective (pyogenic & tuberculous) - fibrosarcoma / malignant fibrous histiocy- - crystal arthropathies toma - pyrophosphate arthropathy - haematopoietic and reticuloentholelial - hydroxyapatite deposition disease - giant cell tumour - gout - Langerhans cell histiocytosis - masses - malignant round cell (Ewing’s sarcoma, - ganglion lymphoma & leukaemia) - synovial chondromatosis - myeloma & plasmacytoma - pigmented villonodular synovitis - tumour-like - neuroarthropathy - simple bone cyst - diabetic foot - aneurysmal bone cyst - charcot joints - metastases - pseudo-Charcot (steroid induced) - others - complications of prosthetic joint replacement - chordoma (hip & knee) - adamantinoma 2.7. Congenital, developmental & paediatric* 2.3.2. Soft Tissue - spine - fat origin - scoliosis (congenital & idiopathic)www.ear-online.org 35
  • 38. Detailed Curriculum for the Initial Structured Common Programme - dysraphism vision of on-call service - shoulder - communicating with patients and taking histo- - Sprengel’s deformity ry relevant to the clinical problem - hand & wrist - using all available data (clinical, laboratory, - Madelung deformity (idiopathic & other imaging) to find a concise diagnosis or differ- causes) ential diagnosis - hip - developmental dysplasia 3.2. Core of experience - irritable hip - experience of the relevant contrast medium - Perthes disease examinations (e.g. arthrography) - slipped upper femoral epiphysis - bone dysplasias Optional experience includes: - multiple epiphyseal dysplasia - achondroplasia - reporting radionuclide investigations of the - osteogenesis imperfecta musculoskeletal system, particularly skeletal - sclerosing (osteopetrosis, melorheostosis scintigrams & osteopoikilosis) - awareness of the role and, where practicable, - tumour-like (diaphyseal aclasis & Ollier’s the observation of discography, facet joint in- disease) jections, and vertebroplasty - neurofibromatosis - observation of image-guided bone biopsy and drainage of the musculoskeletal system 2.8. Miscellaneous - interpretation of bone densitometry examina- - Paget’s disease tions - sarcoidosis - familiarity with the application of angiography - hypertrophic osteoarthropathy in the musculoskeletal system - transient or regional migratory osteoporosis - osteonecrosis - characterisation of soft tissue calcification / ossification * These topics may or may not be covered in the paedi- atric component of the radiologists´ training. It is the re- sponsibility of the director of each training scheme to ensure that the topics are adequately covered in either the paediatric or musculoskeletal components. 3 – TECHNIQUE, COMMUNICATION AND DECISION- MAKING SKILLS 3.1. Core of skills - supervising and reporting plain radiographic examinations relevant to the diagnosis of dis- orders of the musculoskeletal system includ- ing musculoskeletal trauma - supervising and reporting CT of the muscu- loskeletal system including trauma - supervising and reporting MRI of the muscu- loskeletal system including trauma - performing and reporting ultrasound of the musculoskeletal system including trauma - supervising and reporting CT and MRI exam- inations of trauma patients, including the pro-36 www.ear-online.org
  • 39. Detailed Curriculum for the Initial Structured Common Programme Neuroradiology 2.6.4. Vascular disease including congenital and acquired malformations 1 – INTRODUCTION 2.6.5. Degenerative diseases of the brain The aim of this core training is for the trainees to famil- iarise themselves and gain core competence in the basics 2.6.6. Hydrocephalus of neuroradiology as well as to develop enough under- standing of neuroradiology so as to be able to recognise 3 - TECHNIQUE, COMMUNICATION AND DECISION- that there is an abnormality and to know where and when MAKING SKILLS to seek help. It should be undertaken under the supervi- sion of a neuroradiologist. Arrangements should be made 3.1. At the end of his / her training, the resident within the training scheme for secondment to another de- should be able to: partment if necessary. Exposure to all imaging techniques - Report plain radiographs in the investigation used in neuroradiology should be achieved. of neurological disorders - Supervise and report cranial and spinal CT 2 - CORE OF KNOWLEDGE scans - Supervise and report cranial and spinal MR 2.1. To know: scans - Neuroanatomy and clinical practice relevant to neuroradiology 3.2. During his / her training, the resident should also - The manifestations of CNS disease as observe: demonstrated on conventional radiography, - Cerebral angiograms and their reporting CT, MRI, and angiography - Carotid ultrasound examination including Doppler 2.2. To understand the indications for a neuroradio- logical examination. 3.3. The resident should get experience in MR and CT angiography and venography to image the 2.3. To recognise normal results on x-ray, ultrasound, cerebral vascular system CT, and MR. 3.4. Optional experience includes the following: 2.4. To be aware of the applications, contraindications - To perform and report cerebral angiograms, and complications of invasive neuroradiological myelograms and carotid ultrasound, including procedures. Doppler and transcranial ultrasound - To observe interventional neuroradiological 2.5. To get familiarity with the application of: procedures, including magnetic resonance - Radionuclide investigations in neuroradiology spectroscopy - CT and MR angiography in neuroradiology - To get experience on functional brain imaging techniques (radionuclide and MRI) 2.6. To get basic competence in the following: 2.6.1. Trauma - Skull and facial injury - Intracranial injury, including child abuse and the complications - Spinal cord injury 2.6.2. Developmental anomalies - Brain anomalies - Spinal cord malformations 2.6.3. Tumours of the brain, orbits and spinal cordwww.ear-online.org 37
  • 40. Detailed Curriculum for the Initial Structured Common Programme Paediatric Radiology 2.1. Imaging techniques 1 – INTRODUCTION The emphasis throughout the attachment is to appreciate the differences between children and adults. All work The aim of this core training is for the trainee to gain basic should be closely supervised and, ideally, a log book kept. understanding of children’s diseases and basic compe- tence of paediatric diagnostic imaging in order to be able 2.1.1. Ultrasound: This should include duplex, to recognise whether there is an abnormality and to know colour and Doppler techniques and the where to seek help. It should be undertaken under the su- full age range, including premature pervision of a paediatric radiologist. Arrangements should infants. The trainee should perform the be made within the training scheme for secondment to an- ultrasound examinations under supervi- other department if necessary. Exposure to all imaging sion. The experience should include ex- techniques, including nuclear medicine, should be posure to the following areas: achieved. - Neonatal head - Abdomen: kidneys and urinary tract; liver and Paediatric Radiology covers all the organ disciplines as spleen; gynaecology described in the other curricula but is age-related. A child - Chest: pleurae is defined as a person under 16 years of age. As the child - Soft tissues: neck, scrotum, musculoskeletal approaches adulthood, disease patterns become more system similar to those in adult life. Paediatric Radiology encom- - Doppler studies: neck and abdomen, testes passes diagnostic imaging of the fetus, the newborn, the infant, the child, and the adolescent. 2.1.2. Radiographs: supervised reporting of children’s radiographs, especially in re- 2 – CORE OF KNOWLEDGE lation to A. & E. presentation, muscu- loskeletal system, chest, and abdomen. In the twelve-week course, in addition to acquiring knowl- edge of the paediatric organ system, the trainee is expect- 2.1.3. Fluoroscopy: discussion of indications ed to also acquire a basic understanding of the following: for gastrointestinal fluoroscopy versus specialist paediatric endoscopy with - Principles of integrated imaging in relation to supervisor before initiating studies. paediatric problems; Performing studies under direct super- - Choice of useful imaging technique(s) for vision. common clinical questions; - Technique of bladder catheterisation and per- - Correct sequence of imaging in relation to the formance of micturition cystourethrography clinical problem; (MCU) - Adaptation of imaging techniques for chil- - Observation and conduct of upper and lower dren, i.e. minimising radiation, especially in G.I. contrast studies in neonates relation to CT and fluoroscopy; indications for - Tailored upper and lower gastrointestinal con- and choice of contrast media; trast studies in children for investigation of - Special requirements for children, e.g. envi- gastro-oesophageal reflux, aspiration and ronment, sedation and anaesthesia, physiolo- constipation in neurologically normal and im- gy of the young infant, and psychology of paired children managing children; - Observation of intussusception reduction - Communication with the children and their - Observation of videophonetics if locally per- parents, as well as medical colleagues; formed Importance of clinico-radiological confer- ences, both formal and informal; 2.1.4. Small and large bowel studies - Guidelines for investigation of common clini- cal problems and understanding of risk / ben- 2.1.5. Urography: To understand the indica- efit analysis related to children; tions for intravenous (iv) and MR urogra- - Radiation protection, equipment, and regula- phy; to know how to conduct the iv tion; urography in children.38 www.ear-online.org
  • 41. Detailed Curriculum for the Initial Structured Common Programme 2.1.6. CT: To understand the technique in a - To recognise cystic fibrosis changes paediatric trauma patient and the spe- - To recognise bronchiectasis cial low dose imaging protocols in gener- - To recognise a pleural effusion and empyema al use. Experience of CT of the head and - To recognise a pneumothorax neck, abdomen, chest and muscu- - To recognise complications of asthma loskeletal system, especially in a trauma - To recognise premature lung disease and its patient, should be gained as far as pos- complications sible. - To recognise and know how to investigate suspected inhaled foreign bodies 2.1.7. MR: The experience in MR by observa- - To recognise mass lesions and know how to tion should include neuroimaging (brain further investigate them, including congenital and spinal cord), abdominal and muscu- bronchopulmonary foregut malformation loskeletal imaging. - To recognise metastatic lung disease - To know about specific clinical problems, 2.1.8. Nuclear Medicine: To gain experience in such as stridor and recurrent infection renal imaging – both DMSA scintigraphy - To recognise and know how to assess chest and renography, possibly MAG3, and trauma skeletal imaging. 2.2.2. Mediastinum 2.1.9. Angiography and Interventional Radio- - To recognise and know how to investigate a logy: Understanding of indications and mediastinal mass in children. observation of techniques according to local possibilities. 2.2.3. Diaphragm - To recognise diaphragmatic paralysis, even- 2.1.10. Fetal Imaging: If the opportunity arises tration, and possible paralysis. for exposure to fetal MR and antenatal ultrasound that familiarises the trainee 2.2.4. Cardiovascular System with the indications for these techniques, - To recognise abnormal cardiac size and con- this should be included. The trainee thus tours exposed should also gain an under- - To recognise cardiac failure (left vs. right standing of the multidisciplinary ap- heart failure) proach to the specific problems of fetal - According to local possibilities: To get an un- imaging. derstanding of the role of ultrasound, MR and angio-CT in the investigation of cardiac dis- 2.2. Pathology eases in children. All the following sections should be cross-referenced to 2.2.5. Gastrointestinal Tract: the core curricula for the other organ specialties, as in this - The investigation and imaging of congenital section those diseases are emphasised that are specific gastrointestinal malformations in the neonatal to children. Many of the following pathological conditions period and later. These include: are characteristic of childhood and should be included in - Oesophageal atresia differential diagnostic case discussion during the 12- - Tracheooesophageal fistula week- training period. - Malrotation and situs anomalies - Duodenal obstruction (e.g. atresia and 2.2.1. Chest: Diseases of the tracheobronchial stenosis) tree, lungs and pleura: - Hirschsprung’s Disease - To recognise the radiology of lobar, viral and - Duplication anomalies specific organism infection and pulmonary - The investigation of neonatal bowel obstruc- abscess tion, e.g. - To recognise infiltrative lung disease - Hirschprung’s Disease - To recognise the possibility of tuberculosis - Meconium ileus - To be aware of opportunistic infection in im- - Meconium plug syndrome munocompromised children - The ultrasound appearance of pyloric stenosiswww.ear-online.org 39
  • 42. Detailed Curriculum for the Initial Structured Common Programme - Intussusception - To know when and how to perform a MCU - Inflammatory bowel disease in children and how to read it - Appendicitis - To detect and evaluate VUR - Gastroenteritis - To recognise renal abscess and pyonephro- - Investigation of the following clinical prob- sis lems: - To recognise congenital urinary tract anom- - Abdominal pain alies on ultrasound and understand their fur- - Constipation ther evaluation - Malabsorption - To recognise hydronephrosis / hy- - Suspected bowel obstruction and ileus droureterone-phrosis on ultrasound and un- - The vomiting neonate derstand their further evaluation - Abdominal trauma - To recognise the urinary tract features and - The investigation of an abdominal mass complications of spinal dysraphism and other - The management of ingested foreign bodies neuropathies - To recognise bladder exstrophy radiologically 2.2.6. Hepatobiliary Disease - To know about indications for urodynamic - Approach to the investigation of neonatal studies jaundice - To recognise Wilms’ tumour and understand - Cause and investigation of jaundice in the its further investigation older child - To recognise pelvic and bladder tumours and - Choledocholithiasis in children their further investigations - Congenital malformations of the biliary tree - To recognise polycystic kidney disease; know - Trauma about various forms - Hepatobiliary tumours - To recognise urinary tract lithiasis and under- stand its investigation 2.2.7. Spleen - To understand the investigation of hematuria - Trauma - To be aware of renal manifestations of sys- - Haematological diseases temic disease - Congenital syndromes associated with asple- - To recognise the imaging features of nephrot- nia, polysplenia, etc. ic syndrome and glomerulonephritis 2.2.8. Pancreas 2.2.11. Gynaecology - Trauma - To recognise ovarian cysts, possible torsion - Pancreatitis and tumours in the child and adolescent - Tumor involvement - To recognise neonatal presentation of ovarian cysts and hydro(metro)colpos 2.2.9. Endocrine Disease - To recognise genital and extragenital tumours Understand the approach to the investigation of: and understand their investigation - Thyroid disorders in children - To be aware of cloacal and urogenital sinus - Adrenal disorders in children including neu- anomalies roblastoma - To be aware of intersex anomalies arising in - Growth abnormalities and suspected growth the neonate and at adolescence hormone deficiency - To recognise congenital uterine malformation - To know how to investigate precocious and 2.2.10. Genitourinary tract delayed puberty - To recognise the normal appearance of the organs in any imaging modality 2.2.12. Breast Disease - To understand the urethral anatomy of the boy - To recognise the ultrasonic and MR appear- - To understand the clinical and biological crite- ances of breast cysts ria of UTI - To be able to perform ultrasound of the uri- 2.2.13. Testes nary tract on infants including the use of - To recognise scrotal trauma Doppler40 www.ear-online.org
  • 43. Detailed Curriculum for the Initial Structured Common Programme - To recognise and know how to evaluate tes- - To understand intracranial injury, including ticular torsion child abuse and the complications - To recognise epidydymo-orchitis - To understand the indications for the investi- - To recognise testicular tumours gation of headache, diplopia, and epilepsy - To understand the investigation of unde- - Infection of the brain, meninges, orbits and si- scended testes nuses, and the complications - Hydrocephalus 2.2.14. The Musculoskeletal System - Tumours of the brain, orbits and spinal cord Trauma - Premature brain disease on both ultrasound - To recognise normal variants that may be and MR misinterpreted as pathology - Congenital malformation of brain and spinal - To recognise fractures of the limbs, pelvis, cord and spine - Spinal cord injury - To understand the Salter-Harris classification - Spinal cord malformations and imaging for of fractures and to recognise the therapeutic clinical presentations, e.g. back pain, claw implications foot, or dermal sinus - To recognise the bony lesions of child abuse - To be aware of developmental anomalies: mi- - To recognise sports injuries, such as avulsion grational disorders fracture and enthesopathy - Craniofacial malformations including cran- - To recognise soft tissue injury on X-ray, ultra- iostenosis sound, and MR - Congenital ear disease - To recognise a slipped upper femoral epiph- - Dental radiology ysis - To recognise Legg-Calvé-Perthes disease 2.2.17. Miscellaneous Infection These conditions are often multiorgan in presen- - To recognise the imaging features of bone, tation and are mentioned separately so that the joint, and soft tissue, including spinal infection trainee is aware of their protean manifestation. - To recognise juvenile discitis - Non-accidental injury (NAI) - To recognise conditions that may mimic infec- - AIDS in children tion, such as SAPHO syndrome - Lymphoma in children - To recognise the complications of foreign - Vascular malformations including lymphoedema body penetration - Collagen vascular disease including myofi- - To be familiar with tropical infection bromatosis Congenital Disease - Endocrine disease - To recognise congenital hip dysplasia on ul- - Investigation of small stature and growth dis- trasound and X-ray orders - To gain an approach to the radiology of skele- - Phakomatoses (tuberous sclerosis, neurofi- tal dysplasia and isolated congenital malfor- bromatosis, etc.) mations - Langerhans Cell Histiocytosis - To be aware of need for investigation of con- genital and acquired scoliosis and muscular dystrophy 2.2.15 Rheumatology - To recognise the imaging features of juvenile arthritis and its differential diagnosis. 2.2.16. Neurological Disease - To understand the indications for examination - To recognise normal results on X-ray, ultra- sound, CT, and MR - To recognise trauma: skull and facial injurywww.ear-online.org 41
  • 44. Detailed Curriculum for the Initial Structured Common Programme Urogenital Radiology - Prostate: - To recognise zonal anatomy of the 1 – INTRODUCTION prostate - To identify prostatic zones with US and The aim of establishing a curriculum for training in uro- MRI genital imaging is to ensure trainees have acquired: - Scrotum: - To know the US anatomy of intra-scrotal - Knowledge of the relevant embryological, structures (testicular and extratesticular) anatomical, pathophysiological and clinical - To know the Doppler anatomy of testicular aspects of uronephrology and gynaecology and extratesticular vasculature - Understanding of the major imaging tech- niques relevant to uronephrological and gy- 2.1.3. Imaging techniques naecological diseases and problems - Sonography of urinary tract - Understand the role of radiology in the man- - To choose the appropriate transducer ac- agement of these specialist areas cording to the organ imaged - Knowledge of the indications, contra-indica- - To optimise scanning parameters tions, complications and limitations of proce- - To recognise criteria for a good sono- dures graphic image - To recognise and explain the main arti- 2 – CORE OF KNOWLEDGE facts visible in urinary organs - To be able to get a Doppler spectrum on 2.1. Urinary & male genital tract – Specific objectives intrarenal vessels (for resistive index measurement) and on proximal renal ar- 2.1.1. Renal physiology and kinetics of con- teries for velocity calculation trast agents - IVU - To understand the physiology of renal excre- - To list the remaining indications of IVU tion of contrast medium - To know the main technical aspects: - To understand the enhancement curves with- - Choice of the contrast agent in renal compartments after injection of con- - Doses trast agents - Film timing and sequences - To know the concentrations and doses of - Indication for ureteral compression contrast agents used intravenously - Indication of Frusemide - Cysto-urethrography 2.1.2. Normal anatomy and variants - To list the main indications of cysto-ure- - Retroperitoneum: thrography - To recognise retroperitoneal spaces and - To know the main technical aspects: pathways - Choice of technique: trans-urethral, - Kidney: transabdominal - To understand the triple obliquity of the - Choice of the contrast agent kidney - Film timing and sequences - To know the criteria of normality of the - To remember aseptic technique pyelocaliceal system on IVU - CT of the urinary tract - To recognise normal variants, such as - To define the normal level of density junctional parenchymal defect, column of (in HU) of urinary organs and components Bertin hypertrophy, fœtal lobulation, or - To know the protocol for a renal and adre- lipomatosis of the sinus nal tumour - To identify the main renal malformations, - To know the protocol for urinary obstruc- such as horseshoe kidney, duplications, tion (including stones) ectopia, or fusions - To know the protocol for a bladder tumour - Bladder and urethra: - MR of the urinary tract - To know the anatomy of the bladder wall - To know the appearances of urinary or- and physiology of micturion gans on T1 and T2w images - To identify the segments of male urethra - To know the protocol for a renal and adre- and location of urethral glands nal tumour42 www.ear-online.org
  • 45. Detailed Curriculum for the Initial Structured Common Programme - To know the protocol for urinary obstruc- - To know what aftercare is required tion - US-guided biopsies / cystic drainage, e.g. kid- - To know the protocol for a bladder tumour ney mass, prostate - To know the protocol for a prostatic tu- - CT-guided biopsies mour - Percutaneous nephrostomy 2.1.4. Pathology 2.2. Gynaecological Imaging - Kidney and ureter - Congenital – covered under 2.1.2. 2.2.1. Techniques - Obstruction - US examination - Calculus - To be able to explain the value of a US ex- - Infection amination - Tumours - To be able to explain the advantages and - Cystic diseases limits of abdominal vs. transvaginal ap- - Medical nephropathies proach - Vascular - To know indications and contra-indica- - Renal transplantation tions of hysterosonography - Trauma - Hysterosalpingography - Bladder - To be able to describe the procedure - Congenital – covered under 2.1.2. - To know the possible complications of - Obstruction hysterosalpingography - Inflammatory - To know the contra-indications of hys- - Tumours terosalpingography - Trauma - To explain the choice of contrast agent - Incontinence & functional disorders - To know the different phases of the exam- - Urinary diversion ination - Urethra - CT scan - Congenital - To be able to explain the technique of a - Strictures pelvic CT - Diverticula - To know the possible complications of CT - Trauma - To know the contra-indications of CT - Prostate & Seminal Vesicles . To know the irradiation delivered by a - Congenital pelvic CT - Benign prostatic hypertrophy - To know the required preparation of the - Inflammatory patient and the choice of technical param- - Tumours eters (slice thickness, Kv, mA, number of - Testis & scrotum acquisitions, etc.) depending on indica- - Congenital tions - Inflammatory - MRI - Torsion - To be able to explain the technique of a - Tumours pelvic MRI - Penis - To know the contra-indications of MRI - Impotence - To know the required preparation of the - Adrenal patient and the choice of technical param- - Masses eters (slice thickness, orientation, weight- ing, etc.) depending on indications 2.1.5. Interventional - Angiography - In general - To know the main indications of pelvic an- - To verify indications, satisfactory blood giography in women count, and coagulation status - To know how to perform a pelvic angiog- - To explain the procedure and follow-up to raphy the patient - To know what equipment is requiredwww.ear-online.org 43
  • 46. Detailed Curriculum for the Initial Structured Common Programme 2.2.2. Anatomy 3.2. To validate the request based on - To know main normal dimensions of uterus - Risk factors and ovaries with US - Irradiation involved - To describe variations of uterus and ovaries - Possible alternatives during genital life - To describe variations of uterus and ovaries 3.3. To perform the examination during the menstrual cycle - To know the clinical history and the clinical - To describe normal pelvic compartments questions to be answered - To identify normal pelvic organs and bound- - To know the protocol of examination aries on CT and MRI - To assess the anxiety of the patient before, - To explain the role of levator ani in the physi- during and after the examination, and provide ology of pelvic floor appropriate reassurance - To know what imaging modalities can be used to visualise the pelvic floor 3.4. Communication with the patient and the col- - To know the factors responsible for urinary in- leagues and recommendations for follow-up continence - To explain clearly the results to the patient - To assess the level of understanding of the 2.2.3. Pathology patient - Uterus - To explain the type of follow-up - Congenital anomalies - To assess the degree of emergency - Tumours (benign and malignant) - To produce a clear report of the examination - myometrium - To discuss strategies for further investigation, - endometrium if necessary - cervix - Inflammation - Adenomyosis - Functional disorders - Ovaries / Tubes - Ovary - Cysts - Tumours - Functional disorders, e.g. precocious puberty, polycystic ovaries - Endometriosis - Tubes - Inflammatory disorders - Tumours - Pelvis - Prolapse - Infertility 3 – TECHNICAL, COMMUNICATION AND DECISION- MAKING SKILLS 3.1. Before the examination - To check the clinical information and risk fac- tors (diabetes, allergy, renal failure, etc.) - To validate the request and the choice of ex- amination - To know the specific preparation and proto- cols, if necessary - To explain the examination to the patient and inform him / her about risks44 www.ear-online.org
  • 47. Detailed Curriculum for Subspecialty Training Detailed Curriculum for Subspecialty Training In the fourth and fifth years, the rotations of the radiolo- Formal teaching is organised on the basis of lectures, tu- gists in training should be organised to serve the individ- torials, and workshops. Whatever the chosen subspecialty ual’s needs depending on the availability in the training will be, the trainees should maintain one or two sessions programme, which may be in general radiology or in a of relevant general radiology during the week in order to subspecialty. maintain basic skills and participate in and gain experi- ence in emergency on-call work. General radiology training in the fourth and fifth years is designed to enable the trainee to gain further experience, The curricula for selected subspecialties are included in knowledge and skills in disorders that are present in gen- this document. In general terms, trainees are expected to eral hospitals and private practice in order to reach a level acquire the elements identified below. required to undertake autonomous practice. - Detailed knowledge of current theoretical and This period of training should include an extended period practical developments in their chosen subspe- of time in a minimum of two areas of special interest so as cialty (or subspecialties). to acquire more detailed knowledge and skills. General ra- - Development of clinical knowledge relevant to diologists being in training in areas of special interest may their chosen subspecialty (or subspecialties). wish to use the subspecialty curricula for guidance albeit - Extensive directly observed, or non-observed but recognising that they would not be required to fulfil all as- supervised practical experience in their chosen pects of them. subspecialty (or subspecialties). For trainees entering a subspecialty, the total period of In order to make the curriculum intelligible for each indi- subspecialist training will vary according to the subspe- vidual subspecialty as a stand-alone document, there is cialty but would normally be expected to be completed repetition of some of the generic points. These subspe- during the fourth and fifth years. For those subspecialties cialty curricula have been prepared by different European with a single year of subspecialty training, continued train- societies of specialty in radiology, for which the EAR ing in general radiology during the balance of time will be (ESR) is very grateful. Inevitably certain compromise deci- undertaken. Some subspecialty training may extend be- sions have had to be taken, especially in the face of con- yond the 5th year depending on national training arrange- flicting advice. Furthermore, each curriculum has had to ments relevant to their specialty programme. conform to a uniform style. Subspecialty training may be undertaken in a modular fashion during the fifth and / or fourth year(s) of training. Subspecialty training contains elements of choice to re- flect the requirements of the trainee. It is also appreciated that training in the individual subspecialties may vary from centre to centre. It is recommended for subspecialty rota- tion that there be a minimum commitment of six sessions per week to subspecialty training. It will sometimes be ap- propriate to link system-based expertise with technique- based expertise. Even within a subspecialty, there will be those individuals wishing to train in or have aptitude for certain areas at the relative expense of others. Thus, training in some centres and certain subspecialties may be delivered in a more modular fashion.www.ear-online.org 45
  • 48. Detailed Curriculum for Subspecialty Training Breast Radiology 3 – OVERVIEW 1 – INTRODUCTION - Trainees will have obtained a basic knowledge of breast diagnosis in their initial training. The train- The aim of subspecialised training in breast imaging is to ing outlined below will extend this to the practical prepare a radiologist for a career in which a significant role. portion of his / her time will be devoted to breast imaging - Those clinical radiologists who wish to devote es- and / or breast cancer screening with mammography. sentially all their time as specialists / consultants Such individuals will be expected to provide and promote in breast imaging should undertake 12 months or breast imaging and interventional methods, as well as its equivalent of subspecialty training. Those who new imaging breast cancer screening procedures. wish to practice breast imaging, as one out of a variety of activities would normally expect to un- The aims of establishing a curriculum for subspecialty dertake 6 months. training in breast radiology is to ensure: - Trainees will acquire an extensive knowledge of - An in-depth understanding of breast disease with the pathology and epidemiology of breast dis- particular knowledge of the nature of breast can- eases, both female and male and both primary, of cer in all its guises. local recurrence, as well as distant disease. They - A clear understanding of the role of imaging in should have at least a basic knowledge of the the early diagnosis of breast cancer. treatment of breast disease by surgery, radiother- - Development of the necessary clinical and man- apy and chemotherapy and be aware of the diag- agement skills to enable radiologists to become nostic needs of their surgical, radiotherapy and an integral part of a multidisciplinary breast team oncology colleagues. It would therefore be help- in symptomatic and / or population screening set- ful for trainees to spend time in breast clinics, op- tings. erating theatres, as well as radiotherapy and oncology departments. 2 – EXPERTISE AND FACILITIES - Trainees also must develop skills in the use and interpretation of imaging modalities used in the - Training must be undertaken in a team with ac- diagnosis and treatment of the distant spread of cess to full clinical service in radiology, general a disease, e.g. plain radiographs, ultrasound, CT, surgery / gynaecology and pathology. If possible, MR, and nuclear medicine. They will receive oncology, radiotherapy, plastic surgery, social training in communication with patients and col- and preventive medicine should also be offered. leagues and "breaking bad news". - Training should be supervised by a radiologist - They must obtain extensive experience in all di- with extensive experience in breast imaging and agnostic procedures listed in the syllabus and will breast cancer screening methods (e.g. reporting be expected to be familiar with the current breast 5,000 mammograms per year). The training de- imaging literature, both from standard textbooks partment(s) should fulfil EU guidelines, must and original articles. have mammography, ultrasonography and inter- - As audit is an integral part of the process of ventional equipment including stereotaxic and ul- breast imaging, particularly screening, the trasonically guided biopsy systems. trainee will have ready access to data to analyse - Trainees should also have access to breast MRI, the proficiency of his or her activities. nuclear medicine and acquire knowledge of Additionally, the trainee will be expected to com- breast cancer screening. plete a focused audit and develop an under- - Trainees must also have access to a radiological standing of the process of interval cancer review. library containing senology and radiology text- - They should participate in research and be books along with journals and must have access encouraged to pursue a project up to and includ- to a film library. ing publication. An understanding of the princi- ples and techniques used in research, including the value of clinical trials and basic biostatistics, should be acquired. - They must attend regular multi-disciplinary con- ferences.46 www.ear-online.org
  • 49. Detailed Curriculum for Subspecialty Training 4 – THEORETICAL KNOWLEDGE breasts and associated structures including synchronous and metachronous disease Trainees should attend 40 hours of theoretical training in - Knowledge and understanding of benign and the form of locally delivered tutorials, specialist breast im- malignant diseases of the breast and associ- aging courses as well as national and international breast ated structures and how these processes imaging and breast screening conferences such as those manifest both clinically and on imaging of EUSOBI and ECR. - Knowledge of the spread of breast carcinoma and the pathology in other organs - Clinical training - Imaging techniques - Knowledge of the clinical findings associated Trainees should understand the principles of all with normal, benign and malignant tissue imaging methods including: - Knowledge of the risks of breast disease as- - Relative indications and contraindications sociated with family history, hormone replace- - Complications ment therapy, etc. - Recognition of artefacts - Knowledge of breast surgery, treatment and - Normal appearances, normal variations, be- reconstruction and how these might influence nign and malignant processes (both primary), imaging appearances local recurrence and distant spread - Radiation protection - Limitations of individual techniques, examina- - Knowledge and understanding of the current tions, sequences / views and the complemen- legislation governing the use of ionising radi- tary nature of other techniques and the role of ation and of the responsibilities as defined in each technique in the investigation of breast national and European legislation disease - Knowledge and understanding of the need to - Knowledge and understanding of how imag- minimise the radiation dose received by the ing findings influence decisions by others, patient / client e.g. surgeons, pathologists, oncologists, etc.: - Knowledge and understanding of the risk / - Mammography including additional and benefit analysis associated with breast special views screening using ionising radiation as com- - Ultrasound pared with other techniques, e.g. ultrasound, - MRI MR - Nuclear medicine - Physics - Screening For all imaging modalities - Knowledge and understanding of the aims, - Knowledge and understanding of the physics objectives and principles of population breast of image production and how alteration of screening machine parameters affect the image - Knowledge and understanding of the risks - Knowledge and understanding of image and benefits of screening by the population recording and display systems and how alter- and the individual, including those related to ations in machine parameters affect the age factors, family history, and hormone image replacement therapy - Knowledge and understanding of Quality - Knowledge and understanding of the objec- Assurance Programmes and the impact that tives and principles of Quality Assurance image quality has on clinical performance. - Understanding of the principles and tech- - Knowledge of artefacts, limitations of resolu- niques used in audit and research, including tion, and contrast the value of clinical trials and basic biostatis- - Anatomy and Pathology tics. - Knowledge and understanding of normal em- - Knowledge and understanding of legal liabili- bryology, physiology and anatomy of the ty and processes breast and associated structures in particular changes due to age, lactation, hormonal sta- tus, surgery, radiotherapy, etc. - Knowledge and understanding of normal physiology, pathology and pathophysiology ofwww.ear-online.org 47
  • 50. Detailed Curriculum for Subspecialty Training 5 – TECHNICAL, COMMUNICATION AND DECISION- - Practical experience MAKING SKILLS The trainee must obtain a substantial experience in all clinical, imaging and interventional tech- - Clinical training niques that are listed above. - Ability to undertake physical examination of the breast and associated structures. Minimum experience per month of training: - Interventional techniques - Interpretation of screening mammograms - Trainees should understand the principles of 300 cases all interventional methods including: - Interpretation of symptomatic cases in- - Relative indications and contraindications cluding ultrasound - Complications 80 cases - Advantages and disadvantages - Experience of image-guided procedures - Limitations of individual examinations and 20 cases complementary nature of other tech- niques and the role of each technique in the investigation of breast disease - Knowledge and understanding of how biopsy and interventional techniques in- fluence decisions and treatment planning by others, e.g. surgeons, pathologists, on- cologists, etc. - The applicable procedures are: - Cyst aspiration - Fine needle aspiration cytology (free hand- and / or image-guided) - Mechanical and vacuum-assisted core biopsy (free hand- and / or image-guided) - Image-guided localisation - Abscess management - MR-guided focused ultrasound and any other new techniques - Communication - Knowledge and understanding of the impor- tance of effective communication with both the patient and the members of the multidisci- plinary team - Knowledge and understanding of the princi- ples of breaking bad news and the psychoso- cial consequences of doing this badly - Teamworking - Knowledge of roles and responsibilities of other members of the breast imaging team, e.g. clerical officers, radiographers, nurses, support staff, secretaries, etc. - Knowledge of roles and responsibilities of other members of the Multi-Disciplinary Team - Knowledge and understanding of how imag- ing findings influence decisions by others, e.g. surgeons, pathologists, oncologists, etc.48 www.ear-online.org
  • 51. Detailed Curriculum for Subspecialty Training Cardiac Radiology to combined clinico-radiological conferences. The following clinical interrelationships should be ex- 1 – INTRODUCTION plored: - Cardiology (adult and paediatric) This curriculum outlines the training requirements to pre- - Cardiac surgery (adult and paediatric) pare a radiologist for a career in which a significant pro- - Cardiac pathology portion of his / her time will be devoted to cardiac - Cardiac anaesthesia / critical care and emer- radiology. gency medicine - In some instances, it may be appropriate for the Trainees in radiology should have undergone training and trainee to have a regular attachment to cardiac education in cardiovascular / cardiac radiology prior to out-patient clinics / ward rounds / CCUs in order subspecialty training and will therefore have already ob- to acquire further clinical knowledge relevant to tained basic skills. the subspecialty. - Experience will be documented in logbooks. If It is expected that some trainees will wish to devote the adequate experience cannot be offered in one entire subspecialty training period to cardiac radiology training scheme, it will be necessary for the with a view to devoting a large portion of their future ca- trainee to have a period of secondment at other reer to this area. Other trainees may be more inclined to training schemes with a large active practice in combine elements of this training programme with anoth- another centre. er specialist area, such as vascular or thoracic radiology - The trainee should participate in clinical audit rel- over a two-year-period. This document outlines a frame- evant to the subspecialty. work for both full-time and modular approaches to training - The trainee should be encouraged and given the in cardiac radiology. opportunity to attend appropriate meetings and courses. The aim of establishing a curriculum for subspecialty - The trainee should be involved in research and training in cardiac radiology is to ensure: have the opportunity to present in suitable na- - A detailed knowledge of current theoretical and tional and international meetings. The progres- practical developments in the specialty sion of research projects to formal peer-reviewed - Extensive hands-on experience with graded su- publication should be supported and encouraged pervision by the supervising consultant(s). - Clinical knowledge relevant to cardiology so that - The trainee should be encouraged to participate the trainee may confidently discuss the appropri- in an on-call rota along with an appropriate back- ate imaging modality for the clinical problem with up. the referring clinician - The posts should be approved and recognised - A knowledge of the relevant embryological, for training by the ESCR. anatomical, pathophysiological, biochemical and clinical aspects of cardiac disease 3 – GENERAL OVERVIEW - An in-depth understanding of the major imaging modalities relevant to cardiac disease - The period spent in training will vary according to - Direct practical exposure – with appropriate graded whether the trainee wishes to combine subspe- supervision – in all forms of cardiac imaging cialty training in cardiac radiology with another specialist area (such as thoracic radiology), or 2 – EXPERTISE AND FACILITIES whether the trainee wishes to make cardiac radi- ology alone the prime focus. - UEMS-Training charter in diagnostic radiology identifies the core of knowledge required during - For trainees wishing to specialise primarily in car- the common trunk of radiology training. Basic diac radiology, a period of 12 months substantial- skills in the cardiovascular system will therefore ly devoted (minimum of 8 sessions per week) to have been acquired prior to sub-specialist train- the subject is recommended. ing. - Clinical knowledge will be obtained by a variety of - For trainees wishing to specialise in cardiac radi- means, including close liaison with the appropri- ology together with another area of interest, the ate surgical and medical teams, e.g. by exposure training can be provided in a modular trainingwww.ear-online.org 49
  • 52. Detailed Curriculum for Subspecialty Training programme over two years. media), the trainee should be fully competent in - The exact structure of the training programme basic and advanced life-support. Regular "re- needs to be flexibly interpreted to allow for local fresher" course training should be undertaken at facilities and expertise. Rather than adopt a least on a yearly basis and formal ALS certifica- "number of investigations required" approach, it tion should be considered. is suggested that centres wishing to offer training - The trainee should become aware of the local in cardiac radiology as either a major or minor and national guidelines in obtaining informed pa- subspecialty option make available a fixed num- tient consent where appropriate. ber of sessions offering the requisite experience. An example schedule is given below (per week): 4 – THEORETICAL KNOWLEDGE - CXR film interpretation (1 session) - Echocardiography (1 session) - Basic Sciences - Cardiac CT and MRI (2 sessions) - Basic cardiac and cardiovascular physiology - Coronary angiography / left and right heart - Cardiac and cardiovascular anatomy includ- catheterisations (1 session) ing the heart great vessels, peripheral arterial - Nuclear cardiology (1 session) tree and the pulmonary arteries - Research (2 sessions). - Basic biochemistry related to cardiac diagno- The remaining 2 sessions per week would be sis and treatment used to maintain experience in general radiology - Radiation physics and radiation protection as according to local departmental service require- applied to cardiac diagnosis ments. - Principles of radio-isotope imaging It is stressed that the schedule above is intended - Principles of cardiac gating and cardiac trig- as an example only. Clearly the exact ratio of gering training in the different modalities of cardiac im- - Applied Sciences aging will need to reflect the individual interests - Basic cardiovascular pharmacology use and of the trainee, as well as the experience that can limitations of commonly prescribed cardiac be offered locally. drugs including cardiac stress agents. - In a situation where the interests of a trainee can- - Applied pharmacology of contrast agents and not be met entirely locally, it may be appropriate radionuclide imaging agents to negotiate a period of "external" training either - Applied physiology of cardiac stress testing as a block elective period or as an ongoing regu- - Knowledge of normal cardiac parameters, in- lar day release. cluding the cardiac cycle, blood flow cardiac - Regardless of the imaging modality concerned, output, pressures, and flow-dynamics the trainer or training committee must be satisfied - Clinical Sciences with the trainee being able to consistently inter- - Knowledge of ECG interpretation pret the results of such investigations accurately - Common cardiac pathology and reliably. All studies should be reviewed in a - Common cardiac disease presentations formal reporting session. It is recognised that for - Basic epidemiology of cardiovascular disease some modalities (such as cardiac ultrasound) su- - Current Clinical Practice pervision may be provided by non-consultant - Knowledge of modern therapy rationale in- personnel, provided they are of sufficient seniori- cluding risk assessment ty and experience. - Basic knowledge of cardiac disease presen- - The modalities listed and the time devoted to tation and non-imaging diagnostics each will be reviewed at intervals. It is recognised - Age-based presentations of cardiac disease that some studies will become obsolete and new - Treatment of common cardiac conditions imaging techniques will be developed. - Cardiac Radiology Practice - The trainee should become familiar with provid- - Understanding of principles of each cardiac ing analgesia and / or sedation where required as imaging modality well as the necessary continuous monitoring re- - Selection of appropriate imaging modality for quired to perform this safely. the patient´s condition, including risks and - In view of the use of potentially hazardous tech- benefits niques (e.g. angiography) and substances (e.g. - Limitations and advantages of each method adenosine, dobutamine, iodinated contrast of cardiac imaging50 www.ear-online.org
  • 53. Detailed Curriculum for Subspecialty Training - Management - Principles, uses and interpretation of stress - Principles of managing a cardiac imaging and non-stress echocardiography, including service transoesophageal echocardiography - Purchase and selection of equipment - Principles, uses and limitations of nuclear - Research cardiac imaging - Methodology of research in cardiac imaging - Principles of intravascular imaging and cardiology - Stress testing - Evidence base in cardiac imaging - Principles, uses and limitation of exercise - Knowledge of statistical methods stress testing - Methodology of scientific writing and presen- - Methods of stress testing as applied to car- tation diac imaging - Medico-legal - Patient management of stress testing for car- - Understanding of medico-legal issues relat- diac imaging ing to cardiac radiology - Understanding of uncertainty and error in car- 6 – APPRAISAL AND ASSESSMENT diac imaging practice At the end of the programme, the trainee should: 5 – TECHNICAL, COMMUNICATION AND DECISION- MAKING SKILLS - Be able to supervise technical staff to ensure ap- propriate images are obtained; - Plain Film Interpretation - Discuss significant or unexpected radiological - Limitations, advantages and principles of findings with referring clinicians and know when chest X-ray diagnosis of adult and congenital to contact a clinician; cardiac disease - Be able to recommend the most appropriate im- - CT Interpretation and patient management aging modality, appropriate to the patients´ - CT anatomy of the heart, pulmonary arteries symptoms or pathology or request from the refer- and great vessels ring clinician; - Principles of spiral and ultrafast CT of the - Develop skills in forming protocols, monitoring heart including prospective and retrospective and interpreting cardiac studies, appropriate to gating patient history and other clinical information; - Interpretation of cardiac and pulmonary - Demonstrate the ability to effectively present car- pathology diac imaging in a conference setting. - Contrast administration - Decision-making on the basis of patients´ symptoms and CT diagnosis - MRI Interpretation and patient management - MRI anatomy of the heart, great vessels, pul- monary, and peripheral vascular system - Principles of image sequencing and spe- cialised gating - Interpretation of cardiovascular and pul- monary pathology - Understanding of cardiac physiology related to MRI, including flow sequencing and spe- cialised tagging techniques - Uses, limitations and hazards of MRI cardiac imaging - Cardiac imaging by other modalities - Principles, uses and limitations of cardiac an- giography catheterisation and pressure measurementwww.ear-online.org 51
  • 54. Detailed Curriculum for Subspecialty Training Chest Radiology 2 – EXPERTISE AND FACILITIES 1 – INTRODUCTION The trainee undergoing subspecialty training should be actively involved in thoracic imaging within an educational This curriculum outlines the subspecialty training require- environment with graduated supervision. ments for specialist training in thoracic radiology. This in- volves those aspects of radiology which provide Training must be undertaken in a team with access to ap- information about anatomy, function, disease states and propriate CT, MR, ultrasound, fluoroscopy, and radionu- those aspects of interventional radiology or minimally in- clide imaging facilities. vasive therapy appertaining to the thorax. The trainee should be exposed to a clinical service involv- The aim of subspecialised training in thoracic radiology is ing thoracic medicine, thoracic surgery, respiratory pathol- to enable the trainee to become clinically competent and ogy, and a pulmonary function laboratory. An up-to-date to consistently interpret the results of thoracic investiga- database of "interesting cases" or "teaching files" should tions accurately and reliably. Where appropriate, trainees be present in the training department. also need to be capable of providing a comprehensive and safe interventional diagnostic and therapeutic service. Additionally, the training department should have access to interesting educational sites on the internet. The aim of establishing a curriculum for subspecialty training in thoracic radiology is to ensure the trainee ac- Trainees must also have access to a radiological library con- quires: taining textbooks on thoracic radiology, thoracic medicine, - Knowledge of the relevant embryological, thoracic surgery, pathology, and pulmonary physiology. anatomical, pathophysiological and clinical as- pects of thoracic disease; 3 – THEORETICAL KNOWLEDGE - An in-depth understanding of the major imaging techniques relevant to thoracic disease; The trainee should acquire: - An in-depth understanding of the indications, - A comprehensive knowledge of normal respirato- contraindications and complications of surgical, ry function and thoracic diseases, including: medical and radiological interventions and proce- - The embryology, anatomy, normal variants dures including radiation exposure issues and and pathophysiology relevant to cardiorespi- contrast media; ratory function - Clinical knowledge relevant to thoracic medicine - The pathology of benign and malignant con- and surgery such that the trainee may confident- ditions involving the thorax ly discuss the appropriate imaging strategy for - The epidemiology of lung diseases the clinical problem with the referring clinician; - The principles of population screening for - Detailed knowledge of current technological and lung cancer and other lung diseases clinical developments in the specialty; - The techniques used in thoracic surgery - Direct practical exposure with appropriate graded - The techniques involved in all imaging and in- supervision of all forms of thoracic imaging and terventional procedures used in evaluating intervention; and treating thoracic diseases, including - Competence in basic and advanced life-support. managing the complications of these proce- dures The anticipated outcome at the end of subspecialty train- - Local, national and, where appropriate, inter- ing in thoracic radiology will be that the trainee can select national imaging guidelines relevant to tho- the suitable imaging modality for thoracic problems, su- racic radiology pervise (and perform where appropriate) the examination and accurately report on the examination findings. The - Knowledge of the full range of radiological diag- trainee should be competent in all aspects of thoracic im- nostic techniques available, in particular: aging and intervention. - The indications, contraindications and com- plications of each imaging method - The factors affecting the choice of contrast media and radiopharmaceuticals - The effects and side effects of these agents52 www.ear-online.org
  • 55. Detailed Curriculum for Subspecialty Training - Radiation dose reduction strategies, particu- - Respiratory medicine out-patients exami- larly for paediatric patients nations - Particular emphasis should be placed on the - CT of the thorax including: strengths and weaknesses of the different imag- - The staging of bronchial carcinoma ing methods in various conditions. The appropri- - The investigation of ate choice of imaging techniques and / or the - Pleural lesions appropriate sequence of imaging techniques in - Thoracic wall lesions the investigation of specific clinical problems - Pulmonary lesions should be emphasised. - Mediastinal lesions - Identification and categorisation of diffuse 4 – TECHNICAL, COMMUNICATION AND DECISION- interstitial lung disease MAKING SKILLS - Identification of large and small airways disease - Specific skills to enable: - CT pulmonary angiography - The conduct, supervision and accurate inter- pretation of all imaging techniques used in - MRI in thoracic imaging where applicable the investigation of thoracic diseases to a consistent and high standard; - Radionuclide radiology including: - The accurate localisation and, where appro- - Ventilation / perfusion lung scintigraphy priate, biopsy of pulmonary, mediastinal, (only) pleural and chest wall masses and lymph - PET and its application to lung cancer nodes; staging - Where appropriate, the safe and effective practice of interventional techniques; - Interventional techniques. - Good communication with patients and pro- Trainees should acquire experience in the fol- fessional colleagues; lowing procedures: - Accurate informed consent to be obtained - Biopsy of thoracic wall, pleural, pul- from patients; monary and mediastinal lesions including: - Continuing accreditation and maintenance of - CT-guided life-support skills. - Ultrasound-guided - Other interventional procedures including: - A clear understanding of the purpose of multidis- - Ultrasound-guided thoracocentesis ciplinary meetings, including their role in: - Chest drain insertion - The planning of investigations, including the selection of appropriate tests and imaging - Optional interventional procedures: techniques for the diagnosis of benign and - Bronchoscopy malignant disease; - Airway stenting - The staging of malignant disease; - Vascular (e.g. SVC) stenting - The planning and outcomes of treatment; - Thoracoscopy - The detection of errors in diagnosis and com- plications of treatment. - Clinical knowledge will be acquired by a variety of means, including close liaison with appropriate - During the training period it is recommended that medical, surgical and oncological teams and the trainees obtain experience in the following: combined clinical and radiological meetings. - Plain radiography including: Multidisciplinary cancer meetings should be an - Primary care examinations important component. Inter-relationships with the - Post-operative (cardiac and thoracic sur- following disciplines are also important: gery) examinations - Thoracic medicine - Intensive care and high-dependency unit - Thoracic surgery examinations - Respiratory pathology - Thoracic trauma - Pulmonary physiology - Paediatric examinationswww.ear-online.org 53
  • 56. Detailed Curriculum for Subspecialty Training - It may be useful for the trainee to have a regular Gastrointestinal and attachment to thoracic out patient clinics, ward rounds and bronchoscopy / theatre sessions in Abdominal Radiology order to further clinical knowledge relevant to the 1 – INTRODUCTION subspecialty. The subspecialty training programme in gastrointestinal - The trainee should be encouraged and given the and abdominal imaging further extends the knowledge opportunity to attend and lead appropriate clini- acquired during the common trunk and is dedicated to co-radiological and multidisciplinary meetings. train radiologists with strong devotion to spend major The trainee should be encouraged to attend ap- parts of their professional activity in close cooperation propriate educational meetings and courses. with clinicians practicing gastroenterology and abdominal surgery. The ideal framework is supposed to be a large - The trainee should participate in relevant clinical clinical centre with wide experience in gastroenterology, audit, management and clinical governance and abdominal surgery, oncology, diagnostic and intervention- have a good working knowledge of local and na- al radiology, possessing imaging modalities necessary to tional guidelines in relation to radiological prac- perform state-of-the-art gastrointestinal and abdominal tice. radiology. The principles of evaluation of a resident’s knowledge, skills and overall performance, including the - Trainees will be expected to be familiar with cur- development of professional attitudes, are tailored to fit rent thoracic radiology literature. The trainee the general evaluation system and standards of other should be encouraged to participate in research subspecialties. and to pursue one or more project(s) up to and including publication. An understanding of the 2 – THEORETICAL KNOWLEDGE principles and techniques used in research, in- cluding the value of clinical trials and basic bio- During the training in the subspecialty of gastrointestinal statistics, should be acquired. Presentation of and abdominal radiology, the resident should have research and audit results at national and inter- achieved the following knowledge-based objectives: national meetings should be encouraged. - Anatomy and Physiology 5 – APPRAISAL AND ASSESSMENT - Detailed anatomic knowledge of the sections of the gastrointestinal tract, the diaphragm, - Regular appraisal of the trainee is mandatory the abdominal wall, the pelvic floor, the peri- and the consultant trainer must be satisfied that toneal cavity, the liver, spleen, biliary tract and the trainee is clinically competent, as determined pancreas using plain films, fluoroscopy, bari- by an in-training performance assessment, and um / gastrografin studies, sonography, CT, can consistently interpret the results of investiga- and MRI tions accurately and reliably. - To know the arterial supply and venous drainage of the various portions of the gas- - Methods of trainee assessment include: trointestinal tract; to explain the possible vari- - Regular direct observation of clinical tech- ations of flow in the superior mesenteric niques (including communication skills, ability artery and vein and the portal and hepatic to obtain informed consent and sedation veins skills) by the trainer and / or external observ- - To know the lymphatic drainage of the rele- er; vant organs - Regular formal review of the trainee’s skills in - To know the important variants of anatomy the accurate interpretation of investigations - To have a basic understanding of physiology for thoracic diseases; of the gastrointestinal tract and the abdominal - A final assessment of overall professional organs competence. - Oesophagus - To identify oesophageal perforation on plain films, contrast studies, and CT - To identify mega-oesophagus, diverticulum,54 www.ear-online.org
  • 57. Detailed Curriculum for Subspecialty Training extrinsic compression, fistulae, sliding and phoid hyperplasia of the terminal ileum, and para-oesophageal hiatus hernia, benign stric- the most common mid gut abnormalities tures, varices, oesophagitis and oesophageal (malrotation, internal hernia) cancer on a contrast examination and / or CT; - To perform a CT examination of the small to analyse the criteria for non-resectability bowel, including CT enteroclysis. Identify a and lymph node involvement in oesophageal transitional zone in case of small bowel ob- cancer on CT; to know the TNM staging of oe- struction; to identify a small bowel tumour sophageal cancer and the potential role of (adenocarcinoma, lymphoma, carcinoid tu- PET-CT in this setting mour, stromal tumour); to identify mural pneu- - To understand the basic surgical techniques matosis, vascular engorgement, increased in oesophageal surgery / radiation therapy density of the mesenteric fat, duplication and identify post-surgical / post-radiation cysts and malrotation; to know the potential therapy appearances on imaging examina- role of MRI in examining the small bowel. tions - To determine the cause of small bowel ob- struction on CT (adhesion, band, strangula- - Stomach and Duodenum tion, intussusception, volvulus, internal and - To define the most appropriate imaging ex- external hernias) and their complications; to amination and contrast use in suspected per- identify criteria for emergency surgery foration of the stomach and postoperative follow-up; to name the limitations of each ex- - Colon and Rectum amination for these specific conditions - To determine the optimal imaging examina- - To understand the imaging features (on bari- tion to study the colon according to the sus- um studies and CT) of a variety of conditions, pected disease (obstruction, volvulus, such as benign and malignant tumours, in- diverticulitis, tumour (including lymphoma cluding GIST, infiltrative disorders (e.g. linitis and carcinoid), inflammatory disease, perfo- plastica), gastric ulcers, duodenal diverticu- ration, postoperative evaluation) and know lum, and positional abnormalities including the limitations of each technique gastric volvulus - To know the indications of virtual CT / MRI - To perform a CT examination of the stomach / colonoscopy duodenum, using the most appropriate proto- - To identify rotational abnormalities of the col according to the clinical problem, and colon on contrast studies and CT stage carcinoma and lymphoma on CT; to - To identify the normal appendix on CT and know the potential role of PET-CT in nodal sonography; to know the various features of staging appendicitis on CT and sonography - To know the different features of colon tu- - Small Bowel mours, including GIST, diverticulitis, inflam- - To determine the most appropriate imaging matory diseases, colon ischaemia, and examination in the following cases: small radiation-induced colitis bowel obstruction, inflammatory disease, - To identify a megacolon, colonic diverticulosis small bowel perforation and ischaemia, can- and diverticulitis, colitis, colonic fistula, carci- cer, lymphoma, carcinoid tumour and post- noma, polyps, and postoperative stenosis on operative follow-up; to name the limitations of an enema each examination for these specific cases - To identify colonic diverticulosis, diverticulitis, - To know the features of small bowel diseases tumour stenosis, ileocolic intussusception, on small bowel series, including stenosis, fold colonic fistula, paracolic abscess, intra-peri- thickening, nodules, ulcerations, marked an- toneal fluid collection, colonic pneumatosis, gulation, extrinsic compression, diverticula, and pneumo-peritoneum on CT and fistula - To know the CT features of colo-rectal cancer - To identify on a small bowel series the follow- and identify criteria for local extent (enlarged ing diseases: adenocarcinoma, polyposis, lymph nodes, peritoneal carcinomatosis, he- lymphoma, carcinoid tumour, GIST, Crohn’s patic metastases, and obstruction); to know disease, radiation-induced injury, malrotation, the TNM classification of colo-rectal cancer Meckel’s diverticulum, diverticulosis, lym- and the potential role of PET-CT; to under-www.ear-online.org 55
  • 58. Detailed Curriculum for Subspecialty Training stand the most frequent operative techniques cases and giant haemangioma; to discuss the that may be used to treat colo-rectal cancer indications for CT or MRI as an adjunct to US - To identify tumour recurrence after surgery; to - To describe the usual appearance of focal know the criteria that may help in differentiat- nodular hyperplasia and liver cell adenoma ing between postoperative fibrosis and tu- on sonography, including Doppler US, con- mour recurrence; to know the potential role of trast sonography, CT and MRI PET-CT - To know the appearance of fatty liver, both - To know the MRI appearance of pelvic / peri- homogenous and heterogeneous, on sonog- anal fistula and abscesses as well as the in- raphy, CT and MRI (including in- / out-of- creased risk of anal carcinoma in Crohn’s phase imaging and fat suppression images). disease with long standing perianal complica- - To describe the appearance of iron overload, tions causes and quantitation with MRI - To describe the natural history of hepatocellu- - Peritoneum and abdominal wall lar carcinoma (HCC), major techniques and - To identify the various types of abdominal indications for treatment (surgical resection, wall hernias (inguinal, umbilical, parastomal, chemotherapy, chemoembolisation, percuta- postoperative) on a CT scan neous ablation, liver transplantation). - To identify a mesenteric tumour and to deter- - To describe the appearance of HCC on mine its location on CT sonography (including Doppler and contrast - To know the features of a mesenteric cyst on enhanced sonography), CT and MRI CT - To describe the usual appearance of liver - To recognise the features of mesenteric pan- metastases on sonography (including niculitis and sclerosing mesenteritis Doppler), CT and MRI - To know the normal features of the peri- - To describe the most common morphologic toneum on sonography and CT; to identify the changes associated with liver cirrhosis: lobar following peritoneal diseases on CT: peri- atrophy or hypertrophy, regeneration nodules, toneal carcinomatosis, peritoneal tuberculo- fibrosis; to know the main causes for liver cir- sis and mesenteric lymphoma rhosis - To identify ascites on sonography and CT; to know the features of loculated ascites - Biliary Tract - To know the imaging methods for the detec- - Vessels tion of gall bladder and common bile duct - To identify small bowel infarct on CT stones - To perform and interpret an angiographic - To know the common appearance of acute study of the mesenteric vessels and identify cholecystitis (including emphysematous occlusion and stenosis of the superior cholecystitis) on sonography, including mesenteric artery Doppler, CT and MRI - To list the main causes for gallbladder wall - Liver thickening - To localise a focal liver lesion according to - To describe the appearance of gallbladder liver segmentation and major vessels anato- cancer on sonography, CT and MRI my (hepatic and portal vein, IVC). - To know the appearance of cholangiocarcino- - To describe the appearance of typical biliary ma of the liver hilum (Klatskin tumour) and cyst on sonography, CT and MRI know how to stage it - To describe the appearance of Hydatid cysts - To know the appearance of ampullar carcino- - To list the differences between amoebic ab- ma on sonography, CT and MRI, and list dif- scess and pyogenic abscess of the liver (ap- ferential diagnoses pearance, evolution, treatment, indication for - To describe the common appearance of scle- drainage). rosing cholangitis on sonography, CT and - To describe the most common surgical proce- MRI, including MRCP; to know the natural dures for hepatectomy history of associated cholangiocarcinoma - To know the appearance of liver haeman- - To know the main congenital disorders of the gioma on US, CT, and MRI, including typical bile ducts: Caroli disease, choledochal cyst56 www.ear-online.org
  • 59. Detailed Curriculum for Subspecialty Training (and the risk of cholangiocarcinoma). 3 – TECHNICAL, COMMUNICATION AND DECISION- - To describe the main techniques for surgery MAKING SKILLS of the bile duct and common complications By the end of the fifth year, the resident should have ac- - Pancreas quired the following skills: - To know the natural history of acute and - General Requirements chronic pancreatitis - To know the indications and contra-indica- - To identify pancreatic calcifications on plain tions of the various imaging examinations in films, sonography and CT abdominal imaging - To know the common appearance of extra- - To indicate to the referring physician the most pancreatic fluid collection and phlegmons in appropriate imaging examination according case of acute pancreatitis to the clinical problem - To know the ductal changes in chronic pan- - To determine the best contrast material and creatitis with MRI and secretine its optimal use according to the imaging tech- - To detect a pancreatic pseudocyst nique and the clinical problem - To know the most common appearance - To tailor the examination protocol to the (nodular, infiltrating) of pancreatic adenocar- clinical question cinoma on sonography, CT and MRI, and per- - To supervise technical staff to ensure appro- form staging in order to choose a treatment priate images are obtained - To know the features of endocrine tumours - To evaluate the quality of the imaging exami- - To describe the usual appearance of cystic nations in abdominal imaging tumours of the pancreas, mainly serous and - To know the relative cost of the various imag- mucinous cystadenoma, intraductal muci- ing examinations in abdominal imaging nous tumour and rare cystic tumours - To understand the radiation exposure and - To describe the main techniques for pancre- risks of different investigations atic surgery and potential complications - Specific Requirements - Spleen Plain Abdominal Film - To know the appearance of accessory spleen - To describe patient positioning and know the and splenosis on sonography, CT and MRI three basic indications for a plain radiograph - To name common causes of splenomegaly - To understand the clinical indications for ob- (e.g. lymphoma, portal hypertension, or taining plain radiographs and when further haematological disorders) views or a CT or MRI may be necessary - To identify splenic infarction on sonography, - To diagnose pneumoperitoneum, mechanical CT and MRI obstruction and pseudo obstruction, toxic di- - To know common causes of focal splenic le- latation of the colon, gas in small and large sions (cyst, hydatid cyst, metastasis, lym- bowel wall indicating ischaemia and necrosis, phoma, abscess, haemangioma) pancreatic and biliary calcifications and aerobilia - Trauma Upper Gastrointestinal Tract X-ray Examination - To know the CT technique for trauma patients - To perform and interpret both single and dou- - To identify abdominal hematoma, active ble contrast X-ray examination of the upper bleeding, parenchymal laceration and trau- gastrointestinal tract and to determine the matic lesions of the gastrointestinal tract; to most appropriate contrast material; to under- know the limitations of CT to identify gastroin- stand the principles and limitations of these testinal tract lesions studies, their advantages and disadvantages - To know which conditions require immediate compared to endoscopy embolisation or surgery - To perform and interpret small bowel follow- through and enteroclysis, including catheter (Links for reference cases to be sampled in EURORAD placement beyond the ligament of Treitz; to will be provided later.) appreciate the importance and degree of fill- ing and distension of small bowel loopswww.ear-online.org 57
  • 60. Detailed Curriculum for Subspecialty Training Lower Gastrointestinal Tract X-ray Examination - To have experience in the use of workstations - To perform and interpret a double contrast for multiplanar reconstructions (MPR) and 3D barium enema and a single contrast enema reconstruction based around volume data - To know how to catheterise a stoma for colon sets opacification and how to perform pou- chograms and loopograms Interventional Imaging - To know the indications and contraindications - To perform percutaneous drainage of abdom- for enema techniques and determine the opti- inal collections using CT and sonography mal contrast material and technique to be - To perform percutaneous biopsy of the liver used in each clinical situation and other organs under sonographic and CT - To perform and interpret defecography (with guidance X-ray and MRI) - To perform angiography of the abdominal ar- teries Sonography - To perform selective embolisation of the ab- - To perform an ultrasound examination of the dominal arteries in hemorrhage and treat- liver, gall bladder, biliary tree, pancreas, ment of tumours spleen, and the gastrointestinal tract - To perform percutaneous gastrostomy under - To recognise the retroperitoneal structures image guidance and understand the application and limita- - To perform percutaneous biliary intervention tions of sonography in this area - To perform radiologically guided stenting of - To know the indications and contraindications the biliary system and gastrointestinal sys- of contrast agents tem, using PTFE and expandable metal stents Computed Tomography - To know indications and contraindications of - To perform a CT examination of the abdomen common interventions in gastrointestinal and and to tailor the protocol to the specific organ abdominal radiology or clinical situation to be studied; to determine whether intravenous administration of a con- Endoscopy and endoscopic ultrasound (optional) trast material is needed; to determine the op- - To perform endoscopic evaluation of gastroin- timal protocol for the injection of contrast (rate testinal tract of injection, dose, delay); to know the various - To perform and interpret endoscopic ultra- phases (plain, arterial-dominant, portal-domi- sound examination of the oesophagus, pan- nant, late phase) and their respective values creas, biliary tract, and rectum according to the clinical problem - To determine the best contrast material for - Communication and Decision-Making Skills imaging a specific gastrointestinal segment - To justify and explain the indication and the according to the clinical problem (water, air, examination conduct to the patient fat, iodine or barium containing contrast ma- - To obtain fully informed consent terials) - To inform the patient of the results of the ex- - To have experience in the use of workstations amination and evaluate the patient’s under- for multiplanar reconstructions (MPR) and 3D standing reconstruction based around volume data - To make a precise and concise description of sets the imaging signs present; to answer the clin- - To perform and be able to interpret CT ical problem and make a conclusion accord- colonoscopy ingly; to suggest additional imaging examinations when needed, using appropri- Magnetic Resonance Imaging ate justification; to decide when it is appropri- - To perform MRI of the liver, the biliary tract ate to obtain help from supervisory faculty in (including MRCP), pancreas, and the spleen interpreting imaging findings; to code the find- - To know the various contrast materials that ings of examinations can be used for MRI of the liver and their indi- - To maintain good working relationships with vidual uses referring clinicians; to discuss significant or - To perform MRI of the gastrointestinal tract unexpected radiologic findings with referring58 www.ear-online.org
  • 61. Detailed Curriculum for Subspecialty Training clinicians and know when to contact a clini- abnormalities, even if they are not seen in a resident’s im- cian; to effectively present imaging findings in mediate training environment. a conference setting - To correlate pathologic and clinical data with 4 – APPRAISAL AND ASSESSMENT imaging findings In gastrointestinal and abdominal radiology, as in all other - Conferences parts of radiology training, each trainee should be individ- ually appraised on an annual basis. The purpose of ap- As part of the curriculum in abdominal radiology, the praisal is to assess the progress of the resident over the trainee should attend in-house teaching sessions for radi- past year and to anticipate and correct any deficiencies in ologists as well as clinical conferences with colleagues training at an early stage. In addition, for those residents from other specialties. The latter type of conference rotating through a specialised abdominal radiology sec- should be included to facilitate the radiology residents’ un- tion / department, the attachment should commence and derstanding of the use of imaging and clinical circum- finish with a meeting with the senior trainer in that section stances in which imaging is requested. / department. The purpose of the first meeting is to estab- lish goals for the attachment and the second meeting to The following list gives examples of the types of confer- see whether the goals have been achieved. Logbooks can ences that should be considered part of the curriculum: be used for documenting the skills and experience ob- - Abdominal radiology resident-specific teach- tained. Logbooks are mandatory for all interventional pro- ing conference cedures, irrespective of subspecialty. - Internal medicine / gastroenterology confer- ences - Surgery / abdominal surgery conferences - Oncology conferences - Pathology conferences - Teaching material and suggestions for reading The following English textbooks are recommended to an- swer all questions and address all objectives defined in the curriculum of abdominal radiology. One of these books (titles) serves as "bench book", i.e. it is valid for all training programmes across Europe and aims at unification and standardisation of radiology training in Europe. It is very important that "bench books" be available in the radiology department and the library of each institution. 1. Gore RM, Levine MS. Textbook of Gastrointestinal Radiology (2nd Edition). WB Saunders, Philadelphia, 2000. 2. Eisenberg RL. Gastrointestinal Radiology – A Pattern Approach (4th Edition). Lippincott, Philadelphia, 2003. 3. Abdominal radiology book(s) in local lan- guage - Eurorad (www.eurorad.org) In the sections "Gastrointestinal Imaging" and "Liver, Biliary System, Pancreas Spleen", edited by O. Ekberg and B. Marincek, a subsection will be devoted to curricular cases. These model cases correspond to the knowledge- based objectives and allow a resident to see and studywww.ear-online.org 59
  • 62. Detailed Curriculum for Subspecialty Training Head and Neck Radiology basic understanding of clinical tests which are prerequi- site for imaging (e.g. endoscopy, audiometry) and should 1– INTRODUCTION acquire extensive experience in all the diagnostic modali- ties listed below and in non- angiographic interventional Head and neck radiology is a subspecialty of Radiology. procedures. Because of the complex anatomy and the very diverse pathology, specialty training in head and neck radiology - The trainee should be familiar with clinical termi- may be considered to be complex and demanding. nology so as to communicate without difficulty. They should attend weekly multidisciplinary Head and neck radiology comprises diagnostic imaging meetings to obtain thorough understanding of by all techniques of conditions involving the petrous bone, how patients are treated as well as the role of ra- skull base and cranial nerves, orbit, nasopharynx and si- diology in treatment planning. nuses, oral cavity, the oro- and hypopharynx, larynx, sali- The following list gives examples of the types of vary glands, facial skeleton including the teeth, mandible conferences that should be considered part of and temporomandibular joints, deep spaces of the face the head and neck curriculum. Some of these and neck, thoracic inlet, brachial plexus, and thyroid conferences may be run by the Radiology gland. Department, others may be run by other depart- ments or multidisciplinary programmes. It is rec- More detailed explanatory notes on this curriculum may ommended that the latter type of conference be be obtained by application to the European Society of included to facilitate the trainees understanding Head and Neck Radiology. of the use of imaging and clinical circumstances in which imaging is requested: 2 – EXPERTISE AND FACILITIES - Radiology resident / fellow-specific head and neck teaching conference Before undertaking this curriculum, radiologists in training - An appropriate proportion of radiology grand will have completed the curriculum for general training rounds devoted to head and neck radiology and will have acquired a thorough knowledge of the phys- - Multidisciplinary head and neck tumour board ical principles of the different imaging methods, the con- - Multidisciplinary dysphagia conference tra-indications and complications of different imaging - Radiologic-pathologic correlation rounds techniques, and the effects and side-effects of contrast - Maxillofacial surgery conference media. In addition, they will be familiar with imaging topics - Emergency radiology conference specific for the head and neck, including: The trainee should have at least 30 hours of formal teach- - Positioning / views of the face, temporal bone, ing at his / her institution during these two years. In addi- and mandible tion, during these two years, the trainee should attend at - The principles of radiation protection in the least two annual meetings of the ESHNR or ASHNR or head and neck, as well as of justification of other specialised meetings where head and neck radiolo- referrals gy plays a major role. - Mean exposure doses at skin entrance, lens and thyroid gland for conventional radiogra- They should be familiar with the current literature on head phy, sialography, dacryocystography, and CT and neck radiology, both from standard books and original - Digital imaging and image processing perti- articles. They should be encouraged to participate in re- nent to head and neck radiology search projects to acquire knowledge of the design, exe- - Multislice CT, 2D and 3D reconstructions and cution, and analysis of scientific projects. They should be virtual endoscopy techniques encouraged to present papers at international congresses - MRI sequences commonly used in head and and meet others involved in the field of head and neck ra- neck imaging diology to exchange ideas and experiences. During the subspecialty training period, the trainee must 3 – THEORETICAL KNOWLEDGE spend most of his / her time in this field. They should ac- quire an in-depth knowledge of radiological manifesta- At the end of the training period, the trainee should have tions of disease and should also be acquainted with the achieved the knowledge-based objectives listed below. clinical and pathologic presentation. They should have a Reasonable continuous progression is to be expected60 www.ear-online.org
  • 63. Detailed Curriculum for Subspecialty Training during the training period, bearing in mind that training in- perineural spread and hematogenous stitutions organise their training in different ways. metastasis; to be able to recognise them on CT / MRI - Normal Morphology and Function - Trauma and resulting complications The trainee will have a sound knowledge of the anatomic - Dysplasias regions listed below, including their correct terminology, - Cerebrospinal fluid leaks and rhizotomy inter-relationships and appearance on the full range of injections imaging used in head and neck radiology: - Pathologic conditions involving the cranial - The petrous bone and contents nerves and their nuclei - The skull base and cranial nerves - The orbit and visual pathways - Orbit and visual pathways - The sinuses - Ocular pathology, including congenital, - The nasopharynx, oropharynx and hypopharynx traumatic, vascular and neoplastic le- - The oral cavity sions. - The larynx - Orbital pathology, including developmen- - The neck and vasculature tal abnormalities, inflammatory diseases, - The salivary glands autoimmune disorders, tumours and tu- - The facial skeleton including the teeth, the mour-like conditions, vascular malforma- mandible and temporomandibular joints tions, neural tumours, and lacrimal gland - The deep spaces of the face and neck lesions - The thoracic inlet and the brachial plexus - Pathology of the lacrimal apparatus - The thyroid gland and the parathyroid glands - Pathology of the visual apparatus - Pathology - The sinuses The trainee will have a sound knowledge of the following - Anatomical variations and congenital diseases affecting the head and neck, including their anomalies of the paranasal sinuses presentation, natural history, diagnostic criteria and post- - Inflammatory conditions and orbital com- therapeutic findings, including complications of therapy: plications of sinusitis, mucoceles, cysts, - Temporal bone and polyps - Transmission deafness - Tumours and tumour-like conditions - Perception deafness - Common endoscopic techniques and - Embryology and congenital anomalies of their relevance to imaging and presence the outer ear and middle ear of disease - Temporal bone inflammatory disease - Temporal bone fractures - The pharynx - Otospongiosis and dysplasias of the tem- - Pathologic conditions of the nasopharynx, poral bone particularly benign mucosal lesions, in- - Tumours of the temporal bone and cere- flammatory conditions, tumours such as bello-pontine angle, tumours involving the nasopharyngeal carcinoma, lymphoma, facial nerve, bone tumours of the tempo- minor salivary gland tumours, schwanno- ral bone, metastases, lymphoma, and en- mas and traumatic conditions dolymphatic sac tumours - Pathologic conditions of the oropharynx, - Vascular tinnitus including functional disorders of degluti- tion, inflammatory conditions, tumours - The skull base and cranial nerves such as oropharyngeal carcinoma, lym- - Embryology, congenital and developmen- phoma, minor salivary gland tumours, tal anomalies of the skull base schwannomas, rhabdomyosarcomas, and - Inflammatory conditions traumatic conditions - Tumours and tumour-like conditions, in- - Pathologic conditions of the hypopharynx, cluding those arising from bone, particularly non-neoplastic conditions, meninges, nerves, or vessels such as diverticula, functional disorders of - Secondary tumour involvement of the deglutition and extrinsic lesions, inflam- skull base, particularly direct invasion, matory conditions, tumours such as hy-www.ear-online.org 61
  • 64. Detailed Curriculum for Subspecialty Training popharyngeal, lymphoma, minor salivary paragangliomas, lipomas, and cystic le- gland tumours, schwannomas, lipomas sions and other tumours and traumatic condi- - Vascular pathologies of the internal jugu- tions lar vein and carotid artery - Congenital malformations of the pharynx, particularly branchial cleft cysts and si- - The salivary glands nuses, teratoma, and heterotopic pharyn- - Inflammatory disorders, in particular in- geal brain fection, sialolithias, chronic recurrent sialadenitis, autoimmune diseases, sialo- - The oral cavity sis, and infectious disorders - Pathologic conditions of the oral cavity, in- - Cystic lesions cluding functional disorders of the tongue, - tumours particularly pleomorphic adeno- congenital anomalies, vascular lesions, ma, Warthins tumour, adenoid cystic car- dermoid cysts, thyroglossal duct cysts, lin- cinoma, mucoepidermoid carcinoma, gual thyroid, infectious and inflammatory metastases, lymphoma, lipoma, neuro- lesions such as Ludwigs angina, ranula, genic tumours benign tumours, nerve sheath tumours, - Vascular malformations, particularly lym- malignant tumours such as carcinoma, phangioma and hemangioma lymphoma, adenoid cystic carcinoma, - Periglandular lesions, such as masseteric rhabdomyosarcoma, denervation muscle hypertrophy atrophy, macroglossia and benign masse- teric hypertrophy, and traumatic condi- - The facial skeleton including the teeth, the tions mandible, and temporomandibular joints - Congenital lesions of the midface, includ- - The larynx ing midline cleft lip and defects and inclu- - Pathologic conditions of the larynx, in- sion disease, cephaloceles, and cluding functional disorders of the larynx, premature cranial synostosis congenital anomalies, webs and atresia, - Pathologic conditions of the mandible, in- inflammatory lesions, including rheuma- cluding cysts, odontogenic tumours, non- toid and collagen vascular disease, be- odontogenic tumours, vascular lesions, nign tumours such as lipoma, neurogenic lesions, malignant tumours, rhabdomyoma, nerve sheath tumours, and dental inflammatory lesions pleomorphic adenoma, malignant tu- - Pathologic conditions of the temporo- mours such as carcinoma, chondrosarco- mandibular joint, including disk, os- ma, lymphoma, adenoid cystic teoarthritis, avascular necrosis, carcinoma, and traumatic conditions osteoarthritis dissecans, tumours of the TMJ, trauma and congenital anomalies - The neck - Congenital lesions, in particular cystic le- - The deep spaces of the face and neck sions, thyroid anomalies, malformations - Common pathologic conditions involving of the lymphatic system, and classification the different spaces of the supra- and in- of lymphangiomas frahyoid neck, in particular the masticator - Lymph node disease including clinical sig- space, parapharyngeal space, retropha- nificance, metastatic disease including ryngeal space, carotid space and periver- imaging criteria of disease, extranodal tu- tebral space, and the role of disease mour spread and arterial invasion, lym- location in determining differential diagno- phomas, tuberculosis, nodal calcifications sis and their significance - Inflammatory and infectious conditions, - The thoracic inlet and the brachial plexus including abscess, myositis, necrotising - Pathologic conditions of the thoracic inlet fasciitis, and suppurative adenopathy and brachial plexus, particularly traumatic - Non-nodal masses of the neck including conditions such as avulsion, elongation, angiomas, nerve sheath tumours and compression by hematoma or callus, tho-62 www.ear-online.org
  • 65. Detailed Curriculum for Subspecialty Training racic outlet syndrome, schwannoma, su- - To have a thorough knowledge of the patholo- perior sulcus carcinoma, lymphoma, gy investigated so as to tailor the examination adenopathies, and metastasis - To have a basic understanding of clinical tests which have been performed prior to imaging - The thyroid gland and the parathyroid glands (e.g. endoscopy, audiometry) - Congenital lesions including thyroglossal duct cyst, lingual thyroid gland - Communication skills - Inflammatory lesions, including thyroiditis - To be able to produce accurate, informative - benign thyroid masses and clinical "effective reports", explaining im- - Malignancies of the thyroid gland aging findings in a clinical context - Metabolic diseases of the thyroid gland - To be able to advise referrers on the appropri- - Pathologic conditions of the parathyroid ate use of imaging studies glands, in particular hyperparathyroidism, - To be able to present head and neck exami- adenoma, carcinoma, cysts, and hy- nations effectively in a conference setting poparathyroidism - To be able to recognise when significant or unexpected radiological findings should be 4 – THEORETICAL, COMMUNICATION AND DECISION- communicated urgently to the referrer MAKING SKILLS - Technique The aim of the head and neck radiology subspecialty - To be able to supervise technical staff to en- training curriculum is to prepare the radiologist for activity sure quality control to which he / she will dedicate a substantial amount of - To be able to justify, conduct and interpret the time. Specific skills training should include the following: imaging studies listed below, with particular attention to the features listed below: - The ability to act as a consultant in regular multidisciplinary meetings US (B mode, Doppler, FNP) - Knowledge of the indications and contraindi- - Choice of probe cations of diagnostic procedures in the area - Examination of the major salivary glands, of the head and neck thyroid gland, and neck - The ability to instruct clinical colleagues - Doppler examination of the major salivary about major changes in diagnostic proce- glands, thyroid gland, and neck dures, thereby preventing unnecessary ex- aminations Barium swallow for deglutition disorders - A thorough knowledge of the current litera- - Choice of contrast media ture - Standard examination for the oral phase, - The ability to transmit this specific knowledge pharyngeal phase, and oesophageal to colleagues in general radiology and to edu- phase cate radiologists in speciality training in head - How to document the examination: video and neck radiology alone, video and spot images - When to tailor the examination and limit it At the end of the training period, the trainee should have to a minimum so as to answer the clinical achieved the technical, communication and decision- relevant questions making skills listed below. Reasonable continuous pro- - How to alter the consistency of the bolus gression is to be expected during the training, bearing in and test its influence on deglutition mind that institutions organise their rotations differently. - How to test various deglutition manoeu- vres - Patient Information - To be able to inform the patient in detail about CT (diagnostic, angiography, and FNP): the diagnostic procedure and obtain informed - Radiation dose, technical parameters, consent where relevant and image quality - To be able to explain to the patient how to co- - Acquisition and reconstruction parame- operate during the examination ters - Clinical Background - Post-processing techniqueswww.ear-online.org 63
  • 66. Detailed Curriculum for Subspecialty Training - Appropriate use of contrast media Interventional Radiology - Indications to extend the CT examination to other body areas 1 – INTRODUCTION MRI (diagnostic and angiography) - Interventional radiology includes all image-guid- - Choice of coil ed therapeutic procedures. These procedures - Identification of imaging volume have an important role in clinical management. - Appropriate use of contrast media Although invasive, they are associated with very - Technical parameters for acquisition, re- low morbidity and mortality rates and offer im- construction, and post-processing evalua- proved outcomes compared with similar proce- tion dures performed without image guidance. As - MR angiography image interpretation is an essential skill in their - MR sialography performance, such procedures are best per- formed by radiologists trained in diagnostic imag- Conventional Radiographs ing. - How to avoid artifacts - How to alter parameters to obtain ade- - Procedures that may lead to further image-guid- quate quality ed therapy, e.g. PTA or biliary stenting, should be carried out by appropriately trained intervention- Sialography ists, as they will be the ones to perform such ther- - How to interpret the images and judge the apy. These procedures replace surgery and carry quality of the examination morbidity and mortality rates, which, although less than surgery, are greater than other invasive Dacryocystography radiological procedures such as biopsy or simple - Choice of instruments and contrast drainage. Drainage procedures in the urinary media, and interpretation tract, gastrointestinal tract or hepatobiliary sys- tem fall into this category and therefore should be Guided biopsy performed by those who have received special - In relation to the thyroid or cervical nodes training in interventional radiology. Complex vas- and other masses cular procedures, whether diagnostic or thera- - Choice of guidance method, US, CT, or peutic, should be performed by those trained in MRI interventional radiology (IR) for similar reasons. - Choice of biopsy instrument Interventional procedures requiring a substantial - Appropriate care of the specimen clinical commitment, such as vertebroplasty and - Complications and after-care thermal ablation of tumours, should be performed by radiologists acting as the primary clinicians re- 5 – APPRAISAL AND ASSESSMENT sponsible for the medical care of the patient. Assessment of the progress of the trainee should be con- - The principles are: sistent with national requirements. The performance of the trainee should be appraised at least on annual basis. - All diagnostic radiologists should be able to A logbook account of experience may be helpful in evalu- perform image-guided biopsy and abscess or ating the trainee’s progress. The trainee’s progress should fluid drainage. be reviewed by consultant trainers with particular atten- - Invasive procedures that may progress to tion to practical skills in conducting examinations, efficacy complex therapeutic radiological procedures of clinical requesting, and growth of knowledge. should be performed by those trained in inter- ventional radiology. The European Society of Head and Neck Radiology may - Individual interventional radiologists may not offer a diploma of subspecialty expertise to trainees who perform the whole range of procedures (just have completed this programme, the latter being subject as diagnostic radiologists do not perform to other conditions specified by the Society. every type of diagnostic procedure), but they will have undergone basic training in vascular and non-vascular interventional radiology,64 www.ear-online.org
  • 67. Detailed Curriculum for Subspecialty Training which will allow them to provide an out-of- organ systems in which they carry out therapeu- hours service. tic procedures. - Trainees should develop their IR skills by working - The aim of subspecialised training is to prepare within the IR team under direct supervision, but the radiologist for a career in which he / she de- should also have performed sufficient numbers of votes a substantial portion of his / her time to in- procedures as first operator, both electively and terventional radiology. Such individuals will be on call, so as to be competent when taking up an expected not only to carry out interventional pro- IR post at the end of the training period. cedures but also to discuss medical manage- - They should acquire a detailed knowledge of se- ment with referring clinicians. A strong clinical dation and analgesia techniques. background is essential to the fulfilment of this - They should acquire a detailed knowledge of the role. It is essential that interventional radiology pathological and clinical basis of the specialty. training follow general radiological training and - Trainees must attend regular clinico-radiological that interventional radiologists have a good conferences (at least weekly). grounding in the diagnostic radiology of the - Trainees should take part in outpatient clinics and organ systems in which they carry out therapeu- ward work in order to develop clinical skills. tic procedures. - Trainees will be expected to be familiar with the current subspecialised literature, both from stan- 2 – EXPERTISE AND FACILITIES dard textbooks and original articles. - They should be encouraged to develop a critical - Training must be undertaken in (a) hospital(s) approach in their assessment of literature. with clinical departments of vascular surgery, - They should be involved in research and scientif- cardiology, and preferably cardiac surgery. ic publication. Emergency and intensive care units as well as - They should acquire knowledge of the design, departments related to the fields in which inter- execution, and analysis of research projects. ventional techniques are carried out are clearly - Trainees should enhance their theoretical knowl- mandatory as well. edge by attending and participating actively in the scientific programme and educational activi- - Initially, when subspecialised interventional train- ties of CIRSE and SIR. ing is introduced, a radiologist eligible for full - During their training period, trainees should CIRSE fellowship should supervise it. In the fu- spend the equivalent of 4 months´ clinical training ture, there may be certified subspecialists in in- in a department of vascular surgery, internal terventional radiology who may supervise medicine, or any subspecialty of surgery or inter- training. nal medicine relevant to their IR training. They should also attend weekly outpatient clinics and - The training department(s) must have a full range ward rounds. They should undergo training in of diagnostic equipment, including CT, MRI, communication skills, including the ethics of in- colour Doppler ultrasound, angiography, and formed consent and the process of giving bad other interventional radiology equipment. There news to patients. must be adequate monitoring and access to anaesthetic skills when required. There must be 4 – THEORETICAL KNOWLEDGE access to a radiological library containing e- learning facilities, textbooks, and the most impor- - Technique, indications, contraindications and com- tant journals. plications of the following diagnostic modalities: - Doppler and color Doppler ultrasound 3 – OVERVIEW - CT (including CT angiography) - Magnetic resonance angiography and car- - The training period will be equivalent to two years diac imaging of full-time practice. - Angiography - It is essential that interventional radiology training initially follow general radiological training and - The factors affecting the choice of contrast media that interventional radiologists have a good and radiopharmaceuticals and the effects and grounding in the diagnostic radiology of the side effects of these agentswww.ear-online.org 65
  • 68. Detailed Curriculum for Subspecialty Training - Normal radiological anatomy, anatomy of the laparoscopic surgeons to move trainees much more rap- vascular system and all anatomical regions using idly along the learning curve. any imaging modality Procedures performed must be kept in a logbook. - Normal physiology of the cardiovascular system The numbers indicated for each procedure are for - In-depth knowledge of the physiopathology of guidance only. They are not intended to be an indica- cardiovascular diseases tor of competence at the end of the training period. - Pharmacotherapy of the cardiovascular system Diagnostic procedures Aortography and / or runoff 100 - Basic knowledge of chemotherapy Selective angiography including head and neck 100 Doppler ultrasound and / or duplex ultrasound 50 - Knowledge of physiopathology of all diseases in CT angiography 50 which interventional radiology plays a role MRI angiography and cardiac imaging 50 Phlebography 50 - Techniques and indications of: Any other imaging method related to - Pre-procedural patient assessment the field of interventional procedures - Peripheral angioplasty (incl. recanalisation and stenting) Interventional procedures - Renal angioplasty (incl. recanalisation and Peripheral PTA 100 stenting) Other PTA (renal, etc.) 20 - Supra-aortic angioplasty (incl. recanalisation Complex PTA 20 and stenting) Thrombectomy and thrombolysis 20 - Venous angioplasty (incl. recanalisation and Vascular stenting 10 stenting) Embolisation 20 - Thrombectomy and thrombolysis Complex embolisation 5 - Treatment of arteriovenous malformations Techniques of intravascular chemotherapy 10 - Treatment of bleeding Venous interventions 20 - Gynaecological interventions Complex venous interventions (e.g. TIPS) 5 - Non-vascular upper gastrointestinal, liver and Vena cava filters 10 renal interventions PTC, PTCD, and gallbladder interventions 20 - Post-procedure patient management Percutaneous biopsy 20 Drainage 20 - Theory of advanced life support techniques (in- Foreign body retrieval 5 cluding ECG) Non-vascular interventions & stenting 20 Genitourinary tract procedures (nephrostomy, - Pharmacotherapy and practice of sedation and nephrolithotomy, ureteral procedures, analgesia tubal recanalisation) 20 Combined surgical and percutaneous procedures 5 – TECHNICAL, COMMUNICATION AND DECISION- Combined endoscopic and percutaneous procedures MAKING SKILLS Non-vascular interventions & stenting 20 In-depth practice of advanced life-support techniques The trainee must have a deep knowledge of all imaging modalities including newer imaging modalities of the car- 6 – APPRAISAL AND ASSESSMENT diovascular system, such as CT angiography, colour Doppler ultrasound, and magnetic resonance. In addition, If written examinations are considered necessary, these as more non-invasive diagnostic tools are used, the should include both general and IR modules. amount of aortography available to the trainee will dimin- ish. Virtual Reality Training is now through its infancy and Basic reporting sessions could be the same for IR and DR is a training reality. This must be borne in mind when con- candidates. In addition, the IR candidate would undergo a sidering practical experience. A single week in a VR labo- long reporting session dedicated to IR, which would re- ratory with appropriate trainers has been shown by quire diagnosis and treatment options based on the imag-66 www.ear-online.org
  • 69. Detailed Curriculum for Subspecialty Training ing and clinical scenarios. This should include statements Musculoskeletal of success and complication rates. Radiology For IR candidates, one oral examination could be general 1 – INTRODUCTION and the second could be dedicated to IR. This could test thought process and manual dexterity using models, a Musculoskeletal (MSK) imaging involves all aspects of range of equipment, and computer simulations. Logbooks medical imaging which provide information about anato- would also be examined. my, function, disease states and those aspects of inter- ventional radiology or minimally invasive therapy appertaining to the musculoskeletal system. This will in- clude imaging in orthopaedics, trauma, rheumatology, metabolic and endocrine disease as well as aspects of paediatrics, oncology, and sports imaging. The aim of subspecialised training in MSK imaging is to prepare a radiologist for a career in which a signifi- cant portion of his / her time will be devoted to MSK imaging. Such individuals will be expected to provide and promote MSK imaging and interventional methods. The aims of establishing subspecialty training in MSK ra- diology is to ensure: - An in-depth understanding of diseases of the MSK system; - A clear understanding of the role of imaging in the diagnosis and treatment of MSK diseases; - The development of the necessary clinical and management skills; - The ability of the MSK specialist to perform (com- plex) MSK interventional procedures; - The ability of the MSK specialist to act as a con- sultant in regular multidisciplinary meetings in the field of MSK imaging; - The ability of the MSK specialist to transmit his / her specific knowledge to his / her colleagues in general radiology and to assume the continuity and evolution of radiological diagnosis in the field of MSK radiology (teaching skills). 2 – EXPERTISE AND FACILITIES - Training must be undertaken in a team with ac- cess to full clinical service in radiology, or- thopaedic surgery, rheumatology, and pathology. If possible, dialysis, paediatric orthopaedic sur- gery, orthopaedic oncology, medical genetics and sports medicine should also be offered. - Training should be supervised by a group or a de- partment or training schemes with extensive ex- perience in MSK imaging.www.ear-online.org 67
  • 70. Detailed Curriculum for Subspecialty Training - The training department(s) should have access the principles and techniques used in research, to conventional radiography, CT scan, ultra- including the value of clinical trials and basic bio- sonography, MR Imaging, interventional equip- statistics should be acquired. ment, and bone densitometry. 4 – THEORETICAL KNOWLEDGE - A database of "interesting cases" or "teaching files" should be present at the training depart- - Trainees should attend regular sessions of theo- ment. Alternatively and / or additionally, the train- retical training in the form of locally delivered tuto- ing department can refer to interesting rials, specialist MSK imaging courses, as well as educational sites on the internet. local, national and international MSK imaging con- ferences including formal lectures, scientific pre- - Trainees must also have access to radiological li- sentations or both, and E-learning. brary containing textbooks of MSK radiology, or- thopaedic surgery, rheumatology, and related - Trainees will acquire an extensive knowledge of sciences and journals. the pathology, frequency and epidemiology of MSK diseases both in the paediatric and adult - The training department must provide access to population. They should have a basic knowledge appropriate computed tomography (CT), mag- of the treatment of MSK disease by conservative netic resonance imaging (MRI), radionuclide im- treatment, surgery, radiotherapy and chemothera- aging (optional), and fluoroscopy. Centres should py (if applicable) and be aware of the diagnostic also provide access to relevant specialised ra- needs of their surgical, radiotherapy and oncology dionuclide imaging, e.g. positron emission to- colleagues. They must therefore attend regular mography (PET) (where relevant). Practical multi-disciplinary conferences (e.g. with rheuma- training and / or theoretical teaching and training tologists, orthopaedic surgeons, oncologists, etc.). in bone densitometry techniques should be avail- able. - Trainees should acquire a knowledge of: - The embryology, anatomy and physiology of 3 – OVERVIEW the musculoskeletal system including normal anatomical variants - Trainees should have completed the core skills - The pathological processes of both benign and and knowledge programme according to the EAR malignant disease in the musculoskeletal sys- / UEMS curricula which will include basic knowl- tem edge of diagnosis of MSK diseases in their initial - Local, national and, where appropriate, inter- training. national imaging guidelines and protocols - The subspecialty specialists / consultants in MSK - Knowledge of the full range of radiological diag- imaging undertake 12 months or its equivalent of nostic modalities and techniques available, in par- subspecialty training, either during the fourth and ticular: fifth year of the 5-year radiology training pro- - The indications, contra-indications and compli- gramme or as additional training after their 5-year cations of each imaging method residency / training scheme has been completed. - The factors affecting the choice of contrast media and radiopharmaceuticals - The training outlined below will extend this into - The effects and side effects of these agents the practical role. - Optimisation of imaging protocols of diagnostic procedures - They must obtain extensive experience in the di- agnostic procedures listed below and will be ex- - Particular emphasis should be placed on the pected to be familiar with the current MSK strengths and weaknesses of the different imaging imaging literature, both from standard textbooks methods in various pathological conditions. The and original articles. appropriate choice of imaging techniques and / or the appropriate sequence of imaging techniques - They should participate in audit and research in the investigation of specific clinical problems and should be encouraged to pursue a project up should be emphasised. to and including publication. An understanding of68 www.ear-online.org
  • 71. Detailed Curriculum for Subspecialty Training 5 – TECHNICAL, COMMUNICATION AND DECISION- - MRI MAKING SKILLS - knowledge of basic and new MRI se- quences applied to the musculoskeletal - Technical skills system, such as cartilage sequences, dif- fusion, etc. Acquisition of specific skills to enable: - the use of MRI for the primary diagnosis - The conduct, supervision and accurate inter- of benign and malignant pathology pretation of all imaging techniques used in - staging of tumours involving the muscu- the investigation of musculoskeletal diseases loskeletal system to a high professional standard - detection of direct extension and metasta- - The accurate localisation and the biopsy of tic spread of musculoskeletal tumours soft tissue, bone and lymph node masses - demonstration of spinal anatomy and - Where appropriate, the safe and effective pathology practice of interventional techniques - demonstration of joint anatomy and - Good communication with patients and pro- pathology, including direct and indirect fessional colleagues MR arthrography - Accurate informed consent to be obtained - the investigation of rheumatological disor- - Continuing accreditation of intermediate life- ders support status - the investigation of acute trauma and trau- ma sequels Procedural competence will need to be reviewed at inter- - the investigation of sports injuries, both vals, and this regular review should also assess the num- traumatic and overuse ber of cases required in order to ensure competence. During the training period it is recommended that the - Fluoroscopic procedures including arthrogra- trainee obtain experience in the following: phy - Plain radiography including: A trainee will keep abreast of all other imaging techniques - primary care examinations relevant to their practice. - trauma cases - rheumatological disorders Trainees should acquire experience in the following inter- - general and paediatric orthopaedics ventional procedures guided with fluoroscopy, ultrasound, or CT: - Ultrasonography including: - Biopsy of bone and soft tissue lesions - joints - Arthrography - soft tissues - Non-spinal image-guided diagnostic and - orthopaedic and sports injuries therapeutic procedures - Doppler studies applied to the muscu- - Spinal image-guided therapeutic procedures, loskeletal system such as facet joint injections, sacroiliac injec- tions, epidural, and periradicular infiltrations - CT - Discography - the use of CT for the primary diagnosis of - Optional experience benign and malignant pathology - CT myelography - staging of tumours involving the muscu- - Vertebroplasty loskeletal system - detection of direct extension and metasta- Trainees should acquire experience in all the practical tic spread of musculoskeletal tumours procedures listed above, and the number of cases under- - the investigation of rheumatological disor- taken should be recorded in their logbook. ders - the investigation of trauma and sports in- The trainee should become familiar with providing analge- juries sia and / or sedation where required, as well as the nec- - the use of reconstruction algorithms, mul- essary continuous monitoring required to perform this tiplanar reconstruction, and volume ren- safely. deringwww.ear-online.org 69
  • 72. Detailed Curriculum for Subspecialty Training Regardless of the imaging technique or procedure con- The trainee should be encouraged to participate in re- cerned, the consultant trainer must be satisfied with the search and pursue a project up to and including publica- trainee´s clinical competence, as determined by an in- tion. An understanding of the principles and techniques training performance assessment, and can consistently used in research, including the value of clinical trials and interpret the results of investigations accurately and reli- basic biostatics, should be acquired. Presentation of re- ably, and formulate correct management plans. search and audit results at national and international meetings should be encouraged. - Communication and decision-making skills The trainee should have on-call commitments on a regu- A clear understanding of the role of multidisciplinary lar basis. meetings, including: - Planning of investigations including the selec- Knowledge and understanding of the importance of effec- tion of appropriate tests and imaging tech- tive communication with both the patient and the mem- niques for the diagnosis of benign and bers of the multidisciplinary team. malignant disease - Staging of malignant disease Knowledge of roles and responsibilities of other members - Planning and outcomes of treatment of the MSK imaging team, e.g. radiographers, nurses, - The detection of errors in diagnosis and com- support staff, secretaries, etc. plications of treatment - Promoting an understanding of relevant mus- Knowledge of roles and responsibilities of other members culoskeletal pathology of the Multi-Disciplinary Team. Clinical knowledge will be acquired by a variety of means, Knowledge and understanding of how imaging findings in- including close liaison with appropriate medical, surgical fluence decisions by others, e.g. surgeons, pathologists, and oncological teams as well as combined clinical and oncologists, etc. radiological meetings. Multidisciplinary meetings should be emphasised. The following inter-relationships are im- - Training schedule and content portant: - Orthopaedics (general and paediatric) and During the training period, the following weekly commit- rehabilitation ments are suggested as a work profile for subspecialty - Rheumatology trainees for the 12-month period, which will permit an inte- - Metabolic and endocrine medicine grated use of different modalities for the diagnosis and - Bone and soft tissue oncology treatment of MSK disorders. - Trauma, including accident and emergency - MRI (two to three sessions) - Spinal surgery - CT (one to two sessions) - Sports medicine / surgery - US (one to two sessions) - Nuclear medicine - Radionuclide imaging (one session) (where available) The trainee should be encouraged and given the opportu- - Plain film reporting (two to three sessions) nity to attend and lead appropriate clinico-radiological and - Fluoroscopy with or without intervention (one multidisciplinary meetings. session) - Bone densitometry: 100 examinations have to The trainee should be encouraged to attend appropriate be supervised and reported educational meetings and courses. - Trainees must attend regular clinico-radiolog- ical conferences (at least weekly) The trainee should participate in relevant clinical audit, - Optional experience in radionuclide reporting management, and clinical governance, and have a good of the MSK system working knowledge of local and national guidelines in re- lation to radiological practice. The techniques listed and the time devoted to each will be reviewed at intervals. It is recognised that some studies Trainees will be expected to be familiar with current mus- will become obsolete and new imaging techniques will be culoskeletal radiology literature. developed.70 www.ear-online.org
  • 73. Detailed Curriculum for Subspecialty Training The training department is free to organise an alternative Neuroradiology framework throughout the year as long as an equivalent amount of examinations for each modality is met at the 1 – INTRODUCTION completion of the training. This includes a modality-based programme where the trainee sequentially spends dedi- - Neuroradiology is a branch of medicine con- cated periods of time in MRI, CT, US, etc. cerned with both diagnostic imaging and inter- ventional procedures related to brain, spine and For image-guided interventional procedures, hands-on spinal cord, head, neck, and organs of special experience with graded supervision will be required de- senses in adults and children. pending on the trainees’ future career goals. The training in and supervision of such procedures may be provided - The aim of specific training in neuroradiology is by musculoskeletal or interventional trainers, depending to prepare a specialist for a career in which his / on the local practices and expertise. her clinical and research time will be devoted to diagnosis and treatment of diseases of the areas Experience will be documented in a logbook, including a cited above using imaging modalities. summary of the theoretical (documented by CME certifi- cates) and practical training and certified by the supervis- - Neuroradiologist will also be expected to adopt ing radiology department or group (3). The numbers and develop new imaging and interventional indicated for each procedure are for guidance only. They methods, to disseminate neuroradiological are not intended to be an indicator of competence at the knowledge and, from a basis of strong clinical end of the training period. background, be able to discuss with the referring clinicians the diagnosis and treatment. The contents of the training needs to be flexible and ap- propriate to the career goal of the trainee. - This curriculum outlines the subspecialty training Musculoskeletal radiology is an expanding and evolving requirements for neuroradiology, including inter- specialty, with developments of different imaging tech- ventional neuroradiology as a subspecialty of ra- niques and interventional procedures. Some trainees may diology. require additional training in such developing areas. - In Europe, trainees will enter into neuroradiology 6 – APPRAISAL AND ASSESSMENT training during the fourth and fifth years of clinical training. This training is in diagnostic neuroradiol- At the end of the training, a certificate of subspecialty ex- ogy and may have some components of interven- pertise will be awarded by the training department in ac- tional neuroradiology. cordance with the law of each country. - All residents in radiology will have obtained basic Formal testing should be up to the authority of the respec- knowledge of neuroradiology diagnosis during tive country in which the training has been fulfilled. core training and will have already acquired basic skills. Acknowledgement to the Royal College of Radiologists for - This document outlines the training curriculum for incorporating parts of the document "Structured Training In Radiology", Ref. No.: EBCR(00)1. a consultant neuroradiologist. A minimum of 24 months of full-time training in neuroradiology is recommended. A trainee undertaking additional training in neurointerventional procedures re- quires more than two years neuroradiological training. - Dedicated neuroradiology training received at a neuroscience centre within an accredited radiolo- gy-training scheme may be taken into considera- tion.www.ear-online.org 71
  • 74. Detailed Curriculum for Subspecialty Training - The aim of subspecialty training in neuroradiolo- - The trainee should be encouraged and given the gy is to enable the trainee to become clinically opportunity to attend and lead appropriate clini- competent and to consistently interpret the re- co-radiological meetings. sults of neuroradiological investigations accu- rately and reliably. Where appropriate, trainees - The trainee should participate in relevant clinical should also be capable of providing a compre- audit, management and clinical governance and hensive and safe interventional diagnostic and have a good working knowledge of local and na- therapeutic service. tional guidelines in relation to radiological prac- tice. - The content of training needs to be flexible and appropriate to the ultimate goal of the trainee. - The trainee should be involved in research and Neuroradiology is an expanding specialty with have the opportunity to attend and present at na- development of interventional services, paedi- tional and international meetings. The progres- atric neuroradiology, and functional brain imag- sion of research projects to formal peer-reviewed ing, including MR spectroscopy. Some trainees publication should be supported and encouraged may wish to obtain extra training in these areas. by the supervising consultant(s). 2 – OVERVIEW - Attendance at National, European and American Neuroradiology Societies should be encouraged. - Basic skills in neuroradiology will have been ac- quired before subspecialty training. - The trainee should be encouraged to become an associate member of the appropriate National - A training scheme responsible for training in neu- Neuroradiology Society and the European roradiology must provide access to appropriate Society of Neuroradiology. CT, MRI, digital subtraction angiography, ultra- sound and radionuclide imaging facilities. - The trainee is expected to participate in under- Trainees should also have access to neonatal graduate and postgraduate teaching, including cranial ultrasound. the European Course in Neuroradiology or other courses of similar scope and quality. - Clinical knowledge will be obtained by a variety of means. This will include close liaison with the ap- - The trainee should, where possible, participate in propriate surgical and medical teams and partici- the neuroradiology on-call rota, after adequate pation in combined clinical and radiological training with appropriate consultant cover. meetings. Clinical interrelationships are neces- sary with: - Subspecialty training in neuroradiology is as- - Neurosurgery (paediatric and adult) sessed and accredited by the Provisional - Neurology (paediatric and adult) European Board of Neuroradiology under the ap- - Neuropathology proval by European Society of Neuroradiology. - Neurophysiology - Neuroanaesthesia / critical care and emer- 3 – THEORETICAL KNOWLEDGE gency medicine - Trauma The accredited training of neuroradiologists will have to achieve the following: - Other specialties will also provide important train- ing opportunities, in particular ophthalmology, - An in-depth knowledge of anatomy, including de- otology, genetics, endocrinology, psychiatry, veloping anatomy and its radiological applica- neuro-oncology, maxillo-facial surgery, spinal tions to the central and peripheral nervous surgery, and rehabilitation services. system, organs of special senses, head and neck, and spine and spinal cord in adults and - It may be appropriate for the trainee to have a children regular attachment to ward rounds, outpatient clinics and theatre sessions in order to further - Knowledge of and radio-pathological correlation clinical knowledge relevant to the subspecialty. of diseases and variations of the CNS, including the spine and cranium and disorders of the oph-72 www.ear-online.org
  • 75. Detailed Curriculum for Subspecialty Training talmological and otorhinolaryngological systems, - Knowledge of the current developments in neuro- including appropriate indications, contraindica- radiology tions and complications of imaging studies of neurological diseases and interpretation of the - If experience to fulfil the requirements of subspe- various imaging modalities cialty training cannot be gained in one training centre, it will be necessary for the trainee to have - Knowledge of proper experience and under- a period of attachment(s) to other training cen- standing of physical principles and technical tres. There are, in any case, advantages for background for performance and interpretative trainees in visiting other departments at home or skills of computed tomography (CT), magnetic abroad to follow particular interests in greater resonance imaging (MRI), angiography, ultra- depth. sound, conventional imaging, and myelography for the diagnostic imaging of the head and spine - The expected outcome at the end of this subspe- and spinal cord, head, neck, and organs of spe- cialty training in neuroradiology will be for the res- cial senses in adults and children so that they ident to be competent in all aspects of diagnostic can, with confidence, discuss with their col- neuroradiology imaging and, where applicable, leagues the choice of best imaging method for a basic interventional neuroradiology. particular clinical problem 4 – TECHNICAL, COMMUNICATION AND DECISION- - Knowledge of functional and imaging aspects of MAKING SKILLS MR spectroscopy, MR functional imaging, and nuclear medicine studies (SPECT & PET) as - Essential is competence in clinical neuroradio- they relate to neuroradiology logical skills in adults and children, including: - Diagnostic and interpretative skills - Knowledge and commitments to the clinical ap- - Manual and procedural skills plications of neuroradiology as they apply to all - Basic endovascular and therapeutic knowl- aspects of neuroradiology so that the trainee may edge confidently discuss patients with colleagues - Computer skills in imaging acquisition and post-processing - Knowledge of indications, techniques and clinical - Outpatient consultation when relevant outcome of interventional neuroradiology, as well as the hazards and potential complications of in- - Ability to manage post-procedural care for inva- vasive procedures, both diagnostic and thera- sive diagnostic and therapeutic techniques as peutic well as neuroradiological emergencies - Knowledge of pharmacology, particularly with re- - Ability to manage patients and to obtain valid in- spect to contrast material and invasive proce- formed consent for all procedures dures - Competence in effective consultation, presenta- - Knowledge of patient’s protection and safety in tion of scholarship material and ability to teach neuroradiology neuroradiology to peers and residents in other disciplines - The trainee should be fully competent in interme- diate and advanced life-support. - Ability to evaluate medical literature critically and to conduct neuroradiological research - Knowledge of the importance of informed con- sent and patient information - Competence in style of reporting - Understanding of fundamentals of quality assur- - Ability to conduct or supervise quality assurance ance in neuroradiology - To keep an authorised logbook of experience - Understanding risk management, data banking, and evidence-based medicinewww.ear-online.org 73
  • 76. Detailed Curriculum for Subspecialty Training - Competence in communicating clinical and sci- and myelography for the diagnostic imaging of entific topics to various learned and scientific the head, spine and spinal cord, neck, and or- communities within neuroscience gans of special senses in adults and children. - Responsible use of financial and other resources - The subspecialty resident should know the inher- ent strengths and limitations of these modalities, - Interactions with colleagues and administration as well as appropriate imaging protocols for neu- roradiological consultation. - Ethical and responsible - Knowledge of the techniques involved in the im- - Appropriate and considerate with patients aging used to evaluate and treat neurological dis- eases, including interventional procedures and - Respecting confidentiality in patient care the management of the complications of these procedures - Ability to interact well with peers and the rest of staff - Knowledge and competence at imaging of brain function. - Awareness of the obligation of continuing med- ical education and commitment to the continuing - Knowledge of pharmacology, particularly with re- assessment of the quality of neuroradiology spect to contrast media and invasive procedures 5 – REQUIREMENTS OF SUBSPECIALTY TRAINING - Knowledge of patient protection and safety in neuroradiology - A comprehensive knowledge of normal brain function and neurological diseases, including: - Understanding of fundamentals of quality assur- - The embryology, anatomy, normal variants ance (management) in neuroradiology and physiology of the central and peripheral nervous system, organs of special senses, - Acquisition of specific skills to enable compe- head and neck, and spine and spinal cord in tence in clinical neuroradiological skills in chil- adults and children dren and adults, including: - The pathological correlation of diseases and - Diagnostic and interpretative skills variations of the CNS, including the spine and - Manual and procedural skills cranium and disorders of the ophthalmologi- - Basic endovascular and therapy skills cal and otorhinolaryngological systems, in- - Computer skills in imaging acquisition and cluding appropriate applications and post-processing interpretation of the various imaging modali- - The conduct, supervision and accurate inter- ties pretation of all imaging techniques used in - Local, national and, where appropriate, inter- the investigation of neurological diseases to a national imaging guidelines high professional standard - Good communication with patients and pro- - Knowledge and understanding of the physical fessional colleagues principles and technical background for the per- - Competence in the style of reporting formance of CT, MRI, angiography, ultrasound, - The ability to manage post-procedure care for conventional imaging, and myelography for the invasive diagnostic and therapeutic tech- diagnostic imaging of the head, spine and spinal niques as well as neuroradiological emergen- cord, neck, and organs of special senses in cies adults and children. Exposure to MRS / function- - The ability to manage patients and to obtain al imaging and nuclear medicine studies valid informed consent for all procedures (SPECT, PET) related to neuroradiology should - The competence in effective consultation, be available. presentation of scholarship material, and abil- ity to teach neuroradiology to peers and resi- - To develop the interpretative skills of CT, MRI, dents in other disciplines angiography, ultrasound, conventional imaging - The ability to evaluate medical literature criti-74 www.ear-online.org
  • 77. Detailed Curriculum for Subspecialty Training cally and to conduct neuroradiological re- some procedures may become obsolete and new search techniques will be developed (e.g. functional brain imaging and MR spectroscopy). - Ability to conduct or supervise quality assur- - The trainee should become familiar with provid- ance ing analgesia and / or sedation where required, as well as the necessary continuous monitoring - The core requirements for a neuroradiologist or a required to perform this safely. specialist interventional neuroradiologist are sim- ilar, apart from the total number of interventional - The trainee should become fully aware of the procedures performed (see below). local and national guidelines in obtaining in- formed patient consent. - Regardless of the imaging technique concerned, the consultant trainer must be satisfied with the 6 – INTERVENTIONAL NEURORADIOLOGY REQUIRE- trainee being clinically competent, as determined MENTS by an in-training performance assessment, and being able to consistently interpret the results of - All subspecialist residents training in neuroradiolo- such investigations accurately and reliably. gy should have a basic understanding of interven- tional techniques so that they have full knowledge - During the training period it is recommended that of indications, technical problems, contraindica- the trainee receive the following: tions, and risks of procedures. Trainees with a - CT – the equivalent of one or two sessions special interest in interventional neuroradiology will per week need more extensive experience. - MRI – the equivalent of two or three sessions per week - All trainees in interventional neuroradiology - Angiography – the equivalent of two sessions should complete at least one year of diagnostic per week neuroradiology training. - Interventional neuroradiology – see below - Study / meetings – the equivalent of one ses- - Trainees who wish to spend a significant part of sion per week their work as a consultant in interventional neuro- - Research – the equivalent of one session per radiology should spend around one year in a week training post in which substantially the whole time - Myelography – the opportunity to observe is devoted to interventional neuroradiology. and, whenever possible, obtain hands-on ex- perience of the limited number of these pro- - These trainees will need to extend their subspe- cedures now carried out cialty training beyond two years required for neu- roradiology. However, earlier and more focussed - During the training period the trainee should also individualised training in neuroradiology is being gain experience in the following: encouraged for those trainees with previous neu- - Plain radiography, including: roscience / neurovascular experience. - Primary care examinations - Skull, facial and spinal trauma - Trainees need to develop clinical judgement. The - Paediatric examinations including child risks and benefits of each therapeutic procedure abuse need to be appreciated. Training might include a clinical attachment. - Optional experience: - Radionuclide radiology including SPECT im- - Trainees should have adequate exposure to neu- aging and PET rosurgical operations and ward / HDU manage- - Ultrasound including neonatal cranial US and ment of acutely ill patients. Doppler - Regular involvement in neurosciences audit and - The techniques listed and the time devoted to mortality / morbidity meetings is necessary to un- each will be reviewed at intervals along with the derstand risk management for different clinical number of cases required, as it is recognised that conditions.www.ear-online.org 75
  • 78. Detailed Curriculum for Subspecialty Training - It is the responsibility of the trainee to be aware of Paediatric Radiology the current local and national guidelines in ob- taining informed patient consent. 1 – INTRODUCTION - All interventional trainees must have thorough The aim of sub-specialised training in paediatric radiology knowledge of techniques of sedation and analge- is to prepare the radiologist for a career in which a sub- sia required to perform these procedures, as well stantial proportion of his / her time will be devoted to pae- as patient monitoring throughout and following diatric radiology. Such individuals will be expected not the procedures. only to provide a paediatric radiology service but also adopt and develop new imaging and interventional meth- - Trainees should be aware of the full range of ods and to disseminate paediatric radiological knowledge intra- and post-operative complications and their to their colleagues in general radiology. management. 2 – EXPERTISE AND FACILITIES - The interventional trainee should participate in around 80 neuroradiological interventional proce- Specialist training in paediatric radiology must take place dures, of which a substantial proportion will be for in hospitals with the full range of clinical paediatric spe- intracranial vascular lesions. The trainee should cialities available on site. These include gastrointestinal be the first operator in around a third of cases. tract, genito-urinary tract, chest, endocrine, neonatal, musculoskeletal, neurology and neurosurgery, cardiovas- - It is desirable that the trainee also attend other cular, and A&E facilities. Medical and surgery facilities centres, especially if range and quantity of inter- must be available. Where facilities are not available on ventional procedures are limited. site, arrangements should be made for secondment to an appropriate unit so that such training is available. 7 – APPRAISAL AND ASSESSMENT The training department must have a full range of diag- - Regular appraisal of the trainee will occur ac- nostic equipment, including access to specialised ses- cording to national guidelines. sions on nuclear medicine, CT and MRI. Interventional radiology experience, both angiographic and non-angio- - Methods of trainee assessment will include: graphic, must also be available. There must be access to - Regular direct observation of clinical tech- a library with radiological and clinical textbooks and jour- niques (including communication skills, ability nals. A film library must also be available. to obtain informed consent and sedation skills) by the trainer and / or external observer 3 – OVERVIEW - Regular formal review of the trainee’s skills in the accurate interpretation of investigations The training period will be the equivalent of one - two for neurological diseases years of practice. During this period, the trainee must de- - Final assessment of overall professional com- vote his / her time to paediatric radiology. Trainees should petence acquire a deep knowledge of the pathological and clinical basis of the specialty. They should obtain extensive expe- - Review of subspecialty curriculum rience in all of the diagnostic methods listed in the syl- - The Training Committee of the European labus. Trainees must attend regular clinicoradiological Society of Neuroradiology will regularly re- conferences (at least weekly) with their clinical col- view this subspecialty curriculum to ensure leagues. Trainees will be expected to be familiar with the that it complies with current neuroradiological current paediatric radiological literature, both from stan- practice. dard textbooks and original articles. They should be en- couraged to develop a critical approach in their assessment of the literature. They should be involved in a research project (or projects) and should acquire knowl- edge of the design, execution, and analysis of research projects.76 www.ear-online.org
  • 79. Detailed Curriculum for Subspecialty Training 4 – THEORETICAL KNOWLEDGE - Clinical problems, e.g. investigations of stridor - Theoretical training - Investigation of recurrent chest infection - Intensive care chest radiology Teaching is organised on the basis of lectures, tutorials, and workshops. Trainees are to be encouraged to attend - The Musculoskeletal System national and international conferences on paediatric radi- - Trauma: Salter classification of physeal in- ology, such as those given by the European Society of juries Paediatric Radiology (ESPR), the Society of Paediatric - Fracture complications Radiology (SPR), and the European Congress of - Cervical Spine Radiology (ECR). - Pelvic Fractures - Irritable hip, Perthes’ disease - General principles - Sports injuries - Polytrauma - Understanding of the principles of paediatric - Infection / bone – joint – disc / how to ap- radiology as an integrated imaging concept. proach diagnosis and integrated imaging - Knowledge of special needs of children: envi- - Multifocal osteomyelitis / chronic granulo- ronment, sedation, psychology of handling matous diseases children. Organisation of a paediatric section - Scoliosis and orthopaedic problems within a general department, guidelines for in- - Arthritis and metabolic disease vestigation, contrast: factors affecting the - Neoplastic: benign and malignant bony choice of contrast, indications and contraindi- and soft tissue tumours cations, including radiopharmaceuticals. - Skeletal dysplasia - Detailed knowledge of dose reduction tech- niques in paediatric radiology: - The Abdomen - Equipment choice, film / speed combina- - Neonate tion, use of grids / video, Q.A. [quality as- - Oesophageal disease, reflux surance] programme - Pyloric stenosis - Role of lateral film, PA v AP views, com- - GI bleeding parison view, choice of examination, cost / - Inflammatory bowel disease, appendicitis risk benefit and gastro-enteritis - To understand the ALARA [as low as rea- - Constipation sonably achievable] principle. IRMER - Intussusception 2000 regulations - Ulcer disease - Malabsorption - Knowledge relevant to normal anatomy, normal - Obstruction variations, development, and physiology of the - Pancreatitis prenatal, neonate and growing child - Abdominal trauma – to include liver, spleen and pancreas, and bowel tumours - In-depth understanding and knowledge relevant (liver, small bowel and pancreas) to medical and surgical management of paedi- - To understand the limits of ultrasound in atric diseases. the evaluation of traumatic lesions of the liver and spleen - The Chest - To know the indications of CT / to be able - Neonatal: to include surgical problems to perform CT - Infection: bacterial, viral, opportunistic, TB and ITU complications - Genito-urinary tract - Cardiac - Infection – UTI [Abscess and pyonephro- - Trauma sis and how to investigate) - Foreign bronchial bodies - To recognise the normal appearance of - Infiltrative disease the organs in any imaging modality - Asthma - To understand the urethral anatomy of the - Mass lesions boywww.ear-online.org 77
  • 80. Detailed Curriculum for Subspecialty Training - To understand the clinical and biological - Collagen vascular disease (+ myofibro- criteria of UTI matosis, etc.) - To be able to perform ultrasound of the - Endocrine disease urinary tract on infants using Doppler - Investigation of small stature + growth dis- - To know when and how to perform a orders VCUG and how to read it - Non-accidental injury (NAI) - To detect and evaluate VUR - Teeth (incl. craniofacial malformations) - Congenital anomalies and hydronephrosis - Phakomatoses [tuberose sclerosis, neu- - Haematuria and stones rofibromatosis, etc]. - Renal mass lesions (incl. polycystic disease) - Langerhans Cell Histiocytosis - Pelvic tumours - Trauma 5 – TECHNICAL, COMMUNICATION AND DECISION- - Neuropathic bladder MAKING SKILLS - Diverticula - Urodynamic studies - The trainees must know in depth the full range of - Gynaecological disease paediatric radiological diagnostic techniques de- - Intersex tailed below. They should understand the princi- - Testicular diseases ples of all the methods, and in particular emphasis should be placed on the strengths and - Neuro weaknesses of the different imaging methods in - Trauma: Skull and facial injury the diagnosis of the different pathological condi- - Intracranial injury tions. The proper choice of imaging techniques - Infection and / or the appropriate sequence of imaging - Tumours (including spinal cord) techniques to solve specific clinical problems - Ultrasound of the neonatal brain should be emphasised. The ability to discuss with - Premature brain disease parents / carers and older children should be - Developmental anomalies (structural) demonstrated. - Normal myelination - Craniosynostosis - During the training period, it is recommended - Ophthalmology: trauma that the trainee obtain experience in the follow- - Tumor ing: - Infection - Plain radiography, to include the full range of - FB clinical subspecialties, e.g. trauma, accident - Developmental anomalies: migrational and emergency, orthopaedics, rheumatology, - Epilepsy chest, and abdomen - Hydrocephalus - Undertaking and reporting ultrasound exami- - Vascular disease (including malforma- nation: tions and acquired) - of the abdomen, gastrointestinal tract (in- - Spinal cord malformations (including im- cluding bowel), genitor-urinary tract, aging for clinical presentations, e.g. back chest, head, and musculoskeletal system pain, claw foot) - Doppler studies, including spectral, basic - Craniofacial malformations colour and power Doppler, as well as - ENT congenital ear disease and deafness basic calculations - Infection - Undertaking and reporting routine fluoro- - Trauma scopic examinations of the gastrointestinal - Airway and urinary tract, together with more complex - Dental radiology investigation, such as: - Small bowel enema - Miscellaneous - Reduction of intussusception - AIDS in children - Management of neonatal distal intestinal ob- - Lymphoma in children struction - Vascular malformations (limb, lymphoede- - Velopalatal competence and studies of phonation ma) - Disorders of swallowing78 www.ear-online.org
  • 81. Detailed Curriculum for Subspecialty Training - Undertaking and reporting paediatric CT Urogenital Radiology and MR examination - Undertaking (optional) and reporting 1 – INTRODUCTION basic paediatric radionuclide imaging ex- aminations: The aim of establishing a curriculum for subspecialty - Static and dynamic renal studies, in- training in urogenital imaging is to prepare trainees for an cluding cystography activity in which he / she will dedicate a substantial - Musculoskeletal imaging amount of time to radiology of the urogenital system. His / - Ventilation and perfusion lung scintig- her specific skill should include the following: raphy - Gastrointestinal studies, including - In-depth knowledge of the relevant embryologi- pertechnetate studies for Meckel’s di- cal, anatomical, pathophysiological, and clinical verticulum aspects of radiology in the field of uronephrology - Identification of a GI bleeding site and gynaecology - Thyroid imaging - A clear understanding of the role of radiology in - MIBG studies the management of these specialist areas - Dynamic biliary examination - Complete knowledge of the indications, contra- - Interventional techniques indications, complications, and limitations of pro- - Trainees should acquire experience in cedures the following procedures: - In-depth knowledge and expertise in the exami- - Biopsy procedures nation techniques for imaging procedures to - Abscess drainage urological, nephrological, and gynaecological - Insertion of percutaneous nephros- diseases and problems tomies - Joint aspiration (e.g. hip) Furthermore, the subspecialist should be able to promote - Optional experience may include: and advance urogenital imaging in his / her environment. - Arthrography Then, the curriculum is aimed at developing the following: - Angiography - Balloon dilatation of oesophageal - The ability to act as a consultant in multidiscipli- strictures nary meetings - Embolisation techniques - The ability to transmit subspecialty knowledge to - Musculoskeletal intervention other radiology colleagues - The ability to assume the continuity and the evo- 6 – APPRAISAL AND ASSESSMENT lution of radiology in the field of urological, nephrological, and gynaecological diseases and - Methods of trainee assessment will include: problems - regular direct observation of clinical tech- niques (including communication skills, 2 – EXPERTISE AND FACILITIES ability to obtain informed consent and se- dation skills) by the trainer and / or exter- - Training in urogenital imaging must be undertak- nal observer en in a training centre with access to full clinical - regular formal review of the trainee’s skills services in radiology, nephrology and dialysis, in the accurate interpretation of investiga- urology, obstetrics and gynaecology and patholo- tions for paediatric diseases gy; it is preferable that also radiation therapy and - a final assessment of overall professional oncology be available. competence - The radiology department should have access to all routine and advanced imaging modalities (conventional radiology, CT, MRI, ultrasound, Doppler, and interventional radiology). Equipment should be in sufficient number and of state-of-the-art quality.www.ear-online.org 79
  • 82. Detailed Curriculum for Subspecialty Training - A library must be readily accessible. It should They should be encouraged to present papers at contain an adequate selection of the major text- international congresses, to meet other people books in urogenital radiology, as well as provide involved in the field of urogenital imaging in order access to major radiology journals. The library to exchange ideas and experiences. should allow also access to major journals in urology, nephrology, and gynaecology. 4 – THEORETICAL KNOWLEDGE - A teaching file should be available and continu- At the end of the training period, the trainee should have ously updated. The trainee will be expected to achieved the knowledge-based objectives listed below. contribute with cases from his / her experience Reasonable progression is to be expected during training, during his / her training period. with responsibilities assumed gradually until complete professional independence is reached. 3 –OVERVIEW - Urinary & Male Genital Tract - During the training in urogenital radiology, the trainee must spend most of his / her time in this - Renal physiology and kinetics of contrast field of interest. Although the primary scope of agents the curriculum is to acquire in-depth knowledge - To understand the physiology of renal ex- of radiological techniques and imaging findings, cretion of contrast medium (both iodinat- the trainee is expected to acquire knowledge of ed and gadolinium-based ones) the clinical and pathologic presentation of dis- - To understand the enhancement curves eases of the urogenital system too, as well as an within renal compartments after injection understanding of the tests which are the prereq- of contrast agents (both iodinated and uisites for imaging examinations (i.e. laboratory, gadolinium-based ones) endoscopy, urodynamics). - To know the concentrations and doses of contrast agents used intravenously (both - Because angiographic interventions require addi- iodinated and gadolinium-based ones). tional special skills, they are not required for the - Knowledge on the following aspects of curriculum in urogenital imaging. However, the contrast media (both iodinated and trainee is expected to develop capabilities in gadolinium-based ones) nephrotoxicity image-guided biopsy procedures (renal and ad- would be required: renal masses, prostate, lymph nodes) and - Definition of contrast media nephro- drainages of lesions and organs of the urogenital toxicity system (nephrostomy, abscess drainage). - Risk factors of contrast media nephro- Additional training may be required for proce- toxicity dures such as varicocele embolisation, renal tu- - How to identify patients at high risk of mour embolisation, and fibroid embolisation. contrast media nephrotoxicity Management of renal artery stenosis may at - Measures to reduce the risk of con- times be under the remit of urogenital radiology. trast nephrotoxicity - Precautions in diabetics taking met- - The trainee should be familiar with clinical termi- formin and requiring intravascular ad- nology so as to communicate without difficulty ministration of CM with clinical colleagues. He / she should attend - For these items, please refer to the multidisciplinary meetings to get a thorough idea ESUR guidelines on CM of patient treatment, as well as of the role of im- aging methods in clinical practice. - Normal anatomy and variants - Retroperitoneum - The trainee should become familiar with the cur- - To recognise retroperitoneal spaces rent literature in urogenital imaging, both from and pathways standard textbooks and original articles. They - Kidney should be encouraged to participate in research - To understand the triple obliquity of projects and acquire knowledge of the design, the kidney execution, and analysis of scientific projects. - To know the criteria of normality of80 www.ear-online.org
  • 83. Detailed Curriculum for Subspecialty Training pyelocaliceal system on IVU and CTU - Choice of the contrast agent - To recognise normal variants, such as - Film timing and sequences junctional parenchymal defect column - To remember aseptic technique of Bertin hypertrophy, fœtal lobulation, - CT of the urinary tract and lipomatosis of the sinus - To define the normal level of density - To identify the main renal malforma- (in HU) of urinary organs and compo- tions such as horseshoe kidney, dupli- nents cations, ectopia, and fusions - To know the protocol for a renal and - Bladder and urethra adrenal tumour - To know the anatomy of bladder wall - To know the protocol for urinary ob- and the physiology of micturition struction (including stones) - To identify the segments of male ure- - To know the protocol for a bladder tu- thra and location of urethral glands mour - Prostate - CT urography (CTU): techniques, indi- - To recognise zonal anatomy of the cations, contraindications, and limita- prostate tions - To identify prostatic zones with US - MR of the urinary tract and MRI - To know the appearances of urinary - Scrotum organs on T1 and T2 images - To know the US and MRI anatomy of - To know the appearances of urinary intra-scrotal structures (testicular and organs on T1 and T2 contrast-en- extratesticular) hanced sequences - To know the Doppler anatomy of tes- - To know the protocol for a renal and ticular and extratesticular vasculature adrenal tumour - To know the protocol for urinary ob- - Imaging techniques struction - Sonography of urinary tract - To know the protocol for a bladder tu- - To choose the appropriate transducer mour according to the organ imaged - To know the protocol for a prostatic tu- - To optimise scanning parameters. mour - To recognise criteria for a good sono- - "Conventional" pelvic MRI for the graphic image prostate: possibilities and limits - To recognise and explain the main ar- - Use of rectal probes tifacts visible in urinary organs - Prostate MRI spectroscopy - To be able to obtain a Doppler spec- - MR Urography (MRU) trum on intrarenal vessels (for resis- - T2 MRU tive index measurement) and on - Excretory MRU: technique, indica- proximal renal arteries for velocity cal- tions, contraindications, and limita- culation tions - IVU - To list the remaining indications of IVU - To accurately diagnose the presence of the - To know the main technical aspects, following pathologies: including: - Kidney and ureter - Choice of the contrast agent - Congenital - Doses - Obstruction - Film timing and sequences - Calculus - Indication for ureteral compression - Infection - Indication of frusemide - Tumours - Cysto-urethrograpy - Cystic diseases - To list the main indications of cysto- - Medical renal diseases urethrography - Vascular - To know the main technical aspects: - Renal transplantation - Choice of technique: trans-ure- - Trauma thral, transabdominalwww.ear-online.org 81
  • 84. Detailed Curriculum for Subspecialty Training - Retroperitoneum - US-guided biopsies / cystic drainage, e.g. - Congenital kidney mass, prostate - Infection - To become familiar with ultrasound - Trauma probes - Tumours - To become familiar with different guid- - Bladder ance techniques - Congenital - free hand - Obstruction - guidance devices - Inflammatory - To become familiar with different biop- - Tumours sy devices and needles - Trauma - To become familiar with drainage - Incontinence & functional disorders tubes and fixation devices - Urinary diversion - To become able to liaise with patholo- - Urethra gists and referring physicians - Congenital - CT-guided biopsies - Strictures - To become familiar with CT scanners - Diverticula and CT-guided biopsy / drainage tech- - Trauma niques - Prostate & Seminal Vesicles - Percutaneous nephrostomy - Congenital - To verify and discuss indication with - Benign prostatic hypertrophy referring clinicians - Inflammatory - To verify patient preparation and posi- - Tumours tioning - Testis & scrotum - To become familiar with sedo-anelge- - Congenital sia, local anaesthesia, and antibiotic - Inflammatory policies - Torsion - To become familiar with guidance - Trauma techniques - Tumours - US guidance - Penis - Fluoroscopic guidance - Impotence - To become familiar with puncture - Trauma techniques - Tumours - To become familiar with guidewires - Adrenal and tissue dilatators - Masses - To become familiar with nephrostomy tubes: - Interventional - locked - In general - unlocked - To verify indications to the procedure - To become familiar with fixation de- and patient risk factors (such as satis- vices, dressings, and drainage bags factory blood count, coagulation sta- - To become proficient in nephrostomy tus, etc.) placement as well as in nephrostomy - To explain the procedure and follow- change up to the patient - Antegrade ureteric stent insertion - To obtain informed consent - To become proficient in nephrostomy - To know what equipment is required insertion (see above) - To know what aftercare is required - To become familiar with guidance - To know the complications, impor- catheters tance of early detection, and manage- - To become familiar with ureteric dilata- ment tors - Teflon - Balloon82 www.ear-online.org
  • 85. Detailed Curriculum for Subspecialty Training - To become familiar with ureteric stents - CT scan - double J stents - To be able to explain the technique of - metallic stents a pelvic CT - To liaise with urologists for stent man- - To know the possible complications of agement CT - To know the contra-indications of CT - Percutaneous nephrolithotomy - To know the irradiation delivered by a - To work in close cooperation with pelvic CT endo-urologists - To know the required preparation of - To discuss case preoperatively the patient and the choice of technical - To become familiar with access tech- parameters (slice thickness, Kv, mA, niques and tract dilatation number of acquisitions, etc.) depend- - To become familiar with available ing on indications lithotripsors - MRI - Angiography - To be able to explain the technique of Detailed angiographic techniques, includ- a pelvic MRI ing selective angiography and embolisa- - To know the contra-indications of MRI tion techniques, are better acquired - To know the required preparation of during an attachment to a vascular an- the patient and the choice of technical giography slot during training. parameters (slice thickness, orienta- tion, weighting, etc.) depending on in- At the end of the training period the trainee should be- dications, including pelvic floor come proficient with performing the basic interventional disorders techniques and be familiar with the more complex proce- - Angiography dures (exact number of different procedures is not always - To know the main indications of pelvic relevant, as the degree of dexterity and proficiency will angiography in women vary from trainee to trainee). - To know how to perform a pelvic an- giography - Female genital tract - Anatomy - To know main normal dimensions of - Techniques uterus and ovaries with US - US examination - To describe variations of uterus and - To be able to explain the value of an ovaries during genital life US examination - To describe variations of uterus and - To be able to explain the advantages ovaries during the menstrual cycle and limits of abdominal vs. transvagi- - To describe normal pelvic compart- nal approach ments - To be able to perform a transvaginal - To identify normal pelvic organs and US examination boundaries on CT and MRI - To know indications and contra-indica- - To explain the role of levator ani in the tions of hysterosonography physiology of the pelvic floor - To be able to perform a hysterosono- - To know what imaging modalities can graphic examination be used to visualise the pelvic floor - Hysterosalpingography - To know the factors responsible for uri- - To be able to describe the procedure nary incontinence - To know the possible complications of hysterosalpingography - To accurately diagnose the presence of the - To know the contra-indications of hys- following pathologies: terosalpingography - Uterus - To explain the choice of contrast agent - Congenital anomalies - To know the different phases of the ex- - Tumours (benign and malignant) amination - Myometrium - To be able to perform the procedure - Endometriumwww.ear-online.org 83
  • 86. Detailed Curriculum for Subspecialty Training - Cervix - To perform the examination - Inflammation - To know the clinical history and the clinical - Adenomyosis questions to be answered - Functional disorders - To know the protocol of examination - Ovaries / Tubes - To assess the anxiety of the patient before, - Ovary during and after the examination and provide - Tumours (benign and malignant) appropriate reassurance - Functional disorders, e.g. function- al cysts of the follicle or corpus lu- - Communication with the patient and recommen- teum, precocious puberty, and dations for follow-up polycystic ovaries - To explain clearly the results to the patient - Endometriosis - To assess the level of understanding of the - Tubes patient - Inflammatory disorders - To explain the type of follow-up - Tumours - To assess the degree of emergency - Pelvis - To produce a clear report of the examination - Prolapse - To discuss strategies for further investigation, - The "acute female pelvis" if necessary - Endometriosis, including extra-ovarian locations of endometriosis - Communications and interaction with colleagues - Pelvic location of peritoneal pathology - To dictate useful and intelligible reports - Infertility - To be able to discuss significant or unexpect- - Vagina ed imaging findings with colleagues and to - Congenital abnormalities know when to contact a clinician - Benign and malignant tumours - To be able to interact with colleagues in clini- co-radiological conferences Depending on clinical practices and availabilities, - To be able to take part in multidisciplinary training in fetal US and MRI can be offered. teams dealing with patients with urological, nephrologic, or genital diseases 5 – TECHNICAL, COMMUNICATION AND DECISION- MAKING SKILLS At the end of the training period, the trainee should have achieved the following technical, communication and de- cision-making skills. Reasonable progression is to be ex- pected during the two years of training, with responsibilities assumed gradually until complete profes- sional independence. - Before the examination - To check the clinical information and risk fac- tors (diabetes, allergy, renal failure, etc.) - To validate the request and the choice of ex- amination - To know the specific preparation, if neces- sary, and protocols - To explain the examination to the patient and inform him / her about risks - To justify the examination request based on: - Risk factors - Irradiation involved - Possible (better?) alternatives84 www.ear-online.org
  • 87. The following documents can be downloaded from the EAR website at www.ear-online.org EAR Annual Report 2005 European Training Charter for Clinical Radiology, Detailed Curriculum for the Initial Structured Common Programme, Detailed Curriculum for Subspecialty Training Radiological Training Programmes in Europe - Analysis of Survey EIBIR Newsletter, November 2005 Teleradiology 2004 Good Practice Guide for European Radiologists Risk Management in Radiology in Europe CME / CPD Guidelines EAR Annual Report 2003 / 2004 Benchmarking Radiological Services in EuropeEuropean Association of RadiologyFor further information please visit the EAR website at www.ear-online.org
  • 88. www.ear-online.org