european training charter for clinical radiology

www.ear-online.orgEuropean Association of Radiology

EUROPEAN TRAINING CHARTERFOR CLINICAL RADIOLOGY

DETAILED CURRICULUM FORTHE INITIAL STRUCTUREDCOMMON PROGRAMME

DETAILED CURRICULUM FORSUBSPECIALTY TRAINING

European Associationof Radiology

Radiology Section ofthe Union of European

Medical Specialists

EAR EXECUTIVE BUREAU

Prof.Dr. N. GourtsoyiannisPRESIDENT

Prof.Dr. I.W. McCallVICE-PRESIDENTProf. Dr. G. FrijaSECRETARY-GENERALProf. Dr. L. BonomoTREASURER

Prof.Dr. P.A. GrenierEDUCATIONDr. B. SilbermanPROFESSIONAL ORGANISATIONProf.Dr. G.P. KrestinRESEARCHProf. Dr. J.I. BilbaoSUBSPECIALTIESProf. Dr. A. PalkóNATIONAL MEMBERS

Prof.Dr. A.L. BaertEUROPEAN RADIOLOGYProf. Dr. A. ChiesaECR CHAIRMAN

TABLE OF CONTENTS

Preface 1

European Training Charterfor Clinical Radiology 2 - 10

Detailed Curriculum for theInitial Structured Common Programme 11 - 44

Breast Radiology 11-12Cardiac Radiology 12-14Chest Radiology 15-21Gastrointestinal and Abdominal Radiology 22-28Head and Neck Radiology 28-30Interventional Radiology 31-33Musculoskeletal Radiology 34-36Neuroradiology 37Paediatric Radiology 38-41Urogenital Radiology 42-44

Detailed Curriculum for Subspecialty Training 45 - 84

Breast Radiology 46-48Cardiac Radiology 49-51Chest Radiology 52-54Gastrointestinal and Abdominal Radiology 54-59Head and Neck Radiology 60-64Interventional Radiology 64-67Musculoskeletal Radiology 67-71Neuroradiology 71-76Paediatric Radiology 76-79Urogenital Radiology 79-84

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Neutorgasse 9/2a / AT-1010 Vienna, AustriaTel +43 1 533 40 64 - 33 / Fax +43 1 535 70 [email protected]

EAR OFFICE

Vienna, November 2005Coordination: Isabella Grabensteiner, EAR Office, ViennaGraphics: ECR graphic_link / a department of ECR

Preface

www.ear-online.org 1

The European Association of Radiology (EAR) elaboratedin conjunction with the Union of European MedicalSpecialists (UEMS) Radiology Section a revised charterfor training which replaces the previous 2003 charter. Thisnew version is a response to the rapid expansion of therole and diversity of radiology in recent years. The charteris designed to provide increased flexibility for trainees inthe latter part of training to enable them to pursue agreater variety of training opportunities within the overalldefined training period.

The charter reiterates that the training period for radiologyis five years which recognises the vast amount of knowl-edge and skills required to deliver a general radiologyservice. This knowledge includes cell function, physiology,anatomy and physics as well as a wide understanding ofall disease manifestations, natural history and treatment.Competence in undertaking and interpreting a wide rangeof imaging modalities and disease manifestations alsotakes a considerable time which cannot be condensedinto shorter training periods.

The charter recognises that most radiologists work in agroup providing a general service to a broad range of clin-ical specialists. However, the increased complexity ofmodern medicine and the impact of multi-disciplinarymeetings requires a deeper knowledge of diseaseprocesses in many circumstances. Therefore, the charteremphasises the need for general radiologists in their finaltwo years of training to develop a more focussed anddeeper knowledge of at least two areas in order to en-hance the service provided by the group of general radiol-ogists.

Finally, the charter recognises that for more specialisedservices a greater degree of specialisation by radiologistsis required and that training in the latter years must be fo-cussed in order to obtain the necessary knowledge and

skills. However, it is essential for this group to have abroad understanding of radiology and the wide variety ofimaging modalities that they will use prior to subspeciali-sation particularly as many diseases are not restricted toone organ system. Those radiologists providing therapyand particularly interventional radiologists will also requiresufficient clinical time to become competent in patientmanagement.

Two detailed curricula have also been produced whichprovide a in-depth check list for radiology trainers andtrainees to ensure that the appropriate areas of knowl-edge and competence have been addressed and ob-tained. The first curriculum covers the initial structuredtraining programme. The second provides guidance forthose wishing to spend their career working predominant-ly in one organ-based subspecialty area. The subspecial-ty curricula also highlight the importance of thespecialised scientific literature to this group. The generalradiologist undertaking training in areas of special interestin the latter part of their training may also wish to use thesubspecialty curricula for guidance albeit recognising thatthey would not be required to fulfil all aspects of them.

The detailed curricula for both the initial structured train-ing programme and the subspecialties have been devel-oped by the Subspecialty Societies of EAR. This hasinvolved an immense amount of time and patience andthe EAR Executive Bureau is extremely grateful to allthose in the Subspecialty Societies who have contributedto the process. EAR believes that the charter and the de-tailed curricula will provide a valuable template for trainingradiologists and will enhance the quality of care for pa-tients throughout Europe. EAR hopes that the documentswill also be helpful for National Societies in their discus-sions with governments to ensure a high-quality, five-yeartraining programme in every European country.

Preface

Professor N. GourtsoyiannisEAR President

Professor I.W. McCallEAR Vice-President

Professor P.A. GrenierEAR Education Committee Chairman

European Training Charter for Clinical Radiology

2 www.ear-online.org

European Training Charter for Clinical RadiologyIntroduction: Radiology is a medical specialty involvingall aspects of medical imaging which provide informationabout the anatomy, pathology, histopathology and func-tion of disease states. It also involves interventional tech-niques for diagnosis and minimally invasive therapyinvolving image-guided systems. The duration of trainingis five years.

Contents:1. Core of knowledge2. Training programmes3. Training facilities

Article 1

CORE OF KNOWLEDGE

1.1 Basic sciencesa. Radiation physics;b. Radiobiology;c. The physical basis of image formation includ-

ing conventional x-ray, computed tomogra-phy, nuclear medicine, magnetic resonanceimaging and ultrasound;

d. Quality control;e. Radiation protection;f. Anatomy, physiology, biochemistry and tech-

niques related to radiological procedures;g. Cell biology, DNA, RNA, and cell activity;h. Pharmacology and the application of contrast

media;i. Basic understanding of computer science,

image post processing, image archiving andimage communication and teleradiology.

1.2 Pathological sciencesA knowledge of pathology and pathophysiologyas related to diagnostic and interventional radiol-ogy.

1.3 Current clinical practiceA basic knowledge of current clinical practice asrelated to clinical radiology. Competence in pro-ducing a radiological report and in communica-tion with clinicians and patients.

1.4 Clinical radiologyAn expert knowledge of current clinical radiology.This knowledge should include:a. Organ- or system-based specialties, e.g. car-

diac, chest, dental, oto-rhino-laryngology,gastrointestinal, genito-urinary, mammogra-phy, musculoskeletal, neuro, obstetric andvascular radiology, including the applicationof conventional x-rays, angiography, comput-ed tomography, magnetic resonance imag-ing, ultrasound and, where applicable,nuclear medicine.

b. Age-based specialties, i.e. paediatric radiolo-gy.

c. Common interventional procedures, e.g.guided biopsy and drainage procedures.

d. Dealing with emergency cases.

1.5 Administration and managementA knowledge of the principles of administrationand management applied to a clinical depart-ment with multi-disciplinary staff and high-costequipment.

1.6 ResearchA knowledge of basic elements of scientificmethods and evidence base, including statisticsnecessary for critical assessment and under-standing of published papers and the promotionof personal research.

1.7 Medico-legalAn understanding of the medico-legal implica-tions of radiological practice. An understandingof uncertainty and error in radiology togetherwith the methodology of learning from mistakes.

Article 2

TRAINING PROGRAMMES

2.1 The specialty of radiology involves all aspects ofmedical imaging, which provide informationabout morphology, function and cell activity andthose aspects of interventional radiology or mini-mally invasive therapy (MIT), which fall under theremit of the department of radiology.



2.2 Clinical experience. Radiologists are cliniciansand require a good clinical background in otherdisciplines. This is usually achieved through clini-cal experience and training prior to entering radi-ology, but may also require additional clinicalexperience during radiology training whichshould not impact negatively on the achievementof the full radiological training curriculum. Thefully trained radiologist should be capable ofworking independently when solving the majorityof common clinical problems. In particular thoseundertaking interventional procedures may re-quire sufficient clinical knowledge to accept directreferrals and to manage cases as out-patientsand in-patients.

2.3 A general radiologist should be conversant withall aspects of the core of knowledge for generalradiology to ensure an understanding of those ra-diological skills required in a general or commu-nity hospital or in a general radiological practice.

2.4 Radiological training should be based on clinicalsystems and not on modalities such as CT, MRIand US. Understanding of the value and use ofthese modalities and training in the practice ofthe techniques should be gained during the re-spective system-based module.

2.5 The duration of training in radiology is five years;the content of the first three years is a structuredcommon programme for radiological anatomy,disease manifestations and core radiologicalskills. The fourth and fifth year are structuredmore flexibly to develop sufficient competence tofunction autonomously as a general radiologistand to facilitate subspecialty training. The fourthand fifth years of training for those preparing toprovide a general radiology service will includegaining additional experience in all organ sys-tems, but trainees should also develop at leasttwo special areas of interest.

2.6 Radiologists in training should be available on afull-time basis for the five years of training.Arrangements may vary for those undertakingflexible training, but the total time of training willbe equivalent to a full-time trainee. It is recog-nised that the starting date for radiological train-ing programmes will vary throughout Europe.

2.7 The precise structure of the system-based mod-ules may vary a little from country to country and

from department to department, but the time bal-ance should reflect the importance of the systemto the core of radiological practice.

2.8 The training programme in years one to three

2.8.1 Early in this three-year period, trainees shouldacquire the necessary knowledge of the basicsciences, i.e. the physical basis of image forma-tion in all imaging modalities, picture archivingcomputer systems (PACS), radiology and hospi-tal information systems, quality control, radiationprotection, radiation physics, radiation biology,anatomy, physiology, cell biology and molecularstructure, biochemistry and techniques related toradiological procedures, the pharmacology andapplication of contrast media and a basic under-standing of computer science as outlined in thecore of knowledge for general radiology.

2.8.2 The radiology training should ensure the under-standing and implementation of the process ofjustification and optimisation as laid down inEuratom directive 97 / 43.

2.8.3 A detailed knowledge of normal imaging anatomyshould be gained in the early stages of training.

2.8.4 Modular rotations in clinical areas of radiologyshould be system-based involving the use of allrelevant modalities within the module and formu-lated into an integrated programme to cover allaspects of radiology. The distribution of time willreflect the complexity and relevance to generalclinical practice, but as a guideline the musculo-skeletal system, thorax and cardio-vascular sys-tems, gastrointestinal system includingparenchymal organs, central nervous systems in-cluding head and neck and paediatrics are likelyto require similar time balance. The remainingareas being balanced as required.

2.8.5 Trainees should participate in clinical radiologyexaminations and activities and the extent andcomplexity should gradually increase during thefirst year in line with experience. It is importantthat trainees participate in all sections of the de-partment of radiology to gain experience in alltechniques so that they understand the functionand role and learn how to use the technology inpractice of the following imaging methods:- Conventional radiology including film pro-

cessing and archiving,



- Fluoroscopy,- Ultrasound,- Computed tomography,- Magnetic resonance imaging,- Radionuclide imaging where possible. All ra-

diology trainees should have a knowledge oftechniques available and diagnostic featuresof the studies.

2.8.6 The first three years of the five-year training pro-gramme should include the following elements:- Chest diseases- Central nervous system - Musculoskeletal system - Gastrointestinal system including the hepato-

biliary system - Urogenital system- Paediatrics- Cardiac diseases- Head and neck, maxillo-facial and dental

radiology- Obstetrics and gynaecology- Breast diseases - Endocrine system - Vascular and lymphatic system- Oncology- Emergency department radiology - Basic interventional techniques

2.8.6 The trainee should be involved in the radiologicalexamination and diagnosis of patients presentingin the emergency department and be able to ap-propriately evaluate patients who are severely orcritically ill. It is not anticipated that a traineewould enter into an emergency on-call rotationentailing clinical responsibility until the end of thefirst year of training.

2.8.7 Trainee radiologists at the end of three yearsshould be fully conversant with the basic aspectsof the common trunk for general radiology. Thiswill be achieved by a mixture of didactic andpractical training.

2.8.8 In the common trunk, the trainees in radiologyshould develop a knowledge of the radiologicalsigns and techniques in line with the followingoutline targets. All trainees should undertakebasic interventional procedures during this peri-od. The trainees should be closely supervised bya fully qualified radiologist. Some detailed curric-ula for the use of trainers and trainees are pre-sented on pages 11-44.

Musculoskeletal

Core knowledge- Musculoskeletal anatomy, normal skeletal

variants which mimic disease and commoncongenital dysplasias

- Clinical knowledge of medical, surgical andpathology related to musculoskeletal system

- Trauma involving skeleton and soft tissue andthe value of different imaging modalities

- Degenerative disorders and their clinical rele-vance

- Manifestations of musculoskeletal infection,inflammation and metabolic diseases includ-ing osteoporosis and bone densitometry

- Recognition and management of tumours

Core skills- Reporting plain radiographs, radionuclide in-

vestigations, CT and MR of common muscu-loskeletal disorders

- Performing and reporting Ultrasound exami-nations of muscle, tendons and ligamentswhere appropriate

- Managing and reporting radiographs, CT andMR of musculoskeletal trauma

- Observing image guided biopsies anddrainages in the musculoskeletal system

- Observing minimally invasive therapeutic pro-cedures of the musculoskeletal system

Thorax

Core knowledge- Anatomy of the respiratory system, heart and

vessels, mediastinum and chest wall on radi-ographs, CT and MR.

- Recognise and state significance of genericsigns on chest radiographs

- Features on radiographs and CT and differen-tial diagnosis of atelectasis, diffuse infiltrativeand alveolar lung disease, airways and ob-structive lung disease

- Recognise solitary and multiple pulmonarynodules, benign and malignant neoplasms,hyperlucencies and their potential aetiology

- Thoracic diseases in immuno-compromisedpatients and congenital lung disease

- Disorders of the pulmonary vascular systemand great vessels including the diagnosticrole of radiographs, radionuclides, CT andMR in diagnosis



- Abnormalities of the chest wall mediastinumand pleura and including the post operativechest and trauma

Core skills- Managing and reporting radiographs, chest

radiographs, V/Q scans, high- resolution CTincluding CT pulmonary angiography

- Drainage of pleural space collections underimage guidance and observation of imageguided biopsies of lesions within the thorax

Gastrointestinal

Core knowledge- Anatomy of the abdomen including internal

viscera, abdominal organs, omentum,mesentery and peritoneum on radiographs,barium and other contrast studies, CT, USand MR

- Recognise features of abdominal trauma andacute conditions including perforation, haem-orrhage, inflammation, infection, obstruction,ischaemia and infarction on radiographs, ul-trasound and CT

- Imaging features and differential diagnosis ofprimary and secondary tumours of the solidorgans, oesophagus, stomach, small bowel,colon and rectum

- Imaging features of the stage and extent oftumours including features which indicate un-resectability and knowledge of the role of en-doscopy and endoscopic US

- Radiological manifestations of inflammatorybowel diseases, malabsorption syndromesand infection

- Recognition of motility disorders, hernias anddiverticula

- Radiological manifestation of vascular lesionsincluding varices, ischaemia, infarction,haemorrhage and vascular malformations

- Understanding of the applications of angiog-raphy, vascular interventional techniques,stenting and porto-systemic decompressionprocedures

Core skills - Performance of plain film reporting - Performing and reporting contrast examina-

tions of the pharynx, oesophagus, stomach,small and large bowel

- Performing and reporting trans-abdominal ul-

trasound of the gastrointestinal system, ab-dominal viscera and their vessels

- Managing and reporting CT of the abdomen - Understanding and where possible and ap-

propriate observation and experience oftransrectal, transvaginal and endoscopic ul-trasound

- Performing US and CT guided drainage andbiopsy

- Experience of the manifestations of abdomi-nal disease on MRI

- Understanding and, where appropriate, expe-rience of radionuclide investigations of the GItract and abdominal organs

- Observation of angiography and vascular in-terventional techniques

Neuroradiology

Core knowledge- Knowledge of the normal anatomy and nor-

mal variants of the brain, spinal cord andnerve roots

- Understanding the rationale for selecting cer-tain imaging modalities, and the use of con-trast enhancement, in diagnosing diseases ofthe central nervous system

- Imaging features on CT and MR and differen-tial diagnosis of stroke, haemorrhage, andother vascular lesions of the brain and spinalcord and of the application of CT and MR an-giography

- Diagnosis of skull and spinal trauma and itsneurological sequelae

- Imaging features and differential diagnosis ofwhite matter disease, inflammation and de-generation

- Diagnosis of benign and malignant tumoursof the brain, spinal cord and cranial nerves

- Understanding the role of nuclear medicineincluding PET in neurological disorders

Core skills- Reporting radiographs of the skull and spine - Managing and reporting cranial and spinal

CT and MR - Observation of cerebral angiography - Observation of carotid ultrasound including

Doppler - Observation of interventional procedures



Urogenital

Core knowledge (See also obstetrics and gynaecology.)

- Knowledge of the normal anatomy of the kid-neys, ureters, bladder and urethra includingnormal variants

- Knowledge of the normal anatomy of theretroperitoneum, female pelvis and male gen-ital tract

- Understanding of renal function, the diagno-sis of renal parenchymal diseases includinginfection and renovascular disease includingmanagement of renal failure

- Imaging features and appropriate investiga-tion of calculus disease

- Investigation and features of urinary tract ob-struction and reflux including radionuclidestudies

- Imaging features and differential diagnosis oftumours of the kidney and urinary tract

- Imaging features and investigation of renaltransplants

- Imaging features and differential diagnosis ofthe retroperitoneum, prostate and testis

Core skills- Reporting radiographs of the urinary tract - Performing and reporting intravenous

urograms, retrograde pyelo-ureterography,loopogram, nephrostograms, ascending ure-thrograms and micturating cysto-urethro-grams

- Performing and reporting transabdominal ul-trasound imaging of the urinary tract andtestis

- Managing and reporting computed tomogra-phy and MR imaging of the retroperitoneum,urinary tract and pelvis

- Observing nephrostomies, image guidedrenal biopsies and angiography as applied tothe urinary tract

Cardiac, vascular and lymphatics

Core knowledge- Normal anatomy of the heart and vessels in-

cluding lymphatic system as demonstrated byradiographs, echocardiography and doppler,contrast enhanced CT and MR

- General principles and classification of con-genital heart disease and the diagnostic fea-tures on conventional radiographs

- Natural history and anatomic deformitiescausing central cyanosis

- Radiological and echocardiographic featuresand causes of cardiac enlargement includingacquired valvular disease

- Diagnosis of ischaemic heart disease includ-ing radionuclide imaging and coronary an-giography

- Diagnostic features of vasculitis, atheroma,thrombosis and aneurysmal dilatation of ar-teries and veins

- Radiological and ultrasound diagnosis ofpericardial disease

Core skills- Reporting radiographs relevant to cardio-vas-

cular disease.- Femoral artery and venous puncture tech-

niques, and the introduction of guidewiresand catheters into the arterial and venoussystem

- Performing and reporting aortography andlower limb angiography

- Performing ultrasound of arteries and veins- Managing and reporting CT and MR of the

vascular system including image manipula-tion

Paediatric

Core knowledge- Normal paediatric anatomy and normal vari-

ants with particular relevance to normal matu-ration and growth

- Disease entities specific to the paediatric agegroup and their clinical and radiological mani-festations using all modalities

- The value and indications for ultrasound, CTand MR in children

- Disorders and imaging features of theneonate

- Understanding the role of radionuclide imag-ing in paediatrics

Core skills- Reporting conventional radiographs in the in-

vestigation of paediatric disorders - Performing and reporting ultrasound of the

abdomen, head and musculoskeletal systemin the paediatric age group

- Performing and reporting routine fluoroscopiccontrast studies of the gastrointestinal sys-tem and urinary tract

- Managing and reporting CT and MR exami-nations



Head and neck

Core knowledge- Normal anatomy and congenital lesions of

the head and neck including paranasal sinus-es oral cavity, pharynx and larynx, inner ear,orbit, teeth and temporo-mandibular joint

- Manifestations of diseases and the investiga-tion of the eye and orbit including trauma, for-eign bodies, inflammation and tumours

- Diagnosis of faciomaxillary trauma and tu-mours and disorders of the teeth

- Diagnosis of lesions and abnormal function ofthe temporomandibular joint

- Diagnosis of disorders of the thyroid, parathy-roid and salivary glands including hypo andhyperactivity and tumours and awareness ofthe role of radionuclide imaging

- Imaging features of trauma, inflammation, in-fection and tumours of the paranasal sinuses,oral cavity, larynx and pharynx

- Understanding the role of US and CT guidedpunctures of salivary glands, lymph nodesand thyroid

Core skills- Reporting radiographs performed to show

ENT/dental disease - Performing and reporting fluoroscopic exami-

nations including barium swallows, sialogra-phy and dacrocystography

- Performing and reporting ultrasound evalua-tion of the neck including thyroid, parathyroidand salivary glands

- Managing and reporting CT and MR of neck,ear, nose, throat and skull base disorders

Breast

Core knowledge- Normal anatomy and pathology of the breast

relevant to clinical radiology - Understanding of the radiographic and ultra-

sound techniques employed in screening anddiagnostic mammography

- Diagnosis of both benign and malignant ab-normalities in the breast

- Understanding current practice in breast im-aging, breast interventions and screening forbreast cancer

- Awareness of the role of other techniques forbreast imaging

Core skills- Mammography and ultrasound reporting of

common breast diseases - Observation of interventions especially for

biopsies and localisations

Gynaecology and obstetrics

Core knowledge- Normal anatomy of the female reproductive

organs and physiological changes affectingimaging

- Changes in foetal anatomy during gestationand the imaging appearances of foetal abnor-malities

- Imaging features of disorders of the ovaries,uterus and vagina as demonstrated on ultra-sound, CT and MR

- Awareness of the applications of angiographyand vascular interventional techniques

Core skills- Reporting radiographs performed for gynae-

cological disorders - Performing and reporting trans-abdominal

and, where possible, endo-vaginal ultrasoundexaminations in gynaecological disorders

- Observing and, where possible, performingobstetric ultrasound

- Managing and reporting CT and MR in gy-naecological disorders

Oncology

Core knowledge- Familiarity with tumour staging nomenclature - Application of all imaging and interventional

techniques in staging and monitoring the re-sponse of tumours to therapy

- Radiological manifestations of complicationsin tumour management

Core skills- Reporting radiographs performed to assess

tumours - Performing and reporting ultrasound, CT, MR

and, where possible, radionuclide examina-tions for staging and monitoring tumours

2.8.9 Trainees should become familiar with clinicalproblems presenting in the emergency depart-ment and be able to manage the appropriate im-



aging of cases in acutely ill or traumatised pa-tients.

2.8.10 An assessment process should be instituted dur-ing the clinical radiological training programme.This should be a structured process with writtenassessments of the trainees by the trainers at theend of each rotation. The extent of assessmentand appraisal will vary from country to country,but a regular dialogue between trainer andtrainee is desirable to monitor progress and torectify any weaknesses that may be manifested.Formal written / oral examination and / or a scien-tific thesis may be required in some countriesduring or at the end of this period of training. It isrecommended that a log-book (carnet de stage)of clinical radiological activities and periods of ro-tation should be maintained during the trainingperiod. Such a log-book might include the num-ber of clinical examinations performed.

It is recommended that personal guidance andcontinuous assessment should be provided by anominated tutor.

2.9 Fourth and fifth year of training

2.9.1 In the fourth and fifth year the rotations of the ra-diologist in training should be organised to servethe individual’s needs, dependent on the avail-ability within the training programme, which maybe in general radiology or in a subspeciality.

2.9.2 General Radiology: General radiology trainingin the fourth and fifth year is designed to enablethe trainee to acquire further experience, knowl-edge and skills in disorders present in generalhospitals and private practice in order to reach alevel required to undertake autonomous practice.This period of training should include an extend-ed period of time in at least two areas of specialinterest to acquire more detailed knowledge andskills. This will enable the general radiologist tohave areas where they may contribute to specificmultidisciplinary meetings and consultations aspart of a radiologists’ team within his / her futuregeneral radiology practice.

2.9.3 Radiological Subspecialty: For those enteringa subspecialty, the total period of subspecialisttraining will vary according to the subspecialty,but would normally be expected to be completed

during the fourth and fifth year. For those subspe-cialties with a single year of subspecialty trainingcontinued training in general radiology during thebalance of time will be undertaken.

2.9.4 A period of training in approved hospitals otherthan those in which the trainee is based in eitherthe same country or abroad may be required for avariable period according to the national regula-tions.

2.9.5 Some subspecialty training may extend beyondthe fifth year depending on national trainingarrangements relevant to their specialist pro-gramme.

2.10 Course participation Attendance at outside-courses will depend onthe stage of training and the relevance of thecourses to the trainees’ stage of training.At least two congress or course attendancesshould be mandatory over the period of thefourth and fifth year of training.

2.11 ResearchA dedicated period of research should be per-missible as part of the overall training pro-gramme. This may be up to one year and mayrequire approval by a national regulatory orEuropean body, especially if any additional timeis involved.Trainees should be encouraged to un-dertake a research project during their training,even if they do not have a dedicated period of re-search. This is particularly valid for those under-taking subspecialty training.

Article 3

TRAINING FACILITIES

3.1 Aims of training: Each training programme shouldoutline the educational goals and objectives ofthe programme with respect to knowledge, skillsand other attributes of residents at each level oftraining and for each major training assignment.

3.1.1 Training should aim at providing sufficient knowl-edge to enable the trainee on completion of thetraining period to be able to work independentlyas a qualified radiologist at radiological depart-ments in hospitals, out-patient departments andprivate practice.



3.1.2 As previously indicated formal trainee appraisaland assessment during the period of specialisttraining should be performed in order to verifythat the appropriate training has been undertak-en and that the required standard has beenachieved towards the award of the certificate ofcompletion of specialist training (CCST) or othernational equivalent.

Assessments must include:- Clinical competences- Technical competences- Attitude and character

3.1.3 Health-care systems in individual Europeancountries differ for a variety of reasons, which in-clude administration, management, equipment,budgeting and tradition. In spite of these differ-ences, recommendations for training facilities forspecialisation in general radiology can be de-fined. The practical implementation of these rec-ommendations must be left to the respectivecountries.

3.2 Requirements for fully accredited training de-partments

3.2.1 The status of a training department can be spec-ified in the following ways:a. Quantity and distribution of radiological ex-

aminations, b. Standards of equipment, c. Availability of modalities, d. Staffing, e. Teaching programme of the radiological de-

partment, f. Teaching materials,g. Research activity.

3.3 Quantity and distribution of radiological ex-aminations

3.3.1 Patient material should be varied enough to en-able the trainee to gain experience in all fields ofclinical radiology. This requires a radiological de-partment situated in a large polyvalent hospital.However, some attachments may be in small orspecialist hospitals providing expert teaching inspecific parts of the curriculum. All training de-partments should have access to expert patholo-gy services.

3.3.2 The number of radiological examinations peryear should be sufficient to enable a comprehen-sive experience of general radiology.

3.4 Standard of equipment

3.4.1 Only departments with adequate imaging equip-ment and services should be approved.

3.4.2 The equipment should fulfil radiological safetystandards and be in good technical condition.Technical efficiency, security, electric control, ra-diation safety and control should be of adequatestandard and fulfil agreed quality control criteria.

3.4.3 Radioprotection should be organised and radia-tion monitored according to European standards.

3.4.4 Down-time of the equipment for repairs should beminimal and not interfere with training.

3.5 Availability of modalities

3.5.1 The modalities for adequate radiological trainingwill depend on local availability.

3.5.2 The following are mandatory:a. Conventional radiography, b. Angiography, c. Ultrasonography, d. Computed tomography, e. Interventional radiology, f. Magnetic resonance imaging (cooperation

with other radiological training departmentsmay be necessary).

3.5.3 Access to nuclear medicine is desirable.

3.6 Staffing structure

3.6.1 The number of qualified radiologists with teach-ing functions in the department should be suffi-cient to cover the needs of teaching, even at timeof leave or in the event of other staff shortages.

3.6.2 The expertise of the teaching staff should be di-versified and cover the main areas of activity.

3.6.3 Teaching staff should have training in teachingmethods.



3.7 Teaching programme

3.7.1 There must be an approved and structured con-tinuing teaching programme for general radiologyas well as the main subspecialty areas.

3.7.2 The teaching programme should also includeregular clinico-radiological meetings and otherconsultations with clinical departments at leaston a weekly basis. Participation in meetings to re-view radiological errors should be undertaken.

3.7.3 Radiological and clinico-radiological confer-ences, seminars and training courses outside thehospital are recommended.

3.8 Teaching facilities Appropriate demonstration equipment and roomsshould be available in the department of radiolo-gy, sufficient to enable the teaching programmeto be implemented.

3.9 Teaching material

3.9.1 There should be a selection of good and moderntext books as well as other audio-visual materialin a general radiology department, completed bytext books in sub-specialties and modalities (e.g.neuroradiology, paediatric radiology, ultrasonog-raphy, computed tomography, magnetic reso-nance imaging, mammography). Adequatetextbooks in imaging physics and pertinent mate-rial concerning radiation protection should beavailable.

3.9.2 A selection of high-standard radiological journalsshould 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 ishighly desirable.

3.10 Research and Audit

3.10.1 The importance of radiological research andaudit for the training of radiologists should be em-phasised.

3.10.2 There should be an active and ongoing researchand audit programme at the training departmentand trainees should be encouraged to partici-pate.

3.11 Partition of radiological training in university,teaching and non-university hospitals

3.11.1 Part of the training may be at acknowledged andaccredited non-university hospitals, or privatepractices that have been appropriately accredit-ed, but some should be carried out at universitydepartments. The non-university componentshould provide training at least in general radiolo-gy, and may provide some sub-specialty trainingwhich would supplement that provided in the uni-versity departments. The composition of the pa-tient material needs to be taken into account inselecting all hospitals concerned with teaching.

3.11.2 All the university departments and training hospi-tals should be part of a coordinated national orfederal training scheme.

3.11.3 It is of great importance that cooperation existsbetween central authorities (e.g. Ministry ofHealth, Ministry of Education, NationalProfessional Organisations, National Radio-logical Societies, National Health InsuranceFunds etc.) and regional and local authorities,teaching centres and local hospital administra-tions etc.

Detailed Curriculum for the Initial Structured Common Programme


This document details the knowledge-based curriculumfor resident training in radiology. It defines the requiredstandards in terms of the core of knowledge that might bereasonably achieved within the first three years of thetraining programme. The document is presented in organ-based sections plus one section dedicated to paediatricradiology and one to interventional radiology.

The specialty of clinical radiology involves all aspects ofmedical imaging, which provide information about mor-phology, function and cell activity and those aspects of in-terventional radiology or minimally invasive therapy (MIT),which fall under the remit of the department of radiology. Ageneral radiologist should be conversant with all aspectsof the core of knowledge for general radiology to ensurean understanding of those radiological skills required in ageneral or community hospital or in a general radiologicalpractice.

It is important to remind the duration of training in radiolo-gy is 5 years; the content of the first 3 years is a structuredcommon programme for radiological anatomy, diseasemanifestations and core radiological skills. The fourth andfifth years are structured more flexibly to develop sufficientcompetence to function autonomously as a general radi-ologist and to facilitate subspecialty training. General radi-ology training in the fourth and fifth years is designed toenable the trainee to acquire further experience, knowl-edge and skills in disorders present in general hospitalsand private practice in order to reach a level required toundertake autonomous practice. The fully trained radiolo-gist should be capable of working independently whensolving the majority of common clinical problems.

Breast Radiology1 - INTRODUCTION

The aim of this curriculum in breast imaging is to ensurethat the trainee develops a core of knowledge in breastdisease that will form the basis for further training (if de-sired). It will also provide transferable skills that will equipthe trainee for working as a specialist in any branch of ra-diology.

Physics and radiation protection are covered in separatecourses and are not covered in detail unless specific tobreast imaging.

2 - CORE OF KNOWLEDGE

2.1. Breast anatomy and associated structures andhow they change with age.

2.2. Breast pathology and clinical practice relevant tobreast imaging.

2.3. Knowledge and understanding of the physics ofimage production, particularly how they affectimage quality.

2.4 Knowledge and understanding of the risk / benefitanalysis associated with breast screening usingionising radiation as compared with other tech-niques.

2.5. Understanding of the radiographic techniquesemployed in diagnostic mammography.

2.6. Understanding of the principles of current practicein breast imaging and breast cancer screening.

2.7. Awareness of the proper application of other im-aging techniques in this specific field, such asUS, MRI, or radionuclide imaging.

2.8. Knowledge of the indications and contraindica-tions of FNA and core biopsy and their relativeadvantages and disadvantages.

Detailed Curriculum for the InitialStructured Common Programme



2.9. Appearances of cancer and common benign dis-ease on - Mammography - Ultrasound - Magnetic Resonance Imaging.

2.10. Knowledge and understanding of the principlesof communication specifically related to thebreaking of bad news and consent.

3 - TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLS

3.1. To supervise technical staff to ensure appropriateimages are obtained.

3.2. To understand when to utilise ultrasound andother imaging techniques; to produce a report onmammographic and ultrasound breast imagingwith respect to common breast disease.

3.3. To understand when it is appropriate to obtain as-sistance in interpreting and reporting breast im-ages.

3.4. To be able to perform interventional breast proce-dures under ultrasound and X-ray control undersupervision.

3.5. To be able to communicate with patients explain-ing the nature of benign breast disease, givingand observing ‘breaking bad news’.

4 - CONFERENCES

As part of the curriculum in breast imaging, the traineeshould attend in-house teaching sessions for radiologistsas well as multidisciplinary conferences with the rest ofthe breast team where patient management is discussed.The MDT conference should be included to facilitate theradiology residents’ understanding of the use of imagingand its role in the management of breast disease and toallow direct radiological-pathological correlation.

Cardiac Radiology1 - INTRODUCTION

Cardiac radiology is an important and rapidly developingfield in radiology. The use of cardiac imaging has pro-gressed over the last decade to involve all modalities in di-agnostic radiology. Interventional techniques in the hearthave also progressed, and whether or not a radiologist isinvolved in cardiac intervention it is important that there isan understanding of the clinical and diagnostic implica-tions of these techniques. The heart is not an isolatedorgan, and it is equally important that the relationship be-tween the heart and the cardiovascular and cardiopul-monary systems are understood.


2.1. Basic knowledge

The principle is to acquire:

2.1.1. Basic clinical, pathological, and pathophysiologi-cal knowledge in cardiovascular disease.

2.1.2. An understanding of the principles and practiceof screening techniques and risk factors in car-diac disease.

2.1.3. Knowledge of:- The indications, contraindications and poten-

tial hazards (especially radiation hazards) ofprocedures and techniques relevant to car-diovascular disease

- Cardiovascular anatomy in clinical practicerelevant to clinical radiology

- Normal variants, which may mimic disease - Manifestations of cardiovascular disease in-

cluding trauma as demonstrated by conven-tional radiography, CT, MRI, angiography,radionuclide investigations and ultrasound

- Differential diagnosis relevant to clinical pres-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.



2.1.5. An understanding of the various treatmentmodalities for cardiac disease and their relation-ship to cardiac imaging.

2.2. Knowledge in clinical cardiac radiology

The following manifestations of cardiovascular disease,including trauma, have to be covered during the generalradiological training. This should include formal teachingand exposure to clinical case material.

2.2.1. Coronary artery disease including acute coro-nary syndromes- Myocardial ischaemia- Myocardial infarction- Post myocardial infarction syndrome- Ventricular aneurysm- Coronary calcium- Coronary disease in women and specific

coronary disease patterns in different com-munities

- Heart disease in the elderly

2.2.2. Valve disease- Stenosis and incompetence of cardiac valves- Endocarditis- Sub and supra-valvar disease- Subvalvar apparatus disease

2.2.3. The pericardium- Tamponade and restrictive disease- Acute pericarditis- Tuberculous disease- Malignant pericardial disease

2.2.4. Cardiac tumours- Intracardiac tumours, i.e. myxomas, haeman-

giomas, and sarcomas- Secondary tumours- Tumours invading the heart

2.2.5. Cardiomyopathy- Acute myocarditis- Dilated cardiomyopathy- Restrictive and obstructive cardiomyopathy- Cardiomyopathy related to systemic disease- Infiltrative heart disease- Diabetic and renal cardiac disease- Athlete’s heart

2.2.6. Congenital heart disease- Neonatal heart disease- Congenital disease in childhood- Grown-up congenital heart disease

2.2.7. Major vessel disease- Thoracic aneurysm- Marfan’s syndrome- Takayasu’s disease- Relationship between peripheral and cere-

bro-vascular disease and cardiac disease

2.2.8. Right heart disease- Pulmonary embolism- Right heart disease related to pulmonary dis-

ease

2.2.9. Acute cardiac and thoracic vascular trauma- Aortic dissection- Aortic rupture and fracture- Blunt trauma

2.2.10. Arrhythmias- Diagnosis of disease causing or predisposing

to arrhythmias- Cardiac disease in endocrine conditions- Cardiac psychological related illness, i.e.

manifestations of anxiety- Pacemakers - Defibrillators- Ablation

2.2.11. Hypertension- Hypertensive heart disease- Diseases causing hypertension

2.2.12. Medical and invasive treatment- Abnormalities arising from cardiac therapy,

i.e. amioderone treatment- Complications of cardiac catheterisation and

coronary angioplasty- Appearance of stents and stent grafts

2.2.13. Post-operative cardiac disease and findings- By-pass grafts- Valve replacement- Aortic replacement- Ventricular surgery- Pericardectomy



3 - TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLS

At the end of his/her training, the resident should be ableto discuss the appropriate imaging modality for the clinicalproblem with the referring clinician. He / she should beable to understand management and communications is-sues in cardiac disease.

3.1. Modality-based skills

3.1.1. Plain film interpretation- Limitations, advantages and principles of

chest X-ray diagnosis of adult and congenitalcardiac disease

- Ability to recognise cardiac conditions on PA,AP, and lateral radiographs

- Ability to recognise cardiac post-operativefindings on plain radiographs

3.1.2. CT interpretation and patient management- CT anatomy of the heart, pulmonary arteries

and great vessels- Principles of multislice and ultrafast CT of the

heart including prospective and retrospectivegating

- Interpretation of cardiac and pulmonarypathology

- Contrast administration- Decision-making on the basis of patients´

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 pressuremeasurement

- Principles´ uses and interpretation of stressand non-stress echocardiography, includingtrans-oesophageal echocardiography

- Principles´ uses and limitations of nuclearcardiac imaging

- Principles of intravascular imaging

3.2. Stress testing- Principles of exercise stress testing, uses and

limitation- Methods of stress testing as applied to cardiac

imaging- Patient management of stress testing for cardiac

imaging

3.3. Communication and management skills- To be able to supervise technical staff to en-

sure appropriate images are obtained- To discuss significant or unexpected radiolog-

ical findings with referring clinicians and knowwhen to contact a clinician

- To be able to recommend the most appropri-ate imaging modality, appropriate to patients´symptoms or pathology or request from thereferring clinician

- To develop skills in forming protocols, moni-toring and interpreting cardiac studies, appro-priate to the patient history and other clinicalinformation

- To demonstrate the ability to effectively pres-ent cardiac imaging in a conference setting

- To demonstrate the ability to provide a coher-ent report



Chest Radiology1 – INTRODUCTION

Physics, radiography and contrast media are generallycovered in separate courses and are therefore not includ-ed in this document, but physics and radiography topicsspecific to thoracic imaging should be covered either inthe thoracic rotation or included in the physics / radiogra-phy courses, particularly:- Positioning / views of chest radiographs for

adults, newborns, infants and children- Mean exposure doses at skin entrance, kVp,

antiscatter techniques- Principles of digital imaging and image process-

ing pertinent to chest radiology

2 – CORE OF KNOWLEDGE

2.1. Normal anatomy

2-1.1 To be able to:- List the lobar and segmental bronchi- Describe the relationships of the hilar vessels

and bronchi- Define a secondary pulmonary lobule and its

component parts- Use the correct terminology for describing the

site of mediastinal and hilar lymph nodes

2.1.2. Identify the following structures on posteroanteri-or (PA) and lateral chest radiographs:- Right upper, middle and lower lobes; left

upper and lower lobes; and lingula- Fissures – major, minor, superior accessory,

inferior accessory, and azygos- Airway – trachea, carina, main bronchi, pos-

terior wall of intermediate bronchus, andlobar bronchi

- Heart – position of the two atria, two ventricles, left atrial appendage, and the location of the four cardiac valves

- Pulmonary arteries – main, right, left, and interlobar

- Aorta – ascending, arch and descendingaorta

- Arteries – brachiocephalic (innominate),carotid, and subclavian arteries

- Veins – superior and inferior vena cava, azy-gos, left superior intercostal ("aortic nipple"),and left brachiocephalic (innominate) veins

- The components of the thoracic skeleton- Mediastinal stripes and interfaces

- Aortopulmonary window- Both hemidiaphragms

2.1.3. Identify the following structures on chest CT and / or chest MRI:- All pulmonary lobes and segments- A secondary pulmonary lobule - Fissures – major, minor, azygos and common

accessory fissures- Extrapleural fat- Inferior pulmonary ligaments- Airway – trachea, carina, main bronchi, lobar

bronchi, and segmental bronchi- Heart – left ventricle, right ventricle, left atri-

um, left atrial appendage, right atrium, rightatrial appendage

- Pericardium – including superior pericardialrecesses

- Pulmonary arteries – main, right, left, interlo-bar, segmental

- Aorta – sinuses of Valsalva, ascending, arch,and descending aorta

- Arteries – brachiocephalic (innominate), com-mon carotid, subclavian, axillary, vertebral, in-ternal mammary arteries

- Veins – pulmonary, superior vena cava, inferi-or vena cava, brachiocephalic, subclavian, in-ternal jugular, external jugular, azygos,hemiazygos, left superior intercostal, internalmammary

- Esophagus- Thymus- Normal mediastinal and hilar lymph nodes- Azygoesophageal recess- Inferior pulmonary ligaments

2.2. Generic signs on chest radiographs

To be able to recognise and state the significance of thefollowing chest radiographic signs:2.2.1 Silhouette sign - loss of the contour of the heart

or diaphragm indicating adjacent pathology (e.g.atelectasis of the right middle lobe obscures theright heart border).

2.2.2. Air bronchogram - indicates airless alveoli and,therefore, a parenchymal process as distin-guished from a pleural or mediastinal process.

2.2.3. Air crescent sign - indicates solid material in alung cavity, often due to a fungus ball, or crescen-tic cavitation in invasive fungal infection.

2.2.4. Cervicothoracic sign - a mediastinal opacity thatprojects above the clavicles, situated posterior tothe plane of the trachea, while an opacity



projecting at or below the clavicles is situated an-teriorly.

2.2.5. Tapered margins - a lesion in the chest wall, me-diastinum or pleura may have smooth taperedborders and obtuse angles with the chest wall or mediastinum, while parenchymal lesions usuallyform acute angles.

2.2.6. Gloved finger sign - indicates bronchial impaction,e.g. in allergic bronchopulmonary aspergillosis, orother chronic obstructive processes.

2.2.7. Golden S sign - indicates lobar collapse with acentral mass, suggesting an obstructing bron-chogenic carcinoma in an adult.

2.2.8. Deep sulcus sign on a supine radiograph - indi-cates pneumothorax.

2.3. Features of diffuse infiltrative lung diseaseon chest radiographs and chest CT

2.3.1. To recognise the effects of various pathologicalprocesses on the component parts of the sec-ondary pulmonary lobule as seen on HRCT.

2.3.2. To list and be able to identify the following pat-terns: air space shadowing, ground glass opacity(and understand its pathophysiology), reticularpattern, honeycombing, nodular pattern, bronchi-olar opacities ("tree-in-bud"), air trapping, cystsand mosaic attenuation pattern.

2.3.3. To identify septal lines (thickened interlobularsepta) and explain the possible causes.

2.3.4. To make a specific diagnosis of interstitial lungdisease (ILD) when HRCT appearances arecharacteristic or findings are present (e.g. dilatedesophagus and ILD in scleroderma, enlargedheart and a pacemaker or defibrillator in a pa-tient with prior sternotomy and ILD suggestingamiodarone drug toxicity).

2.3.5. To recognise the spectrum of changes of heartfailure on chest radiographs, notably: pleural effu-sions, vascular redistribution on erect chest radi-ographs, and the features of interstitial andalveolar edema, including septal lines and thick-ening of fissures.

2.3.6. To define the terms "asbestos-related pleuraldisease" and "asbestosis"; identify the imagingfindings.

2.3.7. To recognise progressive massive fibrosis / con-glomerate masses secondary to silicosis or coalworker’s pneumoconiosis on radiography andchest CT.

2.4. Differential diagnosis of diffuse infiltrativelung disease

To be able to develop a differential diagnostic list for the fol-lowing patterns taking account of the anatomical and imag-ing distribution of the signs and the clinical information:

2.4.1. On chest radiographs (according to whether thepattern is upper, mid or lower zone predominant;or shows central or peripheral predominance):- Air space shadowing- Ground glass opacity- Nodular pattern- Reticular pattern- Cystic pattern- Widespread septal lines

2.4.2. On HRCT (according to whether the pattern isupper, mid or lower zone predominant; or showsperihilar or subpleural predominance; or showscentrilobular, bronchocentric, lymphatic or peri-lymphatic, or random distributions)- Septal thickening / nodularity- Ground glass opacity - Reticular pattern- Honeycombing- Nodular pattern- Air space consolidation- Tree-in-bud pattern- Mosaic attenuation pattern- Cyst and cyst-like pattern

2.5. Alveolar lung diseases and atelectasis

- To recognise segmental and lobar consolida-tion

- To list four common causes of segmentalconsolidation

- To recognise partial or complete atelectasisof single or combined lobes on chest radi-ographs and list the likely causes

- To recognise complete collapse of the right orleft lung on a chest radiograph and list appro-priate causes for the collapse

- To distinguish lung collapse from massivepleural effusion on a frontal chest radiograph

- To list five of the most common causes ofadult (acute) respiratory distress syndrome

- To name four predisposing causes of or asso-ciations with organising pneumonia

- To recognise the halo sign and suggest a di-agnosis of invasive aspergillosis in an im-munosuppressed patient



2.6. Airways and obstructive lung disease

- To recognise the signs of bronchiectasis onchest radiographs and chest CT

- To name four common causes of bronchiectasis- To recognise the HRCT signs of obliterative

and exudative small airways disease (tree-in-bud, air trapping, mosaic pattern, and associ-ated bronchiectasis)

- To recognise the typical appearance of cysticfibrosis on chest radiographs and chest CT

- To list the causes of wheeze that may be de-tected on chest radiographs

- To recognise tracheal and bronchial stenosison chest CT and name the most commoncauses

- To define centrilobular, paraseptal andpanacinar emphysema

- To recognise the signs of panacinar emphy-sema on chest radiographs and CT

- To recognise the signs of centrilobular em-physema on HRCT

- To state the imaging findings used to identifysurgical candidates for giant bullectomy orlung volume reduction surgery

2.7. Unilateral hyperlucent lung / Hemithorax

- To recognise a unilateral hyperlucent lung onchest radiographs or chest CT

- To give an appropriate differential diagnosiswhen a hyperlucent lung / hemithorax is seenon a chest radiograph, and indicate the signsthat allow a specific diagnosis

2.8. Solitary and multiple pulmonary nodules

- To state the definition of a solitary pulmonarynodule and a pulmonary mass

- To name the four most common causes of asolitary pulmonary nodule, cavitary pul-monary nodules and multiple pulmonary nod-ules

- To provide strategy for managing an inciden-tal or screening-detected solitary pulmonarynodule

- To state the role of contrast-enhanced CTand positron emission tomography (PET) inthe evaluation of a solitary pulmonary nodule

- To describe the features that indicate benigni-ty of a solitary pulmonary nodule and theirlimitations

- To state the complications of percutaneouslung biopsy and their frequency

- To state the indications for chest tube place-ment as a treatment for pneumothorax relat-ed to percutaneous lung biopsy

2.9. Benign and malignant neoplasms of the lung

- To name the four major histologic types ofbronchogenic carcinoma, and state the differ-ence in treatment between non-small cell andsmall cell lung cancer

- To describe the TNM classification for stagingnon-small cell lung cancer, including the com-ponents of each stage (I, II, III, IV, and sub-stages) and the definition of each component(T1-4, N0-3, M0-1)

- To state up to which stage a non-small celllung cancer is generally regarded as surgical-ly resectable for cure

- To state the staging of small cell lung cancer - To name the four most common extrathoracic

metastatic sites for non-small cell lung cancerand for small cell lung cancer

- To recognise abnormal contralateral medi-astinal shift on a post-pneumonectomy chestradiograph and state two possible aetiologiesfor the abnormal shift

- To describe the acute and chronic radi-ographic and CT appearance of radiation in-jury in the thorax (lung, pleura, pericardium)and the temporal relationship to radiationtherapy

- To state the roles of CT and MR in lung can-cer staging To state the role of positron emis-sion tomography (PET) in lung cancer staging

- To name the most common location and ap-pearance of adenoid cystic and carcinoid tu-mours

- To describe the appearances of hamartomaof the lung on chest radiographs and CT

- To state the manifestations and the role of im-aging in thoracic lymphoma

- To describe the typical chest radiograph andchest CT appearances of Kaposi sarcoma



2.10. Thoracic disease in immunocompetent,immunocompromised and post-transplantpatients

- To name and recognise the radiographicmanifestations of pulmonary tuberculosis ona radiograph and CT

- To describe the types of pulmonaryAspergillus disease, understand that theyform part of a continuum, and recognisethese entities on chest radiographs and CT

- To name the major categories of disease-causing chest radiographic or chest CT ab-normalities in the immunocompromisedpatient

- To name two common infections and twocommon neoplasms in patients with AIDSand chest radiographic or chest CT abnor-malities

- To describe the chest radiographic and chestCT appearances of pneumocystis now called"jiroveci" pneumonia

- To name the three most important aetiologiesof hilar and mediastinal adenopathy in pa-tients with AIDS

- To list the differential diagnoses for wide-spread consolidation in an immunocompro-mised host

- To describe the chest radiographic and CTfindings of post-transplant lymphoproliferativedisorders

- To describe the chest radiographic and CTfindings of graft-versus-host-disease

2.11. Congenital lung disease

- To name and recognise the components ofthe pulmonary venolobar syndrome (scimitarsyndrome) on a frontal chest radiograph,chest CT and chest MRI

- To list the signs of intralobar pulmonary se-questration and cystic adenomatoid malfor-mation on chest radiographs and chest CT

- To explain the differences between intralobarand extralobar pulmonary sequestration

- To recognise bronchial atresia on a radi-ograph and chest CT, and state the mostcommon lobes of the lungs in which it occurs

2.12. Pulmonary vascular disease

- To recognise enlarged pulmonary arteries on

a chest radiograph and distinguish them fromenlarged hilar lymph nodes

- To name five of the most common causes ofpulmonary artery hypertension

- To recognise lobar and segmental pulmonaryemboli on CT angiography and chest MRI (in-cluding MR angiography).

- To define the role of ventilation-perfusionscintigraphy, CT pulmonary angiography(CTPA), MRI / MRA, and lower extremity ve-nous studies in the evaluation of a patientwith suspected venous thromboembolic dis-ease, including the advantages and limita-tions of each modality depending on patientpresentation

- To recognise the vascular redistribution seenin raised pulmonary venous pressure

2.13. Pleura and diaphragm

- To recognise the typical chest radiographicappearances of pleural effusion in erect,supine and lateral decubitus chest radio-graphs and name four causes of a large uni-lateral pleural effusion

- To recognise a pneumothorax on an uprightand supine chest radiograph

- To recognise a pleural-based mass with bonedestruction or infiltration of the chest wall on aradiograph or chest CT, and name four likelycauses

- To recognise the various forms of pleural cal-cification on a radiograph or chest CT andsuggest the diagnosis of asbestos exposure(bilateral involvement) or old TB, old empye-ma, or old haemothorax (unilateral involve-ment).

- To recognise unilateral elevation of onehemidiaphragm on chest radiographs and listfive causes (e.g. subdiaphragmatic abscess,diaphragm rupture, and phrenic nerve in-volvement with lung cancer, postcardiac sur-gery, eventration)

- To recognise tension pneumothorax - To recognise diffuse pleural thickening and

list four causes - To recognise the split pleura sign in empyema - To state and recognise the chest radiographic

and CT findings of malignant mesothelioma



2.14. Mediastinal and hilar disease

- To name the four most common causes of ananterior mediastinal mass and localise amass to the anterior mediastinum on chestradiographs, chest CT and chest MRI

- To name the three most common causes of amiddle mediastinal mass and localise a massin the middle mediastinum on chest radi-ographs, chest CT and chest MRI

- To name the most common cause of a poste-rior mediastinal mass and localise a mass inthe posterior mediastinum on chest radi-ographs, chest CT and chest MRI

- To name two causes of a mass that straddlesthe thoracic inlet and localise a mass to thethoracic inlet on chest radiographs, chest CTand chest MRI

- To identify normal vessels or vascular abnor-mality on chest CT and chest MRI that maymimic a solid mass

- To recognise mediastinal and hilar lym-phadenopathy on chest radiographs, CT andMRI

- To name four aetiologies of bilateral hilarlymph node enlargement

- To list the four most common aetiologies of"egg-shell" calcified lymph nodes in the chest

- To name four causes of a mass arising in thethymus

- To list the imaging features and common as-sociations of thymoma

- To list three types of malignant germ cell tu-mour of the mediastinum

- To recognise the imaging signs of benign cys-tic teratoma

- To list five signs of intrathoracic thyroid masses - To recognise a cystic mass in the medi-

astinum and suggest the possible diagnosisof a bronchogenic, pericardial, thymic or oe-sophageal duplication cyst

- To state the mechanisms and list the signs ofpneumomediastinum

2.15. Thoracic aorta and great vessels

- To state the normal dimensions of the tho-racic aorta

- To describe the Stanford A and B classifica-tion of aortic dissection and the implicationsof the classification for medical versus surgi-cal management

- To state and recognise the findings of, anddistinguish between each of the following onchest CT and MR:- aortic aneurysm- aortic dissection- aortic intramural hematoma- penetrating atherosclerotic ulcer- ulcerated plaque- ruptured aortic aneurysm- sinus of Valsalva aneurysm- subclavian or brachiocephalic artery

aneurysm- aortic coarctation- aortic pseudocoarctation- cervical aortic arch

- To state the significance of a right aortic archwith mirror image branching versus an aber-rant subclavian artery

- To recognise the two standard types of rightaortic arch and a double aortic arch on chestradiographs, chest CT and chest MR

- To recognise an aberrant subclavian arteryon chest CT

- To recognise normal variants of aortic archbranching, including the common origin ofbrachiocephalic and left common carotid ar-teries ("bovine arch"), and separate origin ofvertebral artery from arch To define the terms aneurysm and pseudoa-neurysm

- To state and identify the findings seen in ar-teritis of the aorta on chest CT and chest MR

- To state the advantages and disadvantagesof CT, MRI / MRA and transoesophagealechocardiography in the evaluation of the tho-racic aorta

2.16. Chest Trauma

- To identify a widened mediastinum on chestradiographs taken for trauma and state thepossible causes (including aortic / arterial in-jury, venous injury, fracture of sternum orspine)

- To identify the indirect and direct signs of aor-tic injury on contrast-enhanced chest CTscan

- To identify and state the significance of chron-ic traumatic pseudoaneurysm on chest radi-ographs, CT or MRI

- To identify fractured ribs, clavicle, spine andscapula on chest radiographs or chest CT



- To name three common causes of abnormallung opacity following trauma on chest radio-graphs or CT

- To identify an abnormally positioned di-aphragm or loss of definition of a diaphragmon chest radiographs following trauma and beable to suggest the diagnosis of a ruptured di-aphragm

- To identify a pneumothorax and pneumome-diastinum following trauma on chest radio-graphs

- To identify a cavitary lesion following traumaon chest radiographs or chest CT and sug-gest the diagnosis of laceration with pneuma-tocele formation, hematoma or abscesssecondary to aspiration

- To name the three most common causes ofpneumomediastinum following trauma

- To recognise and distinguish between pul-monary contusion, laceration and aspiration

2.17. Monitoring and support devices – "Tubes andlines"

To be able to identify and state the preferred placementof the following devices and lines; to be able to list thecomplications associated with malposition of each ofthe following:

- endotracheal tube- central venous catheter- Swan-Ganz catheter- nasogastric tube- chest tube / drain- intra-aortic balloon pump- pacemaker and pacemaker leads- implantable cardiac defibrillator- left ventricular assistant device- atrial septal defect closure device ("clamshell

device")- pericardial drain- extracorporeal life support cannulae- intraoesophageal manometer, temperature

probe or pH probe- tracheal or bronchial stent

2.18. Postoperative Chest

To identify normal post-operative findings and complicationsof the following procedures on chest radiographs, CT andMRI:

- wedge resection, lobectomypneumonectomy

- coronary artery bypass graft surgery- cardiac valve replacement- aortic graft- aortic stent- transhiatal oesophagectomy- lung transplant- heart transplant- lung volume reduction surgery

3 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLS

At the end of his / her training, the resident should be ableto demonstrate the following:3.1. Dictate intelligible and useful reports on chest ra-

diographs, CT and MR imaging. These reportsshould contain a brief description of the imagingfindings and their significance along with a shortsummary where necessary.

3.2. Supervise technical staff to ensure appropriateimages are obtained.

3.3. Discuss significant or unexpected radiologic find-ings with referring clinicians and know when tocontact a clinician.

3.4. Describe patient positioning and indications for aPA, lateral, decubitus, and lordotic chest radi-ograph.

3.5. Decide when it is appropriate to obtain help fromsupervisory faculty in interpreting radiographs.

3.6. Understand the clinical indications for obtainingchest radiographs and when further views or achest CT or MR may be necessary.

3.7. Develop skills in protocolling, monitoring, and in-terpreting chest CT scans, including HRCT, ap-propriate to patient history and other clinical information.

3.8. Describe a chest CT protocol optimised for evalu-ating each of the following:- thoracic aorta and great vessels- superior vena cava and brachiocephalic vein

stenosis or obstruction- suspected pulmonary embolism- tracheobronchial tree- suspected bronchiectasis- suspected small airway disease



- lung cancer staging- oesophageal cancer staging- superior sulcus tumour- suspected pulmonary metastases- suspected pulmonary nodule on a radiograph- shortness of breath- haemoptysis

3.9. Develop skills in protocolling, monitoring, and in-terpreting chest MR studies.

3.10. Demonstrate the ability to effectively presentchest imaging in a conference setting.

3.11. Recommend the appropriate use of imagingstudies to referring clinicians.

3.12. Be able to perform the following imaging-guidedtransthoracic interventions under appropriatesupervision, and know the indications, contraindi-cations, and management of complications:- paracentesis and drainage of pleural effu-

sions- percutaneous lung biopsy- paracentesis of mediastinal and pericardial

fluid collections- drainage of refractory lung abscess- arteriography of thoracic aorta and great ves-

sels- venography of major intrathoracic systemic

veins of bronchial arteries, anatomy, and im-portant collaterals

- pulmonary arteriography- principles of bronchial artery embolisation:

indications, technique and complications- 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 theRadiology Department, others may be run by other de-partments or multidisciplinary programmes. It is recom-

mended that this latter type of conference be included tofacilitate the radiology residents’ understanding of the useof imaging and clinical circumstances, in which imaging isrequested.

- Radiology resident-specific chest radiologyteaching conference

- An appropriate proportion of radiology grandrounds devoted to chest radiology

- Pulmonary medicine conference- Intensive care unit conference- Thoracic oncology conference - Thoracic surgery conference

5 – TEACHING MATERIAL AND SUGGESTIONS FOR READING

Recommended study materials and mandatory confer-ence attendance are an important component of training,but since they vary between individual departments, a de-tailed listing is not provided in this document. The follow-ing short list of textbooks covering a wide range of topicsshould be available in departmental libraries:

Webb WR, Müller NL, Naidich DP: High-resolution CT ofthe Lung, published by Lippincott Williams & Wilkins.Hansell DM, Armstrong P, Lynch DA, McAdams HP:Imaging of Diseases of the Chest, published by Elsevier.Fraser RS, Müller NL, Colman N, Paré PD: Fraser &Paré’s Diagnosis of Diseases of the Chest, published bySaunders.Colby TV, Lombard C, Yousem SA, Kitaichi M: Atlas ofPulmonary Surgical Pathology, published by Saunders.McCloud TC: Thoracic Radiology: the Requisites, pub-lished by Mosby.



Gastrointestinal andAbdominal Radiology1 – INTRODUCTION

Gastrointestinal and abdominal radiology include all as-pects of medical imaging (diagnostic and interventional),thus covering information relative to the anatomy, patho-physiology and the various diseases that may affect theabdomen. Gastrointestinal and abdominal radiology in-cludes various techniques (ultrasonography, duplexDoppler, conventional X-ray imaging, computed tomogra-phy, magnetic resonance imaging, angiography and otherinterventional procedures) and various organs (pharynx,oesophagus, stomach, duodenum, small bowel, colon,rectum, anus, pancreas, liver, biliary tract, spleen, peri-toneum, abdominal wall and pelvic floor). The aim of thisdocument is to describe a curriculum for training in gas-trointestinal and abdominal radiology.


2.1. Anatomy and physiology

- To know the principal aspects of embryologyof the oesophagus, stomach, duodenum,small bowel, appendix, colon, rectum, anus,pancreas, liver, biliary tract, and spleen

- To know the anatomy of the pharynx, oesoph-agus, stomach, duodenum, small bowel, ap-pendix, colon, rectum, anus, pancreas, liver,biliary tract, spleen, mesentery, and peri-toneum

- To know the anatomy of the pelvic floor andabdominal wall

- To know the arterial supply and venousdrainage, including important variants, of thevarious portions of the gastrointestinal tractTo know the possible variations of flow in thesuperior mesenteric artery and vein and theportal and hepatic veins

- To know the lymphatic drainage of the relevant organs

2.2. Oesophagus

- To be able to identify the abnormalitiesdemonstrable on a video-fluoroscopy study ofthe swallowing mechanism and their implica-tions in conjunction with swallowing thera-pists; to recognise pharyngeal pouch, websand post-cricoid tumours

- To be able to identify oesophageal perforationon plain films and contrast studies

- To be able to identify oesophageal cancer, di-verticulum, extrinsic compression, sub-mu-cosal masses, fistulae, sliding andpara-oesophageal hiatus hernia, benign stric-tures, benign tumours, varices, differentforms of oesophagitis on a contrast examina-tion of the oesophagus

- To understand the significance of Barrett’soesophagus and the manifestations of thisdisease

- To be able to perform a motility assessmentbarium study and understand the appearanceof common motility disorders

- To understand the use and be experienced inthe technique of bolus studies, such as breador marshmallow, in the identification of caus-es of dysphagia

- To know the basic surgical techniques in oe-sophageal surgery and to be able to identifypost-surgical appearances on imaging exam-inations

- To be able to identify a mega oesophagus,oesophageal diverticulum, hiatus hernia, oe-sophageal varices, pneumo-mediastinum,and oesophageal perforation on CT scan

- To be able to identify an oesophageal canceron CT scan and to analyse the criteria fornon-resectability and lymph node involve-ment

- To understand the use of endoscopic ultra-sound in the staging of oesophageal cancerand the technique of endoscopic ultrasoundguided biopsy

2.3. Stomach and duodenum

- To be able to determine the most appropriateimaging examination and contrast use in sus-pected perforation of the stomach and post-operative follow-up; to know the limitationsof each examination for these specificconditions

- To understand the imaging features (on bari-um and CT) of a variety of conditions such asbenign and malignant tumours, infiltrative dis-orders, e.g. linitis plastica, gastric ulcers andpositional abnormalities including gastricvolvulus

- To be able to perform a CT examination of thestomach, using the most appropriate protocolaccording to the clinical problem



- To be able to stage gastric carcinoma andlymphoma on CT and MRI

- To be able to identify duplication cysts of theupper gastrointestinal tract on CT scan

- To understand the appearance of gastro-duo-denal disease on ultrasound

- To understand rotational abnormalities of theduodenum on barium studies and also theappearance of annular pancreas, sub-mucos-al tumours, papillary tumours, inflammatorydisease including ulceration, as well as lym-phoid hyperplasia and gastric metaplasia

2.4. Small bowel

- To be able to determine the most appropriateimaging examination in the following cases:small bowel obstruction, inflammatory dis-ease, infiltrative disease, small bowel perfora-tion and ischaemia, cancer, lymphoma,carcinoid tumour, and post-operative follow-up;to know the limitations of each examinationfor these specific cases

- To be able to identify lymphoid hyperplasia ofthe terminal ileum on small bowel series; tobe able to identify the most common mid gutabnormalities (malrotation, internal hernia)

- To know the features of small bowel diseaseson small bowel series, including stenosis, foldabnormalities, nodules, ulcerations, thicken-ing, marked angulation, extrinsic compres-sion, and fistula

- To be able to identify on a small bowel seriesthe following diseases: adenocarcinoma,polyposis, stromal tumour, lymphoma, carci-noid tumour, Crohn’s disease, mesenteric is-chaemia, haematoma, Whipple’s disease,amyloidosis, radiation-induced injury, malro-tation, Meckel’s diverticulum, coeliac disease,diverticulosis, systemic sclerosis, chronicpseudo-obstruction

- To be able to perform a CT examination of thesmall bowel and to know the main principlesof interpretation; to know the findings in thevarious diseases of the small bowel, and es-pecially to describe a halo sign and a targetsign; to be able to identify a transitional zonein case of small bowel obstruction; to be ableto identify a small bowel tumour (adenocarci-noma, lymphoma, carcinoid tumour, stromaltumour); to be able to identify mural pneu-matosis, vascular engorgement, increased

density of the mesenteric fat, peritoneal ab-normality and malrotation

- To be able to determine the cause of smallbowel obstruction on CT scan (adhesion,band, strangulation, intussusception, volvu-lus, internal and external hernias) and theircomplications; to be able to identify criteria foremergency surgery

- To know the basic principles of MR imaging ofthe small bowel

2.5. Colon and rectum

- To be able to determine the optimal imagingexamination to study the colon according tothe suspected disease (obstruction, volvulus,diverticulitis, benign tumour, inflammatorydisease, cancer, lymphoma, carcinoid tu-mour, stromal tumour, perforation, postopera-tive evaluation) and to know the limitations ofeach technique

- To be able to identify rotational abnormalitiesof the colon on contrast studies and CT

- To be able to identify the normal appendix ona CT scan and a sonographic examination; toknow the various features of appendicitis onCT scan and sonographic examination

- To know the different features of colon tu-mours, diverticulitis, inflammatory diseases,colon ischaemia, radiation-induced colitis

- To be able to identify a megacolon, colonic di-verticulosis, specific and non-specific colitis,colonic fistula, carcinoma, polyps and postop-erative stenosis on an enema

- To be able to identify a colonic diverticulosis,diverticulitis, tumour stenosis, ileocolic intus-susception, colonic fistula, paracolic abscess,epiploic appenditis, intra-peritoneal fluid col-lection, colonic pneumatosis, and pneumo-peritoneum on a CT scan

- To know the CT features of colon cancer on aCT scan; to be able to identify criteria for localextent (enlarged lymph nodes, peritoneal car-cinomatosis, hepatic metastases, and ob-struction)

- To know the TNM classification of colon can-cer and its prognostic value; to understandthe technique and value of both MRI and en-dosonography in the staging of rectal cancer

- To know the basic technique of interventionalradiology in colon cancer, especially ofcolonic stent placement in case of colonic ob-



struction; to know the indications and con-traindications of this technique

- To know the various diseases of the rectumand the anus and the most frequent operativetechniques that may be used to treat them

- To know the anatomy of the rectum, peri-rec-tal tissues and of the anal sphincters

- To know the main functional diseases of thepelvic floor and their features on a defeacog-raphy examination; to know the potential roleof sonography and MR imaging in the evalua-tion of functional diseases of the pelvic floor

- To be able to identify a rectal cancer, tumourrecurrence after surgery and a pelvic fistulaon a CT scan and on a MR examination; toknow the value of CT / PET; to know the crite-ria that may help in differentiating betweenpostoperative fibrosis and tumour recurrence;to be able to select patients who may benefitfrom percutaneous biopsy in case of suspect-ed tumour recurrence

- To know the basic MR imaging technique thatis used to search for a pelvic / perianal fistula;to be able to identify fistulae on MR imaging

- To know the basic MR imaging technique thathas to be used for MRI of rectal cancer

- To know the TNM classification of rectal can-cer and its effect on treatment options

- To be able to identify a rectal cancer and itsrelation to relevant surrounding structures

2.6. Peritoneum and abdominal wall

- To be able to identify the various types of ab-dominal wall hernias (inguinal, umbilical,parastomal, postoperative) on a CT scan; tobe able to identify an abdominal wall herniaon a sonographic examination; to be able toidentify a hernial strangulation on a CT scanand on a sonographic examination

- To be able to identify a mesenteric tumourand to determine its location on a CT scan

- To know the features of a mesenteric cyst ona CT scan

- To know the normal features of the peri-toneum on a sonographic and a CT scan ex-amination; to know the various findings thatcan be seen in cases of peritoneal disease(nodules, thickening, fluid collection)

- To be able to identify an ascites on a sono-graphic and a CT scan examination; to knowthe features of loculated ascites

- To be able to identify the following peritonealdiseases on CT: peritonitis, peritoneal carci-nomatosis, peritoneal tuberculosis, mesen-teric lymphoma, mesenteric and greateromental infarction

2.7. Vessels

- To know the basic principles of duplexDoppler sonography and to be able to identifysuperior mesenteric artery stenosis or occlu-sion on duplex Doppler sonography; to beable to use Doppler to assess the patency ofand the direction of flow in the portal and he-patic veins

- To be able to identify small bowel infarct on aCT scan

- To be able to interpret an angiographic studyof the mesenteric vessels and to identify oc-clusion and stenosis of the superior mesen-teric artery

- To know the basic principles of balloon angio-plasty and stenting of the superior mesentericartery for the treatment of stenosis of the su-perior mesenteric artery

2.8. Liver

- To be able to localise a focal liver lesion ac-cording to liver segmentation and major ves-sels anatomy (hepatic and portal vein, IVC)

- To describe the appearance of typical biliarycyst on US, CT and MRI

- To describe the appearance of Hydatid cystsand to be able to classify into the five cate-gories

- To list the differences between amoebic ab-scess and pyogenic abscess of the liver (ap-pearance, evolution, treatment, indication fordrainage)

- To be able to describe the most common sur-gical procedures for hepatectomy

- To know the appearance of liver haeman-gioma on US, CT and MRI including typicalcases and giant haemangioma; to be able todiscuss the indications for CT or MRI as anadjunct to US

- To describe the usual appearance of FocalNodular Hyperplasia and Liver Cell Adenomaon US including Doppler US, CT and MRI; tobe able to discuss the indications for CT orMRI as an adjunct to US, as well as caseswhen biopsy is necessary



- To know the appearance of fatty liver, homog-enous and heterogeneous, on US, CT, andMRI (including in- / out-of-phase imaging)

- To describe the natural history of hepatocellu-lar carcinoma (HCC), major techniques andindications for treatment (surgical resection,chemotherapy, chemoembolisation, percuta-neous ablation, liver transplantation)

- To describe the appearance of HCC on US(including Doppler), CT, and MRI; to be ableto stage the lesion in order to discuss indica-tions for treatment

- To describe the usual appearance of livermetastases on US (including Doppler), CT,and MRI, sensitivity and specificity for eachBe able to discuss the indications for percuta-neous biopsy

- To be able to discuss the indications for ad-vanced methods (CTAP, MRI with liver specif-ic contrast) in liver metastases staging

- To describe the most common morphologicchanges associated with liver cirrhosis:lobar atrophy or hypertrophy, regenerationnodules, fibrosis; to list the main causes forliver cirrhosis

- To be able to list rare tumours of the liver andto find their radiological appearance using lit-erature sources

- To be able to describe the technique for per-cutaneous guided liver biopsy and its mostcommon indications; to list the complicationwith a precise evaluation of the occurrence ofmorbidity and mortality

2.9. Biliary tract

- To know sensitivity and specificity of imagingmethods for the detection of gall bladder andcommon bile duct stones

- To describe the common appearance ofacute cholecystitis on US (including Doppler),CT, and MRI; to know the unusual featureslike gangrenous, emphysematous, and acal-culous cholecystis

- To list the main causes for gallbladder wallthickening on US

- To describe the appearance of gallbladdercancer on US, CT, and MRI; to be able to dif-ferentiate cancer from subacute cholecystitison US and CT

- To describe the appearance of cholangiocar-cinoma of the liver hilum (Klatskin tumour)

and to be able to perform tumour staging,with regard to treatment options (resectability,indication for palliation)

- To describe the appearance of ampullar car-cinoma on US, CT, MRI, and endoscopic US

- To be able to describe the common appear-ance of sclerosing cholangitis on US, CT, andMRI, including MRCP; to know the naturalhistory and possibility for associated cholan-giocarcinoma and indications for treatment; tobe able to discuss indications for biliary tractopacification

- To describe the main techniques for surgeryof the bile duct and its common complications

- To list the methods for interventional radiolo-gy of the biliary tract and discuss the indica-tions and complications

- To attest participation in five procedures

2.10. Pancreas

- To know the natural history of chronic pancre-atitis; to list the common causes

- To identify pancreatic calcifications on plainfilms, US, and CT

- To know the clinico-biological (Ranson score,APACHE II) and CT (Balthazar’s CT severityscore) methods for the grading of acute pan-creatitis

- To describe the common appearance ofextra-pancreatic fluid collections and phleg-mons in case of acute pancreatitis

- To be able to detect a pancreatic pseudocystand discuss advantages and limitations of dif-ferent treatments (follow-up, interventionalprocedure, percutaneous or endoscopic, sur-gery) according to practical cases

- To describe the most common appearance(nodular, infiltrating) on US, CT, MRI, and en-doscopic US of pancreatic adenocarcinomaand be able to perform staging in order tochoose a treatment

- To be able to describe the usual appearanceof cystic tumours of the pancreas, mainly se-rious and mucinous cystadenoma, intraductalmucinous tumour, and rare cystic tumours; tobe able to give initial indication for tumourcharacterisation

- To be able to describe the main techniquesfor pancreatic surgery and their usual compli-cations




3.1. Patient information and examination conduct

- To be able to tailor the examination protocolto the clinical question

- To be able to justify and explain the indicationand the examination conduct to the patient

- To be able to obtain fully informed consent - To be able to inform the patient of the results

of the examination and to be able to evaluatethe patient’s understanding

3.2. Reporting

- To be able to make a precise and concise de-scription of the imaging signs present

- To be able to answer the clinical problem andmake a conclusion accordingly

- To be able to suggest additional imaging ex-aminations when needed, using appropriatejustification

- To be able to maintain good working relation-ships with referring clinicians

- To be able to code the findings of examina-tions

3.3. Imaging techniques - General requirements

- To know the indications and contra-indica-tions of the various imaging examinations inabdominal imaging

- To be able to indicate to the referring physi-cian the most appropriate imaging examina-tion according to the clinical problem

- To be able to determine the best contrast ma-terial and its optimal use according to the im-aging technique and the clinical problem

- To be able to evaluate the quality of the imag-ing examinations in abdominal imaging

- To know the relative cost of the various imag-ing examinations in abdominal imaging

- To understand the radiation burden and risksof different investigations

3.4. Imaging techniques - Specific requirements

3.4.1. Plain abdominal film- To know the three basic indications for plain

abdominal film - To be able to diagnose pneumoperitoneum,

mechanical obstruction and pseudo obstruc-tion, toxic dilatation of the colon, gas in smalland large bowel wall indicating ischaemia andnecrosis, pancreatic and biliary calcifications,and aerobilia on plain abdominal films

3.4.2. X-ray examination of the upper gastrointestinaltract

- To know how to perform an X-ray examinationof the upper gastrointestinal tract and to de-termine the most appropriate contrast material

- To know how to perform both single and dou-ble contrast studies as well as motility as-sessments; to understand the principles andlimitations of these studies and their advan-tages and disadvantages compared to en-doscopy

- To understand the technique and indicationsof video-fluoroscopy of the swallowing mech-anism in conjunction with speech therapy andENT

- To know how to perform small bowel followthrough and enteroclysis, including catheterplacement beyond the ligament of Treitz; toappreciate the importance and degree of fill-ing and distension of small bowel loops

- To be able to interpret a small bowel series, torecognise normal findings and to be able torecognise the various segments of the smallbowel

3.4.3. X-ray examination of the lower gastrointestinaltract

- To be able to perform a double contrast bari-um enema

- To be able to perform a single contrast enema - To know how to catheterise a stoma for colon

opacification and how to perform pou-chograms and loopograms

- To understand the indication and technique tobe used in an instant enema

- To know the indications and contraindicationsfor enema techniques and to be able to deter-mine the optimal contrast material and tech-nique to be used in each clinical situation

- To be able to interpret an enema, to know thenormal findings and recognise the anatomicalcomponents of the rectum and colon



3.4.4. Sonography

- To be able to perform an ultrasound examina-tion of the liver, gall bladder biliary tree, pan-creas, and spleen

- To be able to perform a duplex Doppler studyof the abdominal vessels; to know the normalfindings of the duplex Doppler study of thehepatic artery, superior mesenteric artery,portal vein, and hepatic veins

- To be able to perform a sonographic study ofthe gastrointestinal tract and to identify thevarious portions (stomach, duodenum, smallbowel, appendix, and colon)

- To recognise the retroperitoneal structuresand understand the application and limita-tions of sonography in this area

- To understand the strengths and limitations ofendosonography, particularly in the oesopha-gus, pancreas, rectum and anal canal

3.4.5. Computed tomography

- To be able to perform a CT examination of theabdomen and to tailor the protocol to the spe-cific organ or clinical situation to be studied;to be able to determine if intravenous admin-istration of a contrast material is needed; todetermine the optimal protocol for the injec-tion of contrast (rate of injection, dose, delay);to know the various phases (plain, arterial-dominant, portal-dominant, late phase) andtheir respective values according to the clini-cal problem

- To be able to determine the best contrast ma-terial for imaging a specific gastrointestinalsegment according to the clinical problem(water, air, fat, iodine or barium containingcontrast materials)

- To know the techniques for CT Colonography;to be aware of the potential of CT enteroclysis

- To understand the technique and limited indi-cation for CT Cholangiography

- To have experience of the use of workstationsfor multiplanar reconstructions (MPR) and 3Dreconstruction based around volume datasets

3.4.6. Magnetic resonance imaging

- To be able to perform an MR examination ofthe liver, the biliary tract and the pancreas; to

be able to tailor the protocol to the specificorgan to be studied; to be able to determine ifintravenous administration of a contrast mate-rial is needed; to determine the optimal proto-col for the injection (rate of injection, dose,delay); to know the various phases (plain, ar-terial-dominant, portal-dominant, late phase)and their respective values according to theclinical problem

- To know the various contrast materials thatcan be used for MR examination of the liverand their individual uses

- To be able to perform an MR examination ofthe biliary tree and the pancreatic duct; toknow the single shot fast spin echo technique(SSFSE) and to be able to place the variousplanes on the axial image

- To be able to perform an MR examination ofthe gastrointestinal tract; to be aware of a po-tential of MR enteroclysis; to know the basicprotocol for MR examination of the anorectum

3.4.7. Interventional imaging

- To know the basic techniques for percuta-neous drainage of abdominal collectionsusing CT and ultrasonography

- To know the basic rules of percutaneousbiopsy of the liver (indications, contraindica-tions) and other organs under sonographicand CT guidance

- To know the basic principles for angiographyof the abdominal arteries (including indica-tions, contraindications); to be able to identifythe hepatic artery and its main anatomicalvariants, the superior and inferior mesentericartery, and the portal vein

- To know the basic principles for selective em-bolisation of the abdominal arteries (includingindications, contra-indications)

- To know the technique of percutaneous gas-trostomy under image guidance

- To know the techniques for percutaneous bil-iary intervention

- To understand the technique for radiologicalguided stenting of the biliary system and gas-trointestinal system, using PTFE and expand-able metal stents



3.4.8. Miscellaneous

- To know the indications, strengths and limita-tions of the other imaging techniques (includ-ing endoscopy, endosonography, nuclearmedicine (including PET) in abdominal imag-ing)

4 – CONFERENCES

As part of the curriculum in abdominal radiology, thetrainee should attend in-house teaching sessions for radi-ologists as well as clinical conferences with colleaguesfrom other specialties. The latter type of conferenceshould be included to facilitate the radiology residents’ un-derstanding of the use of imaging and clinical circum-stances, in which imaging is requested.

The following list gives examples of the types of confer-ences that should be considered part of the curriculum:

1. Abdominal radiology resident-specific teachingconference

2. Internal medicine / gastroenterology conferences3. Surgery / abdominal surgery conferences4. Oncology conferences5. Pathology conferences

5 – TEACHING MATERIAL AND SUGGESTIONS FORREADING

The following English textbooks are recommended to an-swer all questions and address all objectives defined inthe curriculum of abdominal radiology. One of these books(title) serves as "bench book", i.e. it is valid for all trainingprogrammes across Europe and aims at unification andstandardisation of Radiology training in Europe. It is veryimportant that "bench books" be available in the radiologydepartment and the library of each institution.

- Gore RM, Levine MS. Textbook ofGastrointestinal Radiology (2nd Edition). WBSaunders, Philadelphia, 2000

- Eisenberg RL. Gastrointestinal Radiology – APattern Approach (4th Edition). Lippincott,Philadelphia, 2003

- Abdominal radiology book(s) in local lan-guage

Head and Neck Radiology(Including Maxillo-Facial andDental Radiology)

1 – INTRODUCTION

The head and neck imaging curriculum describes:- The knowledge-based objectives for general

head and neck radiology and maxillofacialand dental radiology

- The appropriate technical and communica-tion skills

Physics, radiography and contrast media are generallycovered in separate courses, and therefore are not includ-ed in this document, but physics and radiography topicsspecific to head and neck should be covered either in thehead and neck rotation or included in the physics / radiog-raphy courses, particularly:

- Positioning / views of radiographs for adults,newborns, infants and children

- Mean exposure doses at skin entrance, kVp,antiscatter techniques

- Principles of digital image processing perti-nent to head and neck and maxillofacial dental radiology


2.1. Normal anatomy

- Temporal bone- Facial skeleton, skull base and cranial nerves - Orbit and visual pathways- Sinuses - Pharynx - Oral cavity- Larynx - Neck- Mandible, teeth and temporomandibular

joints- Salivary glands- Deep spaces of the face and neck- Thoracic inlet and brachial plexus- Thyroid gland and parathyroid glands



2.2. Temporal bone

- To know pathologic conditions defining deaf-ness

- To know and recognise on CT and MRI- Temporal bone inflammatory disease - Temporal bone fractures - Tumours of the temporal bone and cere-

bello-pontine angle - To know vascular tinnitus

2.3. The facial skeleton, skull base and cranial nerves

- To know and be able to recognise on CT andMRI - Inflammatory conditions - Tumours and tumour-like conditions - Trauma and resulting complications - Major pathologic conditions involving the

cranial nerves

2.4. Orbit and visual pathways

- To know- Orbital pathology- Pathology of the visual apparatus

2.5. The sinuses

- To know and be able to recognise on CTanatomical variations and congenital anom-alies of the paranasal sinuses

- To know and be able to recognise on CT andMRI inflammatory conditions, tumours and tu-mour-like conditions

- To be familiar with common (FunctionalEndoscopic Sinus Surgery) techniques

- To know how to evaluate the paranasal sinus-es after surgery

2.6. The pharynx

- To know and be able to recognise on US, CTand MRI the pathologic conditions of:- nasopharynx- oropharynx- hypopharynx

2.7. The oral cavity

- To know and be able to recognise on US, CT,MRI and videofluoroscopy the pathologicconditions of the oral cavity

2.8. The larynx

- To know and be able to recognise on CT andMRI the pathologic conditions of the larynx

2.9. The neck

- To know and be able to recognise on US, CTand MRI - Embryology and congenital cystic lesions- The clinical significance of lymph nodes,

metastatic, inflammatory, and infectiousdisease

- Non-nodal masses of the neck - To know and be able to recognise on US, CT,

CT-angiography, MRI, MRI-angiography andconventional angiography vascular diseases

2.10. The mandible, teeth, and temporomandibularjoints

- To know and be able to recognise on or-thopantomography, CT, MRI, and dental radi-ographs pathologic conditions of the mandible

- To get familiarity with dental implants anddental CT programmes

- To know pathologic conditions of the tem-poro-mandibular joint

2.11. The salivary glands

- To know and be able to recognise on US, CT,MRI and MR-sialography inflammatory disor-ders and tumours

- To know and be able to recognise on US,Doppler US, CT and MRI vascular malforma-tions

- To know and be able to recognise on US, CTand MRI periglandular lesions and recognis-ing these on US, CT, MRI

2.12. The deep spaces of the face and neck

- To know the anatomy of the deep cervical fas-cia and of the most common pathologic con-ditions involving the different spaces of thesupra- and infrahyoid neck

2.13. The thoracic inlet and the brachial plexus

- To know and be able to recognise on CT andMRI the most common pathologic conditionsof the thoracic inlet and brachial plexus



2.14. The thyroid gland and the parathyroid glands

- To know and be able to recognise on US,Doppler US, CT and MRI - Congenital lesions - Inflammatory lesions- Benign thyroid masses - Malignancies of the thyroid gland - Pathologic conditions of the parathyroid

glands - To be familiar with the most important findings

of Tc-99m-scintigraphy in specific disease ofthe thyroid gland

- To be able to perform fine needle aspirationbiopsy in easy cases


Diagnostic procedures:Skull radiography + special views: 50Sinus radiography: 50 Head and neck CT (including Dental CT): 100Head and neck MRI: 50Ultrasound of head and neck: 50

3.1. At the end of the 4th year the resident should beable to carry out or supervise the following tech-niques to a level appropriate to practice in a gen-eral hospital.This competence should include theability 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 dynamicfunctional 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 lymphnode aspiration biopsies.

3.3. At the end of his / her training the resident shouldbe able to:

3.3.1. Dictate intelligible and useful reports.The reports should contain a brief description of the imaging findings andtheir significance along with a short sum-mary where necessary.

3.3.2. Recommend the appropriate use of imag-ing studies to referring clinicians.

3.3.3. Demonstrate the ability to present headand neck examinations effectively in aconference setting.

3.3.4. Discuss significant and unexpected radio-logic findings with referring clinicians andknow when to contact a clinician.



Interventional Radiology1 – INTRODUCTION

Interventional Radiology is a vibrant and dynamic special-ty in which, unfortunately, trainees have variable exposureto radiology during training. It is important that radiologytrainees develop the basic skills in interventional radiolo-gy, irrespective of whether they specialise in intervention-al radiology. Basic skills and a core programme ofknowledge will allow the trainees to perform routine pro-cedures using image guidance throughout their careers.This can only serve to strengthen the specialty of radiolo-gy as a whole.

The following is an attempt to develop a core programmeof knowledge for trainees in interventional radiology. It isclear that there is some overlap with some other sectionsin the diagnostic radiology syllabus, but it is neverthelessimportant to define a core programme for interventionalradiology.

Length of trainingIn order for the trainee to achieve basic skills and coreknowledge in interventional radiology, four to six monthsof dedicated time in interventional radiology will be re-quired during basic training.


It is expected that, at the end of residency, the trainee willhave a thorough knowledge of the performance and inter-pretation of diagnostic vascular techniques and a basicunderstanding of common interventional procedures.

2.1. Non-Invasive Vascular Imaging

2.1.1. Doppler UltrasoundThe trainee should demonstrate a thorough un-derstanding and be able to interpret the following:- Duplex ultrasound, including both arterial and

venous examinations- Normal and abnormal Doppler waveforms- Common Doppler examinations, such as

carotid Doppler, hepatic and renal Dopplerstudies and lower extremity venous duplexexaminations

2.1.2. CT AngiographyThe trainee should have a thorough understand-ing of:- The basic physics of single slice helical CT

and multi-detector CT

- CTA protocols including contrast materialsused and reconstruction techniques

- Radiation doses for CTA and methods to re-duce these

- Advantages and disadvantages of CTA ver-sus other techniques

2.1.3. MR Angiography (MRA)The trainee should be familiar with:- MR physics and MRA techniques- Advantages and disadvantages of different

contrast materials used for MRA- Differences between time of flight, phase con-

trast, and contrast-enhanced techniques per-taining to MRA

- Advantages and disadvantages of MRA com-pared to other techniques

2.2. Diagnostic Angiography / Venography

2.2.1. GeneralThe trainee should be familiar with:- The basic chemistry of the different iodinated

contrast materials used, and the advantages /disadvantages of each for angiography

- Mechanisms to minimise nephrotoxicity inrisk patients, such as patients with diabetesor renal impairment

- Cortico-steroid prophylaxis- Treatment of both minor and major allergic re-

actions to iodinated contrast materials

2.2.2. Arterial Puncture TechniqueThe Trainee should have a thorough knowledge of:- Standard groin anatomy, including the posi-

tion of the inguinal ligament and the femoralnerve, artery and vein

- The Seldinger technique of arterial and ve-nous puncture

- Mechanisms for guidewire, sheath andcatheter insertions into the groin

- Mechanisms of puncture site haemostasis in-cluding manual compression and commonclosure devices

- Alternative sites of arterial puncture, such asbrachial, axillary and translumbar

2.2.3. Diagnostic AngiographyThe trainee should be familiar with:- Guidewires, sheaths and catheters used for

common diagnostic angiographic procedures- Digital subtraction angiographic techniques,



bolus chase techniques, road mapping, andpixel shift techniques

- Standard arterial and venous anatomy andvariations in anatomy throughout the body

- Peripheral vascular angiography- Mesenteric and renal angiography- Abdominal aortography- Thoracic aortography- Carotid, vertebral and subclavian angiography- Diagnosis of atherosclerotic disease, vasculi-

tis, aneurysmal disease, thrombosis, em-bolism and other vascular pathology

- The complication rates for common diagnos-tic procedures

- Post-procedural care regimens for standarddiagnostic vascular procedures

2.3. Vascular Intervention

The trainee should be familiar with common vascular in-terventional procedures, such as:

2.3.1. Angioplasty - Angioplasty balloon dynamics, mechanism of

action of angioplasty- Indications for angioplasty- Complications and results in different

anatomic areas- Drugs used during angioplasty- Intra-arterial pressure studies- Common angioplasty procedures, such as

renal, iliac and femoral angioplasties- Groin closure techniques and post-procedur-

al care

2.3.2. Arterial / Venous Stenting- Basic mechanisms for stent deployment and

materials used for stent construction- Indications for stent placement versus angio-

plasty- Complications and results- Post-procedural care

2.4. Venous Intervention

2.4.1. Venous AccessThe trainee should be familiar with the variousforms of venous access including:- PICC lines, Hickman catheters, dialysis

catheters and ports- Indications for use of the above venous ac-

cess catheters

- The technique of venous access in jugularand subclavian veins

- Results and complications

2.4.2. Venoplasty and StentingThe trainee should be familiar with:- Techniques of venoplasty and stenting- Success rates and complications- Post-procedural care

2.4.3. Caval Interruption The trainee should be familiar with:- Indications for caval filter placement- Different filter types available, including re-

trievable filters- Success rates and complications- Post-procedural care

2.5. Non-Vascular Intervention

Trainees should have performed and have a thorough un-derstanding of basic non-vascular interventional tech-niques, such as biopsy, abscess drainage,transhepaticholangiography and nephrostomy tech-niques.

2.5.1. BiopsyThe trainee should be familiar with:- Consent procedures- Pre-procedure coagulation tests and correc-

tion of abnormalities- Differences in image modalities used for guid-

ing biopsy, including CT and ultrasound - Needles used for biopsy procedures including

fine gauge needles, large gauge needles andtrucut biopsy

- Planning a safe access route to the lesion tobe biopsied

- Complication rates associated with individualorgan biopsy

- Indications for fine needle biopsy versus largegauge or core biopsy

- Post-procedural care for chest and abdominalbiopsy

- Algorithms for treatment of common compli-cations, such as pneumothorax and hemor-rhage

2.5.2. Fluid Aspiration and Abscess Drainage.The trainee should be familiar with:- Commonly used chest tubes and abscess

drainage catheters



- Indications for chest drainage, fluid aspira-tion, and abscess drainage

- Imaging modalities used for guidance- Interpretation of gram stain results- Methods of chest tube placement- Underwater seal drainage systems- Fibrinolytic agents used in patients with locu-

lated or complex empyemas- Planning a safe access route for abscess

drainage- Antibiotic regimens used before abscess

drainage- Trocar and Seldinger techniques for catheter

placement- Situations where more than one catheter or

larger catheters are required- Various approaches to pelvic abscess

drainage- Post-procedural care including catheter care,

ward rounds and when to remove catheters

2.5.3. Hepatobiliary InterventionThe trainees should have knowledge of, and beable to perform basic hepatobiliary intervention,such as, transhepaticholangiography and basicpercutaneous biliary drainage (PBD).

The trainee should be familiar with:- Pre-procedure workup, including antibiotic

regimens, coagulation screening and intra-venous fluid replacement

- Performance of transhepaticholangiography- One-stick needle systems for biliary drainage- Catheters used for biliary decompression - Complications of biliary procedures- Aftercare, including knowledge of complica-

tions, catheter care, and ward rounds

2.5.4. Genitourinary InterventionThe trainee should be familiar with:- Indications for percutaneous nephrostomy- Integration of ultrasound, CT and urographic

studies to plan an appropriate nephrostomy- Pre-procedural work-up including coagulation

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-

moval


The goals of basic training in interventional radiology areas follows:

- The trainee should be able to interpret non-in-vasive imaging studies to determine that therequested procedure is appropriate

- To determine the appropriateness of patientselection for a requested interventional pro-cedure through a review of available history,imaging, laboratory values, and proposed orexpected outcomes of the procedure

- To demonstrate an understanding of the his-tory or physical findings that would requirepre-procedure assistance from other special-ty disciplines, such as Cardiology,Anaesthesia, Surgery or Internal Medicine

- To obtain informed consent after discussionof the procedure with the patient, including adiscussion of risks, benefits, and alternativetherapeutic options

- To be familiar with monitoring equipmentused during interventional radiology proce-dures and be able to recognise abnormalitiesand physical signs or symptoms that need im-mediate attention during the procedure

- To demonstrate an understanding of and beable to identify risk factors from the patient’shistory, physical or laboratory examinationsthat indicate potential risk for bleeding,nephrotoxicity, cardiovascular problems,breathing abnormalities, or adverse drug in-teractions during or after the procedure

- Knowledge of agents used for conscious se-dation and analgesia during interventionalprocedures, with ability to identify risk factorsthat may indicate potential risks for conscioussedation

- Knowledge of radiation safety in the interven-tional radiology suite

- Knowledge of methods used to reduce acci-dental exposure to blood and body fluids inthe interventional radiology suite



MusculoskeletalRadiology1 – INTRODUCTION

Musculoskeletal imaging involves all aspects of medicalimaging which provide information about the anatomy,function, disease states and those aspects of interven-tional radiology or minimally invasive therapy appertainingto the musculoskeletal system. This will include imaging inorthopaedics, trauma, rheumatology, metabolic and en-docrine disease as well as aspects of paediatrics and on-cology. Imaging of the spine is included within both themusculoskeletal and neuroradiological fields. It should benoted that elements of musculoskeletal imaging are partof paediatric and emergency radiology and to a lesser ex-tent of oncological imaging.


- Basic clinical knowledge, that is medical, sur-gical and pathology as well as pathophysiolo-gy related to the musculoskeletal system

- Knowledge of current good clinical practice- Knowledge of the indications, contraindications

and potential hazards (especially radiationhazards) of procedures and techniques rele-vant to musculoskeletal disease and trauma

- Knowledge and management of proceduralcomplications

- Knowledge of musculoskeletal anatomy inclinical practice relevant to clinical radiology

- Knowledge of normal skeletal variants, whichmay mimic disease

- Knowledge of the manifestations of muscu-loskeletal disease and trauma (see listbelow), as demonstrated by conventional ra-diography, CT, MRI, arthrography, radionu-clide investigations, and ultrasound

- Knowledge of differential diagnosis relevantto clinical presentation and imaging appear-ance of musculoskeletal disease and traumaas listed below

The following manifestations of musculoskeletal diseaseand trauma have to be covered during the general radio-logical training. This should include formal teaching andexposure to clinical case material.

2.1. Trauma (acute & chronic)

2.1.1. Fractures & Dislocations- types and general classifications

- features in the adult skeleton- features in the immature skeleton* (including

normal development)- articular (chondral & osteochondral) (includ-

ing osteochondritis dissecans)- healing & complications

- delayed union / non-union- avascular necrosis- reflex sympathetic dystrophy- myositis ossificans

- stress (fatigue & insufficiency)- avulsion- pathological- non-accidental injury*

2.1.2. Specific Bony / Joint Injuries- skull & facial bone fractures- spinal fractures (including spondylolysis)- shoulder girdle

- sternoclavicular & acromioclavicular dislo-cations

- clavicular fractures- scapular fractures- shoulder dislocation / instability

- upper limb- humeral fractures- elbow fractures / dislocations- proximal & distal forearm fractures / dislo-

cations- wrist joint fractures / dislocations- hand fractures / dislocations

- pelvic fractures / dislocations (including asso-ciated soft tissue injuries)

- lower limb- hip fractures / dislocations- femoral fractures- tibial & fibular fractures (including ankle

joint)- hindfoot fractures- tarso-metatarsal fractures / dislocations- forefoot fractures / dislocations

2.1.3. Soft Tissues- shoulder

- rotator cuff, glenoid labrum, biceps ten-don

- wrist- triangular fibrocartilage complex

- knee- menisci, cruciate ligaments, collateral lig-

aments- ankle

- principal tendons & ligaments



2.2. Infections - acute, subacute & chronic osteomyelitis

- spine - appendicular skeleton

- post-traumatic osteomyelitis- tuberculosis- spine- appendicular skeleton- rarer infections (e.g. leprosy, brucellosis –

main manifestations only)- commoner parasites worldwide (e.g. echinoc-

coccus)- soft tissue infections- HIV-associated infections

2.3. Tumours & umour-like lesions

2.3.1. Bone- principles of tumour characterisation and

staging- bone-forming

- osteoma & bone islands- osteoid osteoma & osteoblastoma- osteosarcoma (conventional and com-

moner variants)- cartilage-forming

- osteochondroma- enchondroma- chondroblastoma- chondromyxoid fibroma- chondrosarcoma (central & peripheral)

- fibrous origin- fibrous cortical defect / non-ossifying fi-

broma- fibrous dysplasia- fibrosarcoma / malignant fibrous histiocy-

toma- haematopoietic and reticuloentholelial

- giant cell tumour- Langerhans cell histiocytosis- malignant round cell (Ewing’s sarcoma,

lymphoma & leukaemia)- myeloma & plasmacytoma

- tumour-like- simple bone cyst- aneurysmal bone cyst

- metastases- others

- chordoma- adamantinoma

2.3.2. Soft Tissue- fat origin

- lipoma- liposarcoma

- neural origin- neurofibroma- schwannoma

- vascular origin- haemangioma

- soft tissue sarcomas

2.4. Haematological disorders- haemoglobinopathies

- sickle cell disease- thalassaemia

- myelofibrosis

2.5. Metabolic, endocrine & toxic disorders- rickets* & osteomalacia- primary & secondary hyperparathyroidism

(including chronic renal failure)- osteoporosis (including basic concepts of

bone mineral density measurements)- fluorosis

2.6. Joints- degenerative joint disease

- spine (including intervertebral disc & facetjoints)

- peripheral joints- inflammatory joint disease

- rheumatoid arthritis- juvenile rheumatoid arthritis*- ankylosing spondylitis- psoriatic arthritis- enteropathic arthropathies- infective (pyogenic & tuberculous)

- crystal arthropathies- pyrophosphate arthropathy- hydroxyapatite deposition disease- gout

- masses- ganglion- synovial chondromatosis- pigmented villonodular synovitis

- neuroarthropathy- diabetic foot- charcot joints- pseudo-Charcot (steroid induced)

- complications of prosthetic joint replacement(hip & knee)

2.7. Congenital, developmental & paediatric*- spine

- scoliosis (congenital & idiopathic)



- dysraphism- shoulder

- Sprengel’s deformity- hand & wrist

- Madelung deformity (idiopathic & othercauses)

- hip- developmental dysplasia- irritable hip- Perthes disease- slipped upper femoral epiphysis

- bone dysplasias- multiple epiphyseal dysplasia- achondroplasia- osteogenesis imperfecta- sclerosing (osteopetrosis, melorheostosis

& osteopoikilosis)- tumour-like (diaphyseal aclasis & Ollier’s

disease)- neurofibromatosis

2.8. Miscellaneous- Paget’s disease- sarcoidosis- hypertrophic osteoarthropathy- 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 toensure that the topics are adequately covered in eitherthe 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 themusculoskeletal system including trauma

- supervising and reporting CT and MRI exam-inations of trauma patients, including the pro-

vision of on-call service- communicating with patients and taking histo-

ry relevant to the clinical problem- using all available data (clinical, laboratory,

imaging) to find a concise diagnosis or differ-ential diagnosis

3.2. Core of experience- experience of the relevant contrast medium

examinations (e.g. arthrography)

Optional experience includes:

- reporting radionuclide investigations of themusculoskeletal system, particularly skeletalscintigrams

- awareness of the role and, where practicable,the observation of discography, facet joint in-jections, and vertebroplasty

- observation of image-guided bone biopsyand drainage of the musculoskeletal system

- interpretation of bone densitometry examina-tions

- familiarity with the application of angiographyin the musculoskeletal system



Neuroradiology1 – INTRODUCTION

The aim of this core training is for the trainees to famil-iarise themselves and gain core competence in the basicsof neuroradiology as well as to develop enough under-standing of neuroradiology so as to be able to recognisethat there is an abnormality and to know where and whento seek help. It should be undertaken under the supervi-sion of a neuroradiologist. Arrangements should be madewithin the training scheme for secondment to another de-partment if necessary. Exposure to all imaging techniquesused in neuroradiology should be achieved.


2.1. To know:- Neuroanatomy and clinical practice relevant

to neuroradiology- The manifestations of CNS disease as

demonstrated on conventional radiography,CT, MRI, and angiography

2.2. To understand the indications for a neuroradio-logical examination.

2.3. To recognise normal results on x-ray, ultrasound,CT, and MR.

2.4. To be aware of the applications, contraindicationsand complications of invasive neuroradiologicalprocedures.

2.5. To get familiarity with the application of:- Radionuclide investigations in neuroradiology- CT and MR angiography in neuroradiology

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 cord

2.6.4. Vascular disease including congenital and acquired malformations

2.6.5. Degenerative diseases of the brain

2.6.6. Hydrocephalus

3 - TECHNIQUE, COMMUNICATION AND DECISION-MAKING SKILLS

3.1. At the end of his / her training, the residentshould be able to:- Report plain radiographs in the investigation

of neurological disorders- Supervise and report cranial and spinal CT

scans - Supervise and report cranial and spinal MR

scans

3.2. During his / her training, the resident should alsoobserve:- Cerebral angiograms and their reporting- Carotid ultrasound examination including

Doppler

3.3. The resident should get experience in MR andCT angiography and venography to image thecerebral vascular system

3.4. Optional experience includes the following:- To perform and report cerebral angiograms,

myelograms and carotid ultrasound, includingDoppler and transcranial ultrasound

- To observe interventional neuroradiologicalprocedures, including magnetic resonancespectroscopy

- To get experience on functional brain imagingtechniques (radionuclide and MRI)



Paediatric Radiology1 – INTRODUCTION

The aim of this core training is for the trainee to gain basicunderstanding of children’s diseases and basic compe-tence of paediatric diagnostic imaging in order to be ableto recognise whether there is an abnormality and to knowwhere to seek help. It should be undertaken under the su-pervision of a paediatric radiologist. Arrangements shouldbe made within the training scheme for secondment to an-other department if necessary. Exposure to all imagingtechniques, including nuclear medicine, should beachieved.

Paediatric Radiology covers all the organ disciplines asdescribed in the other curricula but is age-related. A childis defined as a person under 16 years of age. As the childapproaches adulthood, disease patterns become moresimilar to those in adult life. Paediatric Radiology encom-passes diagnostic imaging of the fetus, the newborn, theinfant, the child, and the adolescent.


In the twelve-week course, in addition to acquiring knowl-edge of the paediatric organ system, the trainee is expect-ed to also acquire a basic understanding of the following:

- Principles of integrated imaging in relation topaediatric problems;

- Choice of useful imaging technique(s) forcommon clinical questions;

- Correct sequence of imaging in relation to theclinical problem;

- Adaptation of imaging techniques for chil-dren, i.e. minimising radiation, especially inrelation to CT and fluoroscopy; indications forand choice of contrast media;

- Special requirements for children, e.g. envi-ronment, sedation and anaesthesia, physiolo-gy of the young infant, and psychology ofmanaging children;

- Communication with the children and theirparents, as well as medical colleagues;Importance of clinico-radiological confer-ences, both formal and informal;

- Guidelines for investigation of common clini-cal problems and understanding of risk / ben-efit analysis related to children;

- Radiation protection, equipment, and regula-tion;

2.1. Imaging techniques

The emphasis throughout the attachment is to appreciatethe differences between children and adults. All workshould be closely supervised and, ideally, a log book kept.

2.1.1. Ultrasound: This should include duplex,colour and Doppler techniques and thefull age range, including premature infants. The trainee should perform theultrasound examinations under supervi-sion. The experience should include ex-posure to the following areas:

- Neonatal head- Abdomen: kidneys and urinary tract; liver and

spleen; gynaecology- Chest: pleurae- Soft tissues: neck, scrotum, musculoskeletal

system- Doppler studies: neck and abdomen, testes

2.1.2. Radiographs: supervised reporting ofchildren’s radiographs, especially in re-lation to A. & E. presentation, muscu-loskeletal system, chest, and abdomen.

2.1.3. Fluoroscopy: discussion of indicationsfor gastrointestinal fluoroscopy versusspecialist paediatric endoscopy withsupervisor before initiating studies.Performing studies under direct super-vision.

- Technique of bladder catheterisation and per-formance of micturition cystourethrography(MCU)

- Observation and conduct of upper and lowerG.I. contrast studies in neonates

- Tailored upper and lower gastrointestinal con-trast studies in children for investigation ofgastro-oesophageal reflux, aspiration andconstipation in neurologically normal and im-paired children

- Observation of intussusception reduction- Observation of videophonetics if locally per-

formed

2.1.4. Small and large bowel studies

2.1.5. Urography: To understand the indica-tions for intravenous (iv) and MR urogra-phy; to know how to conduct the ivurography in children.



2.1.6. CT: To understand the technique in apaediatric trauma patient and the spe-cial low dose imaging protocols in gener-al use. Experience of CT of the head andneck, abdomen, chest and muscu-loskeletal system, especially in a traumapatient, should be gained as far as pos-sible.

2.1.7. MR: The experience in MR by observa-tion should include neuroimaging (brainand spinal cord), abdominal and muscu-loskeletal imaging.

2.1.8. Nuclear Medicine: To gain experience inrenal imaging – both DMSA scintigraphyand renography, possibly MAG3, andskeletal imaging.

2.1.9. Angiography and Interventional Radio-logy: Understanding of indications andobservation of techniques according tolocal possibilities.

2.1.10. Fetal Imaging: If the opportunity arisesfor exposure to fetal MR and antenatalultrasound that familiarises the traineewith the indications for these techniques,this should be included. The trainee thusexposed should also gain an under-standing of the multidisciplinary ap-proach to the specific problems of fetalimaging.

2.2. Pathology

All the following sections should be cross-referenced tothe core curricula for the other organ specialties, as in thissection those diseases are emphasised that are specificto children. Many of the following pathological conditionsare characteristic of childhood and should be included indifferential diagnostic case discussion during the 12-week- training period.

2.2.1. Chest: Diseases of the tracheobronchialtree, lungs and pleura:

- To recognise the radiology of lobar, viral andspecific organism infection and pulmonaryabscess

- To recognise infiltrative lung disease - To recognise the possibility of tuberculosis- To be aware of opportunistic infection in im-

munocompromised children

- To recognise cystic fibrosis changes- To recognise bronchiectasis- To recognise a pleural effusion and empyema- To recognise a pneumothorax- To recognise complications of asthma- To recognise premature lung disease and its

complications- To recognise and know how to investigate

suspected inhaled foreign bodies- To recognise mass lesions and know how to

further investigate them, including congenitalbronchopulmonary foregut malformation

- To recognise metastatic lung disease- To know about specific clinical problems,

such as stridor and recurrent infection - To recognise and know how to assess chest

trauma

2.2.2. Mediastinum - To recognise and know how to investigate a

mediastinal mass in children.

2.2.3. Diaphragm- To recognise diaphragmatic paralysis, even-

tration, and possible paralysis.

2.2.4. Cardiovascular System- To recognise abnormal cardiac size and con-

tours- To recognise cardiac failure (left vs. right

heart failure)- According to local possibilities: To get an un-

derstanding of the role of ultrasound, MR andangio-CT in the investigation of cardiac dis-eases in children.

2.2.5. Gastrointestinal Tract:- The investigation and imaging of congenital

gastrointestinal malformations in the neonatalperiod and later. These include:- Oesophageal atresia- Tracheooesophageal fistula- Malrotation and situs anomalies- Duodenal obstruction (e.g. atresia and

stenosis)- Hirschsprung’s Disease- Duplication anomalies

- The investigation of neonatal bowel obstruc-tion, e.g.- Hirschprung’s Disease- Meconium ileus- Meconium plug syndrome

- The ultrasound appearance of pyloric stenosis



- Intussusception- Inflammatory bowel disease in children- Appendicitis- Gastroenteritis- Investigation of the following clinical prob-

lems:- Abdominal pain- Constipation- Malabsorption- Suspected bowel obstruction and ileus- The vomiting neonate- Abdominal trauma

- The investigation of an abdominal mass- The management of ingested foreign bodies

2.2.6. Hepatobiliary Disease- Approach to the investigation of neonatal

jaundice- Cause and investigation of jaundice in the

older child- Choledocholithiasis in children- Congenital malformations of the biliary tree- Trauma- Hepatobiliary tumours

2.2.7. Spleen- Trauma- Haematological diseases- Congenital syndromes associated with asple-

nia, polysplenia, etc.

2.2.8. Pancreas - Trauma- Pancreatitis - Tumor involvement

2.2.9. Endocrine DiseaseUnderstand the approach to the investigation of:- Thyroid disorders in children- Adrenal disorders in children including neu-

roblastoma- Growth abnormalities and suspected growth

hormone deficiency

2.2.10. Genitourinary tract- To recognise the normal appearance of the

organs in any imaging modality- To understand the urethral anatomy of the boy- To understand the clinical and biological crite-

ria of UTI- To be able to perform ultrasound of the uri-

nary tract on infants including the use ofDoppler

- To know when and how to perform a MCUand how to read it

- To detect and evaluate VUR- To recognise renal abscess and pyonephro-

sis- To recognise congenital urinary tract anom-

alies on ultrasound and understand their fur-ther evaluation

- To recognise hydronephrosis / hy-droureterone-phrosis on ultrasound and un-derstand their further evaluation

- To recognise the urinary tract features andcomplications of spinal dysraphism and otherneuropathies

- To recognise bladder exstrophy radiologically- To know about indications for urodynamic

studies- To recognise Wilms’ tumour and understand

its further investigation- To recognise pelvic and bladder tumours and

their further investigations- To recognise polycystic kidney disease; know

about various forms- To recognise urinary tract lithiasis and under-

stand its investigation- To understand the investigation of hematuria- To be aware of renal manifestations of sys-

temic disease- To recognise the imaging features of nephrot-

ic syndrome and glomerulonephritis

2.2.11. Gynaecology- To recognise ovarian cysts, possible torsion

and tumours in the child and adolescent - To recognise neonatal presentation of ovarian

cysts and hydro(metro)colpos- To recognise genital and extragenital tumours

and understand their investigation - To be aware of cloacal and urogenital sinus

anomalies - To be aware of intersex anomalies arising in

the neonate and at adolescence- To recognise congenital uterine malformation- To know how to investigate precocious and

delayed puberty

2.2.12. Breast Disease- To recognise the ultrasonic and MR appear-

ances of breast cysts

2.2.13. Testes- To recognise scrotal trauma



- To recognise and know how to evaluate tes-ticular torsion

- To recognise epidydymo-orchitis - To recognise testicular tumours - To understand the investigation of unde-

scended testes

2.2.14. The Musculoskeletal SystemTrauma

- To recognise normal variants that may bemisinterpreted as pathology

- To recognise fractures of the limbs, pelvis,and spine

- To understand the Salter-Harris classificationof fractures and to recognise the therapeuticimplications

- To recognise the bony lesions of child abuse- To recognise sports injuries, such as avulsion

fracture and enthesopathy- To recognise soft tissue injury on X-ray, ultra-

sound, and MR- To recognise a slipped upper femoral epiph-

ysis- To recognise Legg-Calvé-Perthes disease

Infection- To recognise the imaging features of bone,

joint, and soft tissue, including spinal infection- To recognise juvenile discitis- To recognise conditions that may mimic infec-

tion, such as SAPHO syndrome- To recognise the complications of foreign

body penetration- To be familiar with tropical infection

Congenital Disease- To recognise congenital hip dysplasia on ul-

trasound and X-ray- To gain an approach to the radiology of skele-

tal dysplasia and isolated congenital malfor-mations

- To be aware of need for investigation of con-genital and acquired scoliosis and musculardystrophy

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 injury

- To understand intracranial injury, includingchild abuse and the complications

- To understand the indications for the investi-gation of headache, diplopia, and epilepsy

- Infection of the brain, meninges, orbits and si-nuses, and the complications

- Hydrocephalus- Tumours of the brain, orbits and spinal cord- Premature brain disease on both ultrasound

and MR- Congenital malformation of brain and spinal

cord- Spinal cord injury- Spinal cord malformations and imaging for

clinical presentations, e.g. back pain, clawfoot, or dermal sinus

- To be aware of developmental anomalies: mi-grational disorders

- Craniofacial malformations including cran-iostenosis

- Congenital ear disease- Dental radiology

2.2.17. Miscellaneous These conditions are often multiorgan in presen-tation and are mentioned separately so that thetrainee is aware of their protean manifestation.- Non-accidental injury (NAI)- AIDS in children- Lymphoma in children- Vascular malformations including lymphoedema- Collagen vascular disease including myofi-

bromatosis- Endocrine disease- Investigation of small stature and growth dis-

orders- Phakomatoses (tuberous sclerosis, neurofi-

bromatosis, etc.)- Langerhans Cell Histiocytosis



Urogenital Radiology1 – INTRODUCTION

The aim of establishing a curriculum for training in uro-genital imaging is to ensure trainees have acquired:

- Knowledge of the relevant embryological,anatomical, pathophysiological and clinicalaspects of uronephrology and gynaecology

- Understanding of the major imaging tech-niques relevant to uronephrological and gy-naecological diseases and problems

- Understand the role of radiology in the man-agement of these specialist areas

- Knowledge of the indications, contra-indica-tions, complications and limitations of proce-dures


2.1. Urinary & male genital tract – Specific objectives

2.1.1. Renal physiology and kinetics of con-trast agents

- To understand the physiology of renal excre-tion of contrast medium

- To understand the enhancement curves with-in renal compartments after injection of con-trast agents

- To know the concentrations and doses ofcontrast agents used intravenously

2.1.2. Normal anatomy and variants- Retroperitoneum:

- To recognise retroperitoneal spaces andpathways

- Kidney:- To understand the triple obliquity of the

kidney- To know the criteria of normality of the

pyelocaliceal system on IVU- To recognise normal variants, such as

junctional parenchymal defect, column ofBertin hypertrophy, fœtal lobulation, orlipomatosis of the sinus

- To identify the main renal malformations,such as horseshoe kidney, duplications,ectopia, or fusions

- Bladder and urethra:- To know the anatomy of the bladder wall

and physiology of micturion - To identify the segments of male urethra

and location of urethral glands

- Prostate:- To recognise zonal anatomy of the

prostate- To identify prostatic zones with US and

MRI- Scrotum:

- To know the US anatomy of intra-scrotalstructures (testicular and extratesticular)

- To know the Doppler anatomy of testicularand extratesticular vasculature

2.1.3. Imaging techniques - Sonography of urinary tract

- To choose the appropriate transducer ac-cording to the organ imaged

- To optimise scanning parameters- To recognise criteria for a good sono-

graphic image - To recognise and explain the main arti-

facts visible in urinary organs- To be able to get a Doppler spectrum on

intrarenal vessels (for resistive indexmeasurement) and on proximal renal ar-teries for velocity calculation

- IVU- To list the remaining indications of IVU - To know the main technical aspects:

- Choice of the contrast agent- Doses - Film timing and sequences- Indication for ureteral compression- Indication of Frusemide

- Cysto-urethrography - To list the main indications of cysto-ure-

thrography- To know the main technical aspects:

- Choice of technique: trans-urethral,transabdominal

- Choice of the contrast agent- Film timing and sequences- To remember aseptic technique

- CT of the urinary tract- To define the normal level of density

(in HU) of urinary organs and components- To know the protocol for a renal and adre-

nal tumour- To know the protocol for urinary obstruc-

tion (including stones)- To know the protocol for a bladder tumour

- MR of the urinary tract- To know the appearances of urinary or-

gans on T1 and T2w images- To know the protocol for a renal and adre-

nal tumour



- To know the protocol for urinary obstruc-tion

- To know the protocol for a bladder tumour- To know the protocol for a prostatic tu-

mour

2.1.4. Pathology- Kidney and ureter

- Congenital – covered under 2.1.2.- Obstruction- Calculus- Infection- Tumours- Cystic diseases- Medical nephropathies- Vascular- Renal transplantation- Trauma

- Bladder- Congenital – covered under 2.1.2.- Obstruction- Inflammatory- Tumours- Trauma- Incontinence & functional disorders- Urinary diversion

- Urethra- Congenital- Strictures- Diverticula- Trauma

- Prostate & Seminal Vesicles- Congenital- Benign prostatic hypertrophy- Inflammatory- Tumours

- Testis & scrotum- Congenital- Inflammatory- Torsion- Tumours

- Penis- Impotence

- Adrenal- Masses

2.1.5. Interventional- In general

- To verify indications, satisfactory bloodcount, and coagulation status

- To explain the procedure and follow-up tothe patient

- To know what equipment is required

- To know what aftercare is required- US-guided biopsies / cystic drainage, e.g. kid-

ney mass, prostate- CT-guided biopsies- Percutaneous nephrostomy

2.2. Gynaecological Imaging

2.2.1. Techniques- US examination

- To be able to explain the value of a US ex-amination

- To be able to explain the advantages andlimits of abdominal vs. transvaginal ap-proach

- To know indications and contra-indica-tions of hysterosonography

- Hysterosalpingography- To be able to describe the procedure- To know the possible complications of

hysterosalpingography- To know the contra-indications of hys-

terosalpingography- To explain the choice of contrast agent- To know the different phases of the exam-

ination- CT scan

- To be able to explain the technique of apelvic CT

- To know the possible complications of CT- To know the contra-indications of CT. To know the irradiation delivered by a

pelvic CT- To know the required preparation of the

patient and the choice of technical param-eters (slice thickness, Kv, mA, number ofacquisitions, etc.) depending on indica-tions

- MRI- To be able to explain the technique of a

pelvic MRI- To know the contra-indications of MRI- To know the required preparation of the

patient and the choice of technical param-eters (slice thickness, orientation, weight-ing, etc.) depending on indications

- Angiography- To know the main indications of pelvic an-

giography in women- To know how to perform a pelvic angiog-

raphy



2.2.2. Anatomy- To know main normal dimensions of uterus

and ovaries with US- To describe variations of uterus and ovaries

during genital life - To describe variations of uterus and ovaries

during the menstrual cycle - To describe normal pelvic compartments - To identify normal pelvic organs and bound-

aries on CT and MRI- To explain the role of levator ani in the physi-

ology of pelvic floor - To know what imaging modalities can be

used to visualise the pelvic floor- To know the factors responsible for urinary in-

continence

2.2.3. Pathology- Uterus

- Congenital anomalies- Tumours (benign and malignant)

- myometrium- endometrium- 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


3.1. 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 risks

3.2. To validate the request based on- Risk factors- Irradiation involved- Possible alternatives

3.3. To perform the examination - To know the clinical history and the clinical

questions to be answered- To know the protocol of examination - To assess the anxiety of the patient before,

during and after the examination, and provideappropriate reassurance

3.4. Communication with the patient and the col-leagues and recommendations for follow-up- To explain clearly the results to the patient- To assess the level of understanding of the

patient- To explain the type of follow-up - To assess the degree of emergency- To produce a clear report of the examination - To discuss strategies for further investigation,

if necessary

Detailed Curriculum for Subspecialty Training


In the fourth and fifth years, the rotations of the radiolo-gists in training should be organised to serve the individ-ual’s needs depending on the availability in the trainingprogramme, which may be in general radiology or in asubspecialty.

General radiology training in the fourth and fifth years isdesigned to enable the trainee to gain further experience,knowledge and skills in disorders that are present in gen-eral hospitals and private practice in order to reach a levelrequired to undertake autonomous practice.

This period of training should include an extended periodof time in a minimum of two areas of special interest so asto acquire more detailed knowledge and skills. General ra-diologists being in training in areas of special interest maywish to use the subspecialty curricula for guidance albeitrecognising that they would not be required to fulfil all as-pects of them.

For trainees entering a subspecialty, the total period ofsubspecialist training will vary according to the subspe-cialty but would normally be expected to be completedduring the fourth and fifth years. For those subspecialtieswith a single year of subspecialty training, continued train-ing in general radiology during the balance of time will beundertaken. Some subspecialty training may extend be-yond the 5th year depending on national training arrange-ments relevant to their specialty programme.

Subspecialty training may be undertaken in a modularfashion 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 appreciatedthat training in the individual subspecialties may vary fromcentre to centre. It is recommended for subspecialty rota-tion that there be a minimum commitment of six sessionsper 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 individualswishing to train in or have aptitude for certain areas at therelative expense of others. Thus, training in some centresand certain subspecialties may be delivered in a moremodular fashion.

Formal teaching is organised on the basis of lectures, tu-torials, and workshops. Whatever the chosen subspecialtywill be, the trainees should maintain one or two sessionsof relevant general radiology during the week in order tomaintain basic skills and participate in and gain experi-ence in emergency on-call work.

The curricula for selected subspecialties are included inthis document. In general terms, trainees are expected toacquire the elements identified below.

- Detailed knowledge of current theoretical andpractical developments in their chosen subspe-cialty (or subspecialties).

- Development of clinical knowledge relevant totheir chosen subspecialty (or subspecialties).

- Extensive directly observed, or non-observed butsupervised practical experience in their chosensubspecialty (or subspecialties).

In order to make the curriculum intelligible for each indi-vidual subspecialty as a stand-alone document, there isrepetition of some of the generic points. These subspe-cialty curricula have been prepared by different Europeansocieties of specialty in radiology, for which the EAR(ESR) is very grateful. Inevitably certain compromise deci-sions have had to be taken, especially in the face of con-flicting advice. Furthermore, each curriculum has had toconform to a uniform style.




Breast Radiology 1 – INTRODUCTION

The aim of subspecialised training in breast imaging is toprepare a radiologist for a career in which a significantportion of his / her time will be devoted to breast imagingand / or breast cancer screening with mammography.Such individuals will be expected to provide and promotebreast imaging and interventional methods, as well asnew imaging breast cancer screening procedures.

The aims of establishing a curriculum for subspecialtytraining in breast radiology is to ensure:- An in-depth understanding of breast disease with

particular knowledge of the nature of breast can-cer in all its guises.

- A clear understanding of the role of imaging inthe early diagnosis of breast cancer.

- Development of the necessary clinical and man-agement skills to enable radiologists to becomean integral part of a multidisciplinary breast teamin symptomatic and / or population screening set-tings.

2 – EXPERTISE AND FACILITIES

- Training must be undertaken in a team with ac-cess to full clinical service in radiology, generalsurgery / gynaecology and pathology. If possible,oncology, radiotherapy, plastic surgery, socialand preventive medicine should also be offered.

- Training should be supervised by a radiologistwith extensive experience in breast imaging andbreast cancer screening methods (e.g. reporting5,000 mammograms per year). The training de-partment(s) should fulfil EU guidelines, musthave mammography, ultrasonography and inter-ventional equipment including stereotaxic and ul-trasonically guided biopsy systems.

- Trainees should also have access to breast MRI,nuclear medicine and acquire knowledge ofbreast cancer screening.

- Trainees must also have access to a radiologicallibrary containing senology and radiology text-books along with journals and must have accessto a film library.

3 – OVERVIEW

- Trainees will have obtained a basic knowledge ofbreast diagnosis in their initial training. The train-ing outlined below will extend this to the practicalrole.

- Those clinical radiologists who wish to devote es-sentially all their time as specialists / consultantsin breast imaging should undertake 12 months orits equivalent of subspecialty training. Those whowish to practice breast imaging, as one out of avariety of activities would normally expect to un-dertake 6 months.

- Trainees will acquire an extensive knowledge ofthe pathology and epidemiology of breast dis-eases, both female and male and both primary, oflocal recurrence, as well as distant disease. Theyshould have at least a basic knowledge of thetreatment of breast disease by surgery, radiother-apy and chemotherapy and be aware of the diag-nostic needs of their surgical, radiotherapy andoncology colleagues. It would therefore be help-ful for trainees to spend time in breast clinics, op-erating theatres, as well as radiotherapy andoncology departments.

- Trainees also must develop skills in the use andinterpretation of imaging modalities used in thediagnosis and treatment of the distant spread ofa disease, e.g. plain radiographs, ultrasound, CT,MR, and nuclear medicine. They will receivetraining in communication with patients and col-leagues and "breaking bad news".

- They must obtain extensive experience in all di-agnostic procedures listed in the syllabus and willbe expected to be familiar with the current breastimaging literature, both from standard textbooksand original articles.

- As audit is an integral part of the process ofbreast imaging, particularly screening, thetrainee will have ready access to data to analysethe proficiency of his or her activities.Additionally, the trainee will be expected to com-plete a focused audit and develop an under-standing of the process of interval cancer review.

- They should participate in research and beencouraged to pursue a project up to and includ-ing publication. An understanding of the princi-ples and techniques used in research, includingthe value of clinical trials and basic biostatistics,should be acquired.

- They must attend regular multi-disciplinary con-ferences.



4 – THEORETICAL KNOWLEDGE

Trainees should attend 40 hours of theoretical training inthe form of locally delivered tutorials, specialist breast im-aging courses as well as national and international breastimaging and breast screening conferences such as thoseof EUSOBI and ECR.

- Clinical training- Knowledge of the clinical findings associated

with normal, benign and malignant tissue- Knowledge of the risks of breast disease as-

sociated with family history, hormone replace-ment therapy, etc.

- Knowledge of breast surgery, treatment andreconstruction and how these might influenceimaging appearances

- Radiation protection - Knowledge and understanding of the current

legislation governing the use of ionising radi-ation and of the responsibilities as defined innational and European legislation

- Knowledge and understanding of the need tominimise the radiation dose received by thepatient / client

- Knowledge and understanding of the risk /benefit analysis associated with breastscreening using ionising radiation as com-pared with other techniques, e.g. ultrasound,MR

- PhysicsFor all imaging modalities- Knowledge and understanding of the physics

of image production and how alteration ofmachine parameters affect the image

- Knowledge and understanding of imagerecording and display systems and how alter-ations in machine parameters affect theimage

- Knowledge and understanding of QualityAssurance Programmes and the impact thatimage quality has on clinical performance.

- Knowledge of artefacts, limitations of resolu-tion, and contrast

- Anatomy and Pathology- Knowledge and understanding of normal em-

bryology, physiology and anatomy of thebreast and associated structures in particularchanges due to age, lactation, hormonal sta-tus, surgery, radiotherapy, etc.

- Knowledge and understanding of normalphysiology, pathology and pathophysiology of

breasts and associated structures includingsynchronous and metachronous disease

- Knowledge and understanding of benign andmalignant diseases of the breast and associ-ated structures and how these processesmanifest both clinically and on imaging

- Knowledge of the spread of breast carcinomaand the pathology in other organs

- Imaging techniquesTrainees should understand the principles of allimaging methods including:- Relative indications and contraindications - Complications- Recognition of artefacts- Normal appearances, normal variations, be-

nign and malignant processes (both primary),local recurrence and distant spread

- Limitations of individual techniques, examina-tions, sequences / views and the complemen-tary nature of other techniques and the role ofeach technique in the investigation of breastdisease

- Knowledge and understanding of how imag-ing findings influence decisions by others,e.g. surgeons, pathologists, oncologists, etc.:- Mammography including additional and

special views- Ultrasound - MRI - Nuclear medicine

- Screening- Knowledge and understanding of the aims,

objectives and principles of population breastscreening

- Knowledge and understanding of the risksand benefits of screening by the populationand the individual, including those related toage factors, family history, and hormonereplacement therapy

- Knowledge and understanding of the objec-tives and principles of Quality Assurance

- Understanding of the principles and tech-niques used in audit and research, includingthe value of clinical trials and basic biostatis-tics.

- Knowledge and understanding of legal liabili-ty and processes




- Clinical training- Ability to undertake physical examination of

the breast and associated structures.- Interventional techniques

- Trainees should understand the principles ofall interventional methods including:- Relative indications and contraindications - Complications- Advantages and disadvantages- Limitations of individual examinations and

complementary nature of other tech-niques and the role of each technique inthe investigation of breast disease

- Knowledge and understanding of howbiopsy and interventional techniques in-fluence decisions and treatment planningby 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 boththe 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 ofother members of the Multi-Disciplinary Team

- Knowledge and understanding of how imag-ing findings influence decisions by others,e.g. surgeons, pathologists, oncologists, etc.

- Practical experienceThe trainee must obtain a substantial experiencein all clinical, imaging and interventional tech-niques that are listed above.

Minimum experience per month of training:- Interpretation of screening mammograms

300 cases- Interpretation of symptomatic cases in-

cluding ultrasound80 cases

- Experience of image-guided procedures20 cases



Cardiac Radiology1 – INTRODUCTION

This curriculum outlines the training requirements to pre-pare a radiologist for a career in which a significant pro-portion of his / her time will be devoted to cardiacradiology.

Trainees in radiology should have undergone training andeducation in cardiovascular / cardiac radiology prior tosubspecialty training and will therefore have already ob-tained basic skills.

It is expected that some trainees will wish to devote theentire subspecialty training period to cardiac radiologywith a view to devoting a large portion of their future ca-reer to this area. Other trainees may be more inclined tocombine elements of this training programme with anoth-er specialist area, such as vascular or thoracic radiologyover a two-year-period. This document outlines a frame-work for both full-time and modular approaches to trainingin cardiac radiology.

The aim of establishing a curriculum for subspecialtytraining in cardiac radiology is to ensure:- A detailed knowledge of current theoretical and

practical developments in the specialty- Extensive hands-on experience with graded su-

pervision- Clinical knowledge relevant to cardiology so that

the trainee may confidently discuss the appropri-ate imaging modality for the clinical problem withthe referring clinician

- A knowledge of the relevant embryological,anatomical, pathophysiological, biochemical andclinical aspects of cardiac disease

- An in-depth understanding of the major imagingmodalities relevant to cardiac disease

- Direct practical exposure – with appropriate gradedsupervision – in all forms of cardiac imaging


- UEMS-Training charter in diagnostic radiologyidentifies the core of knowledge required duringthe common trunk of radiology training. Basicskills in the cardiovascular system will thereforehave been acquired prior to sub-specialist train-ing.

- Clinical knowledge will be obtained by a variety ofmeans, including close liaison with the appropri-ate surgical and medical teams, e.g. by exposure

to combined clinico-radiological conferences.Thefollowing clinical interrelationships should be ex-plored:- Cardiology (adult and paediatric)- Cardiac surgery (adult and paediatric)- Cardiac pathology- Cardiac anaesthesia / critical care and emer-

gency medicine- In some instances, it may be appropriate for the

trainee to have a regular attachment to cardiacout-patient clinics / ward rounds / CCUs in orderto acquire further clinical knowledge relevant tothe subspecialty.

- Experience will be documented in logbooks. Ifadequate experience cannot be offered in onetraining scheme, it will be necessary for thetrainee to have a period of secondment at othertraining schemes with a large active practice inanother centre.

- The trainee should participate in clinical audit rel-evant to the subspecialty.

- The trainee should be encouraged and given theopportunity to attend appropriate meetings andcourses.

- The trainee should be involved in research andhave the opportunity to present in suitable na-tional and international meetings. The progres-sion of research projects to formal peer-reviewedpublication should be supported and encouragedby the supervising consultant(s).

- The trainee should be encouraged to participatein an on-call rota along with an appropriate back-up.

- The posts should be approved and recognisedfor training by the ESCR.

3 – GENERAL OVERVIEW

- The period spent in training will vary according towhether the trainee wishes to combine subspe-cialty training in cardiac radiology with anotherspecialist area (such as thoracic radiology), orwhether the trainee wishes to make cardiac radi-ology alone the prime focus.

- For trainees wishing to specialise primarily in car-diac radiology, a period of 12 months substantial-ly devoted (minimum of 8 sessions per week) tothe subject is recommended.

- For trainees wishing to specialise in cardiac radi-ology together with another area of interest, thetraining can be provided in a modular training



programme over two years.- The exact structure of the training programme

needs to be flexibly interpreted to allow for localfacilities and expertise. Rather than adopt a"number of investigations required" approach, itis suggested that centres wishing to offer trainingin cardiac radiology as either a major or minorsubspecialty option make available a fixed num-ber of sessions offering the requisite experience.An example schedule is given below (per week):- CXR film interpretation (1 session)- Echocardiography (1 session)- Cardiac CT and MRI (2 sessions)- Coronary angiography / left and right heart

catheterisations (1 session)- Nuclear cardiology (1 session)- Research (2 sessions).The remaining 2 sessions per week would beused to maintain experience in general radiologyaccording to local departmental service require-ments.It is stressed that the schedule above is intendedas an example only. Clearly the exact ratio oftraining in the different modalities of cardiac im-aging will need to reflect the individual interestsof the trainee, as well as the experience that canbe offered locally.

- In a situation where the interests of a trainee can-not be met entirely locally, it may be appropriateto negotiate a period of "external" training eitheras a block elective period or as an ongoing regu-lar day release.

- Regardless of the imaging modality concerned,the trainer or training committee must be satisfiedwith the trainee being able to consistently inter-pret the results of such investigations accuratelyand reliably. All studies should be reviewed in aformal reporting session. It is recognised that forsome modalities (such as cardiac ultrasound) su-pervision may be provided by non-consultantpersonnel, provided they are of sufficient seniori-ty and experience.

- The modalities listed and the time devoted toeach will be reviewed at intervals. It is recognisedthat some studies will become obsolete and newimaging techniques will be developed.

- The trainee should become familiar with provid-ing analgesia and / or sedation where required aswell as the necessary continuous monitoring re-quired to perform this safely.

- In view of the use of potentially hazardous tech-niques (e.g. angiography) and substances (e.g.adenosine, dobutamine, iodinated contrast

media), the trainee should be fully competent inbasic and advanced life-support. Regular "re-fresher" course training should be undertaken atleast on a yearly basis and formal ALS certifica-tion should be considered.

- The trainee should become aware of the localand national guidelines in obtaining informed pa-tient consent where appropriate.


- Basic Sciences- Basic cardiac and cardiovascular physiology- Cardiac and cardiovascular anatomy includ-

ing the heart great vessels, peripheral arterialtree and the pulmonary arteries

- Basic biochemistry related to cardiac diagno-sis and treatment

- Radiation physics and radiation protection asapplied to cardiac diagnosis

- Principles of radio-isotope imaging- Principles of cardiac gating and cardiac trig-

gering- Applied Sciences

- Basic cardiovascular pharmacology use andlimitations of commonly prescribed cardiacdrugs including cardiac stress agents.

- Applied pharmacology of contrast agents andradionuclide imaging agents

- Applied physiology of cardiac stress testing - Knowledge of normal cardiac parameters, in-

cluding the cardiac cycle, blood flow cardiacoutput, pressures, and flow-dynamics

- Clinical Sciences- Knowledge of ECG interpretation- Common cardiac pathology- Common cardiac disease presentations- Basic epidemiology of cardiovascular disease

- Current Clinical Practice- Knowledge of modern therapy rationale in-

cluding risk assessment - Basic knowledge of cardiac disease presen-

tation and non-imaging diagnostics- Age-based presentations of cardiac disease- Treatment of common cardiac conditions

- Cardiac Radiology Practice- Understanding of principles of each cardiac

imaging modality- Selection of appropriate imaging modality for

the patient´s condition, including risks andbenefits

- Limitations and advantages of each methodof cardiac imaging



- Management- Principles of managing a cardiac imaging

service- Purchase and selection of equipment

- Research- Methodology of research in cardiac imaging

and cardiology- Evidence base in cardiac imaging- Knowledge of statistical methods- Methodology of scientific writing and presen-

tation- Medico-legal

- Understanding of medico-legal issues relat-ing to cardiac radiology

- Understanding of uncertainty and error in car-diac imaging practice


- Plain Film Interpretation- Limitations, advantages and principles of

chest X-ray diagnosis of adult and congenitalcardiac disease

- CT Interpretation and patient management- CT anatomy of the heart, pulmonary arteries

and great vessels- Principles of spiral and ultrafast CT of the

heart including prospective and retrospectivegating

- Interpretation of cardiac and pulmonarypathology

- 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 relatedto MRI, including flow sequencing and spe-cialised tagging techniques

- Uses, limitations and hazards of MRI cardiacimaging

- Cardiac imaging by other modalities- Principles, uses and limitations of cardiac an-

giography catheterisation and pressuremeasurement

- Principles, uses and interpretation of stressand non-stress echocardiography, includingtransoesophageal echocardiography

- Principles, uses and limitations of nuclearcardiac imaging

- Principles of intravascular imaging- Stress testing

- Principles, uses and limitation of exercisestress testing

- Methods of stress testing as applied to car-diac imaging

- Patient management of stress testing for car-diac imaging

6 – APPRAISAL AND ASSESSMENT

At the end of the programme, the trainee should:

- Be able to supervise technical staff to ensure ap-propriate images are obtained;

- Discuss significant or unexpected radiologicalfindings with referring clinicians and know whento contact a clinician;

- Be able to recommend the most appropriate im-aging modality, appropriate to the patients´symptoms or pathology or request from the refer-ring clinician;

- Develop skills in forming protocols, monitoringand interpreting cardiac studies, appropriate topatient history and other clinical information;

- Demonstrate the ability to effectively present car-diac imaging in a conference setting.



Chest Radiology1 – INTRODUCTION

This curriculum outlines the subspecialty training require-ments for specialist training in thoracic radiology. This in-volves those aspects of radiology which provideinformation about anatomy, function, disease states andthose aspects of interventional radiology or minimally in-vasive therapy appertaining to the thorax.

The aim of subspecialised training in thoracic radiology isto enable the trainee to become clinically competent andto consistently interpret the results of thoracic investiga-tions accurately and reliably. Where appropriate, traineesalso need to be capable of providing a comprehensive andsafe interventional diagnostic and therapeutic service.

The aim of establishing a curriculum for subspecialtytraining in thoracic radiology is to ensure the trainee ac-quires:- Knowledge of the relevant embryological,

anatomical, pathophysiological and clinical as-pects of thoracic disease;

- An in-depth understanding of the major imagingtechniques relevant to thoracic disease;

- An in-depth understanding of the indications,contraindications and complications of surgical,medical and radiological interventions and proce-dures including radiation exposure issues andcontrast media;

- Clinical knowledge relevant to thoracic medicineand surgery such that the trainee may confident-ly discuss the appropriate imaging strategy forthe clinical problem with the referring clinician;

- Detailed knowledge of current technological andclinical developments in the specialty;

- Direct practical exposure with appropriate gradedsupervision of all forms of thoracic imaging andintervention;

- Competence in basic and advanced life-support.

The anticipated outcome at the end of subspecialty train-ing in thoracic radiology will be that the trainee can selectthe suitable imaging modality for thoracic problems, su-pervise (and perform where appropriate) the examinationand accurately report on the examination findings. Thetrainee should be competent in all aspects of thoracic im-aging and intervention.


The trainee undergoing subspecialty training should beactively involved in thoracic imaging within an educationalenvironment with graduated supervision.

Training must be undertaken in a team with access to ap-propriate CT, MR, ultrasound, fluoroscopy, and radionu-clide imaging facilities.

The trainee should be exposed to a clinical service involv-ing thoracic medicine, thoracic surgery, respiratory pathol-ogy, and a pulmonary function laboratory. An up-to-datedatabase of "interesting cases" or "teaching files" shouldbe present in the training department.

Additionally, the training department should have accessto interesting educational sites on the internet.

Trainees must also have access to a radiological library con-taining textbooks on thoracic radiology, thoracic medicine,thoracic surgery, pathology, and pulmonary physiology.


The trainee should acquire:- A comprehensive knowledge of normal respirato-

ry function and thoracic diseases, including:- The embryology, anatomy, normal variants

and pathophysiology relevant to cardiorespi-ratory function

- The pathology of benign and malignant con-ditions involving the thorax

- The epidemiology of lung diseases- The principles of population screening for

lung cancer and other lung diseases- The techniques used in thoracic surgery- The techniques involved in all imaging and in-

terventional procedures used in evaluatingand treating thoracic diseases, includingmanaging the complications of these proce-dures

- Local, national and, where appropriate, inter-national imaging guidelines relevant to tho-racic radiology

- Knowledge of the full range of radiological diag-nostic techniques available, in particular:- 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 agents



- Radiation dose reduction strategies, particu-larly for paediatric patients

- Particular emphasis should be placed on thestrengths and weaknesses of the different imag-ing methods in various conditions. The appropri-ate choice of imaging techniques and / or theappropriate sequence of imaging techniques inthe investigation of specific clinical problemsshould be emphasised.


- Specific skills to enable:- The conduct, supervision and accurate inter-

pretation of all imaging techniques used inthe investigation of thoracic diseases to aconsistent and high standard;

- The accurate localisation and, where appro-priate, biopsy of pulmonary, mediastinal,pleural and chest wall masses and lymphnodes;

- Where appropriate, the safe and effectivepractice of interventional techniques;

- Good communication with patients and pro-fessional colleagues;

- Accurate informed consent to be obtainedfrom patients;

- Continuing accreditation and maintenance oflife-support skills.

- A clear understanding of the purpose of multidis-ciplinary meetings, including their role in:- The planning of investigations, including the

selection of appropriate tests and imagingtechniques for the diagnosis of benign andmalignant disease;

- The staging of malignant disease;- The planning and outcomes of treatment;- The detection of errors in diagnosis and com-

plications of treatment.

- During the training period it is recommended thatthe trainees obtain experience in the following:- Plain radiography including:

- Primary care examinations- Post-operative (cardiac and thoracic sur-

gery) examinations- Intensive care and high-dependency unit

examinations- Thoracic trauma- Paediatric examinations

- Respiratory medicine out-patients exami-nations

- CT of the thorax including:- The staging of bronchial carcinoma- The investigation of

- Pleural lesions- Thoracic wall lesions- Pulmonary lesions- Mediastinal lesions

- Identification and categorisation of diffuseinterstitial lung disease

- Identification of large and small airwaysdisease

- CT pulmonary angiography

- MRI in thoracic imaging where applicable

- Radionuclide radiology including:- Ventilation / perfusion lung scintigraphy

(only)- PET and its application to lung cancer

staging

- Interventional techniques.Trainees should acquire experience in the fol-lowing procedures:- Biopsy of thoracic wall, pleural, pul-

monary and mediastinal lesions including:- CT-guided- Ultrasound-guided

- Other interventional procedures including:- Ultrasound-guided thoracocentesis- Chest drain insertion

- Optional interventional procedures:- Bronchoscopy- Airway stenting- Vascular (e.g. SVC) stenting- Thoracoscopy

- Clinical knowledge will be acquired by a variety ofmeans, including close liaison with appropriatemedical, surgical and oncological teams andcombined clinical and radiological meetings.Multidisciplinary cancer meetings should be animportant component. Inter-relationships with thefollowing disciplines are also important:- Thoracic medicine- Thoracic surgery- Respiratory pathology- Pulmonary physiology



- It may be useful for the trainee to have a regularattachment to thoracic out patient clinics, wardrounds and bronchoscopy / theatre sessions inorder to further clinical knowledge relevant to thesubspecialty.

- The trainee should be encouraged and given theopportunity to attend and lead appropriate clini-co-radiological and multidisciplinary meetings.The trainee should be encouraged to attend ap-propriate educational meetings and courses.

- The trainee should participate in relevant clinicalaudit, management and clinical governance andhave a good working knowledge of local and na-tional guidelines in relation to radiological prac-tice.

- Trainees will be expected to be familiar with cur-rent thoracic radiology literature. The traineeshould be encouraged to participate in researchand to pursue one or more project(s) up to andincluding publication. An understanding of theprinciples and techniques used in research, in-cluding the value of clinical trials and basic bio-statistics, should be acquired. Presentation ofresearch and audit results at national and inter-national meetings should be encouraged.


- Regular appraisal of the trainee is mandatoryand the consultant trainer must be satisfied thatthe trainee is clinically competent, as determinedby an in-training performance assessment, andcan consistently interpret the results of investiga-tions accurately and reliably.

- Methods of trainee assessment include:- Regular direct observation of clinical tech-

niques (including communication skills, abilityto obtain informed consent and sedationskills) by the trainer and / or external observ-er;

- Regular formal review of the trainee’s skills inthe accurate interpretation of investigationsfor thoracic diseases;

- A final assessment of overall professionalcompetence.

Gastrointestinal andAbdominal Radiology1 – INTRODUCTION

The subspecialty training programme in gastrointestinaland abdominal imaging further extends the knowledgeacquired during the common trunk and is dedicated totrain radiologists with strong devotion to spend majorparts of their professional activity in close cooperationwith clinicians practicing gastroenterology and abdominalsurgery. The ideal framework is supposed to be a largeclinical centre with wide experience in gastroenterology,abdominal surgery, oncology, diagnostic and intervention-al radiology, possessing imaging modalities necessary toperform state-of-the-art gastrointestinal and abdominalradiology. The principles of evaluation of a resident’sknowledge, skills and overall performance, including thedevelopment of professional attitudes, are tailored to fitthe general evaluation system and standards of othersubspecialties.


During the training in the subspecialty of gastrointestinaland abdominal radiology, the resident should haveachieved the following knowledge-based objectives:

- Anatomy and Physiology- Detailed anatomic knowledge of the sections

of the gastrointestinal tract, the diaphragm,the abdominal wall, the pelvic floor, the peri-toneal cavity, the liver, spleen, biliary tract andpancreas using plain films, fluoroscopy, bari-um / gastrografin studies, sonography, CT,and MRI

- To know the arterial supply and venousdrainage of the various portions of the gas-trointestinal tract; to explain the possible vari-ations of flow in the superior mesentericartery and vein and the portal and hepaticveins

- To know the lymphatic drainage of the rele-vant organs

- To know the important variants of anatomy - To have a basic understanding of physiology

of the gastrointestinal tract and the abdominalorgans

- Oesophagus- To identify oesophageal perforation on plain

films, contrast studies, and CT - To identify mega-oesophagus, diverticulum,



extrinsic compression, fistulae, sliding andpara-oesophageal hiatus hernia, benign stric-tures, varices, oesophagitis and oesophagealcancer on a contrast examination and / or CT;to analyse the criteria for non-resectabilityand lymph node involvement in oesophagealcancer on CT; to know the TNM staging of oe-sophageal cancer and the potential role ofPET-CT in this setting

- To understand the basic surgical techniquesin oesophageal surgery / radiation therapyand identify post-surgical / post-radiationtherapy appearances on imaging examina-tions

- Stomach and Duodenum- To define the most appropriate imaging ex-

amination and contrast use in suspected per-foration of the stomach and postoperativefollow-up; to name the limitations of each ex-amination for these specific conditions

- To understand the imaging features (on bari-um studies and CT) of a variety of conditions,such as benign and malignant tumours, in-cluding GIST, infiltrative disorders (e.g. linitisplastica), gastric ulcers, duodenal diverticu-lum, and positional abnormalities includinggastric volvulus

- To perform a CT examination of the stomach /duodenum, using the most appropriate proto-col according to the clinical problem, andstage carcinoma and lymphoma on CT; toknow the potential role of PET-CT in nodalstaging

- Small Bowel- To determine the most appropriate imaging

examination in the following cases: smallbowel obstruction, inflammatory disease,small bowel perforation and ischaemia, can-cer, lymphoma, carcinoid tumour and post-operative follow-up; to name the limitations ofeach examination for these specific cases

- To know the features of small bowel diseaseson small bowel series, including stenosis, foldthickening, nodules, ulcerations, marked an-gulation, extrinsic compression, diverticula,and fistula

- To identify on a small bowel series the follow-ing diseases: adenocarcinoma, polyposis,lymphoma, carcinoid tumour, GIST, Crohn’sdisease, radiation-induced injury, malrotation,Meckel’s diverticulum, diverticulosis, lym-

phoid hyperplasia of the terminal ileum, andthe most common mid gut abnormalities(malrotation, internal hernia)

- To perform a CT examination of the smallbowel, including CT enteroclysis. Identify atransitional zone in case of small bowel ob-struction; to identify a small bowel tumour(adenocarcinoma, lymphoma, carcinoid tu-mour, stromal tumour); to identify mural pneu-matosis, vascular engorgement, increaseddensity of the mesenteric fat, duplicationcysts and malrotation; to know the potentialrole of MRI in examining the small bowel.

- To determine the cause of small bowel ob-struction on CT (adhesion, band, strangula-tion, intussusception, volvulus, internal andexternal hernias) and their complications; toidentify criteria for emergency surgery

- Colon and Rectum- To determine the optimal imaging examina-

tion to study the colon according to the sus-pected disease (obstruction, volvulus,diverticulitis, tumour (including lymphomaand carcinoid), inflammatory disease, perfo-ration, postoperative evaluation) and knowthe limitations of each technique

- To know the indications of virtual CT / MRIcolonoscopy

- To identify rotational abnormalities of thecolon on contrast studies and CT

- To identify the normal appendix on CT andsonography; to know the various features ofappendicitis on CT and sonography

- To know the different features of colon tu-mours, including GIST, diverticulitis, inflam-matory diseases, colon ischaemia, andradiation-induced colitis

- To identify a megacolon, colonic diverticulosisand diverticulitis, colitis, colonic fistula, carci-noma, polyps, and postoperative stenosis onan enema

- To identify colonic diverticulosis, diverticulitis,tumour stenosis, ileocolic intussusception,colonic fistula, paracolic abscess, intra-peri-toneal fluid collection, colonic pneumatosis,and pneumo-peritoneum on CT

- To know the CT features of colo-rectal cancerand identify criteria for local extent (enlargedlymph nodes, peritoneal carcinomatosis, he-patic metastases, and obstruction); to knowthe TNM classification of colo-rectal cancerand the potential role of PET-CT; to under-



stand the most frequent operative techniquesthat may be used to treat colo-rectal cancer

- To identify tumour recurrence after surgery; toknow the criteria that may help in differentiat-ing between postoperative fibrosis and tu-mour recurrence; to know the potential role ofPET-CT

- To know the MRI appearance of pelvic / peri-anal fistula and abscesses as well as the in-creased risk of anal carcinoma in Crohn’sdisease with long standing perianal complica-tions

- Peritoneum and abdominal wall- To identify the various types of abdominal

wall hernias (inguinal, umbilical, parastomal,postoperative) on a CT scan

- To identify a mesenteric tumour and to deter-mine its location on CT

- To know the features of a mesenteric cyst onCT

- To recognise the features of mesenteric pan-niculitis and sclerosing mesenteritis

- To know the normal features of the peri-toneum on sonography and CT; to identify thefollowing peritoneal diseases on CT: peri-toneal carcinomatosis, peritoneal tuberculo-sis and mesenteric lymphoma

- To identify ascites on sonography and CT; toknow the features of loculated ascites

- Vessels- To identify small bowel infarct on CT - To perform and interpret an angiographic

study of the mesenteric vessels and identifyocclusion and stenosis of the superiormesenteric artery

- Liver- To localise a focal liver lesion according to

liver segmentation and major vessels anato-my (hepatic and portal vein, IVC).

- To describe the appearance of typical biliarycyst on sonography, CT and MRI

- To describe the appearance of Hydatid cysts - To list the differences between amoebic ab-

scess and pyogenic abscess of the liver (ap-pearance, evolution, treatment, indication fordrainage).

- To describe the most common surgical proce-dures for hepatectomy

- To know the appearance of liver haeman-gioma on US, CT, and MRI, including typical

cases and giant haemangioma; to discuss theindications for CT or MRI as an adjunct to US

- To describe the usual appearance of focalnodular hyperplasia and liver cell adenomaon sonography, including Doppler US, con-trast sonography, CT and MRI

- To know the appearance of fatty liver, bothhomogenous and heterogeneous, on sonog-raphy, CT and MRI (including in- / out-of-phase imaging and fat suppression images).

- To describe the appearance of iron overload,causes and quantitation with MRI

- To describe the natural history of hepatocellu-lar carcinoma (HCC), major techniques andindications for treatment (surgical resection,chemotherapy, chemoembolisation, percuta-neous ablation, liver transplantation).

- To describe the appearance of HCC onsonography (including Doppler and contrastenhanced sonography), CT and MRI

- To describe the usual appearance of livermetastases on sonography (includingDoppler), CT and MRI

- To describe the most common morphologicchanges associated with liver cirrhosis: lobaratrophy or hypertrophy, regeneration nodules,fibrosis; to know the main causes for liver cir-rhosis

- Biliary Tract- To know the imaging methods for the detec-

tion of gall bladder and common bile ductstones

- To know the common appearance of acutecholecystitis (including emphysematouscholecystitis) on sonography, includingDoppler, CT and MRI

- To list the main causes for gallbladder wallthickening

- To describe the appearance of gallbladdercancer on sonography, CT and MRI

- To know the appearance of cholangiocarcino-ma of the liver hilum (Klatskin tumour) andknow how to stage it

- To know the appearance of ampullar carcino-ma on sonography, CT and MRI, and list dif-ferential diagnoses

- To describe the common appearance of scle-rosing cholangitis on sonography, CT andMRI, including MRCP; to know the naturalhistory of associated cholangiocarcinoma

- To know the main congenital disorders of thebile ducts: Caroli disease, choledochal cyst



(and the risk of cholangiocarcinoma).- To describe the main techniques for surgery

of the bile duct and common complications

- Pancreas- To know the natural history of acute and

chronic pancreatitis - To identify pancreatic calcifications on plain

films, sonography and CT - To know the common appearance of extra-

pancreatic fluid collection and phlegmons incase of acute pancreatitis

- To know the ductal changes in chronic pan-creatitis with MRI and secretine

- To detect a pancreatic pseudocyst - To know the most common appearance

(nodular, infiltrating) of pancreatic adenocar-cinoma on sonography, CT and MRI, and per-form staging in order to choose a treatment

- To know the features of endocrine tumours - To describe the usual appearance of cystic

tumours of the pancreas, mainly serous andmucinous cystadenoma, intraductal muci-nous tumour and rare cystic tumours

- To describe the main techniques for pancre-atic surgery and potential complications

- Spleen- To know the appearance of accessory spleen

and splenosis on sonography, CT and MRI - To name common causes of splenomegaly

(e.g. lymphoma, portal hypertension, orhaematological disorders)

- To identify splenic infarction on sonography,CT and MRI

- To know common causes of focal splenic le-sions (cyst, hydatid cyst, metastasis, lym-phoma, abscess, haemangioma)

- Trauma- To know the CT technique for trauma patients - To identify abdominal hematoma, active

bleeding, parenchymal laceration and trau-matic lesions of the gastrointestinal tract; toknow the limitations of CT to identify gastroin-testinal tract lesions

- To know which conditions require immediateembolisation or surgery

(Links for reference cases to be sampled in EURORADwill be provided later.)


By the end of the fifth year, the resident should have ac-quired the following skills:- General Requirements

- To know the indications and contra-indica-tions of the various imaging examinations inabdominal imaging

- To indicate to the referring physician the mostappropriate imaging examination accordingto the clinical problem

- To determine the best contrast material andits optimal use according to the imaging tech-nique and the clinical problem

- To tailor the examination protocol to theclinical question

- To supervise technical staff to ensure appro-priate images are obtained

- To evaluate the quality of the imaging exami-nations in abdominal imaging

- To know the relative cost of the various imag-ing examinations in abdominal imaging

- To understand the radiation exposure andrisks of different investigations

- Specific Requirements

Plain Abdominal Film- To describe patient positioning and know the

three basic indications for a plain radiograph - To understand the clinical indications for ob-

taining plain radiographs and when furtherviews or a CT or MRI may be necessary

- To diagnose pneumoperitoneum, mechanicalobstruction and pseudo obstruction, toxic di-latation of the colon, gas in small and largebowel wall indicating ischaemia and necrosis,pancreatic and biliary calcifications and aerobilia

Upper Gastrointestinal Tract X-ray Examination- To perform and interpret both single and dou-

ble contrast X-ray examination of the uppergastrointestinal tract and to determine themost appropriate contrast material; to under-stand the principles and limitations of thesestudies, their advantages and disadvantagescompared to endoscopy

- To perform and interpret small bowel follow-through and enteroclysis, including catheterplacement beyond the ligament of Treitz; toappreciate the importance and degree of fill-ing and distension of small bowel loops



Lower Gastrointestinal Tract X-ray Examination- To perform and interpret a double contrast

barium enema and a single contrast enema - To know how to catheterise a stoma for colon

opacification and how to perform pou-chograms and loopograms

- To know the indications and contraindicationsfor enema techniques and determine the opti-mal contrast material and technique to beused in each clinical situation

- To perform and interpret defecography (withX-ray and MRI)

Sonography- To perform an ultrasound examination of the

liver, gall bladder, biliary tree, pancreas,spleen, and the gastrointestinal tract

- To recognise the retroperitoneal structuresand understand the application and limita-tions of sonography in this area

- To know the indications and contraindicationsof contrast agents

Computed Tomography- To perform a CT examination of the abdomen

and to tailor the protocol to the specific organor clinical situation to be studied; to determinewhether intravenous administration of a con-trast material is needed; to determine the op-timal protocol for the injection of contrast (rateof injection, dose, delay); to know the variousphases (plain, arterial-dominant, portal-domi-nant, late phase) and their respective valuesaccording to the clinical problem

- To determine the best contrast material forimaging a specific gastrointestinal segmentaccording to the clinical problem (water, air,fat, iodine or barium containing contrast ma-terials)

- To have experience in the use of workstationsfor multiplanar reconstructions (MPR) and 3Dreconstruction based around volume datasets

- To perform and be able to interpret CTcolonoscopy

Magnetic Resonance Imaging- To perform MRI of the liver, the biliary tract

(including MRCP), pancreas, and the spleen - To know the various contrast materials that

can be used for MRI of the liver and their indi-vidual uses

- To perform MRI of the gastrointestinal tract

- To have experience in the use of workstationsfor multiplanar reconstructions (MPR) and 3Dreconstruction based around volume datasets

Interventional Imaging- To perform percutaneous drainage of abdom-

inal collections using CT and sonography - To perform percutaneous biopsy of the liver

and other organs under sonographic and CTguidance

- To perform angiography of the abdominal ar-teries

- To perform selective embolisation of the ab-dominal arteries in hemorrhage and treat-ment of tumours

- To perform percutaneous gastrostomy underimage guidance

- To perform percutaneous biliary intervention - To perform radiologically guided stenting of

the biliary system and gastrointestinal sys-tem, using PTFE and expandable metalstents

- To know indications and contraindications ofcommon interventions in gastrointestinal andabdominal radiology

Endoscopy and endoscopic ultrasound (optional)- To perform endoscopic evaluation of gastroin-

testinal tract - To perform and interpret endoscopic ultra-

sound examination of the oesophagus, pan-creas, biliary tract, and rectum

- Communication and Decision-Making Skills- To justify and explain the indication and the

examination conduct to the patient - To obtain fully informed consent - To inform the patient of the results of the ex-

amination and evaluate the patient’s under-standing

- To make a precise and concise description ofthe imaging signs present; to answer the clin-ical problem and make a conclusion accord-ingly; to suggest additional imagingexaminations when needed, using appropri-ate justification; to decide when it is appropri-ate to obtain help from supervisory faculty ininterpreting imaging findings; to code the find-ings of examinations

- To maintain good working relationships withreferring clinicians; to discuss significant orunexpected radiologic findings with referring



clinicians and know when to contact a clini-cian; to effectively present imaging findings ina conference setting

- To correlate pathologic and clinical data withimaging findings

- Conferences

As part of the curriculum in abdominal radiology, thetrainee should attend in-house teaching sessions for radi-ologists as well as clinical conferences with colleaguesfrom other specialties. The latter type of conferenceshould be included to facilitate the radiology residents’ un-derstanding of the use of imaging and clinical circum-stances in which imaging is requested.

The following list gives examples of the types of confer-ences that should be considered part of the curriculum:

- Abdominal radiology resident-specific teach-ing conference

- 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 inthe curriculum of abdominal radiology. One of these books(titles) serves as "bench book", i.e. it is valid for all trainingprogrammes across Europe and aims at unification andstandardisation of radiology training in Europe. It is veryimportant that "bench books" be available in the radiologydepartment and the library of each institution.

1. Gore RM, Levine MS. Textbook ofGastrointestinal Radiology (2nd Edition). WBSaunders, Philadelphia, 2000.

2. Eisenberg RL. Gastrointestinal Radiology – APattern 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. Ekbergand B. Marincek, a subsection will be devoted to curricularcases. These model cases correspond to the knowledge-based objectives and allow a resident to see and study

abnormalities, even if they are not seen in a resident’s im-mediate training environment.


In gastrointestinal and abdominal radiology, as in all otherparts of radiology training, each trainee should be individ-ually appraised on an annual basis. The purpose of ap-praisal is to assess the progress of the resident over thepast year and to anticipate and correct any deficiencies intraining at an early stage. In addition, for those residentsrotating through a specialised abdominal radiology sec-tion / department, the attachment should commence andfinish with a meeting with the senior trainer in that section/ department. The purpose of the first meeting is to estab-lish goals for the attachment and the second meeting tosee whether the goals have been achieved. Logbooks canbe used for documenting the skills and experience ob-tained. Logbooks are mandatory for all interventional pro-cedures, irrespective of subspecialty.



Head and Neck Radiology1– INTRODUCTION

Head and neck radiology is a subspecialty of Radiology.Because of the complex anatomy and the very diversepathology, specialty training in head and neck radiologymay be considered to be complex and demanding.

Head and neck radiology comprises diagnostic imagingby all techniques of conditions involving the petrous bone,skull base and cranial nerves, orbit, nasopharynx and si-nuses, oral cavity, the oro- and hypopharynx, larynx, sali-vary glands, facial skeleton including the teeth, mandibleand temporomandibular joints, deep spaces of the faceand neck, thoracic inlet, brachial plexus, and thyroidgland.

More detailed explanatory notes on this curriculum maybe obtained by application to the European Society ofHead and Neck Radiology.


Before undertaking this curriculum, radiologists in trainingwill have completed the curriculum for general trainingand will have acquired a thorough knowledge of the phys-ical principles of the different imaging methods, the con-tra-indications and complications of different imagingtechniques, and the effects and side-effects of contrastmedia. In addition, they will be familiar with imaging topicsspecific for the head and neck, including:

- Positioning / views of the face, temporal bone,and mandible

- The principles of radiation protection in thehead and neck, as well as of justification ofreferrals

- Mean exposure doses at skin entrance, lensand thyroid gland for conventional radiogra-phy, sialography, dacryocystography, and CT

- Digital imaging and image processing perti-nent to head and neck radiology

- Multislice CT, 2D and 3D reconstructions andvirtual endoscopy techniques

- MRI sequences commonly used in head andneck imaging

During the subspecialty training period, the trainee mustspend most of his / her time in this field. They should ac-quire an in-depth knowledge of radiological manifesta-tions of disease and should also be acquainted with theclinical and pathologic presentation. They should have a

basic understanding of clinical tests which are prerequi-site for imaging (e.g. endoscopy, audiometry) and shouldacquire extensive experience in all the diagnostic modali-ties listed below and in non- angiographic interventionalprocedures.

- The trainee should be familiar with clinical termi-nology so as to communicate without difficulty.They should attend weekly multidisciplinarymeetings to obtain thorough understanding ofhow patients are treated as well as the role of ra-diology in treatment planning.The following list gives examples of the types ofconferences that should be considered part ofthe head and neck curriculum. Some of theseconferences may be run by the RadiologyDepartment, others may be run by other depart-ments or multidisciplinary programmes. It is rec-ommended that the latter type of conference beincluded to facilitate the trainee's understandingof the use of imaging and clinical circumstancesin which imaging is requested:- Radiology resident / fellow-specific head and

neck teaching conference- An appropriate proportion of radiology grand

rounds devoted to head and neck radiology- Multidisciplinary head and neck tumour board- Multidisciplinary dysphagia conference- Radiologic-pathologic correlation rounds - Maxillofacial surgery conference- Emergency radiology conference

The trainee should have at least 30 hours of formal teach-ing at his / her institution during these two years. In addi-tion, during these two years, the trainee should attend atleast two annual meetings of the ESHNR or ASHNR orother specialised meetings where head and neck radiolo-gy plays a major role.

They should be familiar with the current literature on headand neck radiology, both from standard books and originalarticles. They should be encouraged to participate in re-search projects to acquire knowledge of the design, exe-cution, and analysis of scientific projects. They should beencouraged to present papers at international congressesand meet others involved in the field of head and neck ra-diology to exchange ideas and experiences.


At the end of the training period, the trainee should haveachieved the knowledge-based objectives listed below.Reasonable continuous progression is to be expected



during the training period, bearing in mind that training in-stitutions organise their training in different ways.

- Normal Morphology and FunctionThe trainee will have a sound knowledge of the anatomicregions listed below, including their correct terminology,inter-relationships and appearance on the full range ofimaging used in head and neck radiology:

- The petrous bone and contents - The skull base and cranial nerves- The orbit and visual pathways- The sinuses- The nasopharynx, oropharynx and hypopharynx- The oral cavity- The larynx- The neck and vasculature- The salivary glands- The facial skeleton including the teeth, the

mandible and temporomandibular joints- The deep spaces of the face and neck - The thoracic inlet and the brachial plexus - The thyroid gland and the parathyroid glands

- PathologyThe trainee will have a sound knowledge of the followingdiseases affecting the head and neck, including theirpresentation, natural history, diagnostic criteria and post-therapeutic findings, including complications of therapy:

- Temporal bone- Transmission deafness- Perception deafness- Embryology and congenital anomalies of

the outer ear and middle ear - Temporal bone inflammatory disease- Temporal bone fractures - Otospongiosis and dysplasias of the tem-

poral bone - Tumours of the temporal bone and cere-

bello-pontine angle, tumours involving thefacial nerve, bone tumours of the tempo-ral bone, metastases, lymphoma, and en-dolymphatic sac tumours

- Vascular tinnitus

- The skull base and cranial nerves- Embryology, congenital and developmen-

tal anomalies of the skull base - Inflammatory conditions - Tumours and tumour-like conditions, in-

cluding those arising from bone,meninges, nerves, or vessels

- Secondary tumour involvement of theskull base, particularly direct invasion,

perineural spread and hematogenousmetastasis; to be able to recognise themon CT / MRI

- Trauma and resulting complications - Dysplasias - Cerebrospinal fluid leaks and rhizotomy

injections - Pathologic conditions involving the cranial

nerves and their nuclei

- Orbit and visual pathways- Ocular pathology, including congenital,

traumatic, vascular and neoplastic le-sions.

- Orbital pathology, including developmen-tal abnormalities, inflammatory diseases,autoimmune disorders, tumours and tu-mour-like conditions, vascular malforma-tions, neural tumours, and lacrimal glandlesions

- Pathology of the lacrimal apparatus - Pathology of the visual apparatus

- The sinuses- Anatomical variations and congenital

anomalies of the paranasal sinuses- Inflammatory conditions and orbital com-

plications of sinusitis, mucoceles, cysts,and polyps

- Tumours and tumour-like conditions - Common endoscopic techniques and

their relevance to imaging and presenceof disease

- The pharynx- Pathologic conditions of the nasopharynx,

particularly benign mucosal lesions, in-flammatory conditions, tumours such asnasopharyngeal carcinoma, lymphoma,minor salivary gland tumours, schwanno-mas and traumatic conditions

- Pathologic conditions of the oropharynx,including functional disorders of degluti-tion, inflammatory conditions, tumourssuch as oropharyngeal carcinoma, lym-phoma, minor salivary gland tumours,schwannomas, rhabdomyosarcomas, andtraumatic conditions

- Pathologic conditions of the hypopharynx,particularly non-neoplastic conditions,such as diverticula, functional disorders ofdeglutition and extrinsic lesions, inflam-matory conditions, tumours such as hy-



popharyngeal, lymphoma, minor salivarygland tumours, schwannomas, lipomasand other tumours and traumatic condi-tions

- Congenital malformations of the pharynx,particularly branchial cleft cysts and si-nuses, teratoma, and heterotopic pharyn-geal brain

- The oral cavity- Pathologic conditions of the oral cavity, in-

cluding functional disorders of the tongue,congenital anomalies, vascular lesions,dermoid cysts, thyroglossal duct cysts, lin-gual thyroid, infectious and inflammatorylesions such as Ludwig's angina, ranula,benign tumours, nerve sheath tumours,malignant tumours such as carcinoma,lymphoma, adenoid cystic carcinoma,rhabdomyosarcoma, denervation muscleatrophy, macroglossia and benign masse-teric hypertrophy, and traumatic condi-tions

- The larynx- Pathologic conditions of the larynx, in-

cluding functional disorders of the larynx,congenital anomalies, webs and atresia,inflammatory lesions, including rheuma-toid and collagen vascular disease, be-nign tumours such as lipoma,rhabdomyoma, nerve sheath tumours,pleomorphic adenoma, malignant tu-mours such as carcinoma, chondrosarco-ma, lymphoma, adenoid cysticcarcinoma, and traumatic conditions

- The neck- Congenital lesions, in particular cystic le-

sions, thyroid anomalies, malformationsof the lymphatic system, and classificationof lymphangiomas

- Lymph node disease including clinical sig-nificance, metastatic disease includingimaging criteria of disease, extranodal tu-mour spread and arterial invasion, lym-phomas, tuberculosis, nodal calcificationsand their significance

- Inflammatory and infectious conditions,including abscess, myositis, necrotisingfasciitis, and suppurative adenopathy

- Non-nodal masses of the neck includingangiomas, nerve sheath tumours and

paragangliomas, lipomas, and cystic le-sions

- Vascular pathologies of the internal jugu-lar vein and carotid artery

- The salivary glands- Inflammatory disorders, in particular in-

fection, sialolithias, chronic recurrentsialadenitis, autoimmune diseases, sialo-sis, and infectious disorders

- Cystic lesions - tumours particularly pleomorphic adeno-

ma, Warthin's tumour, adenoid cystic car-cinoma, mucoepidermoid carcinoma,metastases, lymphoma, lipoma, neuro-genic tumours

- Vascular malformations, particularly lym-phangioma and hemangioma

- Periglandular lesions, such as masseterichypertrophy

- The facial skeleton including the teeth, themandible, and temporomandibular joints- Congenital lesions of the midface, includ-

ing midline cleft lip and defects and inclu-sion disease, cephaloceles, andpremature cranial synostosis

- Pathologic conditions of the mandible, in-cluding cysts, odontogenic tumours, non-odontogenic tumours, vascular lesions,neurogenic lesions, malignant tumours,and dental inflammatory lesions

- Pathologic conditions of the temporo-mandibular joint, including disk, os-teoarthritis, avascular necrosis,osteoarthritis dissecans, tumours of theTMJ, trauma and congenital anomalies

- The deep spaces of the face and neck- Common pathologic conditions involving

the different spaces of the supra- and in-frahyoid neck, in particular the masticatorspace, parapharyngeal space, retropha-ryngeal space, carotid space and periver-tebral space, and the role of diseaselocation in determining differential diagno-sis

- The thoracic inlet and the brachial plexus - Pathologic conditions of the thoracic inlet

and brachial plexus, particularly traumaticconditions such as avulsion, elongation,compression by hematoma or callus, tho-



racic outlet syndrome, schwannoma, su-perior sulcus carcinoma, lymphoma,adenopathies, and metastasis

- The thyroid gland and the parathyroid glands- Congenital lesions including thyroglossal

duct cyst, lingual thyroid gland - Inflammatory lesions, including thyroiditis- benign thyroid masses - Malignancies of the thyroid gland - Metabolic diseases of the thyroid gland- Pathologic conditions of the parathyroid

glands, in particular hyperparathyroidism,adenoma, carcinoma, cysts, and hy-poparathyroidism

4 – THEORETICAL, COMMUNICATION AND DECISION-MAKING SKILLS

The aim of the head and neck radiology subspecialtytraining curriculum is to prepare the radiologist for activityto which he / she will dedicate a substantial amount oftime. Specific skills training should include the following:

- The ability to act as a consultant in regularmultidisciplinary meetings

- Knowledge of the indications and contraindi-cations of diagnostic procedures in the areaof the head and neck

- The ability to instruct clinical colleaguesabout major changes in diagnostic proce-dures, thereby preventing unnecessary ex-aminations

- A thorough knowledge of the current litera-ture

- The ability to transmit this specific knowledgeto colleagues in general radiology and to edu-cate radiologists in speciality training in headand neck radiology

At the end of the training period, the trainee should haveachieved the technical, communication and decision-making skills listed below. Reasonable continuous pro-gression is to be expected during the training, bearing inmind that institutions organise their rotations differently.

- Patient Information- To be able to inform the patient in detail about

the diagnostic procedure and obtain informedconsent where relevant

- To be able to explain to the patient how to co-operate during the examination

- Clinical Background

- To have a thorough knowledge of the patholo-gy investigated so as to tailor the examination

- To have a basic understanding of clinical testswhich have been performed prior to imaging(e.g. endoscopy, audiometry)

- Communication skills- To be able to produce accurate, informative

and clinical "effective reports", explaining im-aging findings in a clinical context

- To be able to advise referrers on the appropri-ate use of imaging studies

- To be able to present head and neck exami-nations effectively in a conference setting

- To be able to recognise when significant orunexpected radiological findings should becommunicated urgently to the referrer

- Technique - To be able to supervise technical staff to en-

sure quality control- To be able to justify, conduct and interpret the

imaging studies listed below, with particularattention to the features listed below:

US (B mode, Doppler, FNP)- Choice of probe- Examination of the major salivary glands,

thyroid gland, and neck- Doppler examination of the major salivary

glands, thyroid gland, and neck

Barium swallow for deglutition disorders- Choice of contrast media- Standard examination for the oral phase,

pharyngeal phase, and oesophagealphase

- How to document the examination: videoalone, video and spot images

- When to tailor the examination and limit itto a minimum so as to answer the clinicalrelevant questions

- How to alter the consistency of the bolusand test its influence on deglutition

- How to test various deglutition manoeu-vres

CT (diagnostic, angiography, and FNP):- Radiation dose, technical parameters,

and image quality - Acquisition and reconstruction parame-

ters - Post-processing techniques



- Appropriate use of contrast media- Indications to extend the CT examination

to other body areas

MRI (diagnostic and angiography)- Choice of coil- Identification of imaging volume- Appropriate use of contrast media- Technical parameters for acquisition, re-

construction, and post-processing evalua-tion

- MR angiography- MR sialography

Conventional Radiographs- How to avoid artifacts- How to alter parameters to obtain ade-

quate quality

Sialography- How to interpret the images and judge the

quality of the examination

Dacryocystography- Choice of instruments and contrast

media, and interpretation

Guided biopsy- In relation to the thyroid or cervical nodes

and other masses- Choice of guidance method, US, CT, or

MRI- Choice of biopsy instrument - Appropriate care of the specimen- Complications and after-care


Assessment of the progress of the trainee should be con-sistent with national requirements. The performance ofthe trainee should be appraised at least on annual basis.A logbook account of experience may be helpful in evalu-ating the trainee’s progress. The trainee’s progress shouldbe reviewed by consultant trainers with particular atten-tion to practical skills in conducting examinations, efficacyof clinical requesting, and growth of knowledge.

The European Society of Head and Neck Radiology mayoffer a diploma of subspecialty expertise to trainees whohave completed this programme, the latter being subjectto other conditions specified by the Society.

Interventional Radiology1 – INTRODUCTION

- Interventional radiology includes all image-guid-ed therapeutic procedures. These procedureshave an important role in clinical management.Although invasive, they are associated with verylow morbidity and mortality rates and offer im-proved outcomes compared with similar proce-dures performed without image guidance. Asimage interpretation is an essential skill in theirperformance, such procedures are best per-formed by radiologists trained in diagnostic imag-ing.

- Procedures that may lead to further image-guid-ed therapy, e.g. PTA or biliary stenting, should becarried out by appropriately trained intervention-ists, as they will be the ones to perform such ther-apy. These procedures replace surgery and carrymorbidity and mortality rates, which, althoughless than surgery, are greater than other invasiveradiological procedures such as biopsy or simpledrainage. Drainage procedures in the urinarytract, gastrointestinal tract or hepatobiliary sys-tem fall into this category and therefore should beperformed by those who have received specialtraining in interventional radiology. Complex vas-cular procedures, whether diagnostic or thera-peutic, should be performed by those trained ininterventional radiology (IR) for similar reasons.Interventional procedures requiring a substantialclinical commitment, such as vertebroplasty andthermal ablation of tumours, should be performedby radiologists acting as the primary clinicians re-sponsible for the medical care of the patient.

- The principles are:

- All diagnostic radiologists should be able toperform image-guided biopsy and abscess orfluid drainage.

- Invasive procedures that may progress tocomplex therapeutic radiological proceduresshould be performed by those trained in inter-ventional radiology.

- Individual interventional radiologists may notperform the whole range of procedures (justas diagnostic radiologists do not performevery type of diagnostic procedure), but theywill have undergone basic training in vascularand non-vascular interventional radiology,



which will allow them to provide an out-of-hours service.

- The aim of subspecialised training is to preparethe radiologist for a career in which he / she de-votes a substantial portion of his / her time to in-terventional radiology. Such individuals will beexpected not only to carry out interventional pro-cedures but also to discuss medical manage-ment with referring clinicians. A strong clinicalbackground is essential to the fulfilment of thisrole. It is essential that interventional radiologytraining follow general radiological training andthat interventional radiologists have a goodgrounding in the diagnostic radiology of theorgan systems in which they carry out therapeu-tic procedures.


- Training must be undertaken in (a) hospital(s)with clinical departments of vascular surgery,cardiology, and preferably cardiac surgery.Emergency and intensive care units as well asdepartments related to the fields in which inter-ventional techniques are carried out are clearlymandatory as well.

- Initially, when subspecialised interventional train-ing is introduced, a radiologist eligible for fullCIRSE fellowship should supervise it. In the fu-ture, there may be certified subspecialists in in-terventional radiology who may supervisetraining.

- The training department(s) must have a full rangeof diagnostic equipment, including CT, MRI,colour Doppler ultrasound, angiography, andother interventional radiology equipment. Theremust be adequate monitoring and access toanaesthetic skills when required. There must beaccess to a radiological library containing e-learning facilities, textbooks, and the most impor-tant journals.

3 – OVERVIEW

- The training period will be equivalent to two yearsof full-time practice.

- It is essential that interventional radiology traininginitially follow general radiological training andthat interventional radiologists have a goodgrounding in the diagnostic radiology of the

organ systems in which they carry out therapeu-tic procedures.

- Trainees should develop their IR skills by workingwithin the IR team under direct supervision, butshould also have performed sufficient numbers ofprocedures as first operator, both electively andon call, so as to be competent when taking up anIR post at the end of the training period.

- They should acquire a detailed knowledge of se-dation and analgesia techniques.

- They should acquire a detailed knowledge of thepathological and clinical basis of the specialty.

- Trainees must attend regular clinico-radiologicalconferences (at least weekly).

- Trainees should take part in outpatient clinics andward work in order to develop clinical skills.

- Trainees will be expected to be familiar with thecurrent subspecialised literature, both from stan-dard textbooks and original articles.

- They should be encouraged to develop a criticalapproach in their assessment of literature.

- They should be involved in research and scientif-ic publication.

- They should acquire knowledge of the design,execution, and analysis of research projects.

- Trainees should enhance their theoretical knowl-edge by attending and participating actively inthe scientific programme and educational activi-ties of CIRSE and SIR.

- During their training period, trainees shouldspend the equivalent of 4 months´ clinical trainingin a department of vascular surgery, internalmedicine, or any subspecialty of surgery or inter-nal medicine relevant to their IR training. Theyshould also attend weekly outpatient clinics andward rounds. They should undergo training incommunication skills, including the ethics of in-formed consent and the process of giving badnews to patients.


- Technique, indications, contraindications and com-plications of the following diagnostic modalities:- Doppler and color Doppler ultrasound - CT (including CT angiography)- Magnetic resonance angiography and car-

diac imaging - Angiography

- The factors affecting the choice of contrast mediaand radiopharmaceuticals and the effects andside effects of these agents



- Normal radiological anatomy, anatomy of thevascular system and all anatomical regions usingany imaging modality

- Normal physiology of the cardiovascular system

- In-depth knowledge of the physiopathology ofcardiovascular diseases

- Pharmacotherapy of the cardiovascular system

- Basic knowledge of chemotherapy

- Knowledge of physiopathology of all diseases inwhich interventional radiology plays a role

- Techniques and indications of:- Pre-procedural patient assessment- Peripheral angioplasty (incl. recanalisation

and stenting)- Renal angioplasty (incl. recanalisation and

stenting)- Supra-aortic angioplasty (incl. recanalisation

and stenting)- Venous angioplasty (incl. recanalisation and

stenting)- Thrombectomy and thrombolysis- Treatment of arteriovenous malformations- Treatment of bleeding- Gynaecological interventions- Non-vascular upper gastrointestinal, liver and

renal interventions- Post-procedure patient management

- Theory of advanced life support techniques (in-cluding ECG)

- Pharmacotherapy and practice of sedation andanalgesia


The trainee must have a deep knowledge of all imagingmodalities including newer imaging modalities of the car-diovascular system, such as CT angiography, colourDoppler ultrasound, and magnetic resonance. In addition,as more non-invasive diagnostic tools are used, theamount of aortography available to the trainee will dimin-ish. Virtual Reality Training is now through its infancy andis a training reality. This must be borne in mind when con-sidering practical experience. A single week in a VR labo-ratory with appropriate trainers has been shown by

laparoscopic surgeons to move trainees much more rap-idly along the learning curve.

Procedures performed must be kept in a logbook.

The numbers indicated for each procedure are forguidance only. They are not intended to be an indica-tor of competence at the end of the training period.

Diagnostic proceduresAortography and / or runoff 100Selective angiography including head and neck 100Doppler ultrasound and / or duplex ultrasound 50CT angiography 50MRI angiography and cardiac imaging 50Phlebography 50Any other imaging method related to the field of interventional procedures

Interventional proceduresPeripheral PTA 100Other PTA (renal, etc.) 20Complex PTA 20Thrombectomy and thrombolysis 20Vascular stenting 10Embolisation 20Complex embolisation 5Techniques of intravascular chemotherapy 10Venous interventions 20Complex venous interventions (e.g. TIPS) 5Vena cava filters 10PTC, PTCD, and gallbladder interventions 20Percutaneous biopsy 20Drainage 20Foreign body retrieval 5Non-vascular interventions & stenting 20Genitourinary tract procedures (nephrostomy, nephrolithotomy, ureteral procedures, tubal recanalisation) 20Combined surgical and percutaneous procedures Combined endoscopic and percutaneous procedures Non-vascular interventions & stenting 20In-depth practice of advanced life-support techniques


If written examinations are considered necessary, theseshould include both general and IR modules.

Basic reporting sessions could be the same for IR and DRcandidates. In addition, the IR candidate would undergo along reporting session dedicated to IR, which would re-quire diagnosis and treatment options based on the imag-



ing and clinical scenarios. This should include statementsof success and complication rates.

For IR candidates, one oral examination could be generaland the second could be dedicated to IR. This could testthought process and manual dexterity using models, arange of equipment, and computer simulations. Logbookswould also be examined.

MusculoskeletalRadiology1 – INTRODUCTION

Musculoskeletal (MSK) imaging involves all aspects ofmedical imaging which provide information about anato-my, function, disease states and those aspects of inter-ventional radiology or minimally invasive therapyappertaining to the musculoskeletal system. This will in-clude imaging in orthopaedics, trauma, rheumatology,metabolic and endocrine disease as well as aspects ofpaediatrics, oncology, and sports imaging.

The aim of subspecialised training in MSK imaging is toprepare a radiologist for a career in which a signifi-cant portion of his / her time will be devoted to MSKimaging. Such individuals will be expected to provide andpromote 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 thefield of MSK imaging;

- The ability of the MSK specialist to transmit his /her specific knowledge to his / her colleagues ingeneral radiology and to assume the continuityand evolution of radiological diagnosis in the fieldof MSK radiology (teaching skills).


- 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 geneticsand 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.



- The training department(s) should have accessto conventional radiography, CT scan, ultra-sonography, MR Imaging, interventional equip-ment, and bone densitometry.

- A database of "interesting cases" or "teachingfiles" should be present at the training depart-ment. Alternatively and / or additionally, the train-ing department can refer to interestingeducational sites on the internet.

- Trainees must also have access to radiological li-brary containing textbooks of MSK radiology, or-thopaedic surgery, rheumatology, and relatedsciences and journals.

- The training department must provide access toappropriate computed tomography (CT), mag-netic resonance imaging (MRI), radionuclide im-aging (optional), and fluoroscopy. Centres shouldalso provide access to relevant specialised ra-dionuclide imaging, e.g. positron emission to-mography (PET) (where relevant). Practicaltraining and / or theoretical teaching and trainingin bone densitometry techniques should be avail-able.

3 – OVERVIEW

- Trainees should have completed the core skillsand knowledge programme according to the EAR/ UEMS curricula which will include basic knowl-edge of diagnosis of MSK diseases in their initialtraining.

- The subspecialty specialists / consultants in MSKimaging undertake 12 months or its equivalent ofsubspecialty training, either during the fourth andfifth year of the 5-year radiology training pro-gramme or as additional training after their 5-yearresidency / training scheme has been completed.

- The training outlined below will extend this intothe practical role.

- They must obtain extensive experience in the di-agnostic procedures listed below and will be ex-pected to be familiar with the current MSKimaging literature, both from standard textbooksand original articles.

- They should participate in audit and researchand should be encouraged to pursue a project upto and including publication. An understanding of

the principles and techniques used in research,including the value of clinical trials and basic bio-statistics should be acquired.


- Trainees should attend regular sessions of theo-retical training in the form of locally delivered tuto-rials, specialist MSK imaging courses, as well aslocal, national and international MSK imaging con-ferences including formal lectures, scientific pre-sentations or both, and E-learning.

- Trainees will acquire an extensive knowledge ofthe pathology, frequency and epidemiology ofMSK diseases both in the paediatric and adultpopulation. They should have a basic knowledgeof the treatment of MSK disease by conservativetreatment, surgery, radiotherapy and chemothera-py (if applicable) and be aware of the diagnosticneeds of their surgical, radiotherapy and oncologycolleagues. They must therefore attend regularmulti-disciplinary conferences (e.g. with rheuma-tologists, orthopaedic surgeons, oncologists, etc.).

- Trainees should acquire a knowledge of:- The embryology, anatomy and physiology of

the musculoskeletal system including normalanatomical variants

- The pathological processes of both benign andmalignant disease in the musculoskeletal sys-tem

- Local, national and, where appropriate, inter-national imaging guidelines and protocols

- Knowledge of the full range of radiological diag-nostic modalities and techniques available, in par-ticular:- The indications, contra-indications and compli-

cations of each imaging method- The factors affecting the choice of contrast

media and radiopharmaceuticals- The effects and side effects of these agents- Optimisation of imaging protocols of diagnostic

procedures

- Particular emphasis should be placed on thestrengths and weaknesses of the different imagingmethods in various pathological conditions. Theappropriate choice of imaging techniques and / orthe appropriate sequence of imaging techniquesin the investigation of specific clinical problemsshould be emphasised.




- Technical skills

Acquisition of specific skills to enable:- The conduct, supervision and accurate inter-

pretation of all imaging techniques used inthe investigation of musculoskeletal diseasesto a high professional standard

- The accurate localisation and the biopsy ofsoft tissue, bone and lymph node masses

- Where appropriate, the safe and effectivepractice of interventional techniques

- Good communication with patients and pro-fessional colleagues

- Accurate informed consent to be obtained- Continuing accreditation of intermediate life-

support status

Procedural competence will need to be reviewed at inter-vals, and this regular review should also assess the num-ber of cases required in order to ensure competence.During the training period it is recommended that thetrainee obtain experience in the following:

- Plain radiography including:- primary care examinations- trauma cases- rheumatological disorders- general and paediatric orthopaedics

- Ultrasonography including:- joints- soft tissues- orthopaedic and sports injuries- Doppler studies applied to the muscu-

loskeletal system

- CT- the use of CT for the primary diagnosis of

benign and malignant pathology- staging of tumours involving the muscu-

loskeletal system- detection of direct extension and metasta-

tic spread of musculoskeletal tumours- the investigation of rheumatological disor-

ders- the investigation of trauma and sports in-

juries- the use of reconstruction algorithms, mul-

tiplanar reconstruction, and volume ren-dering

- MRI- knowledge of basic and new MRI se-

quences applied to the musculoskeletalsystem, such as cartilage sequences, dif-fusion, etc.

- the use of MRI for the primary diagnosisof benign and malignant pathology

- staging of tumours involving the muscu-loskeletal system

- detection of direct extension and metasta-tic spread of musculoskeletal tumours

- demonstration of spinal anatomy andpathology

- demonstration of joint anatomy andpathology, including direct and indirectMR arthrography

- the investigation of rheumatological disor-ders

- the investigation of acute trauma and trau-ma sequels

- the investigation of sports injuries, bothtraumatic and overuse

- Fluoroscopic procedures including arthrogra-phy

A trainee will keep abreast of all other imaging techniquesrelevant to their practice.

Trainees should acquire experience in the following inter-ventional procedures guided with fluoroscopy, ultrasound,or CT:

- Biopsy of bone and soft tissue lesions- Arthrography- Non-spinal image-guided diagnostic and

therapeutic procedures - Spinal image-guided therapeutic procedures,

such as facet joint injections, sacroiliac injec-tions, epidural, and periradicular infiltrations

- Discography- Optional experience- CT myelography- Vertebroplasty

Trainees should acquire experience in all the practicalprocedures listed above, and the number of cases under-taken should be recorded in their logbook.

The trainee should become familiar with providing analge-sia and / or sedation where required, as well as the nec-essary continuous monitoring required to perform thissafely.



Regardless of the imaging technique or procedure con-cerned, the consultant trainer must be satisfied with thetrainee´s clinical competence, as determined by an in-training performance assessment, and can consistentlyinterpret the results of investigations accurately and reli-ably, and formulate correct management plans.

- Communication and decision-making skills

A clear understanding of the role of multidisciplinarymeetings, including:

- Planning of investigations including the selec-tion of appropriate tests and imaging tech-niques for the diagnosis of benign andmalignant disease

- Staging of malignant disease- Planning and outcomes of treatment- The detection of errors in diagnosis and com-

plications of treatment- Promoting an understanding of relevant mus-

culoskeletal pathology

Clinical knowledge will be acquired by a variety of means,including close liaison with appropriate medical, surgicaland oncological teams as well as combined clinical andradiological meetings. Multidisciplinary meetings shouldbe emphasised. The following inter-relationships are im-portant:

- Orthopaedics (general and paediatric) andrehabilitation

- Rheumatology- Metabolic and endocrine medicine- Bone and soft tissue oncology- Trauma, including accident and emergency- Spinal surgery- Sports medicine / surgery- Nuclear medicine

The trainee should be encouraged and given the opportu-nity to attend and lead appropriate clinico-radiological andmultidisciplinary meetings.

The trainee should be encouraged to attend appropriateeducational meetings and courses.

The trainee should participate in relevant clinical audit,management, and clinical governance, and have a goodworking knowledge of local and national guidelines in re-lation to radiological practice.

Trainees will be expected to be familiar with current mus-culoskeletal radiology literature.

The trainee should be encouraged to participate in re-search and pursue a project up to and including publica-tion. An understanding of the principles and techniquesused in research, including the value of clinical trials andbasic biostatics, should be acquired. Presentation of re-search and audit results at national and internationalmeetings should be encouraged.

The trainee should have on-call commitments on a regu-lar basis.

Knowledge and understanding of the importance of effec-tive communication with both the patient and the mem-bers of the multidisciplinary team.

Knowledge of roles and responsibilities of other membersof the MSK imaging team, e.g. radiographers, nurses,support staff, secretaries, etc.

Knowledge of roles and responsibilities of other membersof the Multi-Disciplinary Team.

Knowledge and understanding of how imaging findings in-fluence decisions by others, e.g. surgeons, pathologists,oncologists, etc.

- Training schedule and content

During the training period, the following weekly commit-ments are suggested as a work profile for subspecialtytrainees for the 12-month period, which will permit an inte-grated use of different modalities for the diagnosis andtreatment of MSK disorders.

- MRI (two to three sessions)- CT (one to two sessions)- US (one to two sessions)- Radionuclide imaging (one session) (where

available)- Plain film reporting (two to three sessions)- Fluoroscopy with or without intervention (one

session)- Bone densitometry: 100 examinations have to

be supervised and reported- Trainees must attend regular clinico-radiolog-

ical conferences (at least weekly)- Optional experience in radionuclide reporting

of the MSK system

The techniques listed and the time devoted to each will bereviewed at intervals. It is recognised that some studieswill become obsolete and new imaging techniques will bedeveloped.



The training department is free to organise an alternativeframework throughout the year as long as an equivalentamount of examinations for each modality is met at thecompletion of the training. This includes a modality-basedprogramme where the trainee sequentially spends dedi-cated periods of time in MRI, CT, US, etc.

For image-guided interventional procedures, hands-onexperience with graded supervision will be required de-pending on the trainees’ future career goals. The trainingin and supervision of such procedures may be providedby musculoskeletal or interventional trainers, dependingon the local practices and expertise.

Experience will be documented in a logbook, including asummary of the theoretical (documented by CME certifi-cates) and practical training and certified by the supervis-ing radiology department or group (3). The numbersindicated for each procedure are for guidance only. Theyare not intended to be an indicator of competence at theend of the training period.

The contents of the training needs to be flexible and ap-propriate to the career goal of the trainee.Musculoskeletal radiology is an expanding and evolvingspecialty, with developments of different imaging tech-niques and interventional procedures. Some trainees mayrequire additional training in such developing areas.


At the end of the training, a certificate of subspecialty ex-pertise will be awarded by the training department in ac-cordance with the law of each country.

Formal testing should be up to the authority of the respec-tive country in which the training has been fulfilled.

Acknowledgement to the Royal College of Radiologists forincorporating parts of the document "Structured Training InRadiology", Ref. No.: EBCR(00)1.

Neuroradiology1 – INTRODUCTION

- Neuroradiology is a branch of medicine con-cerned with both diagnostic imaging and inter-ventional procedures related to brain, spine andspinal cord, head, neck, and organs of specialsenses in adults and children.

- The aim of specific training in neuroradiology isto prepare a specialist for a career in which his /her clinical and research time will be devoted todiagnosis and treatment of diseases of the areascited above using imaging modalities.

- Neuroradiologist will also be expected to adoptand develop new imaging and interventionalmethods, to disseminate neuroradiologicalknowledge and, from a basis of strong clinicalbackground, be able to discuss with the referringclinicians the diagnosis and treatment.

- This curriculum outlines the subspecialty trainingrequirements for neuroradiology, including inter-ventional neuroradiology as a subspecialty of ra-diology.

- In Europe, trainees will enter into neuroradiologytraining during the fourth and fifth years of clinicaltraining. This training is in diagnostic neuroradiol-ogy and may have some components of interven-tional neuroradiology.

- All residents in radiology will have obtained basicknowledge of neuroradiology diagnosis duringcore training and will have already acquired basicskills.

- This document outlines the training curriculum fora consultant neuroradiologist. A minimum of 24months of full-time training in neuroradiology isrecommended. A trainee undertaking additionaltraining in neurointerventional procedures re-quires more than two years neuroradiologicaltraining.

- Dedicated neuroradiology training received at aneuroscience centre within an accredited radiolo-gy-training scheme may be taken into considera-tion.



- The aim of subspecialty training in neuroradiolo-gy is to enable the trainee to become clinicallycompetent and to consistently interpret the re-sults of neuroradiological investigations accu-rately and reliably. Where appropriate, traineesshould also be capable of providing a compre-hensive and safe interventional diagnostic andtherapeutic service.

- The content of training needs to be flexible andappropriate to the ultimate goal of the trainee.Neuroradiology is an expanding specialty withdevelopment of interventional services, paedi-atric neuroradiology, and functional brain imag-ing, including MR spectroscopy. Some traineesmay wish to obtain extra training in these areas.

2 – OVERVIEW

- Basic skills in neuroradiology will have been ac-quired before subspecialty training.

- A training scheme responsible for training in neu-roradiology must provide access to appropriateCT, MRI, digital subtraction angiography, ultra-sound and radionuclide imaging facilities.Trainees should also have access to neonatalcranial ultrasound.

- Clinical knowledge will be obtained by a variety ofmeans. This will include close liaison with the ap-propriate surgical and medical teams and partici-pation in combined clinical and radiologicalmeetings. Clinical interrelationships are neces-sary with:- Neurosurgery (paediatric and adult)- Neurology (paediatric and adult)- Neuropathology- Neurophysiology- Neuroanaesthesia / critical care and emer-

gency medicine- Trauma

- Other specialties will also provide important train-ing opportunities, in particular ophthalmology,otology, genetics, endocrinology, psychiatry,neuro-oncology, maxillo-facial surgery, spinalsurgery, and rehabilitation services.

- It may be appropriate for the trainee to have aregular attachment to ward rounds, outpatientclinics and theatre sessions in order to furtherclinical knowledge relevant to the subspecialty.

- The trainee should be encouraged and given theopportunity to attend and lead appropriate clini-co-radiological meetings.

- The trainee should participate in relevant clinicalaudit, management and clinical governance andhave a good working knowledge of local and na-tional guidelines in relation to radiological prac-tice.

- The trainee should be involved in research andhave the opportunity to attend and present at na-tional and international meetings. The progres-sion of research projects to formal peer-reviewedpublication should be supported and encouragedby the supervising consultant(s).

- Attendance at National, European and AmericanNeuroradiology Societies should be encouraged.

- The trainee should be encouraged to become anassociate member of the appropriate NationalNeuroradiology Society and the EuropeanSociety of Neuroradiology.

- The trainee is expected to participate in under-graduate and postgraduate teaching, includingthe European Course in Neuroradiology or othercourses of similar scope and quality.

- The trainee should, where possible, participate inthe neuroradiology on-call rota, after adequatetraining with appropriate consultant cover.

- Subspecialty training in neuroradiology is as-sessed and accredited by the ProvisionalEuropean Board of Neuroradiology under the ap-proval by European Society of Neuroradiology.


The accredited training of neuroradiologists will have toachieve the following:

- An in-depth knowledge of anatomy, including de-veloping anatomy and its radiological applica-tions to the central and peripheral nervoussystem, organs of special senses, head andneck, and spine and spinal cord in adults andchildren

- Knowledge of and radio-pathological correlationof diseases and variations of the CNS, includingthe spine and cranium and disorders of the oph-



talmological and otorhinolaryngological systems,including appropriate indications, contraindica-tions and complications of imaging studies ofneurological diseases and interpretation of thevarious imaging modalities

- Knowledge of proper experience and under-standing of physical principles and technicalbackground for performance and interpretativeskills of computed tomography (CT), magneticresonance imaging (MRI), angiography, ultra-sound, conventional imaging, and myelographyfor the diagnostic imaging of the head and spineand spinal cord, head, neck, and organs of spe-cial senses in adults and children so that theycan, with confidence, discuss with their col-leagues the choice of best imaging method for aparticular clinical problem

- Knowledge of functional and imaging aspects ofMR spectroscopy, MR functional imaging, andnuclear medicine studies (SPECT & PET) asthey relate to neuroradiology

- Knowledge and commitments to the clinical ap-plications of neuroradiology as they apply to allaspects of neuroradiology so that the trainee mayconfidently discuss patients with colleagues

- Knowledge of indications, techniques and clinicaloutcome of interventional neuroradiology, as wellas the hazards and potential complications of in-vasive procedures, both diagnostic and thera-peutic

- Knowledge of pharmacology, particularly with re-spect to contrast material and invasive proce-dures

- Knowledge of patient’s protection and safety inneuroradiology

- The trainee should be fully competent in interme-diate and advanced life-support.

- Knowledge of the importance of informed con-sent and patient information

- Understanding of fundamentals of quality assur-ance in neuroradiology

- Understanding risk management, data banking,and evidence-based medicine

- Knowledge of the current developments in neuro-radiology

- If experience to fulfil the requirements of subspe-cialty training cannot be gained in one trainingcentre, it will be necessary for the trainee to havea period of attachment(s) to other training cen-tres. There are, in any case, advantages fortrainees in visiting other departments at home orabroad to follow particular interests in greaterdepth.

- The expected outcome at the end of this subspe-cialty training in neuroradiology will be for the res-ident to be competent in all aspects of diagnosticneuroradiology imaging and, where applicable,basic interventional neuroradiology.


- Essential is competence in clinical neuroradio-logical skills in adults and children, including:- Diagnostic and interpretative skills- Manual and procedural skills- Basic endovascular and therapeutic knowl-

edge- Computer skills in imaging acquisition and

post-processing- Outpatient consultation when relevant

- Ability to manage post-procedural care for inva-sive diagnostic and therapeutic techniques aswell as neuroradiological emergencies

- Ability to manage patients and to obtain valid in-formed consent for all procedures

- Competence in effective consultation, presenta-tion of scholarship material and ability to teachneuroradiology to peers and residents in otherdisciplines

- Ability to evaluate medical literature critically andto conduct neuroradiological research

- Competence in style of reporting

- Ability to conduct or supervise quality assurance

- To keep an authorised logbook of experience



- Competence in communicating clinical and sci-entific topics to various learned and scientificcommunities within neuroscience

- Responsible use of financial and other resources

- Interactions with colleagues and administration

- Ethical and responsible

- Appropriate and considerate with patients

- Respecting confidentiality in patient care

- Ability to interact well with peers and the rest ofstaff

- Awareness of the obligation of continuing med-ical education and commitment to the continuingassessment of the quality of neuroradiology

5 – REQUIREMENTS OF SUBSPECIALTY TRAINING

- A comprehensive knowledge of normal brainfunction and neurological diseases, including:- The embryology, anatomy, normal variants

and physiology of the central and peripheralnervous system, organs of special senses,head and neck, and spine and spinal cord inadults and children

- The pathological correlation of diseases andvariations of the CNS, including the spine andcranium and disorders of the ophthalmologi-cal and otorhinolaryngological systems, in-cluding appropriate applications andinterpretation of the various imaging modali-ties

- Local, national and, where appropriate, inter-national imaging guidelines

- Knowledge and understanding of the physicalprinciples and technical background for the per-formance of CT, MRI, angiography, ultrasound,conventional imaging, and myelography for thediagnostic imaging of the head, spine and spinalcord, neck, and organs of special senses inadults and children. Exposure to MRS / function-al imaging and nuclear medicine studies(SPECT, PET) related to neuroradiology shouldbe available.

- To develop the interpretative skills of CT, MRI,angiography, ultrasound, conventional imaging

and myelography for the diagnostic imaging ofthe head, spine and spinal cord, neck, and or-gans of special senses in adults and children.

- The subspecialty resident should know the inher-ent strengths and limitations of these modalities,as well as appropriate imaging protocols for neu-roradiological consultation.

- Knowledge of the techniques involved in the im-aging used to evaluate and treat neurological dis-eases, including interventional procedures andthe management of the complications of theseprocedures

- Knowledge and competence at imaging of brainfunction.

- Knowledge of pharmacology, particularly with re-spect to contrast media and invasive procedures

- Knowledge of patient protection and safety inneuroradiology

- Understanding of fundamentals of quality assur-ance (management) in neuroradiology

- Acquisition of specific skills to enable compe-tence in clinical neuroradiological skills in chil-dren and adults, including:- Diagnostic and interpretative skills- Manual and procedural skills- Basic endovascular and therapy skills- Computer skills in imaging acquisition and

post-processing- The conduct, supervision and accurate inter-

pretation of all imaging techniques used inthe investigation of neurological diseases to ahigh professional standard

- Good communication with patients and pro-fessional colleagues

- Competence in the style of reporting- The ability to manage post-procedure care for

invasive diagnostic and therapeutic tech-niques as well as neuroradiological emergen-cies

- The ability to manage patients and to obtainvalid informed consent for all procedures

- The competence in effective consultation,presentation of scholarship material, and abil-ity to teach neuroradiology to peers and resi-dents in other disciplines

- The ability to evaluate medical literature criti-



cally and to conduct neuroradiological re-search

- Ability to conduct or supervise quality assur-ance

- The core requirements for a neuroradiologist or aspecialist interventional neuroradiologist are sim-ilar, apart from the total number of interventionalprocedures performed (see below).

- Regardless of the imaging technique concerned,the consultant trainer must be satisfied with thetrainee being clinically competent, as determinedby an in-training performance assessment, andbeing able to consistently interpret the results ofsuch investigations accurately and reliably.

- During the training period it is recommended thatthe trainee receive the following:- CT – the equivalent of one or two sessions

per week- MRI – the equivalent of two or three sessions

per week- Angiography – the equivalent of two sessions

per week- Interventional neuroradiology – see below- Study / meetings – the equivalent of one ses-

sion per week- Research – the equivalent of one session per

week- Myelography – the opportunity to observe

and, whenever possible, obtain hands-on ex-perience of the limited number of these pro-cedures now carried out

- During the training period the trainee should alsogain experience in the following:- Plain radiography, including:- Primary care examinations- Skull, facial and spinal trauma- Paediatric examinations including child

abuse

- Optional experience:- Radionuclide radiology including SPECT im-

aging and PET- Ultrasound including neonatal cranial US and

Doppler

- The techniques listed and the time devoted toeach will be reviewed at intervals along with thenumber of cases required, as it is recognised that

some procedures may become obsolete and newtechniques will be developed (e.g. functionalbrain imaging and MR spectroscopy).

- The trainee should become familiar with provid-ing analgesia and / or sedation where required,as well as the necessary continuous monitoringrequired to perform this safely.

- The trainee should become fully aware of thelocal and national guidelines in obtaining in-formed patient consent.

6 – INTERVENTIONAL NEURORADIOLOGY REQUIRE-MENTS

- All subspecialist residents training in neuroradiolo-gy should have a basic understanding of interven-tional techniques so that they have full knowledgeof indications, technical problems, contraindica-tions, and risks of procedures. Trainees with aspecial interest in interventional neuroradiology willneed more extensive experience.

- All trainees in interventional neuroradiologyshould complete at least one year of diagnosticneuroradiology training.

- Trainees who wish to spend a significant part oftheir work as a consultant in interventional neuro-radiology should spend around one year in atraining post in which substantially the whole timeis devoted to interventional neuroradiology.

- These trainees will need to extend their subspe-cialty training beyond two years required for neu-roradiology. However, earlier and more focussedindividualised training in neuroradiology is beingencouraged for those trainees with previous neu-roscience / neurovascular experience.

- Trainees need to develop clinical judgement. Therisks and benefits of each therapeutic procedureneed to be appreciated. Training might include aclinical attachment.

- Trainees should have adequate exposure to neu-rosurgical operations and ward / HDU manage-ment of acutely ill patients.

- Regular involvement in neurosciences audit andmortality / morbidity meetings is necessary to un-derstand risk management for different clinicalconditions.



- It is the responsibility of the trainee to be aware ofthe current local and national guidelines in ob-taining informed patient consent.

- All interventional trainees must have thoroughknowledge of techniques of sedation and analge-sia required to perform these procedures, as wellas patient monitoring throughout and followingthe procedures.

- Trainees should be aware of the full range ofintra- and post-operative complications and theirmanagement.

- The interventional trainee should participate inaround 80 neuroradiological interventional proce-dures, of which a substantial proportion will be forintracranial vascular lesions. The trainee shouldbe the first operator in around a third of cases.

- It is desirable that the trainee also attend othercentres, especially if range and quantity of inter-ventional procedures are limited.


- Regular appraisal of the trainee will occur ac-cording to national guidelines.

- Methods of trainee assessment will include:- Regular direct observation of clinical tech-

niques (including communication skills, abilityto obtain informed consent and sedationskills) by the trainer and / or external observer

- Regular formal review of the trainee’s skills inthe accurate interpretation of investigationsfor neurological diseases

- Final assessment of overall professional com-petence

- Review of subspecialty curriculum- The Training Committee of the European

Society of Neuroradiology will regularly re-view this subspecialty curriculum to ensurethat it complies with current neuroradiologicalpractice.

Paediatric Radiology1 – INTRODUCTION

The aim of sub-specialised training in paediatric radiologyis to prepare the radiologist for a career in which a sub-stantial proportion of his / her time will be devoted to pae-diatric radiology. Such individuals will be expected notonly to provide a paediatric radiology service but alsoadopt and develop new imaging and interventional meth-ods and to disseminate paediatric radiological knowledgeto their colleagues in general radiology.


Specialist training in paediatric radiology must take placein hospitals with the full range of clinical paediatric spe-cialities available on site. These include gastrointestinaltract, genito-urinary tract, chest, endocrine, neonatal,musculoskeletal, neurology and neurosurgery, cardiovas-cular, and A&E facilities. Medical and surgery facilitiesmust be available. Where facilities are not available onsite, arrangements should be made for secondment to anappropriate unit so that such training is available.

The training department must have a full range of diag-nostic equipment, including access to specialised ses-sions on nuclear medicine, CT and MRI. Interventionalradiology experience, both angiographic and non-angio-graphic, must also be available. There must be access toa library with radiological and clinical textbooks and jour-nals. A film library must also be available.

3 – OVERVIEW

The training period will be the equivalent of one - twoyears of practice. During this period, the trainee must de-vote his / her time to paediatric radiology. Trainees shouldacquire a deep knowledge of the pathological and clinicalbasis of the specialty. They should obtain extensive expe-rience in all of the diagnostic methods listed in the syl-labus. Trainees must attend regular clinicoradiologicalconferences (at least weekly) with their clinical col-leagues. Trainees will be expected to be familiar with thecurrent paediatric radiological literature, both from stan-dard textbooks and original articles. They should be en-couraged to develop a critical approach in theirassessment of the literature. They should be involved in aresearch project (or projects) and should acquire knowl-edge of the design, execution, and analysis of researchprojects.




- Theoretical training

Teaching is organised on the basis of lectures, tutorials,and workshops. Trainees are to be encouraged to attendnational and international conferences on paediatric radi-ology, such as those given by the European Society ofPaediatric Radiology (ESPR), the Society of PaediatricRadiology (SPR), and the European Congress ofRadiology (ECR).

- General principles

- Understanding of the principles of paediatricradiology as an integrated imaging concept.

- Knowledge of special needs of children: envi-ronment, sedation, psychology of handlingchildren. Organisation of a paediatric sectionwithin a general department, guidelines for in-vestigation, contrast: factors affecting thechoice of contrast, indications and contraindi-cations, including radiopharmaceuticals.

- Detailed knowledge of dose reduction tech-niques in paediatric radiology:- Equipment choice, film / speed combina-

tion, use of grids / video, Q.A. [quality as-surance] programme

- Role of lateral film, PA v AP views, com-parison view, choice of examination, cost /risk benefit

- To understand the ALARA [as low as rea-sonably achievable] principle. IRMER2000 regulations

- Knowledge relevant to normal anatomy, normalvariations, development, and physiology of theprenatal, neonate and growing child

- In-depth understanding and knowledge relevantto medical and surgical management of paedi-atric diseases.

- The Chest- Neonatal: to include surgical problems- Infection: bacterial, viral, opportunistic, TB

and ITU complications- Cardiac- Trauma- Foreign bronchial bodies- Infiltrative disease- Asthma- Mass lesions

- Clinical problems, e.g. investigations ofstridor

- Investigation of recurrent chest infection- Intensive care chest radiology

- The Musculoskeletal System- Trauma: Salter classification of physeal in-

juries - Fracture complications- Cervical Spine- Pelvic Fractures- Irritable hip, Perthes’ disease- Sports injuries- Polytrauma- Infection / bone – joint – disc / how to ap-

proach diagnosis and integrated imaging- Multifocal osteomyelitis / chronic granulo-

matous diseases- Scoliosis and orthopaedic problems- Arthritis and metabolic disease- Neoplastic: benign and malignant bony

and soft tissue tumours- Skeletal dysplasia

- The Abdomen- Neonate- Oesophageal disease, reflux- Pyloric stenosis- GI bleeding- Inflammatory bowel disease, appendicitis

and gastro-enteritis- Constipation- Intussusception- Ulcer disease- Malabsorption- Obstruction- Pancreatitis- Abdominal trauma – to include liver,

spleen and pancreas, and bowel tumours(liver, small bowel and pancreas)

- To understand the limits of ultrasound inthe evaluation of traumatic lesions of theliver and spleen

- To know the indications of CT / to be ableto perform CT

- Genito-urinary tract- Infection – UTI [Abscess and pyonephro-

sis and how to investigate)- To recognise the normal appearance of

the organs in any imaging modality- To understand the urethral anatomy of the

boy



- To understand the clinical and biologicalcriteria of UTI

- To be able to perform ultrasound of theurinary tract on infants using Doppler

- To know when and how to perform aVCUG and how to read it

- To detect and evaluate VUR- Congenital anomalies and hydronephrosis- Haematuria and stones- Renal mass lesions (incl. polycystic disease)- Pelvic tumours- Trauma- Neuropathic bladder- Diverticula- Urodynamic studies- Gynaecological disease- Intersex- Testicular diseases

- Neuro- Trauma: Skull and facial injury- Intracranial injury- Infection- Tumours (including spinal cord)- Ultrasound of the neonatal brain- Premature brain disease- Developmental anomalies (structural)- Normal myelination - Craniosynostosis- Ophthalmology: trauma- Tumor- Infection- FB- Developmental anomalies: migrational- Epilepsy- Hydrocephalus- Vascular disease (including malforma-

tions and acquired)- Spinal cord malformations (including im-

aging for clinical presentations, e.g. backpain, claw foot)

- Craniofacial malformations- ENT congenital ear disease and deafness- Infection- Trauma- Airway- Dental radiology

- Miscellaneous- AIDS in children- Lymphoma in children- Vascular malformations (limb, lymphoede-

ma)

- Collagen vascular disease (+ myofibro-matosis, etc.)

- Endocrine disease- Investigation of small stature + growth dis-

orders- Non-accidental injury (NAI)- Teeth (incl. craniofacial malformations)- Phakomatoses [tuberose sclerosis, neu-

rofibromatosis, etc].- Langerhans Cell Histiocytosis


- The trainees must know in depth the full range ofpaediatric radiological diagnostic techniques de-tailed below. They should understand the princi-ples of all the methods, and in particularemphasis should be placed on the strengths andweaknesses of the different imaging methods inthe diagnosis of the different pathological condi-tions. The proper choice of imaging techniquesand / or the appropriate sequence of imagingtechniques to solve specific clinical problemsshould be emphasised.The ability to discuss withparents / carers and older children should bedemonstrated.

- During the training period, it is recommendedthat the trainee obtain experience in the follow-ing:- Plain radiography, to include the full range of

clinical subspecialties, e.g. trauma, accidentand emergency, orthopaedics, rheumatology,chest, and abdomen

- Undertaking and reporting ultrasound exami-nation:- of the abdomen, gastrointestinal tract (in-

cluding bowel), genitor-urinary tract,chest, head, and musculoskeletal system

- Doppler studies, including spectral, basiccolour and power Doppler, as well asbasic calculations

- Undertaking and reporting routine fluoro-scopic examinations of the gastrointestinaland urinary tract, together with more complexinvestigation, such as:

- Small bowel enema - Reduction of intussusception - Management of neonatal distal intestinal ob-

struction - Velopalatal competence and studies of phonation

- Disorders of swallowing



- Undertaking and reporting paediatric CTand MR examination

- Undertaking (optional) and reportingbasic paediatric radionuclide imaging ex-aminations:- Static and dynamic renal studies, in-

cluding cystography- Musculoskeletal imaging- Ventilation and perfusion lung scintig-

raphy- Gastrointestinal studies, including

pertechnetate studies for Meckel’s di-verticulum

- Identification of a GI bleeding site- Thyroid imaging- MIBG studies- Dynamic biliary examination

- Interventional techniques- Trainees should acquire experience in

the following procedures:- Biopsy procedures- Abscess drainage- Insertion of percutaneous nephros-

tomies- Joint aspiration (e.g. hip)

- Optional experience may include:- Arthrography- Angiography- Balloon dilatation of oesophageal

strictures- Embolisation techniques- Musculoskeletal intervention


- Methods of trainee assessment will include:- regular direct observation of clinical tech-

niques (including communication skills,ability to obtain informed consent and se-dation skills) by the trainer and / or exter-nal observer

- regular formal review of the trainee’s skillsin the accurate interpretation of investiga-tions for paediatric diseases

- a final assessment of overall professionalcompetence

Urogenital Radiology1 – INTRODUCTION

The aim of establishing a curriculum for subspecialtytraining in urogenital imaging is to prepare trainees for anactivity in which he / she will dedicate a substantialamount of time to radiology of the urogenital system. His /her specific skill should include the following:

- In-depth knowledge of the relevant embryologi-cal, anatomical, pathophysiological, and clinicalaspects of radiology in the field of uronephrologyand gynaecology

- A clear understanding of the role of radiology inthe management of these specialist areas

- Complete knowledge of the indications, contra-indications, complications, and limitations of pro-cedures

- In-depth knowledge and expertise in the exami-nation techniques for imaging procedures tourological, nephrological, and gynaecologicaldiseases and problems

Furthermore, the subspecialist should be able to promoteand advance urogenital imaging in his / her environment.Then, the curriculum is aimed at developing the following:

- The ability to act as a consultant in multidiscipli-nary meetings

- The ability to transmit subspecialty knowledge toother radiology colleagues

- The ability to assume the continuity and the evo-lution of radiology in the field of urological,nephrological, and gynaecological diseases andproblems


- Training in urogenital imaging must be undertak-en in a training centre with access to full clinicalservices in radiology, nephrology and dialysis,urology, obstetrics and gynaecology and patholo-gy; it is preferable that also radiation therapy andoncology be available.

- The radiology department should have access toall routine and advanced imaging modalities(conventional radiology, CT, MRI, ultrasound,Doppler, and interventional radiology).Equipment should be in sufficient number and ofstate-of-the-art quality.



- A library must be readily accessible. It shouldcontain an adequate selection of the major text-books in urogenital radiology, as well as provideaccess to major radiology journals. The libraryshould allow also access to major journals inurology, nephrology, and gynaecology.

- A teaching file should be available and continu-ously updated. The trainee will be expected tocontribute with cases from his / her experienceduring his / her training period.

3 –OVERVIEW

- During the training in urogenital radiology, thetrainee must spend most of his / her time in thisfield of interest. Although the primary scope ofthe curriculum is to acquire in-depth knowledgeof radiological techniques and imaging findings,the trainee is expected to acquire knowledge ofthe clinical and pathologic presentation of dis-eases of the urogenital system too, as well as anunderstanding of the tests which are the prereq-uisites for imaging examinations (i.e. laboratory,endoscopy, urodynamics).

- Because angiographic interventions require addi-tional special skills, they are not required for thecurriculum in urogenital imaging. However, thetrainee is expected to develop capabilities inimage-guided biopsy procedures (renal and ad-renal masses, prostate, lymph nodes) anddrainages of lesions and organs of the urogenitalsystem (nephrostomy, abscess drainage).Additional training may be required for proce-dures such as varicocele embolisation, renal tu-mour embolisation, and fibroid embolisation.Management of renal artery stenosis may attimes be under the remit of urogenital radiology.

- The trainee should be familiar with clinical termi-nology so as to communicate without difficultywith clinical colleagues. He / she should attendmultidisciplinary meetings to get a thorough ideaof patient treatment, as well as of the role of im-aging methods in clinical practice.

- The trainee should become familiar with the cur-rent literature in urogenital imaging, both fromstandard textbooks and original articles. Theyshould be encouraged to participate in researchprojects and acquire knowledge of the design,execution, and analysis of scientific projects.

They should be encouraged to present papers atinternational congresses, to meet other peopleinvolved in the field of urogenital imaging in orderto exchange ideas and experiences.


At the end of the training period, the trainee should haveachieved the knowledge-based objectives listed below.Reasonable progression is to be expected during training,with responsibilities assumed gradually until completeprofessional independence is reached.

- Urinary & Male Genital Tract

- Renal physiology and kinetics of contrastagents - To understand the physiology of renal ex-

cretion of contrast medium (both iodinat-ed and gadolinium-based ones)

- To understand the enhancement curveswithin renal compartments after injectionof contrast agents (both iodinated andgadolinium-based ones)

- To know the concentrations and doses ofcontrast agents used intravenously (bothiodinated and gadolinium-based ones).

- Knowledge on the following aspects ofcontrast media (both iodinated andgadolinium-based ones) nephrotoxicitywould be required:- Definition of contrast media nephro-

toxicity- Risk factors of contrast media nephro-

toxicity- How to identify patients at high risk of

contrast media nephrotoxicity- Measures to reduce the risk of con-

trast nephrotoxicity- Precautions in diabetics taking met-

formin and requiring intravascular ad-ministration of CM

- For these items, please refer to theESUR guidelines on CM

- Normal anatomy and variants- Retroperitoneum

- To recognise retroperitoneal spacesand pathways

- Kidney- To understand the triple obliquity of

the kidney- To know the criteria of normality of



pyelocaliceal system on IVU and CTU- To recognise normal variants, such as

junctional parenchymal defect columnof Bertin hypertrophy, fœtal lobulation,and lipomatosis of the sinus

- To identify the main renal malforma-tions such as horseshoe kidney, dupli-cations, ectopia, and fusions

- Bladder and urethra- To know the anatomy of bladder wall

and the physiology of micturition- To identify the segments of male ure-

thra and location of urethral glands- Prostate

- To recognise zonal anatomy of theprostate

- To identify prostatic zones with USand MRI

- Scrotum- To know the US and MRI anatomy of

intra-scrotal structures (testicular andextratesticular)

- To know the Doppler anatomy of tes-ticular and extratesticular vasculature

- Imaging techniques - Sonography of urinary tract

- To choose the appropriate transduceraccording to the organ imaged

- To optimise scanning parameters.- To recognise criteria for a good sono-

graphic image- To recognise and explain the main ar-

tifacts visible in urinary organs- To be able to obtain a Doppler spec-

trum on intrarenal vessels (for resis-tive index measurement) and onproximal renal arteries for velocity cal-culation

- IVU- To list the remaining indications of IVU- To know the main technical aspects,

including:- Choice of the contrast agent- Doses - Film timing and sequences- Indication for ureteral compression- Indication of frusemide

- Cysto-urethrograpy - To list the main indications of cysto-

urethrography- To know the main technical aspects:

- Choice of technique: trans-ure-thral, transabdominal

- Choice of the contrast agent- Film timing and sequences

- To remember aseptic technique - CT of the urinary tract

- To define the normal level of density(in HU) of urinary organs and compo-nents

- To know the protocol for a renal andadrenal tumour

- To know the protocol for urinary ob-struction (including stones)

- To know the protocol for a bladder tu-mour

- CT urography (CTU): techniques, indi-cations, contraindications, and limita-tions

- MR of the urinary tract- To know the appearances of urinary

organs on T1 and T2 images- To know the appearances of urinary

organs on T1 and T2 contrast-en-hanced sequences

- To know the protocol for a renal andadrenal tumour

- To know the protocol for urinary ob-struction

- To know the protocol for a bladder tu-mour

- To know the protocol for a prostatic tu-mour- "Conventional" pelvic MRI for the

prostate: possibilities and limits- Use of rectal probes- Prostate MRI spectroscopy

- MR Urography (MRU)- T2 MRU- Excretory MRU: technique, indica-

tions, contraindications, and limita-tions

- To accurately diagnose the presence of thefollowing pathologies:- Kidney and ureter

- Congenital - Obstruction- Calculus- Infection- Tumours- Cystic diseases- Medical renal diseases- Vascular- Renal transplantation- Trauma



- Retroperitoneum- Congenital - Infection- Trauma- Tumours

- Bladder- Congenital- Obstruction- Inflammatory- Tumours- Trauma- Incontinence & functional disorders- Urinary diversion

- Urethra- Congenital- Strictures- Diverticula- Trauma

- Prostate & Seminal Vesicles- Congenital- Benign prostatic hypertrophy- Inflammatory- Tumours

- Testis & scrotum- Congenital- Inflammatory- Torsion- Trauma- Tumours

- Penis- Impotence- Trauma- Tumours

- Adrenal- Masses

- Interventional- In general

- To verify indications to the procedureand patient risk factors (such as satis-factory blood count, coagulation sta-tus, etc.)

- To explain the procedure and follow-up to the patient

- To obtain informed consent- To know what equipment is required- To know what aftercare is required- To know the complications, impor-

tance of early detection, and manage-ment

- US-guided biopsies / cystic drainage, e.g.kidney mass, prostate- To become familiar with ultrasound

probes- To become familiar with different guid-

ance techniques- free hand- guidance devices

- To become familiar with different biop-sy devices and needles

- To become familiar with drainagetubes and fixation devices

- To become able to liaise with patholo-gists and referring physicians

- CT-guided biopsies- To become familiar with CT scanners

and CT-guided biopsy / drainage tech-niques

- Percutaneous nephrostomy- To verify and discuss indication with

referring clinicians- To verify patient preparation and posi-

tioning- To become familiar with sedo-anelge-

sia, local anaesthesia, and antibioticpolicies

- To become familiar with guidancetechniques

- US guidance- Fluoroscopic guidance- To become familiar with puncture

techniques- To become familiar with guidewires

and tissue dilatators- To become familiar with nephrostomy

tubes:- locked- unlocked

- To become familiar with fixation de-vices, dressings, and drainage bags

- To become proficient in nephrostomyplacement as well as in nephrostomychange

- Antegrade ureteric stent insertion- To become proficient in nephrostomy

insertion (see above)- To become familiar with guidance

catheters- To become familiar with ureteric dilata-

tors- Teflon- Balloon



- To become familiar with ureteric stents- double J stents- metallic stents

- To liaise with urologists for stent man-agement

- Percutaneous nephrolithotomy- To work in close cooperation with

endo-urologists- To discuss case preoperatively- To become familiar with access tech-

niques and tract dilatation- To become familiar with available

lithotripsors- Angiography

Detailed angiographic techniques, includ-ing selective angiography and embolisa-tion techniques, are better acquiredduring an attachment to a vascular an-giography slot during training.

At the end of the training period the trainee should be-come proficient with performing the basic interventionaltechniques and be familiar with the more complex proce-dures (exact number of different procedures is not alwaysrelevant, as the degree of dexterity and proficiency willvary from trainee to trainee).

- Female genital tract

- Techniques- US examination

- To be able to explain the value of anUS examination

- To be able to explain the advantagesand limits of abdominal vs. transvagi-nal approach

- To be able to perform a transvaginalUS examination

- To know indications and contra-indica-tions of hysterosonography

- To be able to perform a hysterosono-graphic examination

- Hysterosalpingography- To be able to describe the procedure- To know the possible complications of

hysterosalpingography- To know the contra-indications of hys-

terosalpingography- To explain the choice of contrast agent- To know the different phases of the ex-

amination- To be able to perform the procedure

- CT scan- To be able to explain the technique of

a pelvic CT- To know the possible complications of

CT- To know the contra-indications of CT- To know the irradiation delivered by a

pelvic CT- To know the required preparation of

the patient and the choice of technicalparameters (slice thickness, Kv, mA,number of acquisitions, etc.) depend-ing on indications

- MRI- To be able to explain the technique of

a pelvic MRI- To know the contra-indications of MRI- To know the required preparation of

the patient and the choice of technicalparameters (slice thickness, orienta-tion, weighting, etc.) depending on in-dications, including pelvic floordisorders

- Angiography- To know the main indications of pelvic

angiography in women- To know how to perform a pelvic an-

giography- Anatomy

- To know main normal dimensions ofuterus and ovaries with US

- To describe variations of uterus andovaries during genital life

- To describe variations of uterus andovaries during the menstrual cycle

- To describe normal pelvic compart-ments

- To identify normal pelvic organs andboundaries on CT and MRI

- To explain the role of levator ani in thephysiology of the pelvic floor

- To know what imaging modalities canbe used to visualise the pelvic floor

- To know the factors responsible for uri-nary incontinence

- To accurately diagnose the presence of thefollowing pathologies:- Uterus

- Congenital anomalies- Tumours (benign and malignant)

- Myometrium- Endometrium



- Cervix- Inflammation- Adenomyosis- Functional disorders

- Ovaries / Tubes- Ovary

- Tumours (benign and malignant)- Functional disorders, e.g. function-

al cysts of the follicle or corpus lu-teum, precocious puberty, andpolycystic ovaries

- Endometriosis- Tubes

- Inflammatory disorders- Tumours

- Pelvis- Prolapse- The "acute female pelvis"- Endometriosis, including extra-ovarian

locations of endometriosis- Pelvic location of peritoneal pathology

- Infertility- Vagina

- Congenital abnormalities- Benign and malignant tumours

Depending on clinical practices and availabilities,training in fetal US and MRI can be offered.


At the end of the training period, the trainee should haveachieved the following technical, communication and de-cision-making skills. Reasonable progression is to be ex-pected during the two years of training, withresponsibilities 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?) alternatives

- To perform the examination - To know the clinical history and the clinical

questions to be answered- To know the protocol of examination- To assess the anxiety of the patient before,

during and after the examination and provideappropriate reassurance

- Communication with the patient and recommen-dations for follow-up- To explain clearly the results to the patient- To assess the level of understanding of the

patient- To explain the type of follow-up- To assess the degree of emergency- To produce a clear report of the examination - To discuss strategies for further investigation,

if necessary

- Communications and interaction with colleagues- To dictate useful and intelligible reports- To be able to discuss significant or unexpect-

ed imaging findings with colleagues and toknow when to contact a clinician

- To be able to interact with colleagues in clini-co-radiological conferences

- To be able to take part in multidisciplinaryteams dealing with patients with urological,nephrologic, or genital diseases

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 Europe

E u r o p e a n A s s o c i a t i o n o f R a d i o l o g yFor further information please visit the EAR website at www.ear-online.org

www.ear-online.org

european training charter for clinical radiology

Documents