17th May, 2019

RCR Admission Ceremony, London

20th-21st May, 2019

Northwest Musculoskeletal

courses: Multi-Modality Upper Limb Course

8th June 2019

Northwest School of Radiology Summer Ball

10th-12th June 2019

United Kingdom Imaging & Oncology

Congress 2019

North West School of RadiologySpring Newsletter

Volume 3 Issue 2 April 2019

Events:

Dear All,

Hope you all had a pleasant Easter 2019 break.

Winter 2018/Spring 2019 has seen a variety ofconferences both nationally and internationally.Trainees have written pieces about theirexperiences. We have also included aninteresting interview article on life as a ClinicalDirector. After much preparation and hard workthe first combined Northwest School ofRadiology Summer Ball has been organized. Seehere for details. Make sure you order yourtickets! We would like to thank all those whohave contributed to the newsletter. If you wouldlike to write a piece for the newsletter or wouldlike to let us know of any exciting/interestingdevelopments please get in contact!

Introduction

Dr Elfadil ElmahdiCo-editor

Mersey Co-Lead SpRmerseyleadsprgmail.com

Page 2: 9th European Multidisciplinary Colorectal Cancer Congress

Page 3: European Congress of Radiology 2019 Spotlight

Page 4:Interventional Radiology Training

Page 5: Northwest School of Radiology Summer Ball 2019

Page 6: RSNA 2018

Pages 7-8: Life as a ‘Clinical Director’

Pages 9-10: Interesting Case Presentation

Contents…

Consultant Editor for Northwest Newsletter

Dr Sumita Chawla

Dr Linda StephensCo-editor

Manchester Lead SpRmcrleadst@gmail.com

Volume 3 Issue 2 Page 1

Congratulations to Consultant Radiologists Dr Caren Landes & Dr John Holemans on their recent success in the RCR elections. Volume 3 Issue 2 Page 2

9th European Multidisciplinary Colorectal Cancer Congress by Dr Sam Alsford (ST1)

In March of this year Dr Chawla, Dr Noreikaitė and myself travelled to Lisbon, Portugal topresent a poster at the 9th European Multidisciplinary Colorectal Cancer Congress (EMCCC). Theevent is run by the Dutch Colorectal Cancer Group who place particular emphasis on the factthat both preclinical and clinical research is becoming much more multidisciplinary in natureand therefore one can expect their events to include talks covering a wide range of specialitiesincluding surgery, medical oncology, radiotherapy, pathology, imaging, gastroenterology andgenetics.

The first day of the conference was warm and inviting, and after a mandatory pastry, coffee andfresh orange juice we attended the first talks of the conference. Whilst some topics were basedmainly in surgery and oncology, others were much more heavily grounded in imaging. One suchtalk that really stood out for me was 'Radiomics in Rectal Cancer' given by Joost vanGriethuysen from the Netherlands. In the past decade, the field of medical image analysis hasgrown exponentially, with an increase in the number of pattern recognition tools and data setsizes. These advances have facilitated the development of processes, collectively referred to asradiomics, that allow for the extraction of quantitative features that result in the conversion ofsimple images into manipulatable data sets that can be used for evidence-based clinicaldecision support. Using oncology as an example, quantitative cross sectional image featuressuch as intensity, shape, size or volume and texture can actually offer information on things liketumour phenotype and habitat that is distinct from that provided by imaging reports, laboratorytests or assays. Whilst this may sound similar to CAD, radiomics has a much deeper potential.CAD systems have been traditionally useful in areas such a breast cancer for answering singlequestions such as 'is there a lesion/cancer?', however radiomics is designed to gather data for alarge sample size, place this data into a shared database and then potentially combine it withother information such as patient characteristics or genetic profiles in order to create and testdifferent hypotheses and ultimately improve clinical decision making. Clearly, with such broadapplications this could prove an incredibly valuable tool for the future, but it is also yet anotherstriking milestone set to highlight that our fundamental role as radiologists is going to changesignificantly in the near future.

With new knowledge havingbeen acquired and yet morepastries having been eaten,we moved towards theannex and waited to presentour poster project, whichwas based on a study lookingat the accuracy of identifyingliver metastases on limitedliver sequences performedsimultaneously during theprimary rectal MRI scan.

We used this time to absorb some of the other posters around us and with this being my firstinternational conference. I was immediately impressed by the breadth and quality of some ofthe work on show. It soon became very apparent that the majority of the top tier posters hadbeen contributed by the Netherlands. Admittedly, the conference was of Dutch origin, howeverthe overall impression was that there was a far greater emphasis placed on clinical researchthere than in the UK, where at times I have felt that audit and quality improvement projects canfeel more like box ticking than for the sake of actual improvement. Ultimately, it was a verypositive environment and quite inspiring to see doctors who were eager to engage inconversation and discuss the merits of their work standing alongside their well thought out andhighly polished posters. On our way back to the airport, my lasting impression of the conferencewas one of a group of passionate, hard working people coming together to share theirknowledge and learn from each other so that they might improve their practice at home.

European Congress of Radiology 2019 Spotlight by Dr Uzoma Nnajiuba (ST3)

Volume 3 Issue 2 Page 3

The European Congress of Radiology (ECR) 2019 took place over 5 days this year from February27th to March 3rd . The conference is the second largest radiological conference in the world afterRSNA and the largest in Europe and it certainly lived up to the billing.

As usual the conference was held in the Vienna Centre, which is a massive convention centre 15minutes drive outside of central Vienna and probably the only space big enough to host theconference in the city. The entire venue was very impressively decked out in ECR themedartwork (this year was a marine theme) from the station; along the 100m walkway leading to thecentre and outside practically every building and huge 20ft red octopus greeted you as youentered the main lobby.

For a Radiology meeting the programme was extremely varied and there were dozens of eventstaking place in different buildings at all times. There were the usual scientific sessions and handson workshops which were really useful from a clinical perspective. As well as all thetechnological exhibitions with vendors showing off anything from virtual reality devices to 3Dprinting technology and cinematic rendering.

Artificial Intelligence (AI) was of course allthe rage and had its own separate buildingthat was packed with inquisitive delegatesand vendors showing off their shiny newkit. The AIX session also took place here,which had an interesting format withdifferent AI companies standing up in frontof a packed room of Radiologists trying tosell their companies and explain how theywere better than the competition. Thatwhole area definitely had a bit of afrenzied marketplace feel.

Another interesting session that took placeand one which I was especially interestedin was the Social Media session.

The session included talks from a number of Radiologists with a strong social media presence,such as the Radiology Café founder Dr Chris Clarke. The media presence in general at ECR wasconsiderable and everywhere you looked there were TV screens beaming out interviews witheminent Radiologists. On one occasion I saw the ECR President get stopped every 5 yards as hewas walking through the main lobby so delegates could take selfies with him with their nationsflags.The “Women In Focus” session was held for the first time this year which was an event createdto celebrate the achievements of women in Radiology and other areas of medicine and science.Speakers included various heads of industry such as the President of GE Europe CatherineEstrampes and NHS National Cancer Director Cally Palmer. They mostly shared their experiencesof being a woman in senior management. It was a really thought provoking session and slightlymore provocative than you'd expect from a scientific meeting.

Other highlights of ECR included the opening and closing ceremony. These were spectacularaffairs with musicians and performers. Outside the conference there was plenty to explore in thecity of Vienna. Its a beautiful historic city with lots of amazing architecture. There are a plethoraof cathedrals architectural wonders you can visit and it's famous for it's Opera, if you're that wayinclined. Fortunately this year the weather was really mild too which was a massive relief havingheard stories of how the Danube had frozen over the year before.

ECR 2019 was a enjoyable experience. It’s impressive to see the scale of the event. I wouldrecommend it to anyone that hasn’t been and will definitely be looking to go again in future.

Mr. Philip Ward, Editor-in-Chief

AuntMinnie Europe

Interventional Radiology Training by Dr Elfadil Elmahdi (ST5)

Congratulations to all ST1s on their success in the recent FRCR Part 1 and ST4/5s on their final FRCR 2b!

Volume 3 Issue 2 Page 4

Interventional Radiology (IR) is an exciting and growing field in Radiology. I started radiology withan open mind following a short stint as an SHO in A&E on a small island off the south coast ofEngland. I found myself more and more interested in Interventional Radiology through coreradiology training and chose it as my subspecialty. What I enjoyed most about IR is the varietyand breadth of procedures. Although a full day of IR can be challenging, I found that focussingand accomplishing technical tasks and using clinical knowledge and experience didn’t just feelrewarding, it made time fly.

Currently in the Mersey region trainees declare a subspecialty on completion of their 2aexaminations. Year 4 and 5 are spent doing a mix of diagnostic and interventional radiology. TheLiverpool IR on calls start part way through fifth year.

Difficulties in training include exposure to certain emergency procedures. Unlike diagnostics, IRcan be unpredictable and thus exposure to procedures such as embolization can be haphazard.Thankfully there are many transferable skills from routine procedures such as Trans arterialChemoembolization (TACE) and Testicular vein embolization. Training in IR is like anapprenticeship in which you learn from working with consultants on a one-on-one basis withimmediate feedback on performance. The difficulties with this is that training is self directed.Although the RCR provide a syllabus for IR training, this is assessed indirectly through Mini-ipxsand DOPs assessments.

Currently there is no exit examination for IR in the UK. Having said this there is a Europe widecertificate known as the European Board of Interventional Radiology (EBIR). This is a voluntarywritten examination designed to test both the technical and clinical knowledge in IR. Theimportance of this examination for a UK based radiologist is debateable and depends on yourcircumstances. If you plan to work outside the UK, particularly within the EU, this can beextremely useful as an objective demonstration of your knowledge, much like the FRCRfellowship. However without delving into the current climate of political uncertainty, working inthe EU is less plausible for most of us in the immediate future. Also British IR training isrecognise in both Canada and Australia for post CCT fellowships. It can be argued that sitting theexam during your final years of IR training provides academic rigour and motivation to keep upto date with the current literature in IR. However most of us on completion of the FRCR find itvery hard to motivate ourselves to again take on further post-graduate examinations. In any casethere is current discussion on the introduction of a UK based exam.

If you are a junior trainee thinking about interventional radiology there are a few things you cando to develop your skills early on. Also if you have no interest in IR these skills are still valuableas diagnosticians who can intervene are highly employable (this cannot be outsource) and insome centres vital. Be keen and show up on time to your session. Make notes on the steps ofprocedures you are involved in. Then next time you scrub impress the consultant by handingthem the wire/catheter/etc before they ask for it. Once you know the procedure, ask if you canperform the next procedure. They can only say no. It shows that you are interested and keen.Keep a separate logbook of procedures you have been involved in with comments on whetheryou were the first operator, assistant or observer. Although you may have not performed aprocedure, demonstrating that you’ve observed it 47 times is still useful.

Many trainees start radiology with an interest in IR but this interest quickly subsides. This is dueto a combination of life circumstances, the onerous on calls and relatively little scope for privatework. This may seem bleak but IR can have a transformative impact on patient care; It canshorten a prolonged hospital stay and even make a difference between life and death for somepatients.

The First Northwest School of Radiology Summer Ball 2019

Volume 3 Issue 2 Page 5

Northwest School of Radiology

Summer Ball The Midland, Manchester

Saturday 8th of June

Dinner | Dancing | Entertainment

For all registrars and consultants

Partners welcomed

Tickets £60 pp

RSVP and pay by May 1st

nwsorsummerball@gmail.com

See you there!

Volume 3 Issue 2 Page 6

RSNA 2018by Dr Linda Stephens (ST5)

Each year the annual meeting of the Radiological Society of North America is held at McCormickPlace in Chicago, Illinois. It is the largest scientific meeting for radiologists in the world withmore than 50,000 delegates attending each year.I remember, as a junior trainee, being told by one of the senior trainees to go to RSNA as it is afantastic educational opportunity. So, I went on a mission to find a project to present andsubmitted a poster ‘From Mucous to Malignancy: A Pictorial Review of Paediatric Skull BaseLesions Involving the Sphenoid Bone’ with Dr Neville Wright. Happily, it was accepted, and I waspart way on my journey to Chicago.

Finally, the first day had come. On the walk up to theconvention centre, I was pretty overwhelmed by thesize of the place. McCormick Place Is the largestconvention centre in North America, consisting of 4interconnecting buildings and an arena, hence it canbe difficult to find your way around. If you aremeeting people, ensure that you specify a time andplace as you may not cross paths otherwise! Pick up amap as soon as you register too! Other useful items

to collect are the specialty specific programmes for the conference which makes it much easierto plan your personal calendar for the duration of the conference.

This year the focus of the meeting was “Tomorrow’sRadiology Today”. There was an emphasis onartificial intelligence and the implications of AI onradiology. Precision medicine innovations and thecritical role of imaging in addiction treatment werealso a focus of the meeting as was machine learningand 3D printing. A new IR zone for those interestedin Interventional radiology was also a great newaddition. The technical exhibition hall was immense.The variety of exhibits and new and excitingtechnology was incredible, really interesting to see.

There are a huge variety of presentations related to all radiological subspecialties, scientificsessions as well as instructional and educational presentations. Multiple focused sessions onradiological emergencies were particularly useful for trainees, as were the case based reviewsessions that were interactive in which you logged on to a voting application to post youranswers. These would be particularly useful for those doing the FRCR 2B examination as thecases were often ones that you could see in the examination. Industry provided sessions werealso useful such as presentations on contrast enhanced ultrasound as were the hands-onsessions.Between sessions there was ample opportunity to meet people and enjoy some of theentertainment which included a live band every lunchtime. There was even a photo booth andan RSNA Shop where you could purchase RSNA merchandise. An entire hall dedicated to posterand digital presentations was a great place to go between sessions as the standard of exhibitswas very high. There was also a dedicated trainee area which was also a great place to meetpeople and enjoy some refreshments.I also stayed a couple of extra days in the city after theconference and had a great time exploring. The ArtInstitute of Chicago was incredible, and I would highlyrecommend going on an architectural walking tour of thecity as there are so many unusual and beautiful buildings.Chicago is also a great place for sports fans, watch baseballat Wrigley Field, catch a Chicago Bulls basketball game or aChicago Blackhawks ice hockey game.

Overall, I had a fantastic time. Attending RSNA is a must do for all radiologists and I would highlyrecommend doing this as a trainee, and do not forget to explore this amazing city too!Attending the meeting before sitting the FRCR 2B is a great idea as there are so manyeducational opportunities that are exam focused. A last word of advice be prepared for the coldweather!

Volume 3 Issue 2 Page 7

Perspective on the role of Clinical Director: An Interview with Dr Rob Hawkes, Consultant Paediatric Radiologist and Clinical Director,

Department of Paediatric Radiology, Royal Manchester Children’s Hospital

the consultant body with 2 recent consultant appointments which is exciting. We also haveapproximately 25 radiographers in the team, with several newly appointed radiographersstarting in the next few months. Our resources include a CT scanner, MRI scanner, severalultrasound machines, screening rooms and plain radiography rooms. We also work closely withthe Nuclear Medicine department providing a wide range of examinations.

As Clinical Director, what are your main responsibilities?My main responsibility is to oversee the day to day running of the department working closelywith the Departmental Clinical Manager, with a main focus on managing the radiologistworkforce. Within this role it is important that I ensure that the trust vision and values are afocus in our day to day practice and to diffuse this down to the rest of the department. Otherresponsibilities include ensuring that the consultant body are up to date with regards to theirmandatory training and continuous professional development including the appraisal process.Job planning is another key component of the role and is a challenge to balance radiologist’sskills with the service requirement ensuring that a radiologist has an interesting and varied jobplan while ensuring that service requirements are fulfilled. I also receive great support from mydeputy clinical director who manages the daily rota, on call rota and leave requests. I also havea number of coordinating roles in conjunction with the Departmental Clinical Manager. Wemeet on a daily basis to highlight potential risks within the department for that day, for examplestaff shortages or equipment problems, and instigate strategies to modify that risk. Thisfacilitates communication within the department and allows me to keep the consultant body upto date with any problems. I also have a role in strategic planning within the department andwithin the Clinical Scientific Services, our division within the trust. On a weekly basis, I attend atwo-hour strategic meeting with the medical director of CSS and the Clinical Manager ofDiagnostic Imaging within the trust, which includes adult radiology and nuclear medicinerepresentatives.

What are the main challenges that you have encountered while in this role?One of the main challenges is providing a high-quality service to patients within a timelymanner while faced with ageing equipment and continued budgetary constraints. We areexperiencing an increase in demand for all our services and increasing pressure from cliniciansto reduce our reporting turnaround time. Our aim is to provide examinations and reports asquickly as possible, however, we do not always meet the expectations of service users, bothpatients and clinicians, and this is when the complaints come in.Another challenge is managing the consultant body and matching their skills and requirementsto service needs. One has to ensure that service provision is maintained but also consultantsneed to be allowed to pursue their particular subspecialty interest to ensure that they arefulfilled and remain engaged within the department.

Thank you for agreeing to take part in thisinterview. I understand that you are the ClinicalDirector of the Department of PaediatricRadiology at Royal Manchester Children’sHospital. So, could you tell me a bit about yourdepartment please?We are one of the biggest paediatric radiologydepartments in the country, providing primary andsecondary care to a large proportion of the childrenof Greater Manchester and we also provide tertiaryand quaternary level care for the region of theNorth West and beyond. We currently have 6 fulltime Consultant Paediatric Radiologists, 2 full timeConsultant Paediatric Neuroradiologists, andseveral consultant radiologists that provide regularcontribution to the workforce with 2 sessions in thedepartment per week. We are currently expanding

Volume 3 Issue 2 Page 8

Perspective on the role of Clinical Director: An Interview with Dr Rob Hawkes, Consultant Paediatric Radiologist and Clinical Director,

Department of Paediatric Radiology, Royal Manchester Children’s Hospital

What do you find most enjoyable and rewarding about the role?I like being able to plan and genuinely have an impact on the future development and directionof the department, and which consultant colleagues are going to join the team. Before I took onthis role, I thought that recruiting staff was heavily points driven and that if you said the rightthings, you scored the points and that determines the colleague that you work with. However,your experience of working with a colleague or the impression you get from interactions withthem prior to the interview can have a significant impact on decision making, as long as theinterviewee performs well on the day! Recruiting great colleagues is a really nice way to be ableto shape and mould the department and I think that we have achieved this over the last fewyears as we have a consultant body that works very well together and supports each other.

So, who are the most important members of your team?The main people are the Departmental Clinical Manager who I work closely with on a daily basisand have a great relationship with. I also work very closely with all the consultants, particularlythe deputy Clinical Director and my immediate boss, the Medical Director of the Division. It isextremely important that I meet with her on a regular basis. There is a lot of support thatcomes higher up within the division, particularly in this trust. Having worked previously foranother trust, I have found that the support is really useful here and much more structured.

Can you tell me about any interesting projects that you have been involved in during yourrole as Clinical Director?So, our biggest undertaking at the moment is the Intraoperative MRI scanner project. We havejust managed to raise £6,000,000 to fund the project, £2,000,00 more than our target, which isfantastic. I think that whenever the public are asked to contribute to these projects that focuson children with cancer, it really brings out people’s generosity. We are currently going throughthe procurement process at the moment. This project is going to revolutionise the care ofchildren with brain tumours and will free up capacity so that we can get more scanningperformed under general anaesthetic. Another big part of the job is procuring the rightequipment. A looming challenge for us at the moment is that all our equipment is 10 years oldas the department was built 10 years ago. So, we will have to procure everything, ultrasound,CT, MRI.

How does the CD role impact on your role as a Consultant Paediatric Radiologist?Well, you have to be flexible as problems can occur at any time, even when you are doingclinical work. You have to be very flexible with your timetable and it is great that I have verysupportive colleagues who can step in to cover if needed. For instance, I have to attend arandom 2 hour meeting this morning, which was not scheduled, and I have never been to itbefore, and I am meant to be reporting. As long as my colleagues understand that and supportme, I can attend these meetings. And you have to have a pretty flexible job plan which meansthat I have more reporting sessions than other people so this means that I can flex in and out sothat I can attend meetings and things. If you have a fixed list things get more tricky. It certainlyhas made me a better radiologist and has given me more in-depth appreciation of the criticalimportance of governance and I know what is high in the departmental agenda.

What is the best advice that you can give to someone taking on the Clinical Director role forthe first time?It is important to know the structure of your hospital, the management structure and wheredecisions are made. This knowledge comes with time and involvement in management withinthe trust and really things often only become clear when you take on the role. It is importantnot to be scared of it, because if you have the right support at a level higher up and supportwithin the department, then you get through things together and you find the right way. It is abit like an MDT, you are never on your own making decisions, it is always a committee decision.You may think that the CD has to make a lot of decisions, but this is not the reality. It is reallyuseful to get involved in management as trainees, and as CD, I would be very open to traineesattending meetings and getting involved so that they can see how things work.

Dr Hawkes, thank you for answering all these questions, it has been very informative.

Volume 3 Issue 2 Page 9

An Unusual Pathology Causing EncephalopathyStephens L, Pavaine J, Tang V

Department of Paediatric Radiology, Royal Manchester Children’s Hospital.

A 6 year old girl presented to the emergency department after being found unresponsive by herparents. This was on a background of recent illness with pyrexia over the preceding 4 days.During admission she demonstrated abnormal behaviour and had focal seizures. She went on torequire intubation and ventilation and PICU admission.

Selected MRI Head images are included below.

Axial T2WI Axial T2WI Axial T2WI

Coronal FLAIR Axial T1WI SWI

DWI ADC Post contrast T1WI

Questions:

Describe the salient findings on MRI.

Formulate a differential diagnosis for the above changes considering the clinical history that you have been provided with.

Answers are on the following page

Volume 3 Issue 2 Page 10

An Unusual Pathology Causing EncephalopathyStephens L, Pavaine J, Tang V

Department of Paediatric Radiology, Royal Manchester Children’s Hospital.

Answers:

Salient features:

Bilateral symmetric changes are seen in the basal ganglia, thalami and brainstem. T2/FLAIR hyperintensity in the subinsular regions with involvement of the external capsule and posterolateral putamina, thalamocapsular regions, hippocampal structures and in the midbrain and pons. These regions are T1 hypointense and demonstrate restricted diffusion. T2/FLAIR hyperintensity is more extensive than the amount of restricted diffusion in keeping with associated vasogenic oedema. There is vague thin peripheral enhancement around the areas of restricted diffusion in the thalami bilaterally. Multiple microhaemorrhages are also evident in the thalami.

There was no evidence of venous sinus thrombosis or arterial occlusion (images not provided).

Differential Diagnosis:

Acute Necrotising Encephalopathy of Childhood (ANEC)HSV encephalitisAnti NMDA receptor encephalitisDemyelination (ADEM and variants)Metabolic conditions, particularly Leigh Syndrome

Diagnosis:

Acute Necrotising Encephalopathy of Childhood (ANEC), confirmed mutation in RANBP2 gene.The aetiology and pathogenesis of this disease remain unknown. Although influenza A virus, mycoplasma, herpes simplex virus, and human herpes virus-6 have been reported as common causative agents, it is now believed that this disease is most likely immune-mediated or metabolic. The clinical course of ANEC is fulminant, with a rapid onset of convulsions, impaired consciousness, vomiting, and variable degrees of hepatic dysfunction. Affected patients have high mortality and severe neurologic sequelae.

Recommended reading:

Ho VB, Fitz CR, Chuang SH, Geyer CA. Bilateral basal ganglia lesions: pediatric differential considerations. Radiographics. 1993 Mar;13(2):269-92.

Bekiesinska-Figatowskaa M, Mierzewskab H, Jurkiewiczc E. Basal ganglia lesions in children and adults. European Journal of Radiology 82 (2013): 837–849.

Wong AM, Simon EM, Zimmerman RA, Wang HS, Toh CH, Ng SH. Acute Necrotizing Encephalopathy of Childhood: Correlation of MR Findings and Clinical Outcome. American Journal of Neuroradiology October 2006, 27 (9) 1919-1923.