EUROPEAN TRAINING CHARTER FOR CLINICAL RADIOLOGY ...

EUROPEAN TRAINING CHARTERFOR CLINICAL RADIOLOGYEuropean Associationof RadiologyRadiology Section ofthe Union of EuropeanMedical SpecialistsDETAILED CURRICULUM FORTHE INITIAL STRUCTUREDCOMMON PROGRAMMEDETAILED CURRICULUM FORSUBSPECIALTY TRAININGEuropean Association of Radiologywww.ear-online.org

EAR EXECUTIVE BUREAUProf.Dr. N. GourtsoyiannisPRESIDENTProf.Dr. I.W. McCallVICE-PRESIDENTProf. Dr. G. FrijaSECRETARY-GENERALProf. Dr. L. BonomoTREASURERProf.Dr. P.A. GrenierEDUCATIONDr. B. SilbermanPROFESSIONAL ORGANISATIONProf.Dr. G.P. KrestinRESEARCHProf. Dr. J.I. BilbaoSUBSPECIALTIESProf. Dr. A. PalkóNATIONAL MEMBERSProf.Dr. A.L. BaertEUROPEAN RADIOLOGYProf. Dr. A. ChiesaECR CHAIRMANTABLE OF CONTENTSPreface 1European Training Charterfor Clinical Radiology 2 - 10Detailed Curriculum for theInitial Structured Common Programme 11 - 44Breast 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 42-44Detailed Curriculum for Subspecialty Training 45 - 84Breast 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 79-84Vienna, November 2005Coordination: Isabella Grabensteiner, EAR Office, ViennaGraphics: ECR graphic_link / a department of ECREAR OFFICENeutorgasse 9/2a / AT-1010 Vienna, AustriaTel +43 1 533 40 64 - 33 / Fax +43 1 535 70 37office@ear-online.orgwww.ear-online.org© all rights reserved by theEUROPEAN ASSOCIATION OF RADIOLOGY (EAR)

PrefacePrefaceThe 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 knowledgeand 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 clinicalspecialists. 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 enhancethe service provided by the group of general radiologists.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 focussedin order to obtain the necessary knowledge andskills. 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 subspecialisationparticularly 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 knowledgeand competence have been addressed and obtained.The first curriculum covers the initial structuredtraining programme. The second provides guidance forthose wishing to spend their career working predominantlyin one organ-based subspecialty area. The subspecialtycurricula 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 trainingprogramme and the subspecialties have been developedby 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 detailedcurricula will provide a valuable template for trainingradiologists and will enhance the quality of care for patientsthroughout Europe. EAR hopes that the documentswill also be helpful for National Societies in their discussionswith governments to ensure a high-quality, five-yeartraining programme in every European country.Professor N. GourtsoyiannisEAR PresidentProfessor I.W. McCallEAR Vice-PresidentProfessor P.A. GrenierEAR Education Committee Chairmanwww.ear-online.org 1

European Training Charter for Clinical RadiologyEuropean Training Charterfor Clinical RadiologyIntroduction: Radiology is a medical specialty involvingall aspects of medical imaging which provide informationabout the anatomy, pathology, histopathology and functionof disease states. It also involves interventional techniquesfor diagnosis and minimally invasive therapyinvolving image-guided systems. The duration of trainingis five years.Contents:1. Core of knowledge2. Training programmes3. Training facilitiesArticle 1CORE OF KNOWLEDGE1.1 Basic sciencesa. Radiation physics;b. Radiobiology;c. The physical basis of image formation includingconventional x-ray, computed tomography,nuclear medicine, magnetic resonanceimaging and ultrasound;d. Quality control;e. Radiation protection;f. Anatomy, physiology, biochemistry and techniquesrelated to radiological procedures;g. Cell biology, DNA, RNA, and cell activity;h. Pharmacology and the application of contrastmedia;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 radiology.1.3 Current clinical practiceA basic knowledge of current clinical practice asrelated to clinical radiology. Competence in producinga radiological report and in communicationwith 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. cardiac,chest, dental, oto-rhino-laryngology,gastrointestinal, genito-urinary, mammography,musculoskeletal, neuro, obstetric andvascular radiology, including the applicationof conventional x-rays, angiography, computedtomography, magnetic resonance imaging,ultrasound and, where applicable,nuclear medicine.b. Age-based specialties, i.e. paediatric radiology.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 departmentwith multi-disciplinary staff and high-costequipment.1.6 ResearchA knowledge of basic elements of scientificmethods and evidence base, including statisticsnecessary for critical assessment and understandingof published papers and the promotionof personal research.1.7 Medico-legalAn understanding of the medico-legal implicationsof radiological practice. An understandingof uncertainty and error in radiology togetherwith the methodology of learning from mistakes.Article 2TRAINING PROGRAMMES2.1 The specialty of radiology involves all aspects ofmedical imaging, which provide informationabout morphology, function and cell activity andthose aspects of interventional radiology or minimallyinvasive therapy (MIT), which fall under theremit of the department of radiology.2 www.ear-online.org

European Training Charter for Clinical Radiology2.2 Clinical experience. Radiologists are cliniciansand require a good clinical background in otherdisciplines. This is usually achieved through clinicalexperience and training prior to entering radiology,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 requiresufficient 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 radiologicalskills required in a general or communityhospital 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 respectivesystem-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 systems,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 recognisedthat the starting date for radiological trainingprogrammes will vary throughout Europe.2.7 The precise structure of the system-based modulesmay vary a little from country to country andfrom department to department, but the time balanceshould reflect the importance of the systemto the core of radiological practice.2.8 The training programme in years one to three2.8.1 Early in this three-year period, trainees shouldacquire the necessary knowledge of the basicsciences, i.e. the physical basis of image formationin all imaging modalities, picture archivingcomputer systems (PACS), radiology and hospitalinformation 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 understandingof computer science as outlined in thecore of knowledge for general radiology.2.8.2 The radiology training should ensure the understandingand 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 formulatedinto 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 musculoskeletalsystem, thorax and cardio-vascular systems,gastrointestinal system includingparenchymal organs, central nervous systems includinghead 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 departmentof 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 processingand archiving,www.ear-online.org 3

European Training Charter for Clinical Radiology- Fluoroscopy,- Ultrasound,- Computed tomography,- Magnetic resonance imaging,- Radionuclide imaging where possible. All radiologytrainees should have a knowledge oftechniques available and diagnostic featuresof the studies.2.8.6 The first three years of the five-year training programmeshould include the following elements:- Chest diseases- Central nervous system- Musculoskeletal system- Gastrointestinal system including the hepatobiliarysystem- Urogenital system- Paediatrics- Cardiac diseases- Head and neck, maxillo-facial and dentalradiology- Obstetrics and gynaecology- Breast diseases- Endocrine system- Vascular and lymphatic system- Oncology- Emergency department radiology- Basic interventional techniques2.8.6 The trainee should be involved in the radiologicalexamination and diagnosis of patients presentingin the emergency department and be able to appropriatelyevaluate 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 period.The trainees should be closely supervised bya fully qualified radiologist. Some detailed curriculafor the use of trainers and trainees are presentedon pages 11-44.MusculoskeletalCore knowledge- Musculoskeletal anatomy, normal skeletalvariants 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 relevance- Manifestations of musculoskeletal infection,inflammation and metabolic diseases includingosteoporosis and bone densitometry- Recognition and management of tumoursCore skills- Reporting plain radiographs, radionuclide investigations,CT and MR of common musculoskeletaldisorders- Performing and reporting Ultrasound examinationsof 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 proceduresof the musculoskeletal systemThoraxCore knowledge- Anatomy of the respiratory system, heart andvessels, mediastinum and chest wall on radiographs,CT and MR.- Recognise and state significance of genericsigns on chest radiographs- Features on radiographs and CT and differentialdiagnosis of atelectasis, diffuse infiltrativeand alveolar lung disease, airways and obstructivelung 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 diagnosis4 www.ear-online.org

European Training Charter for Clinical Radiology- Abnormalities of the chest wall mediastinumand pleura and including the post operativechest and traumaCore skills- Managing and reporting radiographs, chestradiographs, 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 thoraxGastrointestinalCore knowledge- Anatomy of the abdomen including internalviscera, 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, haemorrhage,inflammation, infection, obstruction,ischaemia and infarction on radiographs, ultrasoundand 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 unresectabilityand knowledge of the role of endoscopyand 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 angiography,vascular interventional techniques,stenting and porto-systemic decompressionproceduresCore skills- Performance of plain film reporting- Performing and reporting contrast examinationsof the pharynx, oesophagus, stomach,small and large bowel- Performing and reporting trans-abdominal ultrasoundof the gastrointestinal system, abdominalviscera and their vessels- Managing and reporting CT of the abdomen- Understanding and where possible and appropriateobservation and experience oftransrectal, transvaginal and endoscopic ultrasound- Performing US and CT guided drainage andbiopsy- Experience of the manifestations of abdominaldisease on MRI- Understanding and, where appropriate, experienceof radionuclide investigations of the GItract and abdominal organs- Observation of angiography and vascular interventionaltechniquesNeuroradiologyCore knowledge- Knowledge of the normal anatomy and normalvariants of the brain, spinal cord andnerve roots- Understanding the rationale for selecting certainimaging modalities, and the use of contrastenhancement, in diagnosing diseases ofthe central nervous system- Imaging features on CT and MR and differentialdiagnosis of stroke, haemorrhage, andother vascular lesions of the brain and spinalcord and of the application of CT and MR angiography- Diagnosis of skull and spinal trauma and itsneurological sequelae- Imaging features and differential diagnosis ofwhite matter disease, inflammation and degeneration- Diagnosis of benign and malignant tumoursof the brain, spinal cord and cranial nerves- Understanding the role of nuclear medicineincluding PET in neurological disordersCore skills- Reporting radiographs of the skull and spine- Managing and reporting cranial and spinalCT and MR- Observation of cerebral angiography- Observation of carotid ultrasound includingDoppler- Observation of interventional procedureswww.ear-online.org 5

European Training Charter for Clinical RadiologyUrogenitalCore knowledge (See also obstetrics and gynaecology.)- Knowledge of the normal anatomy of the kidneys,ureters, bladder and urethra includingnormal variants- Knowledge of the normal anatomy of theretroperitoneum, female pelvis and male genitaltract- Understanding of renal function, the diagnosisof renal parenchymal diseases includinginfection and renovascular disease includingmanagement of renal failure- Imaging features and appropriate investigationof calculus disease- Investigation and features of urinary tract obstructionand 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 testisCore skills- Reporting radiographs of the urinary tract- Performing and reporting intravenousurograms, retrograde pyelo-ureterography,loopogram, nephrostograms, ascending urethrogramsand micturating cysto-urethrograms- Performing and reporting transabdominal ultrasoundimaging of the urinary tract andtestis- Managing and reporting computed tomographyand MR imaging of the retroperitoneum,urinary tract and pelvis- Observing nephrostomies, image guidedrenal biopsies and angiography as applied tothe urinary tract- Radiological and echocardiographic featuresand causes of cardiac enlargement includingacquired valvular disease- Diagnosis of ischaemic heart disease includingradionuclide imaging and coronary angiography- Diagnostic features of vasculitis, atheroma,thrombosis and aneurysmal dilatation of arteriesand veins- Radiological and ultrasound diagnosis ofpericardial diseaseCore skills- Reporting radiographs relevant to cardio-vasculardisease.- Femoral artery and venous puncture techniques,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 thevascular system including image manipulationPaediatricCore knowledge- Normal paediatric anatomy and normal variantswith particular relevance to normal maturationand growth- Disease entities specific to the paediatric agegroup and their clinical and radiological manifestationsusing all modalities- The value and indications for ultrasound, CTand MR in children- Disorders and imaging features of theneonate- Understanding the role of radionuclide imagingin paediatricsCardiac, vascular and lymphaticsCore knowledge- Normal anatomy of the heart and vessels includinglymphatic system as demonstrated byradiographs, echocardiography and doppler,contrast enhanced CT and MR- General principles and classification of congenitalheart disease and the diagnostic featureson conventional radiographs- Natural history and anatomic deformitiescausing central cyanosisCore skills- Reporting conventional radiographs in the investigationof paediatric disorders- Performing and reporting ultrasound of theabdomen, head and musculoskeletal systemin the paediatric age group- Performing and reporting routine fluoroscopiccontrast studies of the gastrointestinal systemand urinary tract- Managing and reporting CT and MR examinations6 www.ear-online.org

European Training Charter for Clinical RadiologyHead and neckCore knowledge- Normal anatomy and congenital lesions ofthe head and neck including paranasal sinusesoral cavity, pharynx and larynx, inner ear,orbit, teeth and temporo-mandibular joint- Manifestations of diseases and the investigationof the eye and orbit including trauma, foreignbodies, inflammation and tumours- Diagnosis of faciomaxillary trauma and tumoursand disorders of the teeth- Diagnosis of lesions and abnormal function ofthe temporomandibular joint- Diagnosis of disorders of the thyroid, parathyroidand salivary glands including hypo andhyperactivity and tumours and awareness ofthe role of radionuclide imaging- Imaging features of trauma, inflammation, infectionand tumours of the paranasal sinuses,oral cavity, larynx and pharynx- Understanding the role of US and CT guidedpunctures of salivary glands, lymph nodesand thyroidCore skills- Reporting radiographs performed to showENT/dental disease- Performing and reporting fluoroscopic examinationsincluding barium swallows, sialographyand dacrocystography- Performing and reporting ultrasound evaluationof the neck including thyroid, parathyroidand salivary glands- Managing and reporting CT and MR of neck,ear, nose, throat and skull base disordersBreastCore knowledge- Normal anatomy and pathology of the breastrelevant to clinical radiology- Understanding of the radiographic and ultrasoundtechniques employed in screening anddiagnostic mammography- Diagnosis of both benign and malignant abnormalitiesin the breast- Understanding current practice in breast imaging,breast interventions and screening forbreast cancer- Awareness of the role of other techniques forbreast imagingCore skills- Mammography and ultrasound reporting ofcommon breast diseases- Observation of interventions especially forbiopsies and localisationsGynaecology and obstetricsCore knowledge- Normal anatomy of the female reproductiveorgans and physiological changes affectingimaging- Changes in foetal anatomy during gestationand the imaging appearances of foetal abnormalities- Imaging features of disorders of the ovaries,uterus and vagina as demonstrated on ultrasound,CT and MR- Awareness of the applications of angiographyand vascular interventional techniquesCore skills- Reporting radiographs performed for gynaecologicaldisorders- Performing and reporting trans-abdominaland, where possible, endo-vaginal ultrasoundexaminations in gynaecological disorders- Observing and, where possible, performingobstetric ultrasound- Managing and reporting CT and MR in gynaecologicaldisordersOncologyCore knowledge- Familiarity with tumour staging nomenclature- Application of all imaging and interventionaltechniques in staging and monitoring the responseof tumours to therapy- Radiological manifestations of complicationsin tumour managementCore skills- Reporting radiographs performed to assesstumours- Performing and reporting ultrasound, CT, MRand, where possible, radionuclide examinationsfor staging and monitoring tumours2.8.9 Trainees should become familiar with clinicalproblems presenting in the emergency departmentand be able to manage the appropriate im-www.ear-online.org 7

European Training Charter for Clinical Radiologyaging of cases in acutely ill or traumatised patients.2.8.10 An assessment process should be instituted duringthe 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 scientificthesis 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 rotationshould be maintained during the trainingperiod. Such a log-book might include the numberof clinical examinations performed.It is recommended that personal guidance andcontinuous assessment should be provided by anominated tutor.2.9 Fourth and fifth year of training2.9.1 In the fourth and fifth year the rotations of the radiologistin training should be organised to servethe individual’s needs, dependent on the availabilitywithin 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, knowledgeand 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 extendedperiod 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 completedduring the fourth and fifth year. For those subspecialtieswith 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 regulations.2.9.5 Some subspecialty training may extend beyondthe fifth year depending on national trainingarrangements relevant to their specialist programme.2.10 Course participationAttendance 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 permissibleas part of the overall training programme.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 undertakea research project during their training,even if they do not have a dedicated period of research.This is particularly valid for those undertakingsubspecialty training.Article 3TRAINING FACILITIES3.1 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 knowledgeto enable the trainee on completion of thetraining period to be able to work independentlyas a qualified radiologist at radiological departmentsin hospitals, out-patient departments andprivate practice.8 www.ear-online.org

European Training Charter for Clinical Radiology3.1.2 As previously indicated formal trainee appraisaland assessment during the period of specialisttraining should be performed in order to verifythat the appropriate training has been undertakenand 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 character3.1.3 Health-care systems in individual Europeancountries differ for a variety of reasons, which includeadministration, management, equipment,budgeting and tradition. In spite of these differences,recommendations for training facilities forspecialisation in general radiology can be defined.The practical implementation of these recommendationsmust be left to the respectivecountries.3.2 Requirements for fully accredited training departments3.2.1 The status of a training department can be specifiedin the following ways:a. Quantity and distribution of radiological examinations,b. Standards of equipment,c. Availability of modalities,d. Staffing,e. Teaching programme of the radiological department,f. Teaching materials,g. Research activity.3.3 Quantity and distribution of radiological examinations3.3.1 Patient material should be varied enough to enablethe trainee to gain experience in all fields ofclinical radiology. This requires a radiological departmentsituated in a large polyvalent hospital.However, some attachments may be in small orspecialist hospitals providing expert teaching inspecific parts of the curriculum. All training departmentsshould have access to expert pathologyservices.3.3.2 The number of radiological examinations peryear should be sufficient to enable a comprehensiveexperience of general radiology.3.4 Standard of equipment3.4.1 Only departments with adequate imaging equipmentand services should be approved.3.4.2 The equipment should fulfil radiological safetystandards and be in good technical condition.Technical efficiency, security, electric control, radiationsafety and control should be of adequatestandard and fulfil agreed quality control criteria.3.4.3 Radioprotection should be organised and radiationmonitored 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 modalities3.5.1 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 (cooperationwith other radiological training departmentsmay be necessary).3.5.3 Access to nuclear medicine is desirable.3.6 Staffing structure3.6.1 The number of qualified radiologists with teachingfunctions in the department should be sufficientto 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 diversifiedand cover the main areas of activity.3.6.3 Teaching staff should have training in teachingmethods.www.ear-online.org 9

European Training Charter for Clinical Radiology3.7 Teaching programme3.7.1 There must be an approved and structured continuingteaching 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 reviewradiological errors should be undertaken.3.7.3 Radiological and clinico-radiological conferences,seminars and training courses outside thehospital are recommended.3.8 Teaching facilitiesAppropriate demonstration equipment and roomsshould be available in the department of radiology,sufficient to enable the teaching programmeto be implemented.3.9 Teaching material3.9.1 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, ultrasonography,computed tomography, magnetic resonanceimaging, mammography). Adequatetextbooks in imaging physics and pertinent materialconcerning radiation protection should beavailable.3.10.2 There should be an active and ongoing researchand audit programme at the training departmentand trainees should be encouraged to participate.3.11 Partition of radiological training in university,teaching and non-university hospitals3.11.1 Part of the training may be at acknowledged andaccredited non-university hospitals, or privatepractices that have been appropriately accredited,but some should be carried out at universitydepartments. The non-university componentshould provide training at least in general radiology,and may provide some sub-specialty trainingwhich would supplement that provided in the universitydepartments. The composition of the patientmaterial needs to be taken into account inselecting all hospitals concerned with teaching.3.11.2 All the university departments and training hospitalsshould 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 RadiologicalSocieties, National Health InsuranceFunds etc.) and regional and local authorities,teaching centres and local hospital administrationsetc.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 library.3.9.4 Computer technology for teaching, research purposes,image processing and communication ishighly desirable.3.10 Research and Audit3.10.1 The importance of radiological research andaudit for the training of radiologists should be emphasised.10 www.ear-online.org

Detailed Curriculum for the Initial Structured Common ProgrammeDetailed Curriculum for the InitialStructured Common ProgrammeThis 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 organbasedsections 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 morphology,function and cell activity and those aspects of interventionalradiology 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 radiologyis 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 radiologistand to facilitate subspecialty training. General radiologytraining in the fourth and fifth years is designed toenable the trainee to acquire further experience, knowledgeand skills in disorders present in general hospitalsand private practice in order to reach a level required toundertake autonomous practice. The fully trained radiologistshould be capable of working independently whensolving the majority of common clinical problems.Breast Radiology1 - INTRODUCTIONThe 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 desired).It will also provide transferable skills that will equipthe trainee for working as a specialist in any branch of radiology.Physics and radiation protection are covered in separatecourses and are not covered in detail unless specific tobreast imaging.2 - CORE OF KNOWLEDGE2.1. 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 techniques.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 imagingtechniques in this specific field, such asUS, MRI, or radionuclide imaging.2.8. Knowledge of the indications and contraindicationsof FNA and core biopsy and their relativeadvantages and disadvantages.www.ear-online.org 11

Detailed Curriculum for the Initial Structured Common Programme2.9. Appearances of cancer and common benign diseaseon- 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 SKILLS3.1. 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 assistancein interpreting and reporting breast images.3.4. To be able to perform interventional breast proceduresunder ultrasound and X-ray control undersupervision.3.5. To be able to communicate with patients explainingthe nature of benign breast disease, givingand observing ‘breaking bad news’.4 - CONFERENCESAs 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 - INTRODUCTIONCardiac radiology is an important and rapidly developingfield in radiology. The use of cardiac imaging has progressedover the last decade to involve all modalities in diagnosticradiology. 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 implicationsof these techniques. The heart is not an isolatedorgan, and it is equally important that the relationship betweenthe heart and the cardiovascular and cardiopulmonarysystems are understood.2 - CORE OF KNOWLEDGE2.1. Basic knowledgeThe principle is to acquire:2.1.1. Basic clinical, pathological, and pathophysiologicalknowledge in cardiovascular disease.2.1.2. An understanding of the principles and practiceof screening techniques and risk factors in cardiacdisease.2.1.3. Knowledge of:- The indications, contraindications and potentialhazards (especially radiation hazards) ofprocedures and techniques relevant to cardiovasculardisease- Cardiovascular anatomy in clinical practicerelevant to clinical radiology- Normal variants, which may mimic disease- Manifestations of cardiovascular disease includingtrauma as demonstrated by conventionalradiography, CT, MRI, angiography,radionuclide investigations and ultrasound- Differential diagnosis relevant to clinical presentationand imaging appearance of cardiovasculardisease- Calcium scoring- Relevant embryological, anatomical, pathophysiological,biochemical and clinical aspectsof cardiac disease2.1.4. Knowledge and management of procedural complicationsin cardiac treatment and diagnosis.12 www.ear-online.org

Detailed Curriculum for the Initial Structured Common Programme2.1.5. An understanding of the various treatmentmodalities for cardiac disease and their relationshipto cardiac imaging.2.2. Knowledge in clinical cardiac radiologyThe 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 coronarysyndromes- Myocardial ischaemia- Myocardial infarction- Post myocardial infarction syndrome- Ventricular aneurysm- Coronary calcium- Coronary disease in women and specificcoronary disease patterns in different communities- Heart disease in the elderly2.2.2. Valve disease- Stenosis and incompetence of cardiac valves- Endocarditis- Sub and supra-valvar disease- Subvalvar apparatus disease2.2.3. The pericardium- Tamponade and restrictive disease- Acute pericarditis- Tuberculous disease- Malignant pericardial disease2.2.4. Cardiac tumours- Intracardiac tumours, i.e. myxomas, haemangiomas,and sarcomas- Secondary tumours- Tumours invading the heart2.2.5. Cardiomyopathy- Acute myocarditis- Dilated cardiomyopathy- Restrictive and obstructive cardiomyopathy- Cardiomyopathy related to systemic disease- Infiltrative heart disease- Diabetic and renal cardiac disease- Athlete’s heart2.2.6. Congenital heart disease- Neonatal heart disease- Congenital disease in childhood- Grown-up congenital heart disease2.2.7. Major vessel disease- Thoracic aneurysm- Marfan’s syndrome- Takayasu’s disease- Relationship between peripheral and cerebro-vasculardisease and cardiac disease2.2.8. Right heart disease- Pulmonary embolism- Right heart disease related to pulmonary disease2.2.9. Acute cardiac and thoracic vascular trauma- Aortic dissection- Aortic rupture and fracture- Blunt trauma2.2.10. Arrhythmias- Diagnosis of disease causing or predisposingto arrhythmias- Cardiac disease in endocrine conditions- Cardiac psychological related illness, i.e.manifestations of anxiety- Pacemakers- Defibrillators- Ablation2.2.11. Hypertension- Hypertensive heart disease- Diseases causing hypertension2.2.12. Medical and invasive treatment- Abnormalities arising from cardiac therapy,i.e. amioderone treatment- Complications of cardiac catheterisation andcoronary angioplasty- Appearance of stents and stent grafts2.2.13. Post-operative cardiac disease and findings- By-pass grafts- Valve replacement- Aortic replacement- Ventricular surgery- Pericardectomywww.ear-online.org 13

Detailed Curriculum for the Initial Structured Common Programme3 - TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLSAt 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 issuesin cardiac disease.3.1. Modality-based skills3.1.1. Plain film interpretation- Limitations, advantages and principles ofchest 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 radiographs3.1.2. CT interpretation and patient management- CT anatomy of the heart, pulmonary arteriesand great vessels- Principles of multislice and ultrafast CT of theheart including prospective and retrospectivegating- Interpretation of cardiac and pulmonarypathology- Contrast administration- Decision-making on the basis of patients´symptoms and CT diagnosis- Principles´ uses and limitations of nuclearcardiac imaging- Principles of intravascular imaging3.2. Stress testing- Principles of exercise stress testing, uses andlimitation- Methods of stress testing as applied to cardiacimaging- Patient management of stress testing for cardiacimaging3.3. Communication and management skills- To be able to supervise technical staff to ensureappropriate images are obtained- To discuss significant or unexpected radiologicalfindings with referring clinicians and knowwhen to contact a clinician- To be able to recommend the most appropriateimaging modality, appropriate to patients´symptoms or pathology or request from thereferring clinician- To develop skills in forming protocols, monitoringand interpreting cardiac studies, appropriateto the patient history and other clinicalinformation- To demonstrate the ability to effectively presentcardiac imaging in a conference setting- To demonstrate the ability to provide a coherentreport3.1.3. MRI interpretation and patient management- MRI anatomy of the heart, great vessels,pulmonary and peripheral vascular system- Principles of image sequencing andspecialised gating- Interpretation of cardiovascular andpulmonary pathology- Understanding of cardiac physiology relatedto MRI, including flow sequencing andspecialised tagging techniques- Use of MRI contrast- Uses limitations and hazards of MRI cardiacimaging3.1.4. Cardiac imaging by other modalities- Principles´ uses and limitations of cardiac angiographycatheterisation and pressuremeasurement- Principles´ uses and interpretation of stressand non-stress echocardiography, includingtrans-oesophageal echocardiography14 www.ear-online.org

Detailed Curriculum for the Initial Structured Common ProgrammeChest Radiology1 – INTRODUCTIONPhysics, radiography and contrast media are generallycovered in separate courses and are therefore not includedin this document, but physics and radiography topicsspecific to thoracic imaging should be covered either inthe thoracic rotation or included in the physics / radiographycourses, particularly:- Positioning / views of chest radiographs foradults, newborns, infants and children- Mean exposure doses at skin entrance, kVp,antiscatter techniques- Principles of digital imaging and image processingpertinent to chest radiology2 – CORE OF KNOWLEDGE2.1. Normal anatomy2-1.1 To be able to:- List the lobar and segmental bronchi- Describe the relationships of the hilar vesselsand bronchi- Define a secondary pulmonary lobule and itscomponent parts- Use the correct terminology for describing thesite of mediastinal and hilar lymph nodes2.1.2. Identify the following structures on posteroanterior(PA) and lateral chest radiographs:- Right upper, middle and lower lobes; leftupper and lower lobes; and lingula- Fissures – major, minor, superior accessory,inferior accessory, and azygos- Airway – trachea, carina, main bronchi, posteriorwall of intermediate bronchus, andlobar bronchi- Heart – position of the two atria, twoventricles, left atrial appendage, and thelocation of the four cardiac valves- Pulmonary arteries – main, right, left, andinterlobar- Aorta – ascending, arch and descendingaorta- Arteries – brachiocephalic (innominate),carotid, and subclavian arteries- Veins – superior and inferior vena cava, azygos,left superior intercostal ("aortic nipple"),and left brachiocephalic (innominate) veins- The components of the thoracic skeleton- Mediastinal stripes and interfaces- Aortopulmonary window- Both hemidiaphragms2.1.3. Identify the following structures on chestCT and / or chest MRI:- All pulmonary lobes and segments- A secondary pulmonary lobule- Fissures – major, minor, azygos and commonaccessory fissures- Extrapleural fat- Inferior pulmonary ligaments- Airway – trachea, carina, main bronchi, lobarbronchi, and segmental bronchi- Heart – left ventricle, right ventricle, left atrium,left atrial appendage, right atrium, rightatrial appendage- Pericardium – including superior pericardialrecesses- Pulmonary arteries – main, right, left, interlobar,segmental- Aorta – sinuses of Valsalva, ascending, arch,and descending aorta- Arteries – brachiocephalic (innominate), commoncarotid, subclavian, axillary, vertebral, internalmammary arteries- Veins – pulmonary, superior vena cava, inferiorvena cava, brachiocephalic, subclavian, internaljugular, external jugular, azygos,hemiazygos, left superior intercostal, internalmammary- Esophagus- Thymus- Normal mediastinal and hilar lymph nodes- Azygoesophageal recess- Inferior pulmonary ligaments2.2. Generic signs on chest radiographsTo be able to recognise and state the significance of thefollowing chest radiographic signs:2.2.1 Silhouette sign - loss of the contour of the heartor 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 distinguishedfrom a pleural or mediastinal process.2.2.3. Air crescent sign - indicates solid material in alung cavity, often due to a fungus ball, or crescenticcavitation 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 opacitywww.ear-online.org 15

Detailed Curriculum for the Initial Structured Common Programmeprojecting at or below the clavicles is situated anteriorly.2.2.5. Tapered margins - a lesion in the chest wall, mediastinumor pleura may have smooth taperedborders and obtuse angles with the chest wall ormediastinum, 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 bronchogeniccarcinoma in an adult.2.2.8. Deep sulcus sign on a supine radiograph - indicatespneumothorax.2.3. Features of diffuse infiltrative lung diseaseon chest radiographs and chest CT2.3.1. To recognise the effects of various pathologicalprocesses on the component parts of the secondarypulmonary lobule as seen on HRCT.2.3.2. To list and be able to identify the following patterns:air space shadowing, ground glass opacity(and understand its pathophysiology), reticularpattern, honeycombing, nodular pattern, bronchiolaropacities ("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 patientwith prior sternotomy and ILD suggestingamiodarone drug toxicity).2.3.5. To recognise the spectrum of changes of heartfailure on chest radiographs, notably: pleural effusions,vascular redistribution on erect chest radiographs,and the features of interstitial andalveolar edema, including septal lines and thickeningof fissures.2.3.6. To define the terms "asbestos-related pleuraldisease" and "asbestosis"; identify the imagingfindings.2.3.7. To recognise progressive massive fibrosis / conglomeratemasses secondary to silicosis or coalworker’s pneumoconiosis on radiography andchest CT.2.4. Differential diagnosis of diffuse infiltrativelung diseaseTo be able to develop a differential diagnostic list for the followingpatterns taking account of the anatomical and imagingdistribution 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 lines2.4.2. On HRCT (according to whether the pattern isupper, mid or lower zone predominant; or showsperihilar or subpleural predominance; or showscentrilobular, bronchocentric, lymphatic or perilymphatic,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 pattern2.5. Alveolar lung diseases and atelectasis- To recognise segmental and lobar consolidation- To list four common causes of segmentalconsolidation- To recognise partial or complete atelectasisof single or combined lobes on chest radiographsand list the likely causes- To recognise complete collapse of the right orleft lung on a chest radiograph and list appropriatecauses 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 associationswith organising pneumonia- To recognise the halo sign and suggest a diagnosisof invasive aspergillosis in an immunosuppressedpatient16 www.ear-online.org

Detailed Curriculum for the Initial Structured Common Programme2.6. 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 obliterativeand exudative small airways disease (tree-inbud,air trapping, mosaic pattern, and associatedbronchiectasis)- To recognise the typical appearance of cysticfibrosis on chest radiographs and chest CT- To list the causes of wheeze that may be detectedon 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 emphysemaon chest radiographs and CT- To recognise the signs of centrilobular emphysemaon HRCT- To state the imaging findings used to identifysurgical candidates for giant bullectomy orlung volume reduction surgery2.7. 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 diagnosis2.8. 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 pulmonarynodules and multiple pulmonary nodules- To provide strategy for managing an incidentalor 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 benignityof a solitary pulmonary nodule and theirlimitations- To state the complications of percutaneouslung biopsy and their frequency- To state the indications for chest tube placementas a treatment for pneumothorax relatedto percutaneous lung biopsy2.9. Benign and malignant neoplasms of the lung- To name the four major histologic types ofbronchogenic carcinoma, and state the differencein treatment between non-small cell andsmall cell lung cancer- To describe the TNM classification for stagingnon-small cell lung cancer, including the componentsof each stage (I, II, III, IV, and substages)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 surgicallyresectable for cure- To state the staging of small cell lung cancer- To name the four most common extrathoracicmetastatic sites for non-small cell lung cancerand for small cell lung cancer- To recognise abnormal contralateral mediastinalshift on a post-pneumonectomy chestradiograph and state two possible aetiologiesfor the abnormal shift- To describe the acute and chronic radiographicand CT appearance of radiation injuryin the thorax (lung, pleura, pericardium)and the temporal relationship to radiationtherapy- To state the roles of CT and MR in lung cancerstaging To state the role of positron emissiontomography (PET) in lung cancer staging- To name the most common location and appearanceof adenoid cystic and carcinoid tumours- To describe the appearances of hamartomaof the lung on chest radiographs and CT- To state the manifestations and the role of imagingin thoracic lymphoma- To describe the typical chest radiograph andchest CT appearances of Kaposi sarcomawww.ear-online.org 17

Detailed Curriculum for the Initial Structured Common Programme2.10. 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 diseasecausingchest radiographic or chest CT abnormalitiesin the immunocompromisedpatient- To name two common infections and twocommon neoplasms in patients with AIDSand chest radiographic or chest CT abnormalities- 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 patientswith AIDS- To list the differential diagnoses for widespreadconsolidation in an immunocompromisedhost- To describe the chest radiographic and CTfindings of post-transplant lymphoproliferativedisorders- To describe the chest radiographic and CTfindings of graft-versus-host-disease2.11. 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 sequestrationand cystic adenomatoid malformationon chest radiographs and chest CT- To explain the differences between intralobarand extralobar pulmonary sequestration- To recognise bronchial atresia on a radiographand chest CT, and state the mostcommon lobes of the lungs in which it occurs2.12. Pulmonary vascular diseasea 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 (includingMR angiography).- To define the role of ventilation-perfusionscintigraphy, CT pulmonary angiography(CTPA), MRI / MRA, and lower extremity venousstudies in the evaluation of a patientwith suspected venous thromboembolic disease,including the advantages and limitationsof each modality depending on patientpresentation- To recognise the vascular redistribution seenin raised pulmonary venous pressure2.13. Pleura and diaphragm- To recognise the typical chest radiographicappearances of pleural effusion in erect,supine and lateral decubitus chest radiographsand name four causes of a large unilateralpleural 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 calcificationon a radiograph or chest CT andsuggest the diagnosis of asbestos exposure(bilateral involvement) or old TB, old empyema,or old haemothorax (unilateral involvement).- To recognise unilateral elevation of onehemidiaphragm on chest radiographs and listfive causes (e.g. subdiaphragmatic abscess,diaphragm rupture, and phrenic nerve involvementwith lung cancer, postcardiac surgery,eventration)- To recognise tension pneumothorax- To recognise diffuse pleural thickening andlist four causes- To recognise the split pleura sign in empyema- To state and recognise the chest radiographicand CT findings of malignant mesothelioma- To recognise enlarged pulmonary arteries on18 www.ear-online.org

Detailed Curriculum for the Initial Structured Common Programme2.14. 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 radiographs,chest CT and chest MRI- To name the most common cause of a posteriormediastinal mass and localise a mass inthe posterior mediastinum on chest radiographs,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 abnormalityon chest CT and chest MRI that maymimic a solid mass- To recognise mediastinal and hilar lymphadenopathyon 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 associationsof thymoma- To list three types of malignant germ cell tumourof the mediastinum- To recognise the imaging signs of benign cysticteratoma- To list five signs of intrathoracic thyroid masses- To recognise a cystic mass in the mediastinumand suggest the possible diagnosisof a bronchogenic, pericardial, thymic or oesophagealduplication cyst- To state the mechanisms and list the signs ofpneumomediastinum2.15. Thoracic aorta and great vessels- To state the normal dimensions of the thoracicaorta- To describe the Stanford A and B classificationof aortic dissection and the implicationsof the classification for medical versus surgicalmanagement- 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 arteryaneurysm- aortic coarctation- aortic pseudocoarctation- cervical aortic arch- To state the significance of a right aortic archwith mirror image branching versus an aberrantsubclavian 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 arteries("bovine arch"), and separate origin ofvertebral artery from archTo define the terms aneurysm and pseudoaneurysm- To state and identify the findings seen in arteritisof the aorta on chest CT and chest MR- To state the advantages and disadvantagesof CT, MRI / MRA and transoesophagealechocardiography in the evaluation of the thoracicaorta2.16. Chest Trauma- To identify a widened mediastinum on chestradiographs taken for trauma and state thepossible causes (including aortic / arterial injury,venous injury, fracture of sternum orspine)- To identify the indirect and direct signs of aorticinjury on contrast-enhanced chest CTscan- To identify and state the significance of chronictraumatic pseudoaneurysm on chest radiographs,CT or MRI- To identify fractured ribs, clavicle, spine andscapula on chest radiographs or chest CTwww.ear-online.org 19

Detailed Curriculum for the Initial Structured Common Programme- To name three common causes of abnormallung opacity following trauma on chest radiographsor CT- To identify an abnormally positioned diaphragmor loss of definition of a diaphragmon chest radiographs following trauma and beable to suggest the diagnosis of a ruptured diaphragm- To identify a pneumothorax and pneumomediastinumfollowing trauma on chest radiographs- To identify a cavitary lesion following traumaon chest radiographs or chest CT and suggestthe diagnosis of laceration with pneumatoceleformation, hematoma or abscesssecondary to aspiration- To name the three most common causes ofpneumomediastinum following trauma- To recognise and distinguish between pulmonarycontusion, laceration and aspiration2.17. 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 ("clamshelldevice")- pericardial drain- extracorporeal life support cannulae- intraoesophageal manometer, temperatureprobe or pH probe- tracheal or bronchial stent2.18. Postoperative ChestTo 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 surgery3 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLSAt the end of his / her training, the resident should be ableto demonstrate the following:3.1. Dictate intelligible and useful reports on chest radiographs,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 findingswith referring clinicians and know when tocontact a clinician.3.4. Describe patient positioning and indications for aPA, lateral, decubitus, and lordotic chest radiograph.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 interpretingchest CT scans, including HRCT, appropriateto patient history and other clinicalinformation.3.8. Describe a chest CT protocol optimised for evaluatingeach of the following:- thoracic aorta and great vessels- superior vena cava and brachiocephalic veinstenosis or obstruction- suspected pulmonary embolism- tracheobronchial tree- suspected bronchiectasis- suspected small airway disease20 www.ear-online.org

Detailed Curriculum for the Initial Structured Common Programme- lung cancer staging- oesophageal cancer staging- superior sulcus tumour- suspected pulmonary metastases- suspected pulmonary nodule on a radiograph- shortness of breath- haemoptysis3.9. Develop skills in protocolling, monitoring, and interpretingchest 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, contraindications,and management of complications:- paracentesis and drainage of pleural effusions- percutaneous lung biopsy- paracentesis of mediastinal and pericardialfluid collections- drainage of refractory lung abscess- arteriography of thoracic aorta and great vessels- venography of major intrathoracic systemicveins of bronchial arteries, anatomy, and importantcollaterals- pulmonary arteriography- principles of bronchial artery embolisation:indications, technique and complications- principles of intrathoracic vein recanalisationand stenting: indications, technique- principles of interventional procedures in thepulmonary circulation:- local thrombolysis- AVM embolisationThe following list gives examples of the types of conferencesthat should be considered part of the chest curriculum.Some of these conferences may be run by theRadiology Department, others may be run by other departmentsor multidisciplinary programmes. It is recommendedthat 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 conference5 – TEACHING MATERIAL AND SUGGESTIONS FORREADINGRecommended study materials and mandatory conferenceattendance are an important component of training,but since they vary between individual departments, a detailedlisting is not provided in this document. The followingshort 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, publishedby Mosby.3.13. Correlate pathologic and clinical data with radiographicand chest CT and MRI findings.4 – CONFERENCESwww.ear-online.org 21

Detailed Curriculum for the Initial Structured Common ProgrammeGastrointestinal andAbdominal Radiology1 – INTRODUCTIONGastrointestinal and abdominal radiology include all aspectsof medical imaging (diagnostic and interventional),thus covering information relative to the anatomy, pathophysiologyand the various diseases that may affect theabdomen. Gastrointestinal and abdominal radiology includesvarious techniques (ultrasonography, duplexDoppler, conventional X-ray imaging, computed tomography,magnetic resonance imaging, angiography and otherinterventional procedures) and various organs (pharynx,oesophagus, stomach, duodenum, small bowel, colon,rectum, anus, pancreas, liver, biliary tract, spleen, peritoneum,abdominal wall and pelvic floor). The aim of thisdocument is to describe a curriculum for training in gastrointestinaland abdominal radiology.2 – CORE OF KNOWLEDGE2.1. 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, oesophagus,stomach, duodenum, small bowel, appendix,colon, rectum, anus, pancreas, liver,biliary tract, spleen, mesentery, and peritoneum- 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 therelevant organs2.2. Oesophagus- To be able to identify the abnormalitiesdemonstrable on a video-fluoroscopy study ofthe swallowing mechanism and their implicationsin conjunction with swallowing therapists;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, diverticulum,extrinsic compression, sub-mucosalmasses, fistulae, sliding andpara-oesophageal hiatus hernia, benign strictures,benign tumours, varices, differentforms of oesophagitis on a contrast examinationof 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 causesof dysphagia- To know the basic surgical techniques in oesophagealsurgery and to be able to identifypost-surgical appearances on imaging examinations- To be able to identify a mega oesophagus,oesophageal diverticulum, hiatus hernia, oesophagealvarices, 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 involvement- To understand the use of endoscopic ultrasoundin the staging of oesophageal cancerand the technique of endoscopic ultrasoundguided biopsy2.3. Stomach and duodenum- To be able to determine the most appropriateimaging examination and contrast use in suspectedperforation of the stomach and postoperativefollow-up; to know the limitationsof each examination for these specificconditions- To understand the imaging features (on bariumand CT) of a variety of conditions such asbenign and malignant tumours, infiltrative disorders,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 problem22 www.ear-online.org

Detailed Curriculum for the Initial Structured Common Programme- 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-duodenaldisease on ultrasound- To understand rotational abnormalities of theduodenum on barium studies and also theappearance of annular pancreas, sub-mucosaltumours, papillary tumours, inflammatorydisease including ulceration, as well as lymphoidhyperplasia and gastric metaplasia2.4. Small bowel- To be able to determine the most appropriateimaging examination in the following cases:small bowel obstruction, inflammatory disease,infiltrative disease, small bowel perforationand 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, thickening,marked angulation, extrinsic compression,and fistula- To be able to identify on a small bowel seriesthe following diseases: adenocarcinoma,polyposis, stromal tumour, lymphoma, carcinoidtumour, Crohn’s disease, mesenteric ischaemia,haematoma, Whipple’s disease,amyloidosis, radiation-induced injury, malrotation,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 especiallyto 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 (adenocarcinoma,lymphoma, carcinoid tumour, stromaltumour); to be able to identify mural pneumatosis,vascular engorgement, increaseddensity of the mesenteric fat, peritoneal abnormalityand malrotation- To be able to determine the cause of smallbowel obstruction on CT scan (adhesion,band, strangulation, intussusception, volvulus,internal and external hernias) and theircomplications; to be able to identify criteria foremergency surgery- To know the basic principles of MR imaging ofthe small bowel2.5. 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 tumour,stromal tumour, perforation, postoperativeevaluation) 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 tumours,diverticulitis, inflammatory diseases,colon ischaemia, radiation-induced colitis- To be able to identify a megacolon, colonic diverticulosis,specific and non-specific colitis,colonic fistula, carcinoma, polyps and postoperativestenosis on an enema- To be able to identify a colonic diverticulosis,diverticulitis, tumour stenosis, ileocolic intussusception,colonic fistula, paracolic abscess,epiploic appenditis, intra-peritoneal fluid collection,colonic pneumatosis, and pneumoperitoneumon 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 carcinomatosis,hepatic metastases, and obstruction)- To know the TNM classification of colon cancerand its prognostic value; to understandthe technique and value of both MRI and endosonographyin the staging of rectal cancer- To know the basic technique of interventionalradiology in colon cancer, especially ofcolonic stent placement in case of colonic ob-www.ear-online.org 23

Detailed Curriculum for the Initial Structured Common Programmestruction; to know the indications and contraindicationsof 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-rectaltissues and of the anal sphincters- To know the main functional diseases of thepelvic floor and their features on a defeacographyexamination; to know the potential roleof sonography and MR imaging in the evaluationof 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 criteriathat may help in differentiating betweenpostoperative fibrosis and tumour recurrence;to be able to select patients who may benefitfrom percutaneous biopsy in case of suspectedtumour 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 cancerand its effect on treatment options- To be able to identify a rectal cancer and itsrelation to relevant surrounding structures2.6. Peritoneum and abdominal wall- To be able to identify the various types of abdominalwall 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 peritoneumon a sonographic and a CT scan examination;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 sonographicand a CT scan examination; to knowthe features of loculated ascites2.7. Vessels2.8. Liver- To be able to identify the following peritonealdiseases on CT: peritonitis, peritoneal carcinomatosis,peritoneal tuberculosis, mesentericlymphoma, mesenteric and greateromental infarction- To know the basic principles of duplexDoppler sonography and to be able to identifysuperior mesenteric artery stenosis or occlusionon duplex Doppler sonography; to beable to use Doppler to assess the patency ofand the direction of flow in the portal and hepaticveins- 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 occlusionand stenosis of the superior mesentericartery- To know the basic principles of balloon angioplastyand stenting of the superior mesentericartery for the treatment of stenosis of the superiormesenteric artery- To be able to localise a focal liver lesion accordingto liver segmentation and major vesselsanatomy (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 categories- To list the differences between amoebic abscessand pyogenic abscess of the liver (appearance,evolution, treatment, indication fordrainage)- To be able to describe the most common surgicalprocedures for hepatectomy- To know the appearance of liver haemangiomaon 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 necessary24 www.ear-online.org

Detailed Curriculum for the Initial Structured Common Programme- To know the appearance of fatty liver, homogenousand heterogeneous, on US, CT, andMRI (including in- / out-of-phase imaging)- To describe the natural history of hepatocellularcarcinoma (HCC), major techniques andindications for treatment (surgical resection,chemotherapy, chemoembolisation, percutaneousablation, 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 indicationsfor 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 percutaneousbiopsy- To be able to discuss the indications for advancedmethods (CTAP, MRI with liver specificcontrast) 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 literaturesources- To be able to describe the technique for percutaneousguided liver biopsy and its mostcommon indications; to list the complicationwith a precise evaluation of the occurrence ofmorbidity and mortality2.9. 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 acalculouscholecystis- 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 differentiatecancer from subacute cholecystitison US and CT- To describe the appearance of cholangiocarcinomaof 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 carcinomaon US, CT, MRI, and endoscopic US- To be able to describe the common appearanceof sclerosing cholangitis on US, CT, andMRI, including MRCP; to know the naturalhistory and possibility for associated cholangiocarcinomaand 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 radiologyof the biliary tract and discuss the indicationsand complications- To attest participation in five procedures2.10. Pancreas- To know the natural history of chronic pancreatitis;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 pancreatitis- To describe the common appearance ofextra-pancreatic fluid collections and phlegmonsin case of acute pancreatitis- To be able to detect a pancreatic pseudocystand discuss advantages and limitations of differenttreatments (follow-up, interventionalprocedure, percutaneous or endoscopic, surgery)according to practical cases- To describe the most common appearance(nodular, infiltrating) on US, CT, MRI, and endoscopicUS 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 seriousand 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 complicationswww.ear-online.org 25

Detailed Curriculum for the Initial Structured Common Programme3 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLS3.1. 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 resultsof the examination and to be able to evaluatethe patient’s understanding3.2. Reporting- To be able to make a precise and concise descriptionof the imaging signs present- To be able to answer the clinical problem andmake a conclusion accordingly- To be able to suggest additional imaging examinationswhen needed, using appropriatejustification- To be able to maintain good working relationshipswith referring clinicians- To be able to code the findings of examinations3.3. Imaging techniques - General requirements- To know the indications and contra-indicationsof the various imaging examinations inabdominal imaging- To be able to indicate to the referring physicianthe most appropriate imaging examinationaccording to the clinical problem- To be able to determine the best contrast materialand its optimal use according to the imagingtechnique and the clinical problem- To be able to evaluate the quality of the imagingexaminations in abdominal imaging- To know the relative cost of the various imagingexaminations in abdominal imaging- To understand the radiation burden and risksof different investigations3.4. Imaging techniques - Specific requirements3.4.1. Plain abdominal film- To know the three basic indications for plainabdominal film- To be able to diagnose pneumoperitoneum,mechanical obstruction and pseudo obstruction,toxic dilatation of the colon, gas in smalland large bowel wall indicating ischaemia andnecrosis, pancreatic and biliary calcifications,and aerobilia on plain abdominal films3.4.2. X-ray examination of the upper gastrointestinaltract- To know how to perform an X-ray examinationof the upper gastrointestinal tract and to determinethe most appropriate contrastmaterial- To know how to perform both single and doublecontrast studies as well as motility assessments;to understand the principles andlimitations of these studies and their advantagesand disadvantages compared to endoscopy- To understand the technique and indicationsof video-fluoroscopy of the swallowing mechanismin 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 fillingand 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 smallbowel3.4.3. X-ray examination of the lower gastrointestinaltract- To be able to perform a double contrast bariumenema- To be able to perform a single contrast enema- To know how to catheterise a stoma for colonopacification and how to perform pouchogramsand 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 determinethe optimal contrast material and techniqueto 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 colon26 www.ear-online.org

Detailed Curriculum for the Initial Structured Common Programme3.4.4. Sonography- To be able to perform an ultrasound examinationof the liver, gall bladder biliary tree, pancreas,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 limitationsof sonography in this area- To understand the strengths and limitations ofendosonography, particularly in the oesophagus,pancreas, rectum and anal canal3.4.5. Computed tomography- To be able to perform a CT examination of theabdomen and to tailor the protocol to the specificorgan or clinical situation to be studied;to be able to determine if intravenous administrationof a contrast material is needed; todetermine the optimal protocol for the injectionof contrast (rate of injection, dose, delay);to know the various phases (plain, arterialdominant,portal-dominant, late phase) andtheir respective values according to the clinicalproblem- To be able to determine the best contrast materialfor 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 indicationfor CT Cholangiography- To have experience of the use of workstationsfor multiplanar reconstructions (MPR) and 3Dreconstruction based around volume datasets3.4.6. Magnetic resonance imagingbe able to tailor the protocol to the specificorgan to be studied; to be able to determine ifintravenous administration of a contrast materialis needed; to determine the optimal protocolfor the injection (rate of injection, dose,delay); to know the various phases (plain, arterial-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 potentialof MR enteroclysis; to know the basicprotocol for MR examination of the anorectum3.4.7. Interventional imaging- To know the basic techniques for percutaneousdrainage of abdominal collectionsusing CT and ultrasonography- To know the basic rules of percutaneousbiopsy of the liver (indications, contraindications)and other organs under sonographicand CT guidance- To know the basic principles for angiographyof the abdominal arteries (including indications,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 embolisationof the abdominal arteries (includingindications, contra-indications)- To know the technique of percutaneous gastrostomyunder image guidance- To know the techniques for percutaneous biliaryintervention- To understand the technique for radiologicalguided stenting of the biliary system and gastrointestinalsystem, using PTFE and expandablemetal stents- To be able to perform an MR examination ofthe liver, the biliary tract and the pancreas; towww.ear-online.org 27

Detailed Curriculum for the Initial Structured Common Programme3.4.8. Miscellaneous- To know the indications, strengths and limitationsof the other imaging techniques (includingendoscopy, endosonography, nuclearmedicine (including PET) in abdominal imaging)4 – CONFERENCESAs part of the curriculum in abdominal radiology, thetrainee should attend in-house teaching sessions for radiologistsas well as clinical conferences with colleaguesfrom other specialties. The latter type of conferenceshould be included to facilitate the radiology residents’ understandingof the use of imaging and clinical circumstances,in which imaging is requested.The following list gives examples of the types of conferencesthat should be considered part of the curriculum:1. Abdominal radiology resident-specific teachingconference2. Internal medicine / gastroenterology conferences3. Surgery / abdominal surgery conferences4. Oncology conferences5. Pathology conferences5 – TEACHING MATERIAL AND SUGGESTIONS FORREADINGThe following English textbooks are recommended to answerall 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 (2 nd Edition). WBSaunders, Philadelphia, 2000- Eisenberg RL. Gastrointestinal Radiology – APattern Approach (4 th Edition). Lippincott,Philadelphia, 2003- Abdominal radiology book(s) in local languageHead and Neck Radiology(Including Maxillo-Facial andDental Radiology)1 – INTRODUCTIONThe head and neck imaging curriculum describes:- The knowledge-based objectives for generalhead and neck radiology and maxillofacialand dental radiology- The appropriate technical and communicationskillsPhysics, radiography and contrast media are generallycovered in separate courses, and therefore are not includedin 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 / radiographycourses, 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 pertinentto head and neck and maxillofacialdental radiology2 – CORE OF KNOWLEDGE2.1. Normal anatomy- Temporal bone- Facial skeleton, skull base and cranial nerves- Orbit and visual pathways- Sinuses- Pharynx- Oral cavity- Larynx- Neck- Mandible, teeth and temporomandibularjoints- Salivary glands- Deep spaces of the face and neck- Thoracic inlet and brachial plexus- Thyroid gland and parathyroid glands28 www.ear-online.org

Detailed Curriculum for the Initial Structured Common Programme2.2. Temporal bone- To know pathologic conditions defining deafness- To know and recognise on CT and MRI- Temporal bone inflammatory disease- Temporal bone fractures- Tumours of the temporal bone and cerebello-pontineangle- To know vascular tinnitus2.3. 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 thecranial nerves2.4. Orbit and visual pathways- To know- Orbital pathology- Pathology of the visual apparatus2.5. The sinuses- To know and be able to recognise on CTanatomical variations and congenital anomaliesof the paranasal sinuses- To know and be able to recognise on CT andMRI inflammatory conditions, tumours and tumour-likeconditions- To be familiar with common (FunctionalEndoscopic Sinus Surgery) techniques- To know how to evaluate the paranasal sinusesafter surgery2.6. The pharynx- To know and be able to recognise on US, CTand MRI the pathologic conditions of:- nasopharynx- oropharynx- hypopharynx2.7. The oral cavity- To know and be able to recognise on US, CT,MRI and videofluoroscopy the pathologicconditions of the oral cavity2.8. The larynx- To know and be able to recognise on CT andMRI the pathologic conditions of the larynx2.9. 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 diseases2.10. The mandible, teeth, and temporomandibularjoints- To know and be able to recognise on orthopantomography,CT, MRI, and dental radiographspathologic conditions of the mandible- To get familiarity with dental implants anddental CT programmes- To know pathologic conditions of the temporo-mandibularjoint2.11. The salivary glands- To know and be able to recognise on US, CT,MRI and MR-sialography inflammatory disordersand tumours- To know and be able to recognise on US,Doppler US, CT and MRI vascular malformations- To know and be able to recognise on US, CTand MRI periglandular lesions and recognisingthese on US, CT, MRI2.12. The deep spaces of the face and neck- To know the anatomy of the deep cervical fasciaand of the most common pathologic conditionsinvolving the different spaces of thesupra- and infrahyoid neck2.13. 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 plexuswww.ear-online.org 29

Detailed Curriculum for the Initial Structured Common Programme2.14. 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 parathyroidglands- To be familiar with the most important findingsof Tc-99m-scintigraphy in specific disease ofthe thyroid gland- To be able to perform fine needle aspirationbiopsy in easy cases3 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLSDiagnostic procedures:Skull radiography + special views: 50Sinus radiography: 50Head and neck CT (including Dental CT): 100Head and neck MRI: 50Ultrasound of head and neck: 503.3. 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 briefdescription of the imaging findings andtheir significance along with a short summarywhere necessary.3.3.2. Recommend the appropriate use of imagingstudies 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 radiologicfindings with referring clinicians andknow when to contact a clinician.3.1. At the end of the 4 th year the resident should beable to carry out or supervise the following techniquesto a level appropriate to practice in a generalhospital. This competence should include theability to evaluate and justify referrals for the purposeof 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 salivaryglands- Percutaneous biopsy, guided by ultrasound,CT and / or MRI in straightforward / technicallyeasy cases- Doppler ultrasound- CT of the face, skull base and neck- MRI of the face and neck- Angiography, including digital subtraction orCT angiography- Dental radiology, including the use of CT3.2. The trainee should also have knowledge of orthopantomographyand experience of lymphnode aspiration biopsies.30 www.ear-online.org

Detailed Curriculum for the Initial Structured Common ProgrammeInterventional Radiology1 – INTRODUCTIONInterventional Radiology is a vibrant and dynamic specialtyin which, unfortunately, trainees have variable exposureto radiology during training. It is important that radiologytrainees develop the basic skills in interventional radiology,irrespective of whether they specialise in interventionalradiology. Basic skills and a core programme ofknowledge will allow the trainees to perform routine proceduresusing image guidance throughout their careers.This can only serve to strengthen the specialty of radiologyas 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 requiredduring basic training.2 – CORE OF KNOWLEDGEIt is expected that, at the end of residency, the trainee willhave a thorough knowledge of the performance and interpretationof diagnostic vascular techniques and a basicunderstanding of common interventional procedures.2.1. Non-Invasive Vascular Imaging2.1.1. Doppler UltrasoundThe trainee should demonstrate a thorough understandingand be able to interpret the following:- Duplex ultrasound, including both arterial andvenous examinations- Normal and abnormal Doppler waveforms- Common Doppler examinations, such ascarotid Doppler, hepatic and renal Dopplerstudies and lower extremity venous duplexexaminations2.1.2. CT AngiographyThe trainee should have a thorough understandingof:- The basic physics of single slice helical CTand multi-detector CT- CTA protocols including contrast materialsused and reconstruction techniques- Radiation doses for CTA and methods to reducethese- Advantages and disadvantages of CTA versusother techniques2.1.3. MR Angiography (MRA)The trainee should be familiar with:- MR physics and MRA techniques- Advantages and disadvantages of differentcontrast materials used for MRA- Differences between time of flight, phase contrast,and contrast-enhanced techniques pertainingto MRA- Advantages and disadvantages of MRA comparedto other techniques2.2. Diagnostic Angiography / Venography2.2.1. GeneralThe trainee should be familiar with:- The basic chemistry of the different iodinatedcontrast 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 reactionsto iodinated contrast materials2.2.2. Arterial Puncture TechniqueThe Trainee should have a thorough knowledge of:- Standard groin anatomy, including the positionof the inguinal ligament and the femoralnerve, artery and vein- The Seldinger technique of arterial and venouspuncture- Mechanisms for guidewire, sheath andcatheter insertions into the groin- Mechanisms of puncture site haemostasis includingmanual compression and commonclosure devices- Alternative sites of arterial puncture, such asbrachial, axillary and translumbar2.2.3. Diagnostic AngiographyThe trainee should be familiar with:- Guidewires, sheaths and catheters used forcommon diagnostic angiographic procedures- Digital subtraction angiographic techniques,www.ear-online.org 31

Detailed Curriculum for the Initial Structured Common Programmebolus 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, vasculitis,aneurysmal disease, thrombosis, embolismand other vascular pathology- The complication rates for common diagnosticprocedures- Post-procedural care regimens for standarddiagnostic vascular procedures2.3. Vascular InterventionThe trainee should be familiar with common vascular interventionalprocedures, such as:2.3.1. Angioplasty- Angioplasty balloon dynamics, mechanism ofaction of angioplasty- Indications for angioplasty- Complications and results in differentanatomic areas- Drugs used during angioplasty- Intra-arterial pressure studies- Common angioplasty procedures, such asrenal, iliac and femoral angioplasties- Groin closure techniques and post-proceduralcare2.3.2. Arterial / Venous Stenting- Basic mechanisms for stent deployment andmaterials used for stent construction- Indications for stent placement versus angioplasty- Complications and results- Post-procedural care2.4. Venous Intervention2.4.1. Venous AccessThe trainee should be familiar with the variousforms of venous access including:- PICC lines, Hickman catheters, dialysiscatheters and ports- Indications for use of the above venous accesscatheters- The technique of venous access in jugularand subclavian veins- Results and complications2.4.2. Venoplasty and StentingThe trainee should be familiar with:- Techniques of venoplasty and stenting- Success rates and complications- Post-procedural care2.4.3. Caval InterruptionThe trainee should be familiar with:- Indications for caval filter placement- Different filter types available, including retrievablefilters- Success rates and complications- Post-procedural care2.5. Non-Vascular InterventionTrainees should have performed and have a thorough understandingof basic non-vascular interventional techniques,such as biopsy, abscess drainage,transhepaticholangiography and nephrostomy techniques.2.5.1. BiopsyThe trainee should be familiar with:- Consent procedures- Pre-procedure coagulation tests and correctionof abnormalities- Differences in image modalities used for guidingbiopsy, including CT and ultrasound- Needles used for biopsy procedures includingfine 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 complications,such as pneumothorax and hemorrhage2.5.2. Fluid Aspiration and Abscess Drainage.The trainee should be familiar with:- Commonly used chest tubes and abscessdrainage catheters32 www.ear-online.org

Detailed Curriculum for the Initial Structured Common Programme- Indications for chest drainage, fluid aspiration,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 loculatedor complex empyemas- Planning a safe access route for abscessdrainage- Antibiotic regimens used before abscessdrainage- Trocar and Seldinger techniques for catheterplacement- Situations where more than one catheter orlarger catheters are required- Various approaches to pelvic abscessdrainage- Post-procedural care including catheter care,ward rounds and when to remove catheters2.5.3. 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 antibioticregimens, coagulation screening and intravenousfluid replacement- Performance of transhepaticholangiography- One-stick needle systems for biliary drainage- Catheters used for biliary decompression- Complications of biliary procedures- Aftercare, including knowledge of complications,catheter care, and ward rounds2.5.4. Genitourinary InterventionThe trainee should be familiar with:- Indications for percutaneous nephrostomy- Integration of ultrasound, CT and urographicstudies to plan an appropriate nephrostomy- Pre-procedural work-up including coagulationscreens and antibiotic regimens- Ultrasound / fluoroscopic guidance mechanismfor percutaneous nephrostomy- Catheters used for percutaneous nephrostomy- Placement of percutaneous nephrostomytubes- Complications of percutaneous nephrostomy- Aftercare, including catheter care and removal3 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLSThe goals of basic training in interventional radiology areas follows:- The trainee should be able to interpret non-invasiveimaging studies to determine that therequested procedure is appropriate- To determine the appropriateness of patientselection for a requested interventional procedurethrough a review of available history,imaging, laboratory values, and proposed orexpected outcomes of the procedure- To demonstrate an understanding of the historyor physical findings that would requirepre-procedure assistance from other specialtydisciplines, 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 proceduresand be able to recognise abnormalitiesand physical signs or symptoms that need immediateattention 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 interactionsduring or after the procedure- Knowledge of agents used for conscious sedationand analgesia during interventionalprocedures, with ability to identify risk factorsthat may indicate potential risks for conscioussedation- Knowledge of radiation safety in the interventionalradiology suite- Knowledge of methods used to reduce accidentalexposure to blood and body fluids inthe interventional radiology suitewww.ear-online.org 33

Detailed Curriculum for the Initial Structured Common ProgrammeMusculoskeletalRadiology1 – INTRODUCTIONMusculoskeletal imaging involves all aspects of medicalimaging which provide information about the anatomy,function, disease states and those aspects of interventionalradiology or minimally invasive therapy appertainingto the musculoskeletal system. This will include imaging inorthopaedics, trauma, rheumatology, metabolic and endocrinedisease as well as aspects of paediatrics and oncology.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 extentof oncological imaging.2 – CORE OF KNOWLEDGE- Basic clinical knowledge, that is medical, surgicaland pathology as well as pathophysiologyrelated to the musculoskeletal system- Knowledge of current good clinical practice- Knowledge of the indications, contraindicationsand potential hazards (especially radiationhazards) of procedures and techniques relevantto 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 musculoskeletaldisease and trauma (see listbelow), as demonstrated by conventional radiography,CT, MRI, arthrography, radionuclideinvestigations, and ultrasound- Knowledge of differential diagnosis relevantto clinical presentation and imaging appearanceof musculoskeletal disease and traumaas listed belowThe following manifestations of musculoskeletal diseaseand trauma have to be covered during the general radiologicaltraining. 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* (includingnormal development)- articular (chondral & osteochondral) (includingosteochondritis 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 dislocations- clavicular fractures- scapular fractures- shoulder dislocation / instability- upper limb- humeral fractures- elbow fractures / dislocations- proximal & distal forearm fractures / dislocations- wrist joint fractures / dislocations- hand fractures / dislocations- pelvic fractures / dislocations (including associatedsoft tissue injuries)- lower limb- hip fractures / dislocations- femoral fractures- tibial & fibular fractures (including anklejoint)- hindfoot fractures- tarso-metatarsal fractures / dislocations- forefoot fractures / dislocations2.1.3. Soft Tissues- shoulder- rotator cuff, glenoid labrum, biceps tendon- wrist- triangular fibrocartilage complex- knee- menisci, cruciate ligaments, collateral ligaments- ankle- principal tendons & ligaments34 www.ear-online.org

Detailed Curriculum for the Initial Structured Common Programme2.2. 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. echinoccoccus)- soft tissue infections- HIV-associated infections2.3. Tumours & umour-like lesions2.3.1. Bone- principles of tumour characterisation andstaging- bone-forming- osteoma & bone islands- osteoid osteoma & osteoblastoma- osteosarcoma (conventional and commonervariants)- cartilage-forming- osteochondroma- enchondroma- chondroblastoma- chondromyxoid fibroma- chondrosarcoma (central & peripheral)- fibrous origin- fibrous cortical defect / non-ossifying fibroma- fibrous dysplasia- fibrosarcoma / malignant fibrous histiocytoma- 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- adamantinoma2.3.2. Soft Tissue- fat origin- lipoma- liposarcoma- neural origin- neurofibroma- schwannoma- vascular origin- haemangioma- soft tissue sarcomas2.4. Haematological disorders- haemoglobinopathies- sickle cell disease- thalassaemia- myelofibrosis2.5. Metabolic, endocrine & toxic disorders- rickets* & osteomalacia- primary & secondary hyperparathyroidism(including chronic renal failure)- osteoporosis (including basic concepts ofbone mineral density measurements)- fluorosis2.6. 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)www.ear-online.org 35

Detailed Curriculum for the Initial Structured Common Programme- 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’sdisease)- neurofibromatosis2.8. Miscellaneous- Paget’s disease- sarcoidosis- hypertrophic osteoarthropathy- transient or regional migratory osteoporosis- osteonecrosis- characterisation of soft tissue calcification /ossification3.1. Core of skills- supervising and reporting plain radiographicexaminations relevant to the diagnosis of disordersof the musculoskeletal system includingmusculoskeletal trauma- supervising and reporting CT of the musculoskeletalsystem including trauma- supervising and reporting MRI of the musculoskeletalsystem including trauma- performing and reporting ultrasound of themusculoskeletal system including trauma- supervising and reporting CT and MRI examinationsof trauma patients, including the provisionof on-call service- communicating with patients and taking historyrelevant to the clinical problem- using all available data (clinical, laboratory,imaging) to find a concise diagnosis or differentialdiagnosis3.2. Core of experience- experience of the relevant contrast mediumexaminations (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 injections,and vertebroplasty- observation of image-guided bone biopsyand drainage of the musculoskeletal system- interpretation of bone densitometry examinations- familiarity with the application of angiographyin the musculoskeletal system* These topics may or may not be covered in the paediatriccomponent of the radiologists´ training. It is the responsibilityof 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 SKILLS36 www.ear-online.org

Detailed Curriculum for the Initial Structured Common ProgrammeNeuroradiology1 – INTRODUCTIONThe aim of this core training is for the trainees to familiarisethemselves and gain core competence in the basicsof neuroradiology as well as to develop enough understandingof 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 supervisionof a neuroradiologist. Arrangements should be madewithin the training scheme for secondment to another departmentif necessary. Exposure to all imaging techniquesused in neuroradiology should be achieved.2 - CORE OF KNOWLEDGE2.1. To know:- Neuroanatomy and clinical practice relevantto neuroradiology- The manifestations of CNS disease asdemonstrated on conventional radiography,CT, MRI, and angiography2.2. To understand the indications for a neuroradiologicalexamination.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 neuroradiology2.6. To get basic competence in the following:2.6.4. Vascular disease including congenitaland acquired malformations2.6.5. Degenerative diseases of the brain2.6.6. Hydrocephalus3 - TECHNIQUE, COMMUNICATION AND DECISION-MAKING SKILLS3.1. At the end of his / her training, the residentshould be able to:- Report plain radiographs in the investigationof neurological disorders- Supervise and report cranial and spinal CTscans- Supervise and report cranial and spinal MRscans3.2. During his / her training, the resident should alsoobserve:- Cerebral angiograms and their reporting- Carotid ultrasound examination includingDoppler3.3. The resident should get experience in MR andCT angiography and venography to image thecerebral vascular system3.4. 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)2.6.1. Trauma- Skull and facial injury- Intracranial injury, including child abuse andthe complications- Spinal cord injury2.6.2. Developmental anomalies- Brain anomalies- Spinal cord malformations2.6.3. Tumours of the brain, orbits and spinalcordwww.ear-online.org 37

Detailed Curriculum for the Initial Structured Common ProgrammePaediatric Radiology1 – INTRODUCTIONThe aim of this core training is for the trainee to gain basicunderstanding of children’s diseases and basic competenceof 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 supervisionof a paediatric radiologist. Arrangements shouldbe made within the training scheme for secondment to anotherdepartment 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 encompassesdiagnostic imaging of the fetus, the newborn, theinfant, the child, and the adolescent.2 – CORE OF KNOWLEDGEIn the twelve-week course, in addition to acquiring knowledgeof the paediatric organ system, the trainee is expectedto 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 children,i.e. minimising radiation, especially inrelation to CT and fluoroscopy; indications forand choice of contrast media;- Special requirements for children, e.g. environment,sedation and anaesthesia, physiologyof the young infant, and psychology ofmanaging children;- Communication with the children and theirparents, as well as medical colleagues;Importance of clinico-radiological conferences,both formal and informal;- Guidelines for investigation of common clinicalproblems and understanding of risk / benefitanalysis related to children;- Radiation protection, equipment, and regulation;2.1. Imaging techniquesThe 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 prematureinfants. The trainee should perform theultrasound examinations under supervision.The experience should include exposureto the following areas:- Neonatal head- Abdomen: kidneys and urinary tract; liver andspleen; gynaecology- Chest: pleurae- Soft tissues: neck, scrotum, musculoskeletalsystem- Doppler studies: neck and abdomen, testes2.1.2. Radiographs: supervised reporting ofchildren’s radiographs, especially in relationto A. & E. presentation, musculoskeletalsystem, chest, and abdomen.2.1.3. Fluoroscopy: discussion of indicationsfor gastrointestinal fluoroscopy versusspecialist paediatric endoscopy withsupervisor before initiating studies.Performing studies under direct supervision.- Technique of bladder catheterisation and performanceof micturition cystourethrography(MCU)- Observation and conduct of upper and lowerG.I. contrast studies in neonates- Tailored upper and lower gastrointestinal contraststudies in children for investigation ofgastro-oesophageal reflux, aspiration andconstipation in neurologically normal and impairedchildren- Observation of intussusception reduction- Observation of videophonetics if locally performed2.1.4. Small and large bowel studies2.1.5. Urography: To understand the indicationsfor intravenous (iv) and MR urography;to know how to conduct the ivurography in children.38 www.ear-online.org

Detailed Curriculum for the Initial Structured Common Programme2.1.6. CT: To understand the technique in apaediatric trauma patient and the speciallow dose imaging protocols in generaluse. Experience of CT of the head andneck, abdomen, chest and musculoskeletalsystem, especially in a traumapatient, should be gained as far as possible.2.1.7. MR: The experience in MR by observationshould include neuroimaging (brainand spinal cord), abdominal and musculoskeletalimaging.2.1.8. Nuclear Medicine: To gain experience inrenal imaging – both DMSA scintigraphyand renography, possibly MAG3, andskeletal imaging.2.1.9. Angiography and Interventional Radiology: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 understandingof the multidisciplinary approachto the specific problems of fetalimaging.2.2. PathologyAll 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 immunocompromisedchildren- 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 itscomplications- To recognise and know how to investigatesuspected inhaled foreign bodies- To recognise mass lesions and know how tofurther 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 chesttrauma2.2.2. Mediastinum- To recognise and know how to investigate amediastinal mass in children.2.2.3. Diaphragm- To recognise diaphragmatic paralysis, eventration,and possible paralysis.2.2.4. Cardiovascular System- To recognise abnormal cardiac size and contours- To recognise cardiac failure (left vs. rightheart failure)- According to local possibilities: To get an understandingof the role of ultrasound, MR andangio-CT in the investigation of cardiac diseasesin children.2.2.5. Gastrointestinal Tract:- The investigation and imaging of congenitalgastrointestinal malformations in the neonatalperiod and later. These include:- Oesophageal atresia- Tracheooesophageal fistula- Malrotation and situs anomalies- Duodenal obstruction (e.g. atresia andstenosis)- Hirschsprung’s Disease- Duplication anomalies- The investigation of neonatal bowel obstruction,e.g.- Hirschprung’s Disease- Meconium ileus- Meconium plug syndrome- The ultrasound appearance of pyloric stenosiswww.ear-online.org 39

Detailed Curriculum for the Initial Structured Common Programme- Intussusception- Inflammatory bowel disease in children- Appendicitis- Gastroenteritis- Investigation of the following clinical problems:- 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 bodies2.2.6. Hepatobiliary Disease- Approach to the investigation of neonataljaundice- Cause and investigation of jaundice in theolder child- Choledocholithiasis in children- Congenital malformations of the biliary tree- Trauma- Hepatobiliary tumours2.2.7. Spleen- Trauma- Haematological diseases- Congenital syndromes associated with asplenia,polysplenia, etc.2.2.8. Pancreas- Trauma- Pancreatitis- Tumor involvement2.2.9. Endocrine DiseaseUnderstand the approach to the investigation of:- Thyroid disorders in children- Adrenal disorders in children including neuroblastoma- Growth abnormalities and suspected growthhormone deficiency2.2.10. Genitourinary tract- To recognise the normal appearance of theorgans in any imaging modality- To understand the urethral anatomy of the boy- To understand the clinical and biological criteriaof UTI- To be able to perform ultrasound of the urinarytract 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 pyonephrosis- To recognise congenital urinary tract anomalieson ultrasound and understand their furtherevaluation- To recognise hydronephrosis / hydroureterone-phrosison ultrasound and understandtheir further evaluation- To recognise the urinary tract features andcomplications of spinal dysraphism and otherneuropathies- To recognise bladder exstrophy radiologically- To know about indications for urodynamicstudies- To recognise Wilms’ tumour and understandits further investigation- To recognise pelvic and bladder tumours andtheir further investigations- To recognise polycystic kidney disease; knowabout various forms- To recognise urinary tract lithiasis and understandits investigation- To understand the investigation of hematuria- To be aware of renal manifestations of systemicdisease- To recognise the imaging features of nephroticsyndrome and glomerulonephritis2.2.11. Gynaecology- To recognise ovarian cysts, possible torsionand tumours in the child and adolescent- To recognise neonatal presentation of ovariancysts and hydro(metro)colpos- To recognise genital and extragenital tumoursand understand their investigation- To be aware of cloacal and urogenital sinusanomalies- To be aware of intersex anomalies arising inthe neonate and at adolescence- To recognise congenital uterine malformation- To know how to investigate precocious anddelayed puberty2.2.12. Breast Disease- To recognise the ultrasonic and MR appearancesof breast cysts2.2.13. Testes- To recognise scrotal trauma40 www.ear-online.org

Detailed Curriculum for the Initial Structured Common Programme- To recognise and know how to evaluate testiculartorsion- To recognise epidydymo-orchitis- To recognise testicular tumours- To understand the investigation of undescendedtestes2.2.14. 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 avulsionfracture and enthesopathy- To recognise soft tissue injury on X-ray, ultrasound,and MR- To recognise a slipped upper femoral epiphysis- To recognise Legg-Calvé-Perthes diseaseInfection- To recognise the imaging features of bone,joint, and soft tissue, including spinal infection- To recognise juvenile discitis- To recognise conditions that may mimic infection,such as SAPHO syndrome- To recognise the complications of foreignbody penetration- To be familiar with tropical infectionCongenital Disease- To recognise congenital hip dysplasia on ultrasoundand X-ray- To gain an approach to the radiology of skeletaldysplasia and isolated congenital malformations- To be aware of need for investigation of congenitaland acquired scoliosis and musculardystrophy- To understand intracranial injury, includingchild abuse and the complications- To understand the indications for the investigationof headache, diplopia, and epilepsy- Infection of the brain, meninges, orbits and sinuses,and the complications- Hydrocephalus- Tumours of the brain, orbits and spinal cord- Premature brain disease on both ultrasoundand MR- Congenital malformation of brain and spinalcord- Spinal cord injury- Spinal cord malformations and imaging forclinical presentations, e.g. back pain, clawfoot, or dermal sinus- To be aware of developmental anomalies: migrationaldisorders- Craniofacial malformations including craniostenosis- Congenital ear disease- Dental radiology2.2.17. MiscellaneousThese conditions are often multiorgan in presentationand 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 myofibromatosis- Endocrine disease- Investigation of small stature and growth disorders- Phakomatoses (tuberous sclerosis, neurofibromatosis,etc.)- Langerhans Cell Histiocytosis2.2.15 Rheumatology- To recognise the imaging features of juvenilearthritis and its differential diagnosis.2.2.16. Neurological Disease- To understand the indications for examination- To recognise normal results on X-ray, ultrasound,CT, and MR- To recognise trauma: skull and facial injurywww.ear-online.org 41

Detailed Curriculum for the Initial Structured Common ProgrammeUrogenital Radiology1 – INTRODUCTIONThe aim of establishing a curriculum for training in urogenitalimaging is to ensure trainees have acquired:- Knowledge of the relevant embryological,anatomical, pathophysiological and clinicalaspects of uronephrology and gynaecology- Understanding of the major imaging techniquesrelevant to uronephrological and gynaecologicaldiseases and problems- Understand the role of radiology in the managementof these specialist areas- Knowledge of the indications, contra-indications,complications and limitations of procedures2 – CORE OF KNOWLEDGE2.1. Urinary & male genital tract – Specific objectives2.1.1. Renal physiology and kinetics of contrastagents- To understand the physiology of renal excretionof contrast medium- To understand the enhancement curves withinrenal compartments after injection of contrastagents- To know the concentrations and doses ofcontrast agents used intravenously2.1.2. Normal anatomy and variants- Retroperitoneum:- To recognise retroperitoneal spaces andpathways- Kidney:- To understand the triple obliquity of thekidney- To know the criteria of normality of thepyelocaliceal system on IVU- To recognise normal variants, such asjunctional 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 walland physiology of micturion- To identify the segments of male urethraand location of urethral glands- Prostate:- To recognise zonal anatomy of theprostate- To identify prostatic zones with US andMRI- Scrotum:- To know the US anatomy of intra-scrotalstructures (testicular and extratesticular)- To know the Doppler anatomy of testicularand extratesticular vasculature2.1.3. Imaging techniques- Sonography of urinary tract- To choose the appropriate transducer accordingto the organ imaged- To optimise scanning parameters- To recognise criteria for a good sonographicimage- To recognise and explain the main artifactsvisible in urinary organs- To be able to get a Doppler spectrum onintrarenal vessels (for resistive indexmeasurement) and on proximal renal arteriesfor 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-urethrography- 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 adrenaltumour- To know the protocol for urinary obstruction(including stones)- To know the protocol for a bladder tumour- MR of the urinary tract- To know the appearances of urinary organson T1 and T2w images- To know the protocol for a renal and adrenaltumour42 www.ear-online.org

Detailed Curriculum for the Initial Structured Common Programme- To know the protocol for urinary obstruction- To know the protocol for a bladder tumour- To know the protocol for a prostatic tumour2.1.4. 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- Masses2.1.5. 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. kidneymass, prostate- CT-guided biopsies- Percutaneous nephrostomy2.2. Gynaecological Imaging2.2.1. Techniques- US examination- To be able to explain the value of a US examination- To be able to explain the advantages andlimits of abdominal vs. transvaginal approach- To know indications and contra-indicationsof hysterosonography- Hysterosalpingography- To be able to describe the procedure- To know the possible complications ofhysterosalpingography- To know the contra-indications of hysterosalpingography- To explain the choice of contrast agent- To know the different phases of the examination- 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 apelvic CT- To know the required preparation of thepatient and the choice of technical parameters(slice thickness, Kv, mA, number ofacquisitions, etc.) depending on indications- MRI- To be able to explain the technique of apelvic MRI- To know the contra-indications of MRI- To know the required preparation of thepatient and the choice of technical parameters(slice thickness, orientation, weighting,etc.) depending on indications- Angiography- To know the main indications of pelvic angiographyin women- To know how to perform a pelvic angiographywww.ear-online.org 43

Detailed Curriculum for the Initial Structured Common Programme2.2.2. Anatomy- To know main normal dimensions of uterusand ovaries with US- To describe variations of uterus and ovariesduring genital life- To describe variations of uterus and ovariesduring the menstrual cycle- To describe normal pelvic compartments- To identify normal pelvic organs and boundarieson CT and MRI- To explain the role of levator ani in the physiologyof pelvic floor- To know what imaging modalities can beused to visualise the pelvic floor- To know the factors responsible for urinary incontinence2.2.3. Pathology- Uterus- Congenital anomalies- Tumours (benign and malignant)- myometrium- endometrium- cervix- Inflammation- Adenomyosis- Functional disorders- Ovaries / Tubes- Ovary- Cysts- Tumours- Functional disorders, e.g. precociouspuberty, polycystic ovaries- Endometriosis- Tubes- Inflammatory disorders- Tumours- Pelvis- Prolapse- Infertility3.2. To validate the request based on- Risk factors- Irradiation involved- Possible alternatives3.3. To perform the examination- To know the clinical history and the clinicalquestions to be answered- To know the protocol of examination- To assess the anxiety of the patient before,during and after the examination, and provideappropriate reassurance3.4. Communication with the patient and the colleaguesand recommendations for follow-up- To explain clearly the results to the patient- To assess the level of understanding of thepatient- 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 necessary3 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLS3.1. Before the examination- To check the clinical information and risk factors(diabetes, allergy, renal failure, etc.)- To validate the request and the choice of examination- To know the specific preparation and protocols,if necessary- To explain the examination to the patient andinform him / her about risks44 www.ear-online.org

Detailed Curriculum for Subspecialty TrainingDetailed Curriculum forSubspecialty TrainingIn the fourth and fifth years, the rotations of the radiologistsin training should be organised to serve the individual’sneeds 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 generalhospitals 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 radiologistsbeing 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 aspectsof them.For trainees entering a subspecialty, the total period ofsubspecialist training will vary according to the subspecialtybut would normally be expected to be completedduring the fourth and fifth years. For those subspecialtieswith a single year of subspecialty training, continued trainingin general radiology during the balance of time will beundertaken. Some subspecialty training may extend beyondthe 5 th year depending on national training arrangementsrelevant to their specialty programme.Formal teaching is organised on the basis of lectures, tutorials,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 experiencein 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 subspecialty(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 individualsubspecialty as a stand-alone document, there isrepetition of some of the generic points. These subspecialtycurricula have been prepared by different Europeansocieties of specialty in radiology, for which the EAR(ESR) is very grateful. Inevitably certain compromise decisionshave had to be taken, especially in the face of conflictingadvice. Furthermore, each curriculum has had toconform to a uniform style.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 reflectthe requirements of the trainee. It is also appreciatedthat training in the individual subspecialties may vary fromcentre to centre. It is recommended for subspecialty rotationthat there be a minimum commitment of six sessionsper week to subspecialty training. It will sometimes be appropriateto link system-based expertise with techniquebasedexpertise.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.www.ear-online.org 45

Detailed Curriculum for Subspecialty TrainingBreast Radiology1 – INTRODUCTIONThe 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 withparticular knowledge of the nature of breast cancerin all its guises.- A clear understanding of the role of imaging inthe early diagnosis of breast cancer.- Development of the necessary clinical and managementskills to enable radiologists to becomean integral part of a multidisciplinary breast teamin symptomatic and / or population screening settings.2 – EXPERTISE AND FACILITIES- Training must be undertaken in a team with accessto 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 department(s)should fulfil EU guidelines, musthave mammography, ultrasonography and interventionalequipment including stereotaxic and ultrasonicallyguided 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 textbooksalong 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 trainingoutlined below will extend this to the practicalrole.- Those clinical radiologists who wish to devote essentiallyall 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 undertake6 months.- Trainees will acquire an extensive knowledge ofthe pathology and epidemiology of breast diseases,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, radiotherapyand chemotherapy and be aware of the diagnosticneeds of their surgical, radiotherapy andoncology colleagues. It would therefore be helpfulfor trainees to spend time in breast clinics, operatingtheatres, 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 colleaguesand "breaking bad news".- They must obtain extensive experience in all diagnosticprocedures 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 completea focused audit and develop an understandingof the process of interval cancer review.- They should participate in research and beencouraged to pursue a project up to and includingpublication. An understanding of the principlesand techniques used in research, includingthe value of clinical trials and basic biostatistics,should be acquired.- They must attend regular multi-disciplinary conferences.46 www.ear-online.org

Detailed Curriculum for Subspecialty Training4 – THEORETICAL KNOWLEDGETrainees should attend 40 hours of theoretical training inthe form of locally delivered tutorials, specialist breast imagingcourses as well as national and international breastimaging and breast screening conferences such as thoseof EUSOBI and ECR.- Clinical training- Knowledge of the clinical findings associatedwith normal, benign and malignant tissue- Knowledge of the risks of breast disease associatedwith family history, hormone replacementtherapy, etc.- Knowledge of breast surgery, treatment andreconstruction and how these might influenceimaging appearances- Radiation protection- Knowledge and understanding of the currentlegislation governing the use of ionising radiationand 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 comparedwith other techniques, e.g. ultrasound,MR- PhysicsFor all imaging modalities- Knowledge and understanding of the physicsof image production and how alteration ofmachine parameters affect the image- Knowledge and understanding of imagerecording and display systems and how alterationsin machine parameters affect theimage- Knowledge and understanding of QualityAssurance Programmes and the impact thatimage quality has on clinical performance.- Knowledge of artefacts, limitations of resolution,and contrast- Anatomy and Pathology- Knowledge and understanding of normal embryology,physiology and anatomy of thebreast and associated structures in particularchanges due to age, lactation, hormonal status,surgery, radiotherapy, etc.- Knowledge and understanding of normalphysiology, pathology and pathophysiology ofbreasts and associated structures includingsynchronous and metachronous disease- Knowledge and understanding of benign andmalignant diseases of the breast and associatedstructures 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, benignand malignant processes (both primary),local recurrence and distant spread- Limitations of individual techniques, examinations,sequences / views and the complementarynature of other techniques and the role ofeach technique in the investigation of breastdisease- Knowledge and understanding of how imagingfindings influence decisions by others,e.g. surgeons, pathologists, oncologists, etc.:- Mammography including additional andspecial 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 objectivesand principles of Quality Assurance- Understanding of the principles and techniquesused in audit and research, includingthe value of clinical trials and basic biostatistics.- Knowledge and understanding of legal liabilityand processeswww.ear-online.org 47

Detailed Curriculum for Subspecialty Training5 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLS- Clinical training- Ability to undertake physical examination ofthe 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 andcomplementary nature of other techniquesand the role of each technique inthe investigation of breast disease- Knowledge and understanding of howbiopsy and interventional techniques influencedecisions and treatment planningby others, e.g. surgeons, pathologists, oncologists,etc.- The applicable procedures are:- Cyst aspiration- Fine needle aspiration cytology (freehand- and / or image-guided)- Mechanical and vacuum-assisted corebiopsy (free hand- and / or image-guided)- Image-guided localisation- Abscess management- MR-guided focused ultrasound and anyother new techniques- Communication- Knowledge and understanding of the importanceof effective communication with boththe patient and the members of the multidisciplinaryteam- Knowledge and understanding of the principlesof breaking bad news and the psychosocialconsequences of doing this badly- Teamworking- Knowledge of roles and responsibilities ofother 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 imagingfindings influence decisions by others,e.g. surgeons, pathologists, oncologists, etc.- Practical experienceThe trainee must obtain a substantial experiencein all clinical, imaging and interventional techniquesthat are listed above.Minimum experience per month of training:- Interpretation of screening mammograms300 cases- Interpretation of symptomatic cases includingultrasound80 cases- Experience of image-guided procedures20 cases48 www.ear-online.org

Detailed Curriculum for Subspecialty TrainingCardiac Radiology1 – INTRODUCTIONThis curriculum outlines the training requirements to preparea radiologist for a career in which a significant proportionof 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 obtainedbasic 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 careerto this area. Other trainees may be more inclined tocombine elements of this training programme with anotherspecialist area, such as vascular or thoracic radiologyover a two-year-period. This document outlines a frameworkfor 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 andpractical developments in the specialty- Extensive hands-on experience with graded supervision- Clinical knowledge relevant to cardiology so thatthe trainee may confidently discuss the appropriateimaging 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 imaging2 – EXPERTISE AND FACILITIES- 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 training.- Clinical knowledge will be obtained by a variety ofmeans, including close liaison with the appropriatesurgical and medical teams, e.g. by exposureto combined clinico-radiological conferences. Thefollowing clinical interrelationships should be explored:- Cardiology (adult and paediatric)- Cardiac surgery (adult and paediatric)- Cardiac pathology- Cardiac anaesthesia / critical care and emergencymedicine- In some instances, it may be appropriate for thetrainee 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 relevantto 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 nationaland international meetings. The progressionof 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 backup.- 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 subspecialtytraining in cardiac radiology with anotherspecialist area (such as thoracic radiology), orwhether the trainee wishes to make cardiac radiologyalone the prime focus.- For trainees wishing to specialise primarily in cardiacradiology, a period of 12 months substantiallydevoted (minimum of 8 sessions per week) tothe subject is recommended.- For trainees wishing to specialise in cardiac radiologytogether with another area of interest, thetraining can be provided in a modular trainingwww.ear-online.org 49

Detailed Curriculum for Subspecialty Trainingprogramme over two years.- The exact structure of the training programmeneeds 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 numberof 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 heartcatheterisations (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 requirements.It is stressed that the schedule above is intendedas an example only. Clearly the exact ratio oftraining in the different modalities of cardiac imagingwill 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 cannotbe met entirely locally, it may be appropriateto negotiate a period of "external" training eitheras a block elective period or as an ongoing regularday release.- Regardless of the imaging modality concerned,the trainer or training committee must be satisfiedwith the trainee being able to consistently interpretthe 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) supervisionmay be provided by non-consultantpersonnel, provided they are of sufficient seniorityand 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 providinganalgesia and / or sedation where required aswell as the necessary continuous monitoring requiredto perform this safely.- In view of the use of potentially hazardous techniques(e.g. angiography) and substances (e.g.adenosine, dobutamine, iodinated contrastmedia), the trainee should be fully competent inbasic and advanced life-support. Regular "refresher"course training should be undertaken atleast on a yearly basis and formal ALS certificationshould be considered.- The trainee should become aware of the localand national guidelines in obtaining informed patientconsent where appropriate.4 – THEORETICAL KNOWLEDGE- Basic Sciences- Basic cardiac and cardiovascular physiology- Cardiac and cardiovascular anatomy includingthe heart great vessels, peripheral arterialtree and the pulmonary arteries- Basic biochemistry related to cardiac diagnosisand treatment- Radiation physics and radiation protection asapplied to cardiac diagnosis- Principles of radio-isotope imaging- Principles of cardiac gating and cardiac triggering- 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, includingthe 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 includingrisk assessment- Basic knowledge of cardiac disease presentationand non-imaging diagnostics- Age-based presentations of cardiac disease- Treatment of common cardiac conditions- Cardiac Radiology Practice- Understanding of principles of each cardiacimaging modality- Selection of appropriate imaging modality forthe patient´s condition, including risks andbenefits- Limitations and advantages of each methodof cardiac imaging50 www.ear-online.org

Detailed Curriculum for Subspecialty Training- Management- Principles of managing a cardiac imagingservice- Purchase and selection of equipment- Research- Methodology of research in cardiac imagingand cardiology- Evidence base in cardiac imaging- Knowledge of statistical methods- Methodology of scientific writing and presentation- Medico-legal- Understanding of medico-legal issues relatingto cardiac radiology- Understanding of uncertainty and error in cardiacimaging practice5 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLS- Plain Film Interpretation- Limitations, advantages and principles ofchest X-ray diagnosis of adult and congenitalcardiac disease- CT Interpretation and patient management- CT anatomy of the heart, pulmonary arteriesand great vessels- Principles of spiral and ultrafast CT of theheart 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, pulmonary,and peripheral vascular system- Principles of image sequencing and specialisedgating- Interpretation of cardiovascular and pulmonarypathology- Understanding of cardiac physiology relatedto MRI, including flow sequencing and specialisedtagging techniques- Uses, limitations and hazards of MRI cardiacimaging- Cardiac imaging by other modalities- Principles, uses and limitations of cardiac angiographycatheterisation 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 cardiacimaging- Patient management of stress testing for cardiacimaging6 – APPRAISAL AND ASSESSMENTAt the end of the programme, the trainee should:- Be able to supervise technical staff to ensure appropriateimages are obtained;- Discuss significant or unexpected radiologicalfindings with referring clinicians and know whento contact a clinician;- Be able to recommend the most appropriate imagingmodality, appropriate to the patients´symptoms or pathology or request from the referringclinician;- Develop skills in forming protocols, monitoringand interpreting cardiac studies, appropriate topatient history and other clinical information;- Demonstrate the ability to effectively present cardiacimaging in a conference setting.www.ear-online.org 51

Detailed Curriculum for Subspecialty TrainingChest Radiology1 – INTRODUCTIONThis curriculum outlines the subspecialty training requirementsfor specialist training in thoracic radiology. This involvesthose aspects of radiology which provideinformation about anatomy, function, disease states andthose aspects of interventional radiology or minimally invasivetherapy 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 investigationsaccurately 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 acquires:- Knowledge of the relevant embryological,anatomical, pathophysiological and clinical aspectsof 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 proceduresincluding radiation exposure issues andcontrast media;- Clinical knowledge relevant to thoracic medicineand surgery such that the trainee may confidentlydiscuss 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 trainingin thoracic radiology will be that the trainee can selectthe suitable imaging modality for thoracic problems, supervise(and perform where appropriate) the examinationand accurately report on the examination findings. Thetrainee should be competent in all aspects of thoracic imagingand intervention.2 – EXPERTISE AND FACILITIESThe 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 appropriateCT, MR, ultrasound, fluoroscopy, and radionuclideimaging facilities.The trainee should be exposed to a clinical service involvingthoracic medicine, thoracic surgery, respiratory pathology,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 containingtextbooks on thoracic radiology, thoracic medicine,thoracic surgery, pathology, and pulmonary physiology.3 – THEORETICAL KNOWLEDGEThe trainee should acquire:- A comprehensive knowledge of normal respiratoryfunction and thoracic diseases, including:- The embryology, anatomy, normal variantsand pathophysiology relevant to cardiorespiratoryfunction- The pathology of benign and malignant conditionsinvolving the thorax- The epidemiology of lung diseases- The principles of population screening forlung cancer and other lung diseases- The techniques used in thoracic surgery- The techniques involved in all imaging and interventionalprocedures used in evaluatingand treating thoracic diseases, includingmanaging the complications of these procedures- Local, national and, where appropriate, internationalimaging guidelines relevant to thoracicradiology- Knowledge of the full range of radiological diagnostictechniques available, in particular:- The indications, contraindications and complicationsof each imaging method- The factors affecting the choice of contrastmedia and radiopharmaceuticals- The effects and side effects of these agents52 www.ear-online.org

Detailed Curriculum for Subspecialty Training- Radiation dose reduction strategies, particularlyfor paediatric patients- Particular emphasis should be placed on thestrengths and weaknesses of the different imagingmethods in various conditions. The appropriatechoice of imaging techniques and / or theappropriate sequence of imaging techniques inthe investigation of specific clinical problemsshould be emphasised.4 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLS- Specific skills to enable:- The conduct, supervision and accurate interpretationof all imaging techniques used inthe investigation of thoracic diseases to aconsistent and high standard;- The accurate localisation and, where appropriate,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 professionalcolleagues;- Accurate informed consent to be obtainedfrom patients;- Continuing accreditation and maintenance oflife-support skills.- A clear understanding of the purpose of multidisciplinarymeetings, including their role in:- The planning of investigations, including theselection 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 complicationsof 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 surgery)examinations- Intensive care and high-dependency unitexaminations- Thoracic trauma- Paediatric examinations- Respiratory medicine out-patients examinations- 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 cancerstaging- Interventional techniques.Trainees should acquire experience in the followingprocedures:- Biopsy of thoracic wall, pleural, pulmonaryand 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 physiologywww.ear-online.org 53

Detailed Curriculum for Subspecialty Training- 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 clinico-radiologicaland multidisciplinary meetings.The trainee should be encouraged to attend appropriateeducational meetings and courses.- The trainee should participate in relevant clinicalaudit, management and clinical governance andhave a good working knowledge of local and nationalguidelines in relation to radiological practice.- Trainees will be expected to be familiar with currentthoracic 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, includingthe value of clinical trials and basic biostatistics,should be acquired. Presentation ofresearch and audit results at national and internationalmeetings should be encouraged.5 – APPRAISAL AND ASSESSMENT- 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 investigationsaccurately and reliably.- Methods of trainee assessment include:- Regular direct observation of clinical techniques(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 thoracic diseases;- A final assessment of overall professionalcompetence.Gastrointestinal andAbdominal Radiology1 – INTRODUCTIONThe 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 interventionalradiology, 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.2 – THEORETICAL KNOWLEDGEDuring 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 sectionsof the gastrointestinal tract, the diaphragm,the abdominal wall, the pelvic floor, the peritonealcavity, the liver, spleen, biliary tract andpancreas using plain films, fluoroscopy, barium/ gastrografin studies, sonography, CT,and MRI- To know the arterial supply and venousdrainage of the various portions of the gastrointestinaltract; to explain the possible variationsof flow in the superior mesentericartery and vein and the portal and hepaticveins- To know the lymphatic drainage of the relevantorgans- To know the important variants of anatomy- To have a basic understanding of physiologyof the gastrointestinal tract and the abdominalorgans- Oesophagus- To identify oesophageal perforation on plainfilms, contrast studies, and CT- To identify mega-oesophagus, diverticulum,54 www.ear-online.org

Detailed Curriculum for Subspecialty Trainingextrinsic compression, fistulae, sliding andpara-oesophageal hiatus hernia, benign strictures,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 oesophagealcancer 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 examinations- Stomach and Duodenum- To define the most appropriate imaging examinationand contrast use in suspected perforationof the stomach and postoperativefollow-up; to name the limitations of each examinationfor these specific conditions- To understand the imaging features (on bariumstudies and CT) of a variety of conditions,such as benign and malignant tumours, includingGIST, infiltrative disorders (e.g. linitisplastica), gastric ulcers, duodenal diverticulum,and positional abnormalities includinggastric volvulus- To perform a CT examination of the stomach /duodenum, using the most appropriate protocolaccording 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 imagingexamination in the following cases: smallbowel obstruction, inflammatory disease,small bowel perforation and ischaemia, cancer,lymphoma, carcinoid tumour and postoperativefollow-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 angulation,extrinsic compression, diverticula,and fistula- To identify on a small bowel series the followingdiseases: adenocarcinoma, polyposis,lymphoma, carcinoid tumour, GIST, Crohn’sdisease, radiation-induced injury, malrotation,Meckel’s diverticulum, diverticulosis, lymphoidhyperplasia 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 obstruction;to identify a small bowel tumour(adenocarcinoma, lymphoma, carcinoid tumour,stromal tumour); to identify mural pneumatosis,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 obstructionon CT (adhesion, band, strangulation,intussusception, volvulus, internal andexternal hernias) and their complications; toidentify criteria for emergency surgery- Colon and Rectum- To determine the optimal imaging examinationto study the colon according to the suspecteddisease (obstruction, volvulus,diverticulitis, tumour (including lymphomaand carcinoid), inflammatory disease, perforation,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 tumours,including GIST, diverticulitis, inflammatorydiseases, colon ischaemia, andradiation-induced colitis- To identify a megacolon, colonic diverticulosisand diverticulitis, colitis, colonic fistula, carcinoma,polyps, and postoperative stenosis onan enema- To identify colonic diverticulosis, diverticulitis,tumour stenosis, ileocolic intussusception,colonic fistula, paracolic abscess, intra-peritonealfluid 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, hepaticmetastases, and obstruction); to knowthe TNM classification of colo-rectal cancerand the potential role of PET-CT; to under-www.ear-online.org 55

Detailed Curriculum for Subspecialty Trainingstand 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 differentiatingbetween postoperative fibrosis and tumourrecurrence; to know the potential role ofPET-CT- To know the MRI appearance of pelvic / perianalfistula and abscesses as well as the increasedrisk of anal carcinoma in Crohn’sdisease with long standing perianal complications- Peritoneum and abdominal wall- To identify the various types of abdominalwall hernias (inguinal, umbilical, parastomal,postoperative) on a CT scan- To identify a mesenteric tumour and to determineits location on CT- To know the features of a mesenteric cyst onCT- To recognise the features of mesenteric panniculitisand sclerosing mesenteritis- To know the normal features of the peritoneumon sonography and CT; to identify thefollowing peritoneal diseases on CT: peritonealcarcinomatosis, peritoneal tuberculosisand 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 angiographicstudy of the mesenteric vessels and identifyocclusion and stenosis of the superiormesenteric artery- Liver- To localise a focal liver lesion according toliver segmentation and major vessels anatomy(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 abscessand pyogenic abscess of the liver (appearance,evolution, treatment, indication fordrainage).- To describe the most common surgical proceduresfor hepatectomy- To know the appearance of liver haemangiomaon US, CT, and MRI, including typicalcases 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, contrastsonography, CT and MRI- To know the appearance of fatty liver, bothhomogenous and heterogeneous, on sonography,CT and MRI (including in- / out-ofphaseimaging and fat suppression images).- To describe the appearance of iron overload,causes and quantitation with MRI- To describe the natural history of hepatocellularcarcinoma (HCC), major techniques andindications for treatment (surgical resection,chemotherapy, chemoembolisation, percutaneousablation, 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 cirrhosis- Biliary Tract- To know the imaging methods for the detectionof 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 cholangiocarcinomaof the liver hilum (Klatskin tumour) andknow how to stage it- To know the appearance of ampullar carcinomaon sonography, CT and MRI, and list differentialdiagnoses- To describe the common appearance of sclerosingcholangitis 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 cyst56 www.ear-online.org

Detailed Curriculum for Subspecialty Training(and the risk of cholangiocarcinoma).- To describe the main techniques for surgeryof the bile duct and common complications- Pancreas- To know the natural history of acute andchronic pancreatitis- To identify pancreatic calcifications on plainfilms, sonography and CT- To know the common appearance of extrapancreaticfluid collection and phlegmons incase of acute pancreatitis- To know the ductal changes in chronic pancreatitiswith MRI and secretine- To detect a pancreatic pseudocyst- To know the most common appearance(nodular, infiltrating) of pancreatic adenocarcinomaon sonography, CT and MRI, and performstaging in order to choose a treatment- To know the features of endocrine tumours- To describe the usual appearance of cystictumours of the pancreas, mainly serous andmucinous cystadenoma, intraductal mucinoustumour and rare cystic tumours- To describe the main techniques for pancreaticsurgery and potential complications- Spleen- To know the appearance of accessory spleenand 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 lesions(cyst, hydatid cyst, metastasis, lymphoma,abscess, haemangioma)- Trauma- To know the CT technique for trauma patients- To identify abdominal hematoma, activebleeding, parenchymal laceration and traumaticlesions of the gastrointestinal tract; toknow the limitations of CT to identify gastrointestinaltract lesions- To know which conditions require immediateembolisation or surgery(Links for reference cases to be sampled in EURORADwill be provided later.)3 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLSBy the end of the fifth year, the resident should have acquiredthe following skills:- General Requirements- To know the indications and contra-indicationsof 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 techniqueand the clinical problem- To tailor the examination protocol to theclinical question- To supervise technical staff to ensure appropriateimages are obtained- To evaluate the quality of the imaging examinationsin abdominal imaging- To know the relative cost of the various imagingexaminations in abdominal imaging- To understand the radiation exposure andrisks of different investigations- Specific RequirementsPlain Abdominal Film- To describe patient positioning and know thethree basic indications for a plain radiograph- To understand the clinical indications for obtainingplain radiographs and when furtherviews or a CT or MRI may be necessary- To diagnose pneumoperitoneum, mechanicalobstruction and pseudo obstruction, toxic dilatationof the colon, gas in small and largebowel wall indicating ischaemia and necrosis,pancreatic and biliary calcifications and aerobiliaUpper Gastrointestinal Tract X-ray Examination- To perform and interpret both single and doublecontrast X-ray examination of the uppergastrointestinal tract and to determine themost appropriate contrast material; to understandthe principles and limitations of thesestudies, their advantages and disadvantagescompared to endoscopy- To perform and interpret small bowel followthroughand enteroclysis, including catheterplacement beyond the ligament of Treitz; toappreciate the importance and degree of fillingand distension of small bowel loopswww.ear-online.org 57

Detailed Curriculum for Subspecialty TrainingLower Gastrointestinal Tract X-ray Examination- To perform and interpret a double contrastbarium enema and a single contrast enema- To know how to catheterise a stoma for colonopacification and how to perform pouchogramsand loopograms- To know the indications and contraindicationsfor enema techniques and determine the optimalcontrast 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 theliver, gall bladder, biliary tree, pancreas,spleen, and the gastrointestinal tract- To recognise the retroperitoneal structuresand understand the application and limitationsof sonography in this area- To know the indications and contraindicationsof contrast agentsComputed Tomography- To perform a CT examination of the abdomenand to tailor the protocol to the specific organor clinical situation to be studied; to determinewhether intravenous administration of a contrastmaterial is needed; to determine the optimalprotocol for the injection of contrast (rateof injection, dose, delay); to know the variousphases (plain, arterial-dominant, portal-dominant,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 materials)- To have experience in the use of workstationsfor multiplanar reconstructions (MPR) and 3Dreconstruction based around volume datasets- To perform and be able to interpret CTcolonoscopyMagnetic Resonance Imaging- To perform MRI of the liver, the biliary tract(including MRCP), pancreas, and the spleen- To know the various contrast materials thatcan be used for MRI of the liver and their individualuses- To perform MRI of the gastrointestinal tract- To have experience in the use of workstationsfor multiplanar reconstructions (MPR) and 3Dreconstruction based around volume datasetsInterventional Imaging- To perform percutaneous drainage of abdominalcollections using CT and sonography- To perform percutaneous biopsy of the liverand other organs under sonographic and CTguidance- To perform angiography of the abdominal arteries- To perform selective embolisation of the abdominalarteries in hemorrhage and treatmentof tumours- To perform percutaneous gastrostomy underimage guidance- To perform percutaneous biliary intervention- To perform radiologically guided stenting ofthe biliary system and gastrointestinal system,using PTFE and expandable metalstents- To know indications and contraindications ofcommon interventions in gastrointestinal andabdominal radiologyEndoscopy and endoscopic ultrasound (optional)- To perform endoscopic evaluation of gastrointestinaltract- To perform and interpret endoscopic ultrasoundexamination of the oesophagus, pancreas,biliary tract, and rectum- Communication and Decision-Making Skills- To justify and explain the indication and theexamination conduct to the patient- To obtain fully informed consent- To inform the patient of the results of the examinationand evaluate the patient’s understanding- To make a precise and concise description ofthe imaging signs present; to answer the clinicalproblem and make a conclusion accordingly;to suggest additional imagingexaminations when needed, using appropriatejustification; to decide when it is appropriateto obtain help from supervisory faculty ininterpreting imaging findings; to code the findingsof examinations- To maintain good working relationships withreferring clinicians; to discuss significant orunexpected radiologic findings with referring58 www.ear-online.org

Detailed Curriculum for Subspecialty Trainingclinicians and know when to contact a clinician;to effectively present imaging findings ina conference setting- To correlate pathologic and clinical data withimaging findings- ConferencesAs part of the curriculum in abdominal radiology, thetrainee should attend in-house teaching sessions for radiologistsas well as clinical conferences with colleaguesfrom other specialties. The latter type of conferenceshould be included to facilitate the radiology residents’ understandingof the use of imaging and clinical circumstancesin which imaging is requested.The following list gives examples of the types of conferencesthat should be considered part of the curriculum:- Abdominal radiology resident-specific teachingconference- Internal medicine / gastroenterology conferences- Surgery / abdominal surgery conferences- Oncology conferences- Pathology conferencesabnormalities, even if they are not seen in a resident’s immediatetraining environment.4 – APPRAISAL AND ASSESSMENTIn gastrointestinal and abdominal radiology, as in all otherparts of radiology training, each trainee should be individuallyappraised on an annual basis. The purpose of appraisalis 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 section/ 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 establishgoals for the attachment and the second meeting tosee whether the goals have been achieved. Logbooks canbe used for documenting the skills and experience obtained.Logbooks are mandatory for all interventional procedures,irrespective of subspecialty.- Teaching material and suggestions for readingThe following English textbooks are recommended to answerall 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 (2 nd Edition). WBSaunders, Philadelphia, 2000.2. Eisenberg RL. Gastrointestinal Radiology – APattern Approach (4 th Edition). Lippincott,Philadelphia, 2003.3. Abdominal radiology book(s) in local language- 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 knowledgebasedobjectives and allow a resident to see and studywww.ear-online.org 59

Detailed Curriculum for Subspecialty TrainingHead and Neck Radiology1– INTRODUCTIONHead 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 sinuses,oral cavity, the oro- and hypopharynx, larynx, salivaryglands, 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.2 – EXPERTISE AND FACILITIESBefore undertaking this curriculum, radiologists in trainingwill have completed the curriculum for general trainingand will have acquired a thorough knowledge of the physicalprinciples of the different imaging methods, the contra-indicationsand 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 radiography,sialography, dacryocystography, and CT- Digital imaging and image processing pertinentto head and neck radiology- Multislice CT, 2D and 3D reconstructions andvirtual endoscopy techniques- MRI sequences commonly used in head andneck imagingDuring the subspecialty training period, the trainee mustspend most of his / her time in this field. They should acquirean in-depth knowledge of radiological manifestationsof disease and should also be acquainted with theclinical and pathologic presentation. They should have abasic understanding of clinical tests which are prerequisitefor imaging (e.g. endoscopy, audiometry) and shouldacquire extensive experience in all the diagnostic modalitieslisted below and in non- angiographic interventionalprocedures.- The trainee should be familiar with clinical terminologyso as to communicate without difficulty.They should attend weekly multidisciplinarymeetings to obtain thorough understanding ofhow patients are treated as well as the role of radiologyin 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 departmentsor multidisciplinary programmes. It is recommendedthat 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 andneck teaching conference- An appropriate proportion of radiology grandrounds devoted to head and neck radiology- Multidisciplinary head and neck tumour board- Multidisciplinary dysphagia conference- Radiologic-pathologic correlation rounds- Maxillofacial surgery conference- Emergency radiology conferenceThe trainee should have at least 30 hours of formal teachingat his / her institution during these two years. In addition,during these two years, the trainee should attend atleast two annual meetings of the ESHNR or ASHNR orother specialised meetings where head and neck radiologyplays 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 researchprojects to acquire knowledge of the design, execution,and analysis of scientific projects. They should beencouraged to present papers at international congressesand meet others involved in the field of head and neck radiologyto exchange ideas and experiences.3 – THEORETICAL KNOWLEDGEAt the end of the training period, the trainee should haveachieved the knowledge-based objectives listed below.Reasonable continuous progression is to be expected60 www.ear-online.org

Detailed Curriculum for Subspecialty Trainingduring the training period, bearing in mind that training institutionsorganise 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, themandible 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 posttherapeuticfindings, including complications of therapy:- Temporal bone- Transmission deafness- Perception deafness- Embryology and congenital anomalies ofthe outer ear and middle ear- Temporal bone inflammatory disease- Temporal bone fractures- Otospongiosis and dysplasias of the temporalbone- Tumours of the temporal bone and cerebello-pontineangle, tumours involving thefacial nerve, bone tumours of the temporalbone, metastases, lymphoma, and endolymphaticsac tumours- Vascular tinnitus- The skull base and cranial nerves- Embryology, congenital and developmentalanomalies of the skull base- Inflammatory conditions- Tumours and tumour-like conditions, includingthose 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 rhizotomyinjections- Pathologic conditions involving the cranialnerves and their nuclei- Orbit and visual pathways- Ocular pathology, including congenital,traumatic, vascular and neoplastic lesions.- Orbital pathology, including developmentalabnormalities, inflammatory diseases,autoimmune disorders, tumours and tumour-likeconditions, vascular malformations,neural tumours, and lacrimal glandlesions- Pathology of the lacrimal apparatus- Pathology of the visual apparatus- The sinuses- Anatomical variations and congenitalanomalies of the paranasal sinuses- Inflammatory conditions and orbital complicationsof sinusitis, mucoceles, cysts,and polyps- Tumours and tumour-like conditions- Common endoscopic techniques andtheir relevance to imaging and presenceof disease- The pharynx- Pathologic conditions of the nasopharynx,particularly benign mucosal lesions, inflammatoryconditions, tumours such asnasopharyngeal carcinoma, lymphoma,minor salivary gland tumours, schwannomasand traumatic conditions- Pathologic conditions of the oropharynx,including functional disorders of deglutition,inflammatory conditions, tumourssuch as oropharyngeal carcinoma, lymphoma,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, inflammatoryconditions, tumours such as hy-www.ear-online.org 61

Detailed Curriculum for Subspecialty Trainingpopharyngeal, lymphoma, minor salivarygland tumours, schwannomas, lipomasand other tumours and traumatic conditions- Congenital malformations of the pharynx,particularly branchial cleft cysts and sinuses,teratoma, and heterotopic pharyngealbrain- The oral cavity- Pathologic conditions of the oral cavity, includingfunctional disorders of the tongue,congenital anomalies, vascular lesions,dermoid cysts, thyroglossal duct cysts, lingualthyroid, 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 masseterichypertrophy, and traumatic conditions- The larynx- Pathologic conditions of the larynx, includingfunctional disorders of the larynx,congenital anomalies, webs and atresia,inflammatory lesions, including rheumatoidand collagen vascular disease, benigntumours such as lipoma,rhabdomyoma, nerve sheath tumours,pleomorphic adenoma, malignant tumourssuch as carcinoma, chondrosarcoma,lymphoma, adenoid cysticcarcinoma, and traumatic conditions- The neck- Congenital lesions, in particular cystic lesions,thyroid anomalies, malformationsof the lymphatic system, and classificationof lymphangiomas- Lymph node disease including clinical significance,metastatic disease includingimaging criteria of disease, extranodal tumourspread and arterial invasion, lymphomas,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 andparagangliomas, lipomas, and cystic lesions- Vascular pathologies of the internal jugularvein and carotid artery- The salivary glands- Inflammatory disorders, in particular infection,sialolithias, chronic recurrentsialadenitis, autoimmune diseases, sialosis,and infectious disorders- Cystic lesions- tumours particularly pleomorphic adenoma,Warthin's tumour, adenoid cystic carcinoma,mucoepidermoid carcinoma,metastases, lymphoma, lipoma, neurogenictumours- Vascular malformations, particularly lymphangiomaand hemangioma- Periglandular lesions, such as masseterichypertrophy- The facial skeleton including the teeth, themandible, and temporomandibular joints- Congenital lesions of the midface, includingmidline cleft lip and defects and inclusiondisease, cephaloceles, andpremature cranial synostosis- Pathologic conditions of the mandible, includingcysts, odontogenic tumours, nonodontogenictumours, vascular lesions,neurogenic lesions, malignant tumours,and dental inflammatory lesions- Pathologic conditions of the temporomandibularjoint, including disk, osteoarthritis,avascular necrosis,osteoarthritis dissecans, tumours of theTMJ, trauma and congenital anomalies- The deep spaces of the face and neck- Common pathologic conditions involvingthe different spaces of the supra- and infrahyoidneck, in particular the masticatorspace, parapharyngeal space, retropharyngealspace, carotid space and perivertebralspace, and the role of diseaselocation in determining differential diagnosis- The thoracic inlet and the brachial plexus- Pathologic conditions of the thoracic inletand brachial plexus, particularly traumaticconditions such as avulsion, elongation,compression by hematoma or callus, tho-62 www.ear-online.org

Detailed Curriculum for Subspecialty Trainingracic outlet syndrome, schwannoma, superiorsulcus carcinoma, lymphoma,adenopathies, and metastasis- The thyroid gland and the parathyroid glands- Congenital lesions including thyroglossalduct 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 parathyroidglands, in particular hyperparathyroidism,adenoma, carcinoma, cysts, and hypoparathyroidism4 – THEORETICAL, COMMUNICATION AND DECISION-MAKING SKILLSThe 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 contraindicationsof diagnostic procedures in the areaof the head and neck- The ability to instruct clinical colleaguesabout major changes in diagnostic procedures,thereby preventing unnecessary examinations- A thorough knowledge of the current literature- The ability to transmit this specific knowledgeto colleagues in general radiology and to educateradiologists in speciality training in headand neck radiologyAt the end of the training period, the trainee should haveachieved the technical, communication and decisionmakingskills listed below. Reasonable continuous progressionis 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 aboutthe diagnostic procedure and obtain informedconsent where relevant- To be able to explain to the patient how to cooperateduring the examination- Clinical Background- To have a thorough knowledge of the pathologyinvestigated 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, informativeand clinical "effective reports", explaining imagingfindings in a clinical context- To be able to advise referrers on the appropriateuse of imaging studies- To be able to present head and neck examinationseffectively 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 ensurequality control- To be able to justify, conduct and interpret theimaging 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 salivaryglands, thyroid gland, and neckBarium 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 manoeuvresCT (diagnostic, angiography, and FNP):- Radiation dose, technical parameters,and image quality- Acquisition and reconstruction parameters- Post-processing techniqueswww.ear-online.org 63

Detailed Curriculum for Subspecialty Training- Appropriate use of contrast media- Indications to extend the CT examinationto other body areasMRI (diagnostic and angiography)- Choice of coil- Identification of imaging volume- Appropriate use of contrast media- Technical parameters for acquisition, reconstruction,and post-processing evaluation- MR angiography- MR sialographyConventional Radiographs- How to avoid artifacts- How to alter parameters to obtain adequatequalitySialography- How to interpret the images and judge thequality of the examinationDacryocystography- Choice of instruments and contrastmedia, and interpretationGuided biopsy- In relation to the thyroid or cervical nodesand other masses- Choice of guidance method, US, CT, orMRI- Choice of biopsy instrument- Appropriate care of the specimen- Complications and after-care5 – APPRAISAL AND ASSESSMENTAssessment of the progress of the trainee should be consistentwith national requirements. The performance ofthe trainee should be appraised at least on annual basis.A logbook account of experience may be helpful in evaluatingthe trainee’s progress. The trainee’s progress shouldbe reviewed by consultant trainers with particular attentionto 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-guidedtherapeutic procedures. These procedureshave an important role in clinical management.Although invasive, they are associated with verylow morbidity and mortality rates and offer improvedoutcomes compared with similar proceduresperformed without image guidance. Asimage interpretation is an essential skill in theirperformance, such procedures are best performedby radiologists trained in diagnostic imaging.- Procedures that may lead to further image-guidedtherapy, e.g. PTA or biliary stenting, should becarried out by appropriately trained interventionists,as they will be the ones to perform such therapy.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 systemfall into this category and therefore should beperformed by those who have received specialtraining in interventional radiology. Complex vascularprocedures, whether diagnostic or therapeutic,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 responsiblefor 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 interventionalradiology.- 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,64 www.ear-online.org

Detailed Curriculum for Subspecialty Trainingwhich will allow them to provide an out-ofhoursservice.- The aim of subspecialised training is to preparethe radiologist for a career in which he / she devotesa substantial portion of his / her time to interventionalradiology. Such individuals will beexpected not only to carry out interventional proceduresbut also to discuss medical managementwith 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 therapeuticprocedures.2 – EXPERTISE AND FACILITIES- 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 interventionaltechniques are carried out are clearlymandatory as well.- Initially, when subspecialised interventional trainingis introduced, a radiologist eligible for fullCIRSE fellowship should supervise it. In the future,there may be certified subspecialists in interventionalradiology 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 importantjournals.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 theorgan systems in which they carry out therapeuticprocedures.- 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 sedationand 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 standardtextbooks and original articles.- They should be encouraged to develop a criticalapproach in their assessment of literature.- They should be involved in research and scientificpublication.- They should acquire knowledge of the design,execution, and analysis of research projects.- Trainees should enhance their theoretical knowledgeby attending and participating actively inthe scientific programme and educational activitiesof 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 internalmedicine relevant to their IR training. Theyshould also attend weekly outpatient clinics andward rounds. They should undergo training incommunication skills, including the ethics of informedconsent and the process of giving badnews to patients.4 – THEORETICAL KNOWLEDGE- Technique, indications, contraindications and complicationsof the following diagnostic modalities:- Doppler and color Doppler ultrasound- CT (including CT angiography)- Magnetic resonance angiography and cardiacimaging- Angiography- The factors affecting the choice of contrast mediaand radiopharmaceuticals and the effects andside effects of these agentswww.ear-online.org 65

Detailed Curriculum for Subspecialty Training- 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. recanalisationand stenting)- Renal angioplasty (incl. recanalisation andstenting)- Supra-aortic angioplasty (incl. recanalisationand stenting)- Venous angioplasty (incl. recanalisation andstenting)- Thrombectomy and thrombolysis- Treatment of arteriovenous malformations- Treatment of bleeding- Gynaecological interventions- Non-vascular upper gastrointestinal, liver andrenal interventions- Post-procedure patient management- Theory of advanced life support techniques (includingECG)- Pharmacotherapy and practice of sedation andanalgesia5 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLSThe trainee must have a deep knowledge of all imagingmodalities including newer imaging modalities of the cardiovascularsystem, 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 diminish.Virtual Reality Training is now through its infancy andis a training reality. This must be borne in mind when consideringpractical experience. A single week in a VR laboratorywith appropriate trainers has been shown bylaparoscopic surgeons to move trainees much more rapidlyalong 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 indicatorof 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 tothe field of interventional proceduresInterventional 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 proceduresCombined endoscopic and percutaneous proceduresNon-vascular interventions & stenting 20In-depth practice of advanced life-support techniques6 – APPRAISAL AND ASSESSMENTIf 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 requirediagnosis and treatment options based on the imag-66 www.ear-online.org

Detailed Curriculum for Subspecialty Traininging 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 – INTRODUCTIONMusculoskeletal (MSK) imaging involves all aspects ofmedical imaging which provide information about anatomy,function, disease states and those aspects of interventionalradiology or minimally invasive therapyappertaining to the musculoskeletal system. This will includeimaging 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 significantportion 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 radiologyis to ensure:- An in-depth understanding of diseases of theMSK system;- A clear understanding of the role of imaging inthe diagnosis and treatment of MSK diseases;- The development of the necessary clinical andmanagement skills;- The ability of the MSK specialist to perform (complex)MSK interventional procedures;- The ability of the MSK specialist to act as a consultantin 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).2 – EXPERTISE AND FACILITIES- Training must be undertaken in a team with accessto full clinical service in radiology, orthopaedicsurgery, rheumatology, and pathology.If possible, dialysis, paediatric orthopaedic surgery,orthopaedic oncology, medical geneticsand sports medicine should also be offered.- Training should be supervised by a group or a departmentor training schemes with extensive experiencein MSK imaging.www.ear-online.org 67

Detailed Curriculum for Subspecialty Training- The training department(s) should have accessto conventional radiography, CT scan, ultrasonography,MR Imaging, interventional equipment,and bone densitometry.- A database of "interesting cases" or "teachingfiles" should be present at the training department.Alternatively and / or additionally, the trainingdepartment can refer to interestingeducational sites on the internet.- Trainees must also have access to radiological librarycontaining textbooks of MSK radiology, orthopaedicsurgery, rheumatology, and relatedsciences and journals.- The training department must provide access toappropriate computed tomography (CT), magneticresonance imaging (MRI), radionuclide imaging(optional), and fluoroscopy. Centres shouldalso provide access to relevant specialised radionuclideimaging, e.g. positron emission tomography(PET) (where relevant). Practicaltraining and / or theoretical teaching and trainingin bone densitometry techniques should be available.3 – OVERVIEW- Trainees should have completed the core skillsand knowledge programme according to the EAR/ UEMS curricula which will include basic knowledgeof diagnosis of MSK diseases in their initialtraining.the principles and techniques used in research,including the value of clinical trials and basic biostatisticsshould be acquired.4 – THEORETICAL KNOWLEDGE- Trainees should attend regular sessions of theoreticaltraining in the form of locally delivered tutorials,specialist MSK imaging courses, as well aslocal, national and international MSK imaging conferencesincluding formal lectures, scientific presentationsor 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 chemotherapy(if applicable) and be aware of the diagnosticneeds of their surgical, radiotherapy and oncologycolleagues. They must therefore attend regularmulti-disciplinary conferences (e.g. with rheumatologists,orthopaedic surgeons, oncologists, etc.).- Trainees should acquire a knowledge of:- The embryology, anatomy and physiology ofthe musculoskeletal system including normalanatomical variants- The pathological processes of both benign andmalignant disease in the musculoskeletal system- Local, national and, where appropriate, internationalimaging guidelines and protocols- 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 programmeor 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 diagnosticprocedures listed below and will be expectedto 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- Knowledge of the full range of radiological diagnosticmodalities and techniques available, in particular:- The indications, contra-indications and complicationsof each imaging method- The factors affecting the choice of contrastmedia and radiopharmaceuticals- The effects and side effects of these agents- Optimisation of imaging protocols of diagnosticprocedures- 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.68 www.ear-online.org

Detailed Curriculum for Subspecialty Training5 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLS- Technical skillsAcquisition of specific skills to enable:- The conduct, supervision and accurate interpretationof 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 professionalcolleagues- Accurate informed consent to be obtained- Continuing accreditation of intermediate lifesupportstatusProcedural competence will need to be reviewed at intervals,and this regular review should also assess the numberof 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 musculoskeletalsystem- CT- the use of CT for the primary diagnosis ofbenign and malignant pathology- staging of tumours involving the musculoskeletalsystem- detection of direct extension and metastaticspread of musculoskeletal tumours- the investigation of rheumatological disorders- the investigation of trauma and sports injuries- the use of reconstruction algorithms, multiplanarreconstruction, and volume rendering- MRI- knowledge of basic and new MRI sequencesapplied to the musculoskeletalsystem, such as cartilage sequences, diffusion,etc.- the use of MRI for the primary diagnosisof benign and malignant pathology- staging of tumours involving the musculoskeletalsystem- detection of direct extension and metastaticspread of musculoskeletal tumours- demonstration of spinal anatomy andpathology- demonstration of joint anatomy andpathology, including direct and indirectMR arthrography- the investigation of rheumatological disorders- the investigation of acute trauma and traumasequels- the investigation of sports injuries, bothtraumatic and overuse- Fluoroscopic procedures including arthrographyA trainee will keep abreast of all other imaging techniquesrelevant to their practice.Trainees should acquire experience in the following interventionalprocedures guided with fluoroscopy, ultrasound,or CT:- Biopsy of bone and soft tissue lesions- Arthrography- Non-spinal image-guided diagnostic andtherapeutic procedures- Spinal image-guided therapeutic procedures,such as facet joint injections, sacroiliac injections,epidural, and periradicular infiltrations- Discography- Optional experience- CT myelography- VertebroplastyTrainees should acquire experience in all the practicalprocedures listed above, and the number of cases undertakenshould be recorded in their logbook.The trainee should become familiar with providing analgesiaand / or sedation where required, as well as the necessarycontinuous monitoring required to perform thissafely.www.ear-online.org 69

Detailed Curriculum for Subspecialty TrainingRegardless of the imaging technique or procedure concerned,the consultant trainer must be satisfied with thetrainee´s clinical competence, as determined by an intrainingperformance assessment, and can consistentlyinterpret the results of investigations accurately and reliably,and formulate correct management plans.- Communication and decision-making skillsA clear understanding of the role of multidisciplinarymeetings, including:- Planning of investigations including the selectionof appropriate tests and imaging techniquesfor the diagnosis of benign andmalignant disease- Staging of malignant disease- Planning and outcomes of treatment- The detection of errors in diagnosis and complicationsof treatment- Promoting an understanding of relevant musculoskeletalpathologyClinical 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 important:- 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 medicineThe trainee should be encouraged and given the opportunityto 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 relationto radiological practice.Trainees will be expected to be familiar with current musculoskeletalradiology literature.The trainee should be encouraged to participate in researchand pursue a project up to and including publication.An understanding of the principles and techniquesused in research, including the value of clinical trials andbasic biostatics, should be acquired. Presentation of researchand audit results at national and internationalmeetings should be encouraged.The trainee should have on-call commitments on a regularbasis.Knowledge and understanding of the importance of effectivecommunication with both the patient and the membersof 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 influencedecisions by others, e.g. surgeons, pathologists,oncologists, etc.- Training schedule and contentDuring the training period, the following weekly commitmentsare suggested as a work profile for subspecialtytrainees for the 12-month period, which will permit an integrateduse 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) (whereavailable)- Plain film reporting (two to three sessions)- Fluoroscopy with or without intervention (onesession)- Bone densitometry: 100 examinations have tobe supervised and reported- Trainees must attend regular clinico-radiologicalconferences (at least weekly)- Optional experience in radionuclide reportingof the MSK systemThe 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.70 www.ear-online.org

Detailed Curriculum for Subspecialty TrainingThe 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 dedicatedperiods of time in MRI, CT, US, etc.For image-guided interventional procedures, hands-onexperience with graded supervision will be required dependingon 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 certificates)and practical training and certified by the supervisingradiology 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 appropriateto the career goal of the trainee.Musculoskeletal radiology is an expanding and evolvingspecialty, with developments of different imaging techniquesand interventional procedures. Some trainees mayrequire additional training in such developing areas.6 – APPRAISAL AND ASSESSMENTAt the end of the training, a certificate of subspecialty expertisewill be awarded by the training department in accordancewith the law of each country.Formal testing should be up to the authority of the respectivecountry 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 concernedwith both diagnostic imaging and interventionalprocedures 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 interventionalneuroradiology as a subspecialty of radiology.- In Europe, trainees will enter into neuroradiologytraining during the fourth and fifth years of clinicaltraining. This training is in diagnostic neuroradiologyand may have some components of interventionalneuroradiology.- 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 requiresmore than two years neuroradiologicaltraining.- Dedicated neuroradiology training received at aneuroscience centre within an accredited radiology-trainingscheme may be taken into consideration.www.ear-online.org 71

Detailed Curriculum for Subspecialty Training- The aim of subspecialty training in neuroradiologyis to enable the trainee to become clinicallycompetent and to consistently interpret the resultsof neuroradiological investigations accuratelyand reliably. Where appropriate, traineesshould also be capable of providing a comprehensiveand 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, paediatricneuroradiology, and functional brain imaging,including MR spectroscopy. Some traineesmay wish to obtain extra training in these areas.- The trainee should be encouraged and given theopportunity to attend and lead appropriate clinico-radiologicalmeetings.- The trainee should participate in relevant clinicalaudit, management and clinical governance andhave a good working knowledge of local and nationalguidelines in relation to radiological practice.- The trainee should be involved in research andhave the opportunity to attend and present at nationaland international meetings. The progressionof research projects to formal peer-reviewedpublication should be supported and encouragedby the supervising consultant(s).2 – OVERVIEW- Basic skills in neuroradiology will have been acquiredbefore subspecialty training.- A training scheme responsible for training in neuroradiologymust provide access to appropriateCT, MRI, digital subtraction angiography, ultrasoundand 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 appropriatesurgical and medical teams and participationin combined clinical and radiologicalmeetings. Clinical interrelationships are necessarywith:- Neurosurgery (paediatric and adult)- Neurology (paediatric and adult)- Neuropathology- Neurophysiology- Neuroanaesthesia / critical care and emergencymedicine- Trauma- Other specialties will also provide important trainingopportunities, 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.- 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 undergraduateand 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 assessedand accredited by the ProvisionalEuropean Board of Neuroradiology under the approvalby European Society of Neuroradiology.3 – THEORETICAL KNOWLEDGEThe accredited training of neuroradiologists will have toachieve the following:- An in-depth knowledge of anatomy, including developinganatomy and its radiological applicationsto 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-72 www.ear-online.org

Detailed Curriculum for Subspecialty Trainingtalmological and otorhinolaryngological systems,including appropriate indications, contraindicationsand complications of imaging studies ofneurological diseases and interpretation of thevarious imaging modalities- Knowledge of proper experience and understandingof physical principles and technicalbackground for performance and interpretativeskills of computed tomography (CT), magneticresonance imaging (MRI), angiography, ultrasound,conventional imaging, and myelographyfor the diagnostic imaging of the head and spineand spinal cord, head, neck, and organs of specialsenses in adults and children so that theycan, with confidence, discuss with their colleaguesthe 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 applicationsof 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 invasiveprocedures, both diagnostic and therapeutic- Knowledge of pharmacology, particularly with respectto contrast material and invasive procedures- Knowledge of patient’s protection and safety inneuroradiology- The trainee should be fully competent in intermediateand advanced life-support.- Knowledge of the importance of informed consentand patient information- Understanding of fundamentals of quality assurancein neuroradiology- Understanding risk management, data banking,and evidence-based medicine- Knowledge of the current developments in neuroradiology- If experience to fulfil the requirements of subspecialtytraining cannot be gained in one trainingcentre, it will be necessary for the trainee to havea period of attachment(s) to other training centres.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 subspecialtytraining in neuroradiology will be for the residentto be competent in all aspects of diagnosticneuroradiology imaging and, where applicable,basic interventional neuroradiology.4 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLS- Essential is competence in clinical neuroradiologicalskills in adults and children, including:- Diagnostic and interpretative skills- Manual and procedural skills- Basic endovascular and therapeutic knowledge- Computer skills in imaging acquisition andpost-processing- Outpatient consultation when relevant- Ability to manage post-procedural care for invasivediagnostic and therapeutic techniques aswell as neuroradiological emergencies- Ability to manage patients and to obtain valid informedconsent for all procedures- Competence in effective consultation, presentationof 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 experiencewww.ear-online.org 73

Detailed Curriculum for Subspecialty Training- Competence in communicating clinical and scientifictopics 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 medicaleducation and commitment to the continuingassessment of the quality of neuroradiology5 – REQUIREMENTS OF SUBSPECIALTY TRAINING- A comprehensive knowledge of normal brainfunction and neurological diseases, including:- The embryology, anatomy, normal variantsand 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 ophthalmologicaland otorhinolaryngological systems, includingappropriate applications andinterpretation of the various imaging modalities- Local, national and, where appropriate, internationalimaging guidelines- Knowledge and understanding of the physicalprinciples and technical background for the performanceof 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 / functionalimaging and nuclear medicine studies(SPECT, PET) related to neuroradiology shouldbe available.- To develop the interpretative skills of CT, MRI,angiography, ultrasound, conventional imagingand myelography for the diagnostic imaging ofthe head, spine and spinal cord, neck, and organsof special senses in adults and children.- The subspecialty resident should know the inherentstrengths and limitations of these modalities,as well as appropriate imaging protocols for neuroradiologicalconsultation.- Knowledge of the techniques involved in the imagingused to evaluate and treat neurological diseases,including interventional procedures andthe management of the complications of theseprocedures- Knowledge and competence at imaging of brainfunction.- Knowledge of pharmacology, particularly with respectto contrast media and invasive procedures- Knowledge of patient protection and safety inneuroradiology- Understanding of fundamentals of quality assurance(management) in neuroradiology- Acquisition of specific skills to enable competencein clinical neuroradiological skills in childrenand adults, including:- Diagnostic and interpretative skills- Manual and procedural skills- Basic endovascular and therapy skills- Computer skills in imaging acquisition andpost-processing- The conduct, supervision and accurate interpretationof all imaging techniques used inthe investigation of neurological diseases to ahigh professional standard- Good communication with patients and professionalcolleagues- Competence in the style of reporting- The ability to manage post-procedure care forinvasive diagnostic and therapeutic techniquesas well as neuroradiological emergencies- The ability to manage patients and to obtainvalid informed consent for all procedures- The competence in effective consultation,presentation of scholarship material, and abilityto teach neuroradiology to peers and residentsin other disciplines- The ability to evaluate medical literature criti-74 www.ear-online.org

Detailed Curriculum for Subspecialty Trainingcally and to conduct neuroradiological research- Ability to conduct or supervise quality assurance- The core requirements for a neuroradiologist or aspecialist interventional neuroradiologist are similar,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 sessionsper week- MRI – the equivalent of two or three sessionsper week- Angiography – the equivalent of two sessionsper week- Interventional neuroradiology – see below- Study / meetings – the equivalent of one sessionper week- Research – the equivalent of one session perweek- Myelography – the opportunity to observeand, whenever possible, obtain hands-on experienceof the limited number of these proceduresnow 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 childabuse- Optional experience:- Radionuclide radiology including SPECT imagingand PET- Ultrasound including neonatal cranial US andDoppler- The techniques listed and the time devoted toeach will be reviewed at intervals along with thenumber of cases required, as it is recognised thatsome procedures may become obsolete and newtechniques will be developed (e.g. functionalbrain imaging and MR spectroscopy).- The trainee should become familiar with providinganalgesia 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 informedpatient consent.6 – INTERVENTIONAL NEURORADIOLOGY REQUIRE-MENTS- All subspecialist residents training in neuroradiologyshould have a basic understanding of interventionaltechniques so that they have full knowledgeof indications, technical problems, contraindications,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 neuroradiologyshould spend around one year in atraining post in which substantially the whole timeis devoted to interventional neuroradiology.- These trainees will need to extend their subspecialtytraining beyond two years required for neuroradiology.However, earlier and more focussedindividualised training in neuroradiology is beingencouraged for those trainees with previous neuroscience/ 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 neurosurgicaloperations and ward / HDU managementof acutely ill patients.- Regular involvement in neurosciences audit andmortality / morbidity meetings is necessary to understandrisk management for different clinicalconditions.www.ear-online.org 75

Detailed Curriculum for Subspecialty Training- It is the responsibility of the trainee to be aware ofthe current local and national guidelines in obtaininginformed patient consent.- All interventional trainees must have thoroughknowledge of techniques of sedation and analgesiarequired 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 procedures,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 interventionalprocedures are limited.7 – APPRAISAL AND ASSESSMENT- Regular appraisal of the trainee will occur accordingto national guidelines.- Methods of trainee assessment will include:- Regular direct observation of clinical techniques(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 competence- Review of subspecialty curriculum- The Training Committee of the EuropeanSociety of Neuroradiology will regularly reviewthis subspecialty curriculum to ensurethat it complies with current neuroradiologicalpractice.Paediatric Radiology1 – INTRODUCTIONThe aim of sub-specialised training in paediatric radiologyis to prepare the radiologist for a career in which a substantialproportion of his / her time will be devoted to paediatricradiology. Such individuals will be expected notonly to provide a paediatric radiology service but alsoadopt and develop new imaging and interventional methodsand to disseminate paediatric radiological knowledgeto their colleagues in general radiology.2 – EXPERTISE AND FACILITIESSpecialist training in paediatric radiology must take placein hospitals with the full range of clinical paediatric specialitiesavailable on site. These include gastrointestinaltract, genito-urinary tract, chest, endocrine, neonatal,musculoskeletal, neurology and neurosurgery, cardiovascular,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 diagnosticequipment, including access to specialised sessionson nuclear medicine, CT and MRI. Interventionalradiology experience, both angiographic and non-angiographic,must also be available. There must be access toa library with radiological and clinical textbooks and journals.A film library must also be available.3 – OVERVIEWThe training period will be the equivalent of one - twoyears of practice. During this period, the trainee must devotehis / her time to paediatric radiology. Trainees shouldacquire a deep knowledge of the pathological and clinicalbasis of the specialty. They should obtain extensive experiencein all of the diagnostic methods listed in the syllabus.Trainees must attend regular clinicoradiologicalconferences (at least weekly) with their clinical colleagues.Trainees will be expected to be familiar with thecurrent paediatric radiological literature, both from standardtextbooks and original articles. They should be encouragedto develop a critical approach in theirassessment of the literature. They should be involved in aresearch project (or projects) and should acquire knowledgeof the design, execution, and analysis of researchprojects.76 www.ear-online.org

Detailed Curriculum for Subspecialty Training4 – THEORETICAL KNOWLEDGE- Theoretical trainingTeaching is organised on the basis of lectures, tutorials,and workshops. Trainees are to be encouraged to attendnational and international conferences on paediatric radiology,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: environment,sedation, psychology of handlingchildren. Organisation of a paediatric sectionwithin a general department, guidelines for investigation,contrast: factors affecting thechoice of contrast, indications and contraindications,including radiopharmaceuticals.- Detailed knowledge of dose reduction techniquesin paediatric radiology:- Equipment choice, film / speed combination,use of grids / video, Q.A. [quality assurance]programme- Role of lateral film, PA v AP views, comparisonview, choice of examination, cost /risk benefit- To understand the ALARA [as low as reasonablyachievable] 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 paediatricdiseases.- The Chest- Neonatal: to include surgical problems- Infection: bacterial, viral, opportunistic, TBand 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 injuries- Fracture complications- Cervical Spine- Pelvic Fractures- Irritable hip, Perthes’ disease- Sports injuries- Polytrauma- Infection / bone – joint – disc / how to approachdiagnosis and integrated imaging- Multifocal osteomyelitis / chronic granulomatousdiseases- Scoliosis and orthopaedic problems- Arthritis and metabolic disease- Neoplastic: benign and malignant bonyand soft tissue tumours- Skeletal dysplasia- The Abdomen- Neonate- Oesophageal disease, reflux- Pyloric stenosis- GI bleeding- Inflammatory bowel disease, appendicitisand 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 pyonephrosisand how to investigate)- To recognise the normal appearance ofthe organs in any imaging modality- To understand the urethral anatomy of theboywww.ear-online.org 77

Detailed Curriculum for Subspecialty Training- 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 malformationsand acquired)- Spinal cord malformations (including imagingfor 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, lymphoedema)- Collagen vascular disease (+ myofibromatosis,etc.)- Endocrine disease- Investigation of small stature + growth disorders- Non-accidental injury (NAI)- Teeth (incl. craniofacial malformations)- Phakomatoses [tuberose sclerosis, neurofibromatosis,etc].- Langerhans Cell Histiocytosis5 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLS- The trainees must know in depth the full range ofpaediatric radiological diagnostic techniques detailedbelow. They should understand the principlesof all the methods, and in particularemphasis should be placed on the strengths andweaknesses of the different imaging methods inthe diagnosis of the different pathological conditions.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 following:- Plain radiography, to include the full range ofclinical subspecialties, e.g. trauma, accidentand emergency, orthopaedics, rheumatology,chest, and abdomen- Undertaking and reporting ultrasound examination:- of the abdomen, gastrointestinal tract (includingbowel), genitor-urinary tract,chest, head, and musculoskeletal system- Doppler studies, including spectral, basiccolour and power Doppler, as well asbasic calculations- Undertaking and reporting routine fluoroscopicexaminations of the gastrointestinaland urinary tract, together with more complexinvestigation, such as:- Small bowel enema- Reduction of intussusception- Management of neonatal distal intestinal obstruction- Velopalatal competence and studies of phonation- Disorders of swallowing78 www.ear-online.org

Detailed Curriculum for Subspecialty Training- Undertaking and reporting paediatric CTand MR examination- Undertaking (optional) and reportingbasic paediatric radionuclide imaging examinations:- Static and dynamic renal studies, includingcystography- Musculoskeletal imaging- Ventilation and perfusion lung scintigraphy- Gastrointestinal studies, includingpertechnetate studies for Meckel’s diverticulum- Identification of a GI bleeding site- Thyroid imaging- MIBG studies- Dynamic biliary examination- Interventional techniques- Trainees should acquire experience inthe following procedures:- Biopsy procedures- Abscess drainage- Insertion of percutaneous nephrostomies- Joint aspiration (e.g. hip)- Optional experience may include:- Arthrography- Angiography- Balloon dilatation of oesophagealstrictures- Embolisation techniques- Musculoskeletal intervention6 – APPRAISAL AND ASSESSMENT- Methods of trainee assessment will include:- regular direct observation of clinical techniques(including communication skills,ability to obtain informed consent and sedationskills) by the trainer and / or externalobserver- regular formal review of the trainee’s skillsin the accurate interpretation of investigationsfor paediatric diseases- a final assessment of overall professionalcompetenceUrogenital Radiology1 – INTRODUCTIONThe 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 embryological,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, contraindications,complications, and limitations of procedures- In-depth knowledge and expertise in the examinationtechniques for imaging procedures tourological, nephrological, and gynaecologicaldiseases and problemsFurthermore, 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 multidisciplinarymeetings- The ability to transmit subspecialty knowledge toother radiology colleagues- The ability to assume the continuity and the evolutionof radiology in the field of urological,nephrological, and gynaecological diseases andproblems2 – EXPERTISE AND FACILITIES- Training in urogenital imaging must be undertakenin a training centre with access to full clinicalservices in radiology, nephrology and dialysis,urology, obstetrics and gynaecology and pathology;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.www.ear-online.org 79

Detailed Curriculum for Subspecialty Training- A library must be readily accessible. It shouldcontain an adequate selection of the major textbooksin 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 continuouslyupdated. 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 diseasesof the urogenital system too, as well as anunderstanding of the tests which are the prerequisitesfor imaging examinations (i.e. laboratory,endoscopy, urodynamics).- Because angiographic interventions require additionalspecial skills, they are not required for thecurriculum in urogenital imaging. However, thetrainee is expected to develop capabilities inimage-guided biopsy procedures (renal and adrenalmasses, prostate, lymph nodes) anddrainages of lesions and organs of the urogenitalsystem (nephrostomy, abscess drainage).Additional training may be required for proceduressuch as varicocele embolisation, renal tumourembolisation, and fibroid embolisation.Management of renal artery stenosis may attimes be under the remit of urogenital radiology.- The trainee should be familiar with clinical terminologyso 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 imagingmethods in clinical practice.- The trainee should become familiar with the currentliterature 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.4 – THEORETICAL KNOWLEDGEAt 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 excretionof contrast medium (both iodinatedand 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 nephrotoxicity- Risk factors of contrast media nephrotoxicity- How to identify patients at high risk ofcontrast media nephrotoxicity- Measures to reduce the risk of contrastnephrotoxicity- Precautions in diabetics taking metforminand requiring intravascular administrationof 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 ofthe kidney- To know the criteria of normality of80 www.ear-online.org

Detailed Curriculum for Subspecialty Trainingpyelocaliceal system on IVU and CTU- To recognise normal variants, such asjunctional parenchymal defect columnof Bertin hypertrophy, fœtal lobulation,and lipomatosis of the sinus- To identify the main renal malformationssuch as horseshoe kidney, duplications,ectopia, and fusions- Bladder and urethra- To know the anatomy of bladder walland the physiology of micturition- To identify the segments of male urethraand 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 ofintra-scrotal structures (testicular andextratesticular)- To know the Doppler anatomy of testicularand 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 sonographicimage- To recognise and explain the main artifactsvisible in urinary organs- To be able to obtain a Doppler spectrumon intrarenal vessels (for resistiveindex measurement) and onproximal renal arteries for velocity calculation- 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 cystourethrography- 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 andadrenal tumour- To know the protocol for urinary obstruction(including stones)- To know the protocol for a bladder tumour- CT urography (CTU): techniques, indications,contraindications, and limitations- MR of the urinary tract- To know the appearances of urinaryorgans on T1 and T2 images- To know the appearances of urinaryorgans on T1 and T2 contrast-enhancedsequences- To know the protocol for a renal andadrenal tumour- To know the protocol for urinary obstruction- To know the protocol for a bladder tumour- To know the protocol for a prostatic tumour- "Conventional" pelvic MRI for theprostate: possibilities and limits- Use of rectal probes- Prostate MRI spectroscopy- MR Urography (MRU)- T2 MRU- Excretory MRU: technique, indications,contraindications, and limitations- To accurately diagnose the presence of thefollowing pathologies:- Kidney and ureter- Congenital- Obstruction- Calculus- Infection- Tumours- Cystic diseases- Medical renal diseases- Vascular- Renal transplantation- Traumawww.ear-online.org 81

Detailed Curriculum for Subspecialty Training- 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 satisfactoryblood count, coagulation status,etc.)- To explain the procedure and followupto the patient- To obtain informed consent- To know what equipment is required- To know what aftercare is required- To know the complications, importanceof early detection, and management- US-guided biopsies / cystic drainage, e.g.kidney mass, prostate- To become familiar with ultrasoundprobes- To become familiar with different guidancetechniques- free hand- guidance devices- To become familiar with different biopsydevices and needles- To become familiar with drainagetubes and fixation devices- To become able to liaise with pathologistsand referring physicians- CT-guided biopsies- To become familiar with CT scannersand CT-guided biopsy / drainage techniques- Percutaneous nephrostomy- To verify and discuss indication withreferring clinicians- To verify patient preparation and positioning- To become familiar with sedo-anelgesia,local anaesthesia, and antibioticpolicies- To become familiar with guidancetechniques- US guidance- Fluoroscopic guidance- To become familiar with puncturetechniques- To become familiar with guidewiresand tissue dilatators- To become familiar with nephrostomytubes:- locked- unlocked- To become familiar with fixation devices,dressings, and drainage bags- To become proficient in nephrostomyplacement as well as in nephrostomychange- Antegrade ureteric stent insertion- To become proficient in nephrostomyinsertion (see above)- To become familiar with guidancecatheters- To become familiar with ureteric dilatators- Teflon- Balloon82 www.ear-online.org

Detailed Curriculum for Subspecialty Training- To become familiar with ureteric stents- double J stents- metallic stents- To liaise with urologists for stent management- Percutaneous nephrolithotomy- To work in close cooperation withendo-urologists- To discuss case preoperatively- To become familiar with access techniquesand tract dilatation- To become familiar with availablelithotripsors- AngiographyDetailed angiographic techniques, includingselective angiography and embolisationtechniques, are better acquiredduring an attachment to a vascular angiographyslot during training.At the end of the training period the trainee should becomeproficient with performing the basic interventionaltechniques and be familiar with the more complex procedures(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. transvaginalapproach- To be able to perform a transvaginalUS examination- To know indications and contra-indicationsof hysterosonography- To be able to perform a hysterosonographicexamination- Hysterosalpingography- To be able to describe the procedure- To know the possible complications ofhysterosalpingography- To know the contra-indications of hysterosalpingography- To explain the choice of contrast agent- To know the different phases of the examination- To be able to perform the procedure- CT scan- To be able to explain the technique ofa pelvic CT- To know the possible complications ofCT- To know the contra-indications of CT- To know the irradiation delivered by apelvic CT- To know the required preparation ofthe patient and the choice of technicalparameters (slice thickness, Kv, mA,number of acquisitions, etc.) dependingon indications- MRI- To be able to explain the technique ofa pelvic MRI- To know the contra-indications of MRI- To know the required preparation ofthe patient and the choice of technicalparameters (slice thickness, orientation,weighting, etc.) depending on indications,including pelvic floordisorders- Angiography- To know the main indications of pelvicangiography in women- To know how to perform a pelvic angiography- 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 compartments- 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 urinaryincontinence- To accurately diagnose the presence of thefollowing pathologies:- Uterus- Congenital anomalies- Tumours (benign and malignant)- Myometrium- Endometriumwww.ear-online.org 83

Detailed Curriculum for Subspecialty Training- Cervix- Inflammation- Adenomyosis- Functional disorders- Ovaries / Tubes- Ovary- Tumours (benign and malignant)- Functional disorders, e.g. functionalcysts of the follicle or corpus luteum,precocious puberty, andpolycystic ovaries- Endometriosis- Tubes- Inflammatory disorders- Tumours- Pelvis- Prolapse- The "acute female pelvis"- Endometriosis, including extra-ovarianlocations of endometriosis- Pelvic location of peritoneal pathology- Infertility- Vagina- Congenital abnormalities- Benign and malignant tumoursDepending on clinical practices and availabilities,training in fetal US and MRI can be offered.5 – TECHNICAL, COMMUNICATION AND DECISION-MAKING SKILLS- To perform the examination- To know the clinical history and the clinicalquestions 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 recommendationsfor follow-up- To explain clearly the results to the patient- To assess the level of understanding of thepatient- 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 unexpectedimaging findings with colleagues and toknow when to contact a clinician- To be able to interact with colleagues in clinico-radiologicalconferences- To be able to take part in multidisciplinaryteams dealing with patients with urological,nephrologic, or genital diseasesAt the end of the training period, the trainee should haveachieved the following technical, communication and decision-makingskills. Reasonable progression is to be expectedduring the two years of training, withresponsibilities assumed gradually until complete professionalindependence.- Before the examination- To check the clinical information and risk factors(diabetes, allergy, renal failure, etc.)- To validate the request and the choice of examination- To know the specific preparation, if necessary,and protocols- To explain the examination to the patient andinform him / her about risks- To justify the examination request based on:- Risk factors- Irradiation involved- Possible (better?) alternatives84 www.ear-online.org

The following documents can be downloaded from theEAR website at www.ear-online.orgEAR Annual Report 2005European Training Charter for Clinical Radiology,Detailed Curriculum for the Initial Structured CommonProgramme, Detailed Curriculum for Subspecialty TrainingRadiological Training Programmesin Europe - Analysis of SurveyEIBIR Newsletter, November 2005Teleradiology 2004Good Practice Guide for European RadiologistsRisk Management in Radiology in EuropeCME / CPD GuidelinesEAR Annual Report 2003 / 2004Benchmarking Radiological Services in EuropeEuropean Association of RadiologyFor further information please visit the EAR website at www.ear-online.org

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