Resident Education

Revised Curriculum on Cardiothoracic Radiology for Diagnostic Radiology With Goals and Objectives Related to General Competencies1

Prepared by the Education Committee of the Society of Thoracic Radiology: Jannette Collins, MD, MEd, FCCP, Gerald F. Abbott, MD, John M. Holbert, MD, FCCP, Brian F. Mullan, MD, FCCP, Ella A. Kazerooni, MD, Michael B. Gotway, MD, Michelle S. Ginsberg, MD, Joan M. Lacomis, MD, Shawn D. Teague, MD, Gautham P. Reddy, MD, John A. Worrell, MD, Andetta Hunsaker, MD

This document is a revision of a previously published cardiothoracic curriculum for diagnostic radiology residency (1), and reflects interval changes in the clinical practice of cardiothoracic radiology and changes in the Accreditation Council for Graduate (ACGME) requirements for diagnostic radiology training programs. The revised ACGME Program Requirements for Residency Education in Diagnostic Radiology (2) went into effect December 2003.

© AUR, 2005

The residency program director is responsible for the tudes required and provide educational experiences as “preparation of a written statement outlining the educa- needed for their residents to demonstrate competence in tional goals of the program with respect to knowledge, the following six areas: patient care, medical knowledge, skills, and other attributes of residents for each major as- professionalism, interpersonal/communication skills, prac- signment and each level of the program” (2). Since the tice-based learning and improvement, and systems-based first cardiothoracic curriculum was published, the practice. These six areas, as they specifically relate to ACGME has added new language to the program require- radiology, have been defined previously (3). ments regarding six areas of competency. Programs must The nine areas of a radiology residency define the specific knowledge, skills, behaviors, and atti- program listed in the ACGME requirements are neurora- diology, musculoskeletal radiology, vascular and interven- tional radiology, radiology, breast imaging, abdomi- Acad Radiol 2005; 12:210–223 nal radiology, pediatric radiology, ultrasonography (in- 1 From the Department of Radiology, University of Wisconsin and cluding obstetrical and vascular ultrasound), and nuclear , E3/311 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792–3252 (J.C.); Brown , Providence, RI (G.F.A.); Texas radiology (2). Note that although there is no specific sub- A&M University, Temple, TX (J.F.H.); University of Iowa Hospital and Clin- specialty defined as cardiac radiology, ACGME requires ics, Iowa City, IA (B.F.M.); Medical Center, Ann Arbor, MI (E.A.K.); University of California San Francisco and San Francisco training and experience in radiographic interpretation, General Hospital, San Francisco, CA (M.B.G.); Memorial Sloan-Kettering computed tomography (CT), magnetic resonance imaging Center, New York, NY (M.S.G.); Medical Center, Pittsburgh, PA (J.M.L.); School of , (MRI), angiography, and nuclear radiology examinations Indianapolis, IN (S.D.T.); University of California San Francisco and San of the cardiovascular system ( and ). Francisco Veterans Affairs Medical Center, San Francisco, CA (G.P.R.); Vanderbilt University School of Medicine, Nashville, TN (J.A.W.); Brigham and Didactic instruction is required in cardiac anatomy, physi- Women’s Hospital, , MA (A.H.). Received and accepted December ology, and , including the coronary arteries, as 7, 2004. Address correspondence to: J.C. e-mail: [email protected] essential to the interpretation of studies, © AUR, 2005 doi:10.1016/j.acra.2004.12.013 and to include both the adult and the pediatric age group.

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The Society of Thoracic Radiology Education Committee variations in training programs. Goals and objectives en- has therefore incorporated traditional “thoracic” or pulmo- compassing clinical knowledge, technical, communication, nary, pleural, and mediastinal radiology with adult-ac- and decision-making skills are outlined for each level of quired and congenital cardiac radiology into a single cur- training, based on three rotations in thoracic radiology. riculum document on cardiothoracic radiology. Because the timing of resident exposure to each part of This curriculum document focuses on adult radiology, the curriculum will depend on the organization of individ- because pediatric radiology is recognized as a separate ual residency programs, the individual program should subspecialty by the ACGME. Similarly, nuclear radiology modify this curriculum as appropriate. Recommended is listed as a separate subspecialty. Components of a car- study materials and required conference attendance are an diothoracic radiology curriculum may practically occur important component of a complete curriculum document. during one or more organ-specific or technology-specific Similarly, because they are often specific to individual rotations during residency, including rotations in thoracic departments, a detailed listing is not provided in this radiology, cardiac radiology, pediatric radiology, nuclear document. radiology, magnetic resonance imaging, computed tomog- raphy, or vascular and . Recogniz- ing that it is difficult to draw clear boundaries between YEAR ONE (FIRST 4-WEEK ROTATION) , aspects of other radiology subspecialties pertinent to adult thoracic radiology are also included in I. Goals this curriculum document. Physics, as applied to cardio- After completion of the first thoracic radiology rota- thoracic radiology, is generally covered in a separate tion, the resident will be able to: physics course and is not included in this document. The cardiothoracic curriculum should reflect an appro- 1. demonstrate learning of the knowledge-based objec- priate balance of chest , chest CT, chest MRI, tives. and procedural experience. Integrated rotations encom- 2. accurately and concisely dictate a passing all of these activities, or dedicated thoracic radiol- report. ogy cross-sectional rotations are preferred, rather than 3. communicate effectively with referring clinicians thoracic radiology as part of a general “body imaging” and supervisory staff. rotation. 4. understand standard patient positioning in thoracic The residency program director is responsible for regu- radiology. lar evaluation of residents’ knowledge, skills, and overall 5. obtain pertinent patient information relative to ra- performance, including the development of professional diologic examinations. attitudes consistent with being a . The evaluation 6. demonstrate knowledge of the clinical indications must concern itself with intellectual abilities, attitudes and for obtaining chest radiographs and when a chest character skills, and clinical and technical competence, in CT or MR may be necessary. addition to the six competencies listed previously. The 7. demonstrate a responsible work ethic. goals and objectives provided in this graduated curricu- 8. perform image-guided procedures of the chest. lum can be used as a template by program directors or 9. participate in quality improvement/quality assurance thoracic radiology faculty as part of the evaluation pro- and other operational activities. cess. Objectives that relate to specific competencies are indicated in this document with the following labeling II. Objectives system: medical knowledge (MK), patient care (PC), pro- fessionalism (P), interpersonal/communication skills A. Knowledge-based (ICS), practice-based learning and improvement (PBLI), At the end of the first thoracic radiology rotation, and systems-based practice (SBP). the resident will demonstrate learning of at least This curriculum, prepared by the Society of Thoracic one-third of the knowledge-based objectives (see Radiology Education Committee, is based on three Addendum) (PC) (MK). 4-week rotations in thoracic radiology. Programs may be B. Technical, communication, and decision-making organized into a different number of rotations of different skills length, and this curriculum can be modified to reflect At the end of the first thoracic radiology rotation,

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the resident will demonstrate the following techni- nomenclature when dictating reports and con- cal, communication, and decision-making skills: sulting with professionals (ICS). 1. Dictate accurate and concise chest radiograph reports that include patient name, patient medi- cal record number, date of exam, date of com- III. CONFERENCES AND parison exam, type of exam, indication for STUDY MATERIALS exam, brief and concise description of the find- ings, and short impression (ICS) 2. Communicate with ordering about all A. Conferences significant or unexpected radiologic findings and The ACGME requires didactic conferences as document who was called and the date and time part of the radiology residency training program. Examples of the types of conferences that should be of the call in the dictated report (IPC) (PC) part of a resident’s educational program are listed in 3. Obtain relevant patient history from electronic the following section. Thoracic radiology teaching records, dictated reports, or by communicating conferences are mandatory. Other conferences, such with referring clinicians (PC) as a transplantation conference, are not avail- 4. Describe patient positioning and indications for able at all training programs; when available, they posteroanterior (PA), anteroposterior (A), lateral should be considered for inclusion in the curriculum decubitus, and lordotic chest radiographs (PC) depending on the specifics of the individual training (MK) program and medical center. Note that although 5. When assisting referring clinicians with imaging some of these conferences are sponsored by a radi- interpretation and patient management, decide ology department, others may be sponsored by other when it is appropriate to obtain help from super- departments or multidisciplinary programs. It is rec- visory faculty (P) ommended that this latter type of conference be 6. Arrive for the rotation assignment on time and included to facilitate the radiology residents’ under- prepared after reviewing recommended study standing of the use of imaging and clinical circum- materials (P) stances in which imaging is requested. It is desir- 7. Successfully perform thoracic biopsies and im- able that residents actively participate in the prepa- age-guided (eg, pleural drainage and ration and presentation of conferences (MK) (PBLI) if performed at the insti- (SBP). tution) with faculty supervision commensurate ● Radiology resident-specific thoracic radiology with experience and individual competence (PC) teaching conference 8. Before performing interventional procedures, ● Journal review counsel patients and obtain informed consent ● Radiology grand rounds (eg, explain conduct and purpose for procedure, ● Pulmonary medicine conference ● explain risks, benefits and alternatives, solicit Intensive care unit conference ● and answer patient questions) without discrimi- Thoracic conference ● Cardiothoracic conference nating based on religious, ethnic, sexual, or edu- ● conference cational differences and honoring patient confi- ● Quality assurance/quality improvement conference dentiality (ICS) (P) (departmental and institutional) 9. Document (via electronic or written format) the ● Other performance, interpretation, and complications of B. Teaching all procedures performed (PBLI) Supervise or act as consultants to junior residents 10. Participate in discussions with faculty regarding and medical students (PBLI). operational challenges and potential systems so- C. Study materials lutions regarding all aspects of radiologic service Many types of educational materials may be in- and patient care (SBP) cluded in this portion of a curriculum document, 11. Use appropriate chest radiograph, CT, and MRI including books, book chapters, or review articles.

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Hard-copy teaching files (eg, American College of ● Pulmonary arteries—main, right, left, interlobar, seg- Radiology (ACR) or individual department file), mental computer-based educational programs, and radiol- ● —ascending, sinuses of Valsalva, arch, descend- ogy education web sites or teaching files (eg, ACR ing CD-ROM) should also be included, as recom- ● Arteries—brachiocephalic (innominate), common ca- mended by the residency program director or desig- rotid, subclavian, axillary, vertebral, internal mammary, nated faculty within the subspecialty of thoracic intercostal radiology (MK). ● Veins—pulmonary, , inferior vena cava, brachiocephalic, subclavian, axillary, internal jug- ular, external jugular, azygos, hemiazygos, left superior YEAR 2 (OR SECOND 4-WEEK ROTATION) intercostal, internal mammary ● Bones—ribs and costochondral cartilages, clavicles, I. Goals scapulae, , spine After completion of the second thoracic radiology rota- ● tion, and in addition to those goals listed for Year 1, the ● resident will: ● Thyroid gland ● Muscles—sternocleidomastoid, anterior and middle scalene, infrahyoid, pectoralis major and minor, deltoid, 1. demonstrate learning of the knowledge-based learn- trapezius, infraspinatus, supraspinatus, subscapularis, ing objectives. latissimus dorsi, serratus anterior 2. continue to build on chest radiograph interpretive ● Aortopulmonary window skills. ● Azygoesophageal recess 3. develop skills in protocoling, monitoring, and inter- ● Gastrohepatic ligament, celiac axis preting chest CT scans. ● Diaphragm 4. demonstrate an understanding of ACR Appropriate- ● Identify the following additional structures on chest ness Criteria and ACR Practice Standards and Tech- CT: nical Guidelines for thoracic radiology. ● —all lobes and segments; secondary pulmonary 5. demonstrate an ability to generate and interpret lobules multiplanar reformatted (MPR) or three-dimensional ● Fissures—major, minor, azygos, accessory (superior images of CT or MRI studies as appropriate. and inferior) ● Airway—lobar and segmental bronchi II. Objectives ● Inferior pulmonary ligaments A. The resident will demonstrate learning of at least two-thirds of the knowledge-based objectives listed for B. At the end of the second thoracic radiology rota- Year 1 (see Addendum), in addition to identifying the tion, the resident will demonstrate the following technical, following structures on chest CT and chest MRI (MK). communication, and decision-making skills, in addition to those listed for Year 1. ● Lungs—right, left, right upper, middle, and lower lobes, left upper lobe (anteroposterior, anterior and lin- 1. Appropriately protocol all requests for chest CT to gular segments), and left lower lobe include thin-section images, high-resolution images, ● Pleura and extrapleural fat expiratory images, or prone images when appropri- ● Airway—trachea, main bronchi, carina, and lobar bronchi ate, and use of intravenous contrast, given the pa- ● Heart—left , right ventricle, moderator band, tient history (PC) left , left atrial appendage, right atrium, right 2. Monitor all chest CT examinations and determine if atrial appendage, , aortic valve, tricuspid additional imaging is needed before the patient CT valve, , coronary arteries (left main, examination is completed (if this is an institutional left anterior descending, left circumflex, right, posterior practice) (PC) descending), coronary veins, coronary sinus 3. Demonstrate the ability to effectively present tho- ● —including pericardial recesses racic radiology cases to other residents in a confer-

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ence setting by appropriately selecting cases, inter- 5. correlate pathologic and clinical data with radio- acting with residents, and presenting a brief discus- graphic and chest CT findings. sion of the diagnosis for each case (PBLI) 4. Demonstrate the ability to manage an intravenous II. Objectives contrast reaction that occurs during a chest CT ex- amination (PC) A. At the end of the third thoracic radiology rotation or 5. Act as a consultant for referring clinicians and rec- senior year of radiology residency, the resident will ommend the appropriate use of imaging studies demonstrate knowledge of all of the knowledge-based (ICS) objectives introduced in Years 1 and 2 (MK). 6. Describe the principles of chest fluoroscopy, includ- B. Technical and communication skills ing the assessment of the diaphragm (PC) After completion of the third thoracic radiology 7. Demonstrate knowledge of CT parameters contrib- rotation, the resident will demonstrate the following uting to patient radiation exposure and techniques technical, communication, and decision-making that can be used to limit radiation exposure (PC). skills, in addition to those listed for Years 1 and 2. 1. Dictate accurate, concise chest radiograph, CT III. Conferences and Study Materials scan, and MR reports with at least 75% accuracy; the reports will contain no major interpretive er- A. Conferences—same as for Year 1 rors (ICS) B. Teaching 2. State the clinical indications for performing chest Supervise or act as consultants to junior resi- CT and MRI (MK) (PC) dents and medical students (PBLI) 3. Describe a chest CT protocol optimized for eval- C. Study materials uating each of the following (PC): Compared with the first rotation, more advanced ● thoracic aorta and great vessels educational resources should be provided for the ● coronary calcium second rotation in thoracic radiology. Although ● pulmonary vein anatomy materials for the first rotation may be books, book ● suspected chapters, or teaching files based primarily on tho- ● tracheobronchial tree racic radiography, more advanced rotations should ● suspected incorporate primary journal citations, and books, ● staging book chapters, or teaching files specific to ad- ● esophageal vanced modalities (eg, chest CT, MRI) or interven- ● suspected pulmonary metastases tional thoracic radiology (eg, lung biopsy). ● suspected pulmonary nodule on a radiograph ● YEARS 3–4 (THIRD 4-WEEK ROTATION) ● ● cardiac mass I. Goals ● coronary arteries After completion of the third thoracic radiology rota- ● suspected pericardial disease tion, and in addition to the goals listed for Years 1 and 2, the resident will: 4. Understand the technical principles of all chest MRI exams and describe a protocol optimized 1. demonstrate learning of the knowledge-based for evaluating each of the following (MK) (PC): objectives. ● thoracic aorta 2. refine skills in interpretation of radiographs and ● pulmonary arteries chest CT scans. ● thoracic veins (superior vena cava, 3. develop skills in protocoling, monitoring, and inter- brachiocephalic veins) preting chest MR studies, including cardiovascular ● pericardium MRI. ● cardiomyopathy and cardiac and paracardiac 4. become a more autonomous consultant and teacher. masses, including tumors

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● ischemic heart disease, including function, via- 3. Define an acinus. bility and 4. Name the lobar and segmental bronchi of both ● valvular heart disease lungs. ● right ventricular dysplasia 5. Identify the following structures on the posteroante- ● congenital heart disease in an adult rior (PA) chest radiograph: ● superior sulcus tumor ● Lungs—right, left, right upper, middle and lower lobes, left upper (including lingula) and lower 5. In collaboration with a pathologist, present an lobes interesting cardiothoracic imaging case, with a ● Fissures—minor, superior accessory, inferior ac- confirmed diagnosis, correlating clinical history cessory, azygos with pathologic and radiologic findings, to resi- ● Airway—trachea, carina, main bronchi dents and faculty (MK) (ICS) (PBLI). ● Heart—right atrium, left atrial appendage, left ven- 6. Work in the reading room independently, assisting tricle, location of the four cardiac valves clinicians with radiologic interpretation, and teach- ● Pulmonary arteries—main, right, left, interlobar, ing other residents and medical students assigned to thoracic radiology (PC) (ICS) (P) (PBLI). truncus anterior ● Aorta—ascending, arch, descending ● III. Conferences and Study Materials Veins—superior vena cava, azygos, left superior intercostal (“aortic nipple”) A. Conferences ● Bones—spine, ribs, clavicles, scapulae, humeri Same as for Year 1; may require preparation ● Right paratracheal stripe and presentation of radiology materials for multi- ● Junction lines—anterior, posterior disciplinary conferences. ● Aortopulmonary window B. Teaching ● Azygoesophageal recess Supervise or act as consultants to junior resi- ● Paraspinal lines dents and medical students (PBLI). ● Left subclavian artery C. Study materials 6. Identify the following structures on the lateral chest In addition to the materials listed for the first radiograph: two rotations, more detailed technical references ● Lungs—right, left, right upper, middle and lower should be assigned, whether in books or supple- lobes, left upper (including lingula) and lower mented by state of the art technical publications in radiology journals (MK). lobes ● Fissures—major, minor, superior accessory ● Airway—trachea, upper lobe bronchi, posterior REFERENCES wall of bronchus intermedius 1. Kazerooni EA, Collins J, Reddy GP, et al. A curriculum in chest radiol- ● ogy for diagnostic radiology residency with goals and objectives. Acad Heart—right ventricle, right ventricular outflow Radiol 2000; 7:730–743. tract, left atrium, left ventricle, the location of the 2. Accreditation Council for Graduate Medical Education. Program require- ments for graduate medical education in diagnostic radiology. Available four cardiac valves online at: http://www.acgme.org/acWebste/RRC_420/420_prIndex/asp ● Pulmonary arteries—right, left Accessed October 7, 2004. ● 3. Collins J, Rosado de Christenson M, Gray L, et al. General competen- Aorta—ascending, arch, descending cies in radiology residency training: definitions, skills, education and as- ● Veins—superior vena cava, inferior vena cava, left sessment. Acad Radiol 2002; 9:721–726. brachiocephalic (innominate), pulmonary vein con- fluence ADDENDUM ● Bones—spine, ribs, scapulae, humeri, sternum ● Retrosternal line Knowledge-Based Objectives ● Posterior tracheal stripe Normal Anatomy.— ● Right and left hemidiaphragms 1. Name and define the three zones of the airways. ● Raider’s triangle 2. Define a secondary pulmonary lobule. ● Brachiocephalic (innominate) artery

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Signs in Thoracic Radiology.— ● or sandwich sign—indicates pericar- 1. Define, identify and state the significance of the fol- dial effusion on lateral chest radiograph lowing on a radiograph: ● scimitar sign—an abnormal pulmonary vein in ● air bronchogram—indicates a parenchymal pro- venolobar syndrome cess, including nonobstructive , as distin- ● double density sign—opacity projecting over the guished from pleural or mediastinal processes right side of the heart, indicating enlargement of ● air —indicates a , often the left atrium resulting from fungal or saprophytic col- ● and hilum convergence sign— onization used to distinguish a hilar mass from a non-hilar ● on a supine radiograph—indicates mass 2. Define, identify and state the significance of the fol- ● continuous diaphragm sign—indicates pneumome- lowing on a chest CT: diastinum ● CT angiogram sign—enhancing pulmonary vessels ● ring around the artery sign (air around pulmonary against a background of low attenuation material artery, particularly on lateral chest radiograph)— in the lung ● indicates pneumomediastinum —suggesting invasive pulmonary as- ● fallen lung sign—indicates a fractured bronchus pergillosis in a leukemic patient ● ● flat waist sign—indicates left lower lobe collapse split pleura sign—a sign of empyema and other inflammatory pleural processes ● gloved finger sign—indicates bronchial impaction, which can be seen in allergic bronchopulmonary Interstitial Lung Disease.— aspergillosis 1. List and identify on a chest radiograph and chest ● —indicates lobar collapse caused by CT four patterns (nodular, reticular, reticulonodu- a central mass, suggesting an obstructing broncho- lar, and linear) of interstitial lung disease (ILD). genic carcinoma in an adult 2. Make a specific diagnosis of ILD when supportive ● luftsichel sign—indicates upper lobe collapse, sug- findings are present in the history or on radiologic gesting an obstructing bronchogenic carcinoma in imaging (eg, dilated esophagus and ILD in sclero- an adult derma, enlarged heart and a pacemaker or defibril- ● Hampton’s hump—pleural-based, wedge-shaped lator in a patient with prior sternotomy and ILD opacity indicating a pulmonary infarct secondary to amiodarone drug toxicity). ● —loss of the contour of the heart, 3. Identify Kerley A and B lines on a chest radio- aorta or diaphragm allowing localization of a pa- graph and explain their etiology. renchymal process (eg, a process involving the 4. Recognize the changes of congestive medial segment of the right middle lobe obscures on a chest radiograph—enlarged cardiac silhou- the right heart border, a lingular process obscures ette, pleural effusions, vascular redistribution, in- the left heart border, a basilar segmental lower terstitial or alveolar edema, , enlarged lobe process obscures the diaphragm) azygos vein, increased ratio of artery to bronchus ● cervicothoracic sign—a mediastinal opacity that diameter. projects above the clavicles is retrotracheal and 5. Define the terms “asbestos-related pleural disease” posteriorly situated, whereas an opacity effaced and “asbestosis”; identify each on a chest radio- along its superior aspect and projecting at or be- graph and chest CT. low the clavicles is situated anteriorly 6. Describe what a “B” reader is as related to the ● tapered margins sign—a lesion in the chest wall, evaluation of pneumoconioses. or pleura may have smooth tapered 7. Identify honeycombing on a radiograph and chest borders and obtuse angles with the chest wall or CT, state the significance of this finding (end-stage mediastinum while parenchymal lesions usually lung disease), and list the common causes of form acute angles honeycomb lung. ● figure 3 sign—abnormal contour of the descending 8. Describe the radiographic classification of sarcoid- aorta, indicating osis.

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9. Recognize progressive massive fibrosis/conglomer- Atelectasis, Airways, and .— ate masses secondary to silicosis or coal worker’s 1. Recognize partial or complete atelectasis of the fol- pneumoconiosis on radiography and chest CT. lowing on a chest radiograph: 10. Recognize the typical appearance and upper lobe ● right upper lobe predominant distribution of irregular lung cysts or ● right middle lobe nodules on chest CT of a patient with Langerhans ● right lower lobe cell histiocytosis. ● right upper and middle lobe 11. List four causes of unilateral ILD. ● right middle and lower lobe 12. List three causes of lower lobe predominant ILD. ● left upper lobe 13. List two causes of upper lobe predominant ILD. ● left lower lobe. 14. Identify a secondary pulmonary lobule on CT. 2. Recognize complete collapse of the right or left lung 15. Recognize findings of lymphangioleiomyomatosis on a chest radiograph and list an appropriate differ- on a chest radiograph and CT. ential diagnosis for the etiology of the collapse. 16. Identify and give appropriate differential diagnoses 3. Distinguish lung collapse from massive pleural effu- when the patterns of septal thickening, perilym- sion on a frontal chest radiograph. phatic nodules, bronchiolar opacities (“tree-in- 4. Name the four types of bronchiectasis and identify bud”), air trapping, cysts, and ground glass opaci- each type on a chest CT. ties are seen on CT. 5. Name five common causes of bronchiectasis. 6. Recognize the typical appearance of cystic fibrosis Alveolar Lung Disease.— on chest radiography and CT. 1. List four broad categories of acute alveolar lung 7. Name the important things to look for on a chest disease (ALD). radiograph when the patient history is “.” 2. List five broad categories of chronic ALD. 8. Define tracheomegaly. 3. Name three pulmonary-renal syndromes. 9. Recognize tracheal and bronchial on chest 4. List five of the most common causes of acute respi- CT and name the most common causes. ratory distress syndrome. 10. Name the three types of pulmonary emphysema and 5. Name four predisposing causes of cryptogenic orga- identify each type on a chest CT. nizing pneumonia. 11. Recognize alpha-1-antitrypsin deficiency on a chest 6. Suggest a specific diagnosis of ALD when sup- radiograph and CT. portive findings are present in the history or on 12. Recognize Kartagener syndrome on a chest radio- the chest radiograph (eg, broken femur and ALD graph and name the three components of the syn- in fat embolization syndrome, ALD and renal drome. failure in a pulmonary-renal syndrome, ALD 13. Define the term giant bulla, differentiate giant bulla treated with bronchoalveolar lavage in alveolar from pulmonary emphysema, and state the role of proteinosis). imaging in patient selection for . 7. Recognize a pattern of peripheral ALD on radiog- 14. State the imaging findings used to identify surgical raphy or chest CT and give an appropriate differ- candidates for giant bullectomy and for lung volume ential diagnosis, including a single most likely reduction surgery. diagnosis when supported by associated radio- 15. Recognize and describe the significance of a pattern logic findings or clinical information (eg, periph- of mosaic lung attenuation on chest CT. eral lung disease associated with paratracheal and bilateral hilar adenopathy in an asymptomatic Mediastinal Masses and Mediastinal/Hilar Lymph patient with “alveolar” , peripheral Node Enlargement.— lung disease associated with a markedly elevated 1. State the anatomic boundaries of the anterior, mid- blood eosinophil count in a patient with eosino- dle, posterior, and superior mediastinum. philic pneumonia, peripheral opacities associated 2. Name the four most common causes of an anterior with multiple rib fractures and pneumothorax in a mediastinal mass and localize a mass to the ante- patient with acute thoracic trauma and pulmonary rior mediastinum on a chest radiograph, CT, and contusions). MRI.

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3. Name the three most common causes of a middle Benign and Malignant Neoplasms of the Lung and mediastinal mass and localize a mass in the middle Esophagus.— mediastinum on a chest radiograph, CT, and MRI. 1. Name the four major histologic types of broncho- 4. Name the most common cause of a posterior me- genic carcinoma and state the difference between diastinal mass and localize a mass in the posterior non–small-cell and small-cell lung cancer. mediastinum on a chest radiograph, CT, and MRI. 2. Name the type of non–small-cell lung cancer that 5. Name two causes of a mass that straddles the tho- most commonly cavitates. racic inlet and localize a mass to the thoracic inlet 3. Name the types of bronchogenic carcinoma that on a chest radiograph, CT, and MRI. are usually central. 6. Identify normal vessels or vascular abnormality on 4. Describe the TNM classification for staging non– chest CT and chest MRI that may mimic a solid small-cell lung cancer, including the components mass. of each stage (I, II, III, IV, and substages) and the 7. Name five etiologies of bilateral hilar lymph node definition of each component (T1-4, N0-3, M0-1). enlargement. 5. Describe the staging of small-cell lung cancer. 8. State the three most common locations (Garland’s 6. Name the four most common extrathoracic sites of triad) of thoracic lymph node enlargement in sar- metastases for non–small-cell and small-cell lung coidosis. cancer. 9. List the four most common etiologies of “egg- 7. Name the stages of non–small-cell lung cancer are shell” calcified lymph nodes in the . potentially resectable. 10. Recognize a cystic mass in the mediastinum and 8. Recognize abnormal contralateral suggest the possible diagnosis of a bronchogenic, on a postpneumonectomy chest radiograph and pericardial, thymic, or esophageal duplication cyst. state five possible etiologies for the abnormal shift. 11. Recognize the findings of mediastinal fibrosis on 9. Name the most common thoracic locations for ad- chest CT. enoid cystic carcinoma and carcinoid tumors to occur. Solitary and Multiple Pulmonary Nodules.— 10. Suggest the possibility of radiation change as a 1. Define the terms pulmonary nodule and pulmonary cause of new apical opacification on a chest radio- mass. 2. Name the three most common causes of a solitary graph of a patient with evidence of mastectomy or pulmonary nodule. axillary node dissection. 3. Name four important considerations in the evalua- 11. Describe the acute and chronic radiographic and tion of a solitary pulmonary nodule. CT appearances of radiation injury in the thorax 4. Name six causes of cavitary pulmonary nodules. (lung, pleura, pericardium, esophagus) and the 5. Name four causes of multiple pulmonary nodules. temporal relationship to radiation . 6. Describe the indications for percutaneous biopsy 12. State the role of MRI in lung cancer staging (eg, of a solitary pulmonary nodule. chest wall invasion, superior sulcus, Pancoast tu- 7. Describe the indications for percutaneous biopsy mor). when there are multiple pulmonary nodules. 13. Describe the role of positron emission tomography 8. Describe the complications and the frequency with in lung cancer staging. which complications occur because of percutane- 14. Describe the TNM classification for staging esoph- ous lung biopsy using CT or fluoroscopic guid- ageal carcinoma, including the components of each ance. stage (I, II, III, IV) and the definition of each 9. Describe the indications for placement component (T, N, and M). as a treatment for pneumothorax related to percu- 15. Describe the role of imaging in the staging of taneous lung biopsy. esophageal carcinoma. 10. Describe the role of positron emission tomography 16. Name the stages of esophageal carcinoma are po- in the evaluation of a solitary pulmonary nodule. tentially resectable. 11. Describe an appropriate imaging algorithm to eval- 17. Describe the classification of lymphoma, the role uate a solitary pulmonary nodule. of imaging in the staging of lymphoma and the

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typical and atypical imaging findings of thoracic tion or infiltration of the chest wall on a chest ra- lymphoma. diograph or CT and name four likely causes. 18. Define primary pulmonary lymphoma. 4. Recognize pleural calcification on a chest radio- 19. Describe the typical chest radiograph and chest CT graph or CT and suggest the diagnosis of asbestos appearances of Kaposi sarcoma. exposure (bilateral involvement) or old tuberculo- sis or trauma (unilateral involvement). Thoracic Trauma.— 5. Recognize the typical chest radiographic appear- 1. Identify a widened mediastinum on a trauma ra- ances of pleural effusion, given differences in pa- diograph and state the differential diagnosis (in- tient positioning, and describe the role of the lat- cluding aortic/arterial injury, venous injury, frac- eral decubitus view to evaluate pleural effusion. ture of sternum or spine). 6. Recognize apparent unilateral elevation of the 2. Identify and describe the indirect and direct signs diaphragm on a chest radiograph and suggest a of aortic injury on contrast-enhanced chest CT. specific etiology with supportive history and asso- 3. Identify and state the significance of chronic trau- ciated chest radiograph findings (eg, subdiaphrag- matic pseudoaneurysm of the aorta on a chest ra- matic abscess after abdominal surgery, diaphragm diograph, CT, or MRI. rupture after trauma, phrenic nerve involvement 4. Identify fractured ribs, clavicle, spine, and scapula with lung cancer). on a chest radiograph or CT. 7. Recognize imaging findings suggesting a tension 5. Name five common causes of abnormal lung opac- pneumothorax and understand the acute clinical ity on a trauma radiograph or CT. implications. 8. Recognize diffuse pleural thickening, as seen in 6. Identify an abnormally positioned diaphragm or fibrothorax, malignant , and pleural loss of definition of a diaphragm on a trauma chest metastases. radiograph and suggest the diagnosis of a ruptured 9. Describe and recognize the radiographic and CT diaphragm. findings of malignant mesothelioma. 7. Recognize and describe the signs of diaphragmatic 10. Describe the difference in appearance of a pulmo- rupture on a chest CT. nary abscess and an empyema on chest CT and 8. Identify a pneumothorax, pneumopericardium, and how the two are differently managed. pneumomediastinum on a trauma chest radiograph. 11. Distinguish pleural from intraperitoneal fluid on 9. Identify the fallen lung sign on a chest radiograph chest CT. or CT and suggest the diagnosis of tracheobron- chial tear. Infection and Immunity.— 10. Identify a cavitary lesion on a posttrauma radio- 1. Describe the radiographic manifestations of pri- graph or chest CT and suggest the diagnosis of mary pulmonary tuberculosis. laceration with pneumatocele formation, hematoma 2. Name the most common segmental sites of in- or abscess secondary to aspiration. volvement for postprimary tuberculosis in the 11. Name the three most common causes of pneumo- lung. mediastinum in the setting of trauma. 3. Define a Ghon lesion (calcified pulmonary paren- 12. Recognize and distinguish between pulmonary chymal granuloma) and Ranke complex (calcified contusion and laceration. node and Ghon lesion); recognize both on a chest radiograph and CT and describe their significance. Chest Wall, Pleura, and Diaphragm.— 4. Name and describe the types of pulmonary as- 1. Recognize and name four causes of a large unilat- pergillus disease. eral pleural effusion on a chest radiograph or CT. 5. Identify an intracavitary fungus ball on chest radi- 2. Recognize a pneumothorax on an upright and su- ography and CT. pine chest radiograph. 6. Describe the radiographic appearances of cytomeg- 3. Recognize a pleural based mass with bone destruc- alovirus pneumonia.

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7. Name the major categories of disease causing Congenital Lung Disease.— chest radiograph or CT abnormalities in the immu- 1. Name the components of pulmonary venolobar syn- nocompromised patient. drome. 8. Other than bacterial infection, name two important 2. Recognize venolobar syndrome on a frontal chest and two important neoplasms to con- radiograph, chest CT, and chest MRI, and explain sider in patients with AIDS and chest radiograph the etiology of the retrosternal band of opacity seen or CT abnormalities. on the lateral radiograph. 9. Describe the chest radiograph and CT appearances 3. Recognize a mass in the posterior segment of a of Pneumocystis carinii (jiroveci) pneumonia lower lobe on a chest radiograph and CT and sug- 10. Name the four most important etiologies of hilar gest the possible diagnosis of pulmonary sequestra- and mediastinal in patients with tion. AIDS. 4. Describe the differences between intralobar and ex- 11. Describe the time course and chest radiographic tralobar sequestration. appearance of a blood transfusion reaction. 5. Recognize bronchial atresia on a chest radiograph 12. Describe the radiographic appearances of myco- and CT and name the most common lobes in which plasma pneumonia. it occurs. 13. Describe the chest radiographic and CT appear- ance of a miliary pattern and provide a differential Pulmonary Vasculature.— diagnosis. 1. Recognize enlarged pulmonary arteries on a chest 14. Name the diagnostic considerations in a patient radiograph and distinguish them from enlarged hilar who presents with recurrent or persistent pneumo- lymph nodes. nias. 2. Recognize enlargement of the central pulmonary 15. Name the endemic mycoses and the specific geo- arteries with diminution of the peripheral pulmonary graphic regions where they are found, and describe arteries on a chest radiograph and suggest the diag- their radiographic manifestations. nosis of pulmonary arterial hypertension. 16. Name the most common pulmonary infections 3. Name five common causes of pulmonary arterial seen after solid-organ (ie, liver, renal, lung, car- hypertension. diac) and bone marrow transplantation. 4. Recognize lobar and segmental pulmonary emboli 17. Describe the chest radiographic and CT findings of on chest CT and chest MRI (including magnetic posttransplant lymphoproliferative disorders. resonance angiography). 5. Define the role of ventilation-perfusion scintigraphy, Unilateral Hyperlucent Hemithorax.— chest CT, chest MRI/MRA, CT venography, and 1. Recognize a unilateral hyperlucent hemithorax on a lower extremity venous ultrasound studies in the chest radiograph or CT. evaluation of a patient with suspected venous 2. Identify the common causes for unilateral hyperlu- thromboembolic disease, including the advantages cent hemithorax on a chest radiograph. and limitations of each modality depending on pa- 3. Give an appropriate differential diagnosis when a tient presentation. hyperlucent hemithorax is seen on a chest radio- 6. Describe the anatomy of and identify the right and graph, and suggest a specific diagnosis when cer- left superior and inferior pulmonary veins on chest tain associated findings are seen (ie, absence of a CT and MRI and the use of radiofrequency ablation breast in a patient after mastectomy, absence of a of pulmonary veins for treatment of atrial fibrilla- pectoralis muscle in a patient with Poland syn- tion. drome, unilateral bullous disease/emphysema, or 7. Recognize variations in pulmonary venous anatomy, air trapping on expiration in a patient with Sw- such as a separate right middle lobe vein and com- yer-James syndrome or an endobronchial foreign mon ostium of the left superior and inferior pulmo- body). nary veins.

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Thoracic Aorta and Great Vessels.— ● left anterior descending coronary artery 1. State the normal dimensions of the thoracic aorta. ● left circumflex coronary artery 2. Describe the classifications of (De- ● obtuse marginal Bakey I, II, III; Stanford A, B) and implications for ● diagonals classification on medical versus surgical manage- ● acute marginals ment. ● septal perforators 3. Describe and recognize the findings of, and distin- 2. Describe the clinical significance of coronary arterial guish between each of the following on CT and MR: calcification on a chest radiograph. ● aortic aneurysm 3. Recognize coronary arterial calcification on CT ● aortic dissection and describe the current role of coronary artery ● aortic intramural hematoma calcium scoring with helical or electron beam CT. ● penetrating atherosclerotic ulcer 4. Name the coronary artery that is usually diseased ● ulcerated plaque when there is papillary muscle dysfunction. ● ruptured aortic aneurysm 5. Describe the common acute complications of ● sinus of Valsalva aneurysm myocardial infarction, including left ventricular ● subclavian or brachiocephalic artery aneurysm failure, myocardial rupture, and papillary muscle ● aortic coarctation ● aortic pseudocoarctation rupture, and recognize radiologic findings indicat- ● pulsation artifact at aortic root ing each. 4. Recognize a right aortic arch and a double aortic 6. Describe the common late complications of myo- arch on a chest radiograph, chest CT, and chest cardial infarction, including ischemic cardiomyop- MRI. athy, left ventricular aneurysm, left ventricular 5. State the significance of a right aortic arch with mir- pseudoaneurysm, coronary-cameral fistula, dyski- ror image branching versus with an aberrant subcla- nesis, and akinesis, and recognize radiologic find- vian artery. ings indicating each. 6. Recognize a cervical aortic arch on a chest radio- 7. Identify signs of left heart failure on a chest radio- graph and CT. graph and CT. 7. Recognize an aberrant subclavian artery on chest 8. Define ejection fraction, including the normal value CT. for left ventricular ejection fraction. 8. Recognize normal variants of aortic arch branch- 9. Identify myocardial calcification on CT and describe ing, including common origin of brachiocephalic the etiology and significance of this finding. and left common carotid arteries (“bovine arch”), 10. Describe the difference between a left ventricular and separate origin of vertebral artery from arch aneurysm and pseudoaneurysm. on CT and MRI/MRA. 11. Define and identify myocardial bridging on CT. 9. Define the terms aneurysm and pseudoaneurysm. 12. Define the role of angiography, , 10. Describe the cardiac anomalies commonly associated stress perfusion scintigraphy, chest CT, and chest with aortic coarctation. MRI in the evaluation of a patient with suspected 11. Describe and identify the findings of Takayasu ar- ischemic heart disease as well as stunned myocar- teritis on chest CT and chest MRI. dium and hibernating myocardium versus areas of 12. Describe the advantages and disadvantages of CT, infarction, including the advantages and limita- MRI/MRA, and transesophageal echocardiography in tions of each modality. the evaluation of the thoracic aorta. 13. Differentiate viable from nonviable myocardium on MRI. Ischemic Heart Disease.— 1. Describe the anatomy of the coronary arteries and 14. Identify myocardial perfusion defects on MRI. identify the following on a coronary arteriogram, 15. Calculate right and left ventricular volumes, in- MRI, and CT: cluding ejection fraction, volume, end-dia- ● right coronary artery stolic volume, and end-systolic volume using MRI ● left main coronary artery and CT.

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Myocardial Disease.— 5. State the most common etiologies of the following: 1. Define the types of cardiomyopathy (dilated, hy- ● aortic stenosis pertrophic, restrictive) and list the common ● aortic regurgitation causes of each. ● mitral stenosis 2. Define right ventricular dysplasia, describe the ● mitral regurgitation role of MRI in its diagnosis, and identify MRI ● tricuspid regurgitation findings that support the diagnosis. ● pulmonary stenosis 3. Name the most common benign primary cardiac 6. Name the cardiac diseases associated with mitral tumors, including myxoma, lipoma, fibroma, and annulus calcification rhabdomyoma. 7. Identify endocarditis or complications of endocar- 4. Name the most common malignant primary car- ditis on a chest radiograph, CT, and MRI. diac tumors, including angiosarcoma, rhabdomyo- 8. Describe the advantages and disadvantages of sarcoma, and lymphoma. echocardiography and MRI for evaluation of val- 5. Distinguish cardiac tumor from thrombus on CT vular heart disease. and MRI. 9. Describe the pulse sequences and appropriate 6. Name the most common malignancies to metasta- planes for evaluating cardiac valvular disease and size to the heart, and describe the appearance on making quantitative measurements including pres- a chest radiograph, chest CT and chest MR sure gradients, regurgitant fractions, and valve 7. Describe the advantages and disadvantages of areas. echocardiography, CT, and MRI for evaluation of cardiomyopathy and cardiac tumors. Pericardial Disease.— 8. Recognize calcification of papillary muscles as 1. Recognize pericardial calcification on a chest radio- distinct from myocardial calcifications and de- graph and CT and name the most common causes. scribe the significance of each. 2. Describe and identify two chest radiographic signs of a pericardial effusion. Cardiac Valvular Disease.— 3. Name five causes of a pericardial effusion. 1. Identify and describe the findings of each on a chest 4. Describe and recognize the findings of each of the radiograph: following on a chest radiograph, CT, and MR: ● enlarged right atrium ● pericardial cyst ● enlarged left atrium ● constrictive pericarditis ● enlarged right ventricle ● pericardial hematoma ● enlarged left ventricle ● pericardial metastases 2. Describe and recognize the chest radiograph findings ● partial and complete absence of the pericardium associated with each of the following valvular dis- ● pneumopericardium eases: 5. Describe the role of MRI in diagnosing constric- ● mitral regurgitation tive pericarditis and differentiating constrictive ● mitral stenosis pericarditis from restrictive cardiomyopathy. ● aortic regurgitation ● aortic stenosis Congenital Heart Disease in the Adult.— ● tricuspid regurgitation 3. Recognize an enlarged ascending aorta and aortic 1. Recognize increased vascularity and decreased vas- valve calcification on a chest radiograph and sug- cularity on a chest radiograph and name the com- gest the diagnosis of aortic stenosis when these mon causes of each. findings are present. 2. Describe and recognize the following on a chest 4. Recognize an enlarged left atrium, vascular redis- radiograph, CT, or MRI. tribution, and mitral valve calcification on a chest Heart disease presenting during adulthood: radiograph and suggest the diagnosis of mitral ● Left-to-right shunts and Eisenmenger physiology stenosis when these findings are present. ● Atrial septal defect

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● Ventricular septal defect ● catheter ● Partial anomalous pulmonary venous connection ● feeding tube ● ● nasogastric tube ● Coarctation of the aorta ● chest tube ● and with ● intra-aortic balloon pump ventricular septal defect ● pacemaker generator and leads (including triple ● Congenitally corrected transposition of the great lead devices) arteries ● automatic implantable cardiac defibrillator ● Persistent left superior vena cava ● left ventricular assist device ● Truncus arteriosus ● atrial septal defect closure device ● Ebstein anomaly ● pericardial drain ● Cardiac malposition, including abnormal situs ● extracorporeal life support cannulae ● Coronary artery anomalies ● intraesophageal manometer, temperature probe or Heart disease originally treated in childhood: pH probe ● Coarctation of the aorta ● tracheal, bronchial or esophageal stent ● Tetralogy of Fallot and pulmonary atresia with 2. Explain how an intra-aortic balloon pump works. ventricular septal defect 3. Describe the venous anatomy and expected course of ● Complete transposition of the great arteries veins from the axillary vein to the right atrium relative ● Congenitally corrected transposition of the great to anatomic landmarks. arteries 4. Recognize the difference between a skinfold and pneu- ● Truncus arteriosus mothorax on a portable chest radiograph. ● Commonly performed surgical corrections for congenital heart disease Postoperative thorax.— 3. Define the role of angiography, echocardiography, chest CT, and chest MRI in the evaluation of an 1. Identify normal postoperative findings and complica- adult patient with congenital heart disease, in- tions of the following procedures on chest radiogra- cluding the advantages and limitations of each phy, CT, and MRI: ● modality depending on patient presentation. , , ● coronary artery bypass graft surgery ● Monitoring and support devices—“tubes and lines”.— cardiac 1. Describe and identify on chest radiography the nor- ● aortic graft mal appearance and complications associated with ● aortic stent each of the following: ● transhiatal ● endotracheal tube ● lung transplantation ● central venous catheter ● ● peripherally inserted central venous catheter ● lung volume reduction surgery.

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