Resident Education What’s New in 10 Years? A Revised Cardiothoracic Curriculum for Diagnostic Radiology with Goals and Objectives Related to General Competencies

Elsie T. Nguyen, MD, FRCPC, Jeanne B. Ackman, MD, Prabhakar Rajiah, MD, FRCR, Brent Little, MD, Carol Wu, MD, Juliana M. Bueno, MD, Mathew D. Gilman, MD, Jared D. Christensen, Rachna Madan, MD, Archana T. Laroia, MBBS, MD, Christopher Lee, Jeffrey P. Kanne, MD, Jannette Collins, MD, MEd, FCCP

This is a cardiothoracic curriculum document for radiology residents meant to serve not only as a study guide for radiology residents but also as a teaching and curriculum reference for radiology educators and radiology residency program directors. This document represents a re- vision of a cardiothoracic radiology resident curriculum that was published 10 years ago in Academic Radiology. The sections that have been significantly revised, expanded, or added are (1) screening, (2) genomic profiling, (3) lung adenocarcinoma revised nomenclature, (4) lung biopsy technique, (5) nonvascular thoracic magnetic resonance, (6) updates to the idiopathic interstitial pneumonias, (7) cardiac computed tomography updates, (8) cardiac magnetic resonance updates, and (9) new and emerging techniques in cardiothoracic imaging. This curriculum was written and endorsed by the Education Committee of the Society of Thoracic Radiology. This curriculum op- erates in conjunction with the Accreditation Council for Graduate (ACGME) milestones project that serves as a framework for semiannual evaluation of resident as they progress through their training in an ACGME-accredited residency or pro- grams. This cardiothoracic curriculum document is meant to serve not only as a more detailed guide for radiology trainees, educators, and program directors but also complementary to and guided by the ACGME milestones. Key Words: curriculum; cardiothoracic; radiology residency; Accreditation Council for Graduate Medical Education (ACGME); American Board of Radiology (ABR); study guide; examination. © 2016 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.

INTRODUCTION his document is a revision of a previously published cardiothoracic curriculum for diagnostic radiology res- idency (1) and reflects interval changes in the clinical Acad Radiol 2016; 23:911–918 T From the Toronto General , , Room 1-295, 585 practice of cardiothoracic radiology, including updates in the University Avenue, Toronto, ON, M5G 2N2 (E.T.N.); Massachusetts Accreditation Council for Graduate Medical Education General Hospital, Harvard University, , Massachusetts (J.B.A., M.D.G.); (ACGME) requirements for diagnostic radiology training University of Texas Southwestern Medical Center, Dallas, Texas (P.R.); Hospital, Emory University, Atlanta, Georgia (B.L.); MD Anderson programs. Cancer Center, University of Texas, Houston, Texas (C.W.); Radiology residency programs must define the specific Medical Center, Charlottesville, Virginia (J.M.B.); Duke University Hospital, Duke University, Durham, North Carolina (J.D.C.); Brigham and Women’s Hospital, knowledge, skills, behaviors, and attitudes required of resi- Harvard University, Boston, Massachusetts (R.M.); University of Iowa dents and must provide adequate educational experience to and , University of Iowa, Iowa City, Iowa (A.T.L.); Keck Hospital of USC, achieve competency in six areas defined by the ACGME: (1) Keck School of at University of Southern California, Los Angeles, California (C.L.); University of Wisconsin School of Medicine and , patient care (PC), (2) medical knowledge (MK), (3) profes- Madison, Wisconsin (J.P.K.); UC Academic Health Center, University of sionalism (P), (4) interpersonal/communication skills (ICS), Cincinnati, Cincinnati, Ohio (J.C.). Received October 11, 2015; revised January 25, 2016; accepted January 28, 2016. Prepared by the EdbBucation Commit- (5) practice-based learning and improvement (PBLI), and (6) tee of the Society of Thoracic Radiology. Address correspondence to: E.T.N. systems-based practice (SBP). These six areas, as they specif- e-mail: [email protected] ically relate to radiology, have been previously published (2). © 2016 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. The 10 areas of radiology residency, as defined http://dx.doi.org/10.1016/j.acra.2016.01.022 by the ACGME, are , musculoskeletal radiology,

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vascular and , cardiac radiology (new since for radiology trainees, educators, and program directors but also 2005), radiology, breast imaging, abdominal radiolo- is complementary to and guided by the ACGME milestones. gy, pediatric radiology, ultrasound (including obstetrical The Entrustable Professional Activities (EPAs) are “units of ultrasound and vascular), and . professional practice, defined as tasks or responsibilities that trainees The Society of Thoracic Radiology (STR) Education Com- are entrusted to perform unsupervised once they have attained mittee has responded to the changing practice of cardiothoracic competence. EPAs are independently executable, observable, and imaging and the revised ACGME guidelines by revising the measurable in their process and outcome, and, therefore, suit- previously published Cardiothoracic Curriculum document. able for entrustment decisions.” EPAs may incorporate multiple There have also been important changes to the structure of competencies as they describe the tasks a particular specialist should radiology residencies across the since the last be able to complete without supervision upon graduation from curriculum document was published (1). The STR Educa- residency and fellowship. The medical knowledge, interpreta- tion Committee decided to keep the structure of the curriculum tive, and procedural skills outlined in this cardiothoracic curriculum document divided into years 1 and 2, then years 3 and 4 com- document reflect the EPAs outlined by the ACGME milestones bined, recognizing that the new residency format with general project that should be achieved by a radiology resident during and subspecialty years may not allow a trainee to achieve all the course of the residency. the educational goals and objectives in years 3 and 4 if the This curriculum document is based on three 4-week rota- trainee has not selected cardiothoracic imaging as a subspe- tions in cardiothoracic imaging. Residency training programs may cialty. Ideally, the third and fourth rotations must occur in organize these blocks into different numbers of cardiac, thorac- year 3 or very early in year 4 so that both occur before the ic, or cardiothoracic blocks of varying length. It is the hope of new core American Board of Radiology (ABR) examina- the STR Education Committee that this document will be com- tion that typically occurs early in year 4. prehensive yet adaptable across many variations in residency training This curriculum document is focused on adult cardiothoracic programs worldwide. Because the timing of the rotations and imaging, as pediatric radiology is considered a separate sub- whether they are purely thoracic, cardiac, or cardiothoracic in specialty by the ACGME. There is overlap, however, between nature may vary across training programs, individual training pro- cardiothoracic imaging and other ACGME and, grams may adapt this document to their practice, as needed. where appropriate, components of other ACGME subspecialties, The sections that have been significantly revised and ex- such as ultrasound or vascular and interventional radiology, panded or newly added to the previously published curriculum are also included. Educational objectives for physics are not are (1) lung cancer screening, (2) lung cancer genomic profiling, included in this document, as most radiology residencies include (3) lung adenocarcinoma revised nomenclature, (4) lung biopsy a physics course with its own course objectives. technique, (5) thoracic magnetic resonance (MR), (6) updates In this document, learning goals and objectives that relate to the idiopathic interstitial pneumonias, (7) cardiac computed to clinical knowledge, technical, communication, and decision- tomography (CT) updates, (8) cardiac MR updates, and (9) new making skills are outlined for each year of training. and emerging techniques in cardiothoracic imaging (Table 1). Six general competencies have been defined by the ACGME Lung cancer screening programs have developed since the (2,3). Throughout this document, the following abbrevia- last publication of the cardiothoracic resident curriculum based tions for the six specific competencies are used: PC, MK, P, on results of large population-based studies such as the Na- ICS, PBLI, and SBP. tional Lung Screening Trial. This landmark trial demonstrated The ACGME has recently completed a milestone project a 20% relative reduction in lung cancer mortality using low- to describe competency-based developmental outcomes with dose CT lung cancer screening as compared to single-view, several purposes. For the radiology residency training programs posteroanterior chest (4). It is therefore impor- (as well as fellowship programs), the ACGME milestones serve tant for radiology residents to be familiar with not only the as a framework for Clinical Competency Committees and guide benefits of CT lung cancer screening but also the reporting curriculum development as well as aid identification of strug- terminology and management recommendations according to gling resident trainees. For the resident trainees, the milestones the American College of Radiology (ACR)-endorsed Lung clearly outline expectations for performance and facilitate self- Imaging Reporting and Data System (5,6). directed learning and assessment. For accreditation purposes, In recent years, the has become the ACGME milestones allow for continuous monitoring of more tailored to the specific genetic mutations expressed by training programs and increased public accountability by fa- the lung tumors. For example, for patients with metastatic non– cilitating reporting of national aggregate competency outcomes small cell lung (especially adenocarcinoma), testing for according to each subspecialty. epidermal growth factor receptor (EGFR) mutations has helped This cardiothoracic curriculum for radiology residents operates identify patients who will benefit from EGFR (tyrosine kinase) in conjunction with the ACGME milestones project that serves inhibitors (ie, gefitinib) rather than standard chemotherapy. as a framework for semiannual evaluation of resident physicians For the radiologist and the radiology trainee, it is important as they progress through their training in an ACGME-accredited to understand that more cellular content in the fine needle residency or fellowship program. This cardiothoracic curricu- aspirate or more core tissue biopsy samples are required to lum document is meant to serve not only as a more detailed guide allow for genetic testing. More detail on lung biopsy technique

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TABLE 1. Nine New Content Sections in the Cardiothoracic Resident Curriculum

Content Comment Lung cancer screening With results of the National Lung Cancer Screening Trial available and lung cancer screening programs being developed in North America and internationally, residents should have some awareness of the evidence and mortality benefit behind lung cancer screening with CT and the LUNG-RADS reporting system. Lung cancer genomic Genetic profiling of lung cancer performed on lung biopsy specimens provides useful information profiling about endothelial growth factor receptor status especially for adenocarcinoma subtype as well as common genetic mutations such as anaplastic lymphoma kinase (ALK) and kirsten rat sarcoma (K-RAS) that help with targeted with EGFR/tyrosine kinase inhibitors versus standard chemotherapy. Revised nomenclature for The International Association for the Study of Lung Cancer (IASLC) revised the adenocarcinoma primary lung classification in 2011 to include adenocarcinoma in situ (AIS, formerly known as adenocarcinoma bronchioloalveolar carcinoma) and added “minimally invasive adenocarcinoma” with reclassification of invasive adenocarcinoma subtypes. Lung biopsy techniques More detail on lung biopsy technique and management of complications were added. Thoracic MR Thoracic MRI applications have been expanded to include protocols such as chemical shift sequences to help differentiate thymic hyperplasia from . Updates on idiopathic Updates on idiopathic interstitial pneumonias have been added. interstitial pneumonias (IIP) Cardiac CT updates More content on cardiac CT have been added to include more specific knowledge requirements. Cardiac MR updates Cardiac MRI applications have been expanded and more detail on clinical applications and disease specific knowledge has been added. New and emerging Since the last curriculum document, new and emerging techniques have developed. Although techniques residents are not expected to have detailed knowledge of these emerging new techniques, an awareness of such techniques is encouraged.

CT, computed tomography; EGFR, epidermal growth factor receptor; LUNG-RADS, Lung Imaging Reporting and Data System; MRI, mag- netic resonance imaging. and management of complications has also been added to this these new and “under development” imaging modalities, some revised curriculum document. awareness of them is desirable. In 2011, the International Association for the Study of Lung Attendance at departmental and interdepartmental educa- Cancer has revised the adenocarcinoma classification to include tional conferences and rounds, as well as local, national, and adenocarcinoma in situ (formerly known as bronchioloalveolar international meetings, is also an important aspect of cardiothoracic carcinoma) and added “minimally invasive adenocarcinoma” education. Because these will vary from institution to institu- with reclassification of invasive adenocarcinoma subtypes. It tion, they are not listed here. However, selected useful resources is important for the radiology resident to be familiar with the for the trainee are provided in Appendix S1 relating to the ma- revised nomenclature of lung adenocarcinoma and have an terial that has been newly added or revised. understanding of the corresponding CT appearance and impact on sub-solid nodule management. YEAR 1 (FIRST 4-WEEK ROTATION) Applications for thoracic magnetic resonance imaging (MRI) Goals have expanded to include thymic and nonvascular indica- tions, and these are outlined in this cardiothoracic curriculum After completion of the first cardiothoracic radiology rota- document. Furthermore, some updates to reporting of idio- tion, the resident will be able to: pathic interstitial pneumonias and other interstitial lung diseases have been added. More detailed updates to cardiac CT and 1. demonstrate learning of the knowledge-based objectives MRI have been included. is an area that has 2. dictate a chest radiographic report accurately and concisely significantly developed in the last 10 years since the last 3. communicate effectively with referring clinicians and cardiothoracic curriculum publication in 2005. Increasingly, supervisory staff the ABR resident syllabus and study guide has included cardiac 4. understand standard patient positioning in cardiothoracic imaging content. This curriculum document has taken into radiology account the ABR syllabus/resident study guide and is con- 5. obtain pertinent patient information relevant to radio- cordant with it. logic examinations Finally, brief mention of some new and emerging cardiothoracic 6. demonstrate knowledge of the clinical indications when imaging techniques has been included. Although radiology obtaining chest radiographs and when CT or MR may residents are not expected to have comprehensive knowledge of be necessary

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7. demonstrate a responsible work ethic 10. Participate in discussions with faculty regarding op- 8. perform image-guided procedures of the chest erational challenges and potential systems solutions 9. participate in quality improvement/quality assurance and regarding all aspects of radiologic service and patient other operational activities care (SBP). 11. Use appropriate chest radiograph, CT, and MR ter- minology when dictating reports and consulting with Objectives health-care professionals (ICS).

A. Knowledge based Conferences and Study Materials At the end of the first cardiothoracic radiology rota- A. Conferences tion, the resident will demonstrate learning of at least one- The ACGME requires didactic conferences as part of the third of the knowledge-based objectives in the Addendum radiology residency training program. Examples of con- of this document (PC, MK). ference types that should be part of a resident’s educational B. Technical, communication, and decision-making skills program are listed in the following section. Thoracic ra- At the end of the first cardiothoracic radiology rota- diology teaching conferences are mandatory. Other tion, the resident will demonstrate the following technical, conferences, such as a lung transplant conference, are not communication, and decision-making skills: available at all training programs but, when available, should 1. Dictate accurate and concise radiographic and be considered for inclusion into the curriculum. Some cardiothoracic CT reports that include patient name, conferences may be sponsored by other departments such number, date of examination, date as medicine or . It is important for the resident to of comparison examination, type of examination, attend these multidisciplinary conferences to learn the clinical indication, concise description of find- role of medical imaging in making decisions that affect ings, and short conclusion (ICS). patient care. Ideally, the residents should be actively in- 2. Communicate with the ordering regard- volved in preparing and presenting cases at these ing all significant or unexpected radiologic findings multidisciplinary conferences (MK, PBLI, SBP, PC, ICS). (especially those that require immediate action by Some examples include: the ordering physician) and document who was • Resident-specific cardiothoracic radiology teaching called and the date and time of the call in the conferences dictated report (IPC, PC). • Journal review/club 3. Obtain relevant patient history from the electron- • Radiology grand rounds ic medical record, previously dictated reports, or • Pulmonary medicine conference by communicating with referring clinicians (PC). • Intensive care unit conference 4. Describe patient positioning and indications for pos- • Thoracic conference teroanterior, anteroposterior, lateral decubitus, and • conference lordotic chest radiographs (PC, MK). • conference 5. Decide when it is appropriate to obtain help from • Lung transplant conference supervisory faculty (P) when assisting referring cli- • Interstitial lung disease conference nicians with imaging interpretation and patient • Quality assurance/quality improvement conference management. • Other 6. Arrive at the rotation assignment on time and prepared B. Teaching after reviewing recommended study materials (P). Supervise or act as consultants to medical students (PBLI). 7. Successfully perform thoracic biopsies and image- C. Study Materials guided (eg, pleural drainage, if performed Many types of educational materials may be included in at the institution) with faculty supervision this portion of a curriculum document, including text- commensurate with experience and individual books, book chapters, and review articles. Hard copy competence (PC). teaching files (eg, ACR or individual department files), 8. Counsel patients and obtain informed consent (eg, computer-based educational programs, and radiology ed- explain conduct and purpose for procedure, explain ucation websites or teaching files (eg, ACR compact discs risks, benefits and alternatives, solicit and answer (CDs)) should also be included, as recommended by the patient questions) before performing interventional residency program director or designated faculty within procedures without discriminating based on reli- the subspecialty of cardiothoracic radiology (MK). gious, ethnic, sexual, or educational differences and honoring patient confidentiality (ICS, P). YEAR 2 (SECOND 4-WEEK ROTATION) 9. Document (via electronic or written format) the performance, interpretation, and complications of After completion of the second cardiothoracic radiology rota- all procedures performed (PBLI). tion, in addition to the goals listed for Year 1, the resident will:

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1. demonstrate learning of the knowledge-based objectives B. At the end of the second cardiothoracic radiology ro- 2. continue to build on chest radiograph interpretive skills tation, the resident will demonstrate the following 3. develop skills in protocoling, monitoring, and interpret- technical, communication, and decision-making skills, in ing cardiothoracic CT studies addition to those listed for Year 1: 4. demonstrate an understanding of ACR Appropriateness 1. Appropriately protocol all requests for cardiothoracic Criteria and ACR Practice Standards and Technical Guide- CT to include thin-section images, high-resolution lines for thoracic radiology images, expiratory images, or prone images when 5. demonstrate ability to generate and interpret multiplanar appropriate, and use of intravenous contrast, tai- reformatted, curved planar reformatted, three-dimensional lored to the patient history and clinical question (PC). shaded surface display, and volume-rendered reconstruc- 2. Monitor all cardiothoracic CT examinations and de- tions and other reconstructions, as appropriate termine if additional imaging is needed before the examination is completed (if this is an institutional Objectives practice) (PC). A. The resident will demonstrate learning of at least two- 3. Demonstrate the ability to effectively present tho- thirds of the knowledge-based objectives listed for Year 1 racic radiology cases to other residents in a conference (see Appendix: Supplementary Material), in addition to setting by appropriately selecting cases, interacting identifying the following structures on cardiothoracic CT with residents, and presenting a brief discussion of and MRI (MK): the diagnosis for each case (PBLI). • —right, left, right upper, middle, and lower 4. Demonstrate the ability to manage an intravenous lobes, left upper (including lingula) and lower lobes; contrast reaction that occurs during a cardiothoracic secondary pulmonary lobule CT or MR examination (PC). • Pleura—fissures such as major, minor, azygos, 5. Act as a consultant for referring clinicians and rec- accessory (superior and inferior) ommend the appropriate use of imaging studies (ICS). • Inferior pulmonary ligaments 6. Describe the principles of chest fluoroscopy, includ- • Extrapleural fat ing the assessment of the diaphragm (PC). • Airways—trachea, carina, mainstem bronchi, lobar, 7. Demonstrate knowledge of CT parameters contrib- and segmental bronchi uting to patient radiation exposure and techniques • —left , right ventricle, left , right that can be used to limit radiation exposure (PC). atrium, , aortic valve, tricuspid valve, pul- monic valve, coronary arteries (left main, left anterior Conferences and Study Materials descending, left circumflex, right, posterior descend- ing), coronary veins, and coronary sinus A. Conferences—same as for Year 1 • —including pericardial recesses B. Teaching • Pulmonary arteries—main, right, left, lobar, inter- Supervise or act as consultants to junior residents and lobar, segmental medical students (PBLI). • —aortic root, ascending, arch, descending C. Study Materials • Arteries—brachiocephalic (innominate), common Compared to the first rotation, more advanced educa- carotid, subclavian, axillary, vertebral, internal tional resources should be provided for the second rotation mammary, intercostal in cardiothoracic radiology. Although materials for the • Veins—pulmonary, , inferior vena first rotation may consist of textbooks, book chapters, cava, brachiocephalic, subclavian, axillary, internal or teaching files based primarily on thoracic radiogra- jugular, external jugular, azygos, hemiazygos, left su- phy, more advanced rotations should incorporate additional perior intercostal, internal mammary journal articles, book or book chapters, or teaching files • Bones—ribs and costochondral cartilages, clavicles, specific to advanced modalities (eg, chest CT, MRI) or scapulae, , vertebrae thoracic interventions (eg, lung biopsy). • • • Thyroid gland YEARS 3–4 (THIRD 4-WEEK ROTATION TO • Muscles—sternocleidomastoid, anterior and middle OCCUR IN YEAR 3 OR EARLY IN YEAR 4 scalene, infrahyoid, pectoralis major and minor, BEFORE CORE EXAMINATION FOR THE deltoid, trapezius, infraspinatus, supraspinatus, ABR EXAMINATION) subscapularis, latissimus dorsi, serratus anterior Goals • Aortopulmonary window • Azygoesophageal recess After completion of the third cardiothoracic radiology • Gastrohepatic ligament, celiac axis rotation, in addition to the goals listed for Years 1 and 2, the • Diaphragm resident will:

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1. demonstrate learning of the knowledge-based objectives • lung cancer screening 2. refine skills in interpretation of radiographs and • lung cardiothoracic CT studies • esophageal cancer staging 3. develop skills in protocoling, monitoring, and interpret- • suspected pulmonary metastases ing cardiothoracic MR studies • suspected pulmonary nodule on chest radiograph 4. become a more autonomous consultant and teacher • shortness of breath 5. correlate pathologic and clinical data with radiographic, • hemoptysis cardiothoracic CT, and MR findings • cardiac mass • coronary arteries • suspected pericardial disease Objectives • ischemic heart disease, including function and viability • valvular heart disease A. At the beginning of the third cardiothoracic radiology • right ventricular dysplasia rotation or senior year of radiology residency, the res- • adult congenital heart disease ident will demonstrate knowledge of all of the • superior sulcus tumor knowledge-based objectives introduced in Years 1 and • mediastinal mass 2 (MK) • diffuse and focal pleural disease B. Technical and communication skills • or hernia After completion of the third cardiothoracic radiology • screening for lymphadenopathy, paragangliomas, rotation, the resident will demonstrate the following tech- thoracic endometriosis nical, communication, and decision-making skills, in 4. Understand (1) MR’s advantages over CT regarding addition to those listed for Years 1 and 2: tissue characterization—more definitive detection of 1. Dictate accurate, concise plain radiography, cardiothoracic solid, cystic/necrotic, and hemorrhagic tissue, micro- CT and MR reports with at least 75% accuracy; the scopic fat, fibrous tissue and smooth muscle (eg, reports will contain no major interpretive errors (ICS). esophageal leiomyoma); (2) varied dynamic enhance- 2. State the clinical indications for the performance of ment patterns and diffusion-weighted signal/ADC values cardiothoracic CT and MR (MK, PC). of mediastinal and other thoracic masses; (3) resultant Thoracic MR indications primarily involve further tissue added diagnostic specificity of MRI; (4) ability to characterization of thoracic masses that are indetermi- detect flow on MR sequences. However, CT also has nate on CT or radiography, scenarios with examples advantages over MRI in the setting of acute trauma including: for the identification of bony and acute lung trauma. • distinguishing cystic lesions and hematomas from solid In general, visualization of lung parenchyma with lesions high-resolution detail is superior with CT as compared • detecting blood products, fibrous material, smooth to MR. muscle, microscopic fat, and/or macroscopic fat within 5. Understand the technical principles of thoracic MRI, lesions including techniques to compensate for and/or eradi- • differentiating normal and hyperplastic thymus from cate cardiorespiratory motion to ensure high-quality thymic neoplasms, including lymphoma vascular and nonvascular thoracic MR imaging. • evaluating the nature and extent of indeterminate 6. Understand the concept and rationale for focused pleural disease on CT thoracic MR imaging of focal lesions. • differentiating tumor from atelectasis 7. Describe thoracic MR protocols optimized for evalu- • evaluating neurovascular and chest wall involve- ation of (MK, PC): ment by thoracic masses • thymic lesions • using signal characteristics, apparent diffusion • other mediastinal masses coefficient (ADC) values, and dynamic contrast en- • diffuse and focal pleural disease hancement patterns to help differentiate mediastinal • well-circumscribed pulmonary nodules ≥1cmtohelp lesions, including hemangiomas, paragangliomas, thy- distinguish between hamartoma, granuloma, carci- momas, and lymphomas, from one another. noid, and malignancy 3. Describe cardiothoracic CT protocols optimized for the • lung cancer recurrence versus postobstructive evaluation of each of the following (MK, PC): pneumonitis/radiation fibrosis • thoracic aorta and • diaphragmatic rupture or hernia • coronary calcium • thoracic lymphadenopathy • pulmonary vein anatomy 8. Describe MR protocols optimized for the evaluation of • suspected pulmonary embolism each of the following (MK, PC): • tracheobronchial tree • thoracic aorta • suspected bronchiectasis • pulmonary arteries

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• thoracic veins (superior vena cava, brachiocephalic correlating clinical history with pathologic and radiologic find- veins) ings, to residents and faculty (MK, ICS, P, PBLI). • pericardium Work in the reading room independently, assisting cli- • cardiomyopathy nicians with radiologic interpretation (PC, MK, ICS, P). • cardiac and paracardiac masses Teach other residents and medical students assigned to the 9. Cardiac CT general technical and communication service (PC, ICS, P, PBLI). objectives (PC, MK): 12. New and emerging imaging technology objectives (PC, Understand currently accepted indications for MK, PBLI, P, SBP): cardiac/coronary computed tomography angiography (CTA), Radiology residents should be exposed to advances in including recent evidence-based guidelines on use of coro- imaging technologies and their potential applications. Re- nary CT for evaluation of acute chest pain in the emergency search and development of new modalities, techniques, and setting. clinical applications is crucial to our subspecialty and man- Understand contemporary cardiac CTA acquisition dates life-long continuing education to provide the highest methods, including electrocardiogram (ECG) gating tech- quality of patient care and imaging services. Recognizing that niques, typical medications administered, radiation dose not every training program will have experience or exper- reduction techniques, and common imaging artifacts encoun- tise in emerging technologies, we should make efforts to expose tered in cardiac CT. trainees to new developments through didactic lectures, vis- Describe coronary artery, cardiac chamber, cardiac valve, iting speakers, and journal clubs, among other resources. and pericardial disease on cardiac CT. Understand the role of cardiac CT in preprocedural plan- ning and assessment of postprocedural complications for selected Conferences and Study Materials techniques, such as transcatheter aortic valve implantation, pul- monary vein isolation/ablation, and ventricular assist devices. A. Conferences 10. Technical and communication skill objectives for lung Same as for Year 1; may additionally require prepara- biopsy (PC, MK): tion and presentation at multidisciplinary conferences. Discuss the different types of lung biopsy techniques (ie, B. Teaching FNA and core needle) and review common indications. Discuss Supervise or act as consultants to junior residents and preprocedural assessment of patients referred for lung biopsy. medical students (PBLI). Know when EGFR mutation analysis may be required and C. Study Materials its impact on acquiring more tissue during CT-guided fine In addition to the materials listed for the first two ro- needle aspiration (FNA) or core needle biopsy. tations, more detailed technical references should be Describe special instructions to the patient before and assigned, whether in books or in state-of-the-art tech- following lung biopsies. nical publications in radiology journals (MK). List complications specific to lung biopsies, including pneu- D. A detailed study guide is provided in the Appendix: mothorax, hemorrhage, hemoptysis, and air embolism. Supplementary Materials located online. 11. Genomic profiling of lung cancer objectives (PC, MK): Understand the importance of genomic profiling in lung cancer diagnosis, treatment, and tumor response (PC, MK, SBP). REFERENCES Learn the recent genomic discoveries in lung cancer and 1. Collins J, Abbott GF, Holbert JM, et al. Revised curriculum on cardiothoracic their implications in imaging and therapeutic decision- radiology for diagnostic radiology residency with goals and objectives related making (PC, MK). to general competencies. Acad Radiol 2005; 12:210–223. Learn the importance of imaging in the assessment of ther- 2. Accreditation Council for Graduate Medical Education. Program require- ments for graduate medical education in diagnostic radiology. Available apeutic response in patients treated with targeted therapies for at: http://www.acgme.org/Specialties/Overview/pfcatid/23 Accessed non–small cell lung cancer (PC, MK). February 2015. Understand the roles of the different imaging modalities 3. Collins J, Rosado de Christenson M, Gray L, et al. General competen- cies in radiology residency training: definitions, skills, education and in the assessment of therapeutic response (PC, MK). assessment. Acad Radiol 2002; 9:721–726. Understand the limitations in the use of conventional as- 4. Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with sessment imaging criteria (ie, Response Evaluation Criteria low-dose computed tomographic screening. N Engl J Med 2011; 365:395– 409. in Solid Tumors (RECIST), World Health Organization 5. Kazerooni EA, Austin JHM, Black WC, et al. ACR-STR practice parame- (WHO)) in patients treated with targeted therapy (PC, ICS, ter for the performance and reporting of lung cancer screening thoracic MK). computed tomography (CT). J Thorac Imaging 2014; 29:310–316. 6. American College of Radiology. ACR Lung Imaging Reporting and Data In collaboration with a pathologist, present an interesting System (Lung-RADS). Available at: http://www.acr.org/Quality-Safety/ cardiothoracic imaging case, with a confirmed diagnosis, Resources/LungRADS. 2014.

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APPENDIX. SUPPLEMENTARY MATERIAL upplementary data to this article can be found online S at doi:10.1016/j.acra.2016.01.022.

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