Multimodality Imaging Training Curriculum — Parts II and III

The following sections of the document (Part II and III) list specific knowledge requirements for appropriate training in multimodality imaging for those whose background is in nuclear medicine and radiology respectively (PET/CT, SPECT/CT). Apart from specified training items it is understood that practising multimodality imaging requires certain skills above and beyond those enumerated under specific pathology areas. These include knowledge of emergency imaging findings as relevant to each specific organ system (BK0Basic Knowledge), interpretation and management of unexpected findings in the imaging of each organ system (CS0Core Skills), an understanding of the process of justification of requests for imaging investigation and appropriateness criteria (CS), creation of a structured, coherent, and clinically relevant imaging report (CS), an understanding of the medico-legal implication of imaging practice (CS), basics of oncogenesis including elements of cell biology and genetics (BK), principles of systemic, regional and targeted therapies (BK), principles and application of screening methodologies (BK).

The following sections of the document (Part II and III) list specific knowledge requirements for appropriate training in multimodality imaging for those whose background is in nuclear medicine and radiology respectively (PET/CT, SPECT/CT).
Apart from specified training items it is understood that practising multimodality imaging requires certain skills above and beyond those enumerated under specific pathology areas. These include knowledge of emergency imaging findings as relevant to each specific organ system (BK0Basic Knowledge), interpretation and management of unexpected findings in the imaging of each organ system (CS0Core Skills), an understanding of the process of justification of requests for imaging investigation and appropriateness criteria (CS), creation of a structured, coherent, and clinically relevant imaging report (CS), an understanding of the medico-legal implication of imaging practice (CS), basics of oncogenesis including elements of cell biology and genetics (BK), principles of systemic, regional and targeted therapies (BK), principles and application of screening methodologies (BK).

PART II Nuclear Medicine Curriculum for those whose Training Background is in Radiology
Preamble to Part II In 2011 the "Multimodality Imaging Training Curriculum -General Recommendations" were published in the EJNMMI (Eur J Nucl Med Mol Imaging DOI 10.1007/s00259-011-1804-2) and in Insights into Imaging (Insights Imaging 2(2): 99-101, DOI: 10.1007/s13244-011-0067-6). Both the European Association of Nuclear Medicine and the European Society of Radiology committed themselves to writing more detailed recommendations regarding skills and knowledge requirements for nuclear medicine physicians in radiology and radiologists in nuclear medicine. Parts II & III of the Multimodality Imaging Training Curriculum were endorsed by the ESR Executive Council in June 2011, as well as the EANM Executive Committee, the EANM Advisory Council and on February 26, 2012 by the extraordinary EANM Delegates Assembly.
The Multimodality Imaging Training Curriculum is a joint European initiative between the EANM and the ESR to define the scope of training for medical specialists in hybrid imaging. The curriculum is a framework outline that may be used by member societies where appropriate to form the basis for discussion on the optimisation of further training of medical specialists.
This curriculum cannot be used to legally justify changes to the organisation, overall specialist training or reimbursement regulations in any member state.
Nuclear Medicine Curriculum for those whose Training Background is in Radiology The following outlines a check list of nuclear medicine training requirements for radiologists to ensure the appropriate level of knowledge is obtained for performing and reading hybrid imaging such as PET/CT and SPECT/CT within a 2-year training period. This checklist differentiates three levels of competence: basic knowledge (BK), detailed knowledge (DK) and core skills (significant practical experience required, CS).
A. Required general training in nuclear medicine Production and properties of radionuclides (BK) The production of radionuclides by cyclotrons, radionuclide generators and reactors The production of PET nuclides by cyclotrons and radionuclide generators Practical issues related to the use of short-lived radionuclides Practical issues related to the use of generators to produce radionuclides The physical properties of commonly used diagnostic radionuclides (physical half-life, photon energy) Tracer principles and techniques (BK) The basic principles of tracer studies The kinetics of radioactive tracers used in nuclear medicine The use of principles of kinetics and modelling techniques to calculate parameters such as glomerular filtration rate Errors associated with quantitative measurements

Radiopharmacy
The principles of localisation of radiopharmaceuticals (BK) Different formulations used in nuclear medicine (BK) Cell labelling techniques (BK) The physicochemical and biological properties of different radiopharmaceuticals in routine clinical practice (biological half-life, biokinetics, dosimetry) (DK)

Legislation
Regulations relating to radiation protection (DK) Specific regulations relating to the use of radionuclides (DK) Specific regulations relating to the manufacture of radionuclides (BK) National and international regulatory requirements for the practice of nuclear medicine (BK) Radiopharmaceutical transport (BK) Waste disposal (BK)

Musculoskeletal (DK)
Benign bone disease (fractures, osteomyelitis, Paget's disease, fibrous dysplasia, sport injuries) Malignant bone disease (primary and secondary) Joint disease (arthritis, infected joints, infected prostheses) Bone marrow studies Understanding of the role of SPECT/CT in addition to planar scintigrams and of PET/CT using FDG, F-18-fluoride and other relevant agents commonly used in musculoskeletal diseases Patient preparation and procedural aspects depending on the clinical question, e.g. three-phase imaging Pulmonary Ventilation/perfusion imaging for the diagnosis of pulmonary thromboembolism (DK) Differential pulmonary lung function studies (BK) Mucociliary clearance studies (BK) Lung permeability studies (BK) GI tract (BK) Salivary gland imaging Oesophageal and intestinal transit studies Meckel's diverticulum studies Radiolabelled red blood cell studies (GI bleeding, liver haemangioma) Liver RES scintigraphy (both dynamic and static studies) Hepatobiliary studies Inflammatory bowel disease Understanding of the role of breath tests in the investigation of malabsorption Urogenital tract (BK) Dynamic renography (differential and absolute function, dilated outflow tract, obstruction, renovascular hypertension) DMSA studies (pyelonephritis, ectopic kidneys, differential function) GFR and ERPF measurement (blood and urine samples, computer-based techniques) Indirect and direct cystourethrography Understanding of related general issues, e.g. concurrent medication and preparation of the patient for the study, including the use of pharmaceutical interventions (e.g. ACEI, AT receptor blockade, furosemide) Endocrine (BK) Benign thyroid disease, thyrotoxicosis, thyroid nodules Interaction of agents such as amiodarone, iodine and drugs used to treat thyroid disease with radiopharmaceuticals Malignant thyroid disease (understanding of the role of radio-iodine) Parathyroid disease (understanding of the role of MIBI and SPECT/CT) Neuroendocrine tumours (understanding of the role of SPECT/CT, if required in addition to planar imaging, and of PET/CT) Adrenal imaging

Lymphatic system
Lymphoedema studies (BK) Sentinel lymph node identification (breast, melanoma, head and neck, urogenital tumours) (DK) Lymphatic leaks (BK) The Multimodality Imaging Training Curriculum is a joint European initiative between the EANM and the ESR to define the scope of training for medical specialists in hybrid imaging. The curriculum is a framework outline that may be used by member societies where appropriate to form the basis for discussion on the optimisation of further training of medical specialists.

Infection/inflammation (DK) Processes involved in infection/inflammation
This curriculum cannot be used to legally justify changes to the organisation, overall specialist training or reimbursement regulations in any member state.

Radiology Curriculum for those whose Training Background is in Nuclear Medicine
The following outlines a check list of radiology training for nuclear medicine physicians to ensure the appropriate level of knowledge is obtained for performing and reading hybrid imaging such as PET/CT and SPECT/CT within a two years training period. This checklist differentiates three levels of knowledge: basic knowledge (BK), detailed knowledge (DK), and core skills (significant practical experience required, CS).
A. Required general training in radiology a. Principles of imaging technology as applied to diagnostic radiology (radiation physics) (BK) b. Radiobiology (BK) c. The physical basis of image formation including conventional x-ray, computed tomography, magnetic resonance imaging (DK) d. Radiographic quality control (DK) e. Radiation protection (DK) f. Anatomy, normal variants, pathological features, physiology, biochemistry and techniques related to radiological procedures (BK) g. Cell biology, DNA, RNA, and cell activity (BK) h. Clinical indications for the administration of intravenous and oral contrast media (BK) i. Basic principles of image acquisition and post-processing to include MPR, MIP and volume rendering principles; understanding of concepts of data acquisition in CT technology and volumetric CT data acquisition; knowledge of detector composition and physics, CT numbers and evaluation of image quality including field size and spatial and contrast resolution; familiarity with major CT artefacts including motion, streak, beam hardening and ring artefacts (DK) j. Basic understanding of computer science, image archiving and image communication and teleradiology (BK) k. Clinical Application and Study Protocols to include: an understanding of patient preparation for PET/CT examinations, venous access and principles of the use of beta-blocking when appropriate (DK) l. Intravascular contrast media to include pharmacology, osmolar types, potential vascular toxicity, soft tissue toxicity, cardiovascular toxicity, neurotoxicity, nephrotoxicity and effects on thyroid function tests.