BSNR Trainee Days 2019

The 2019 BSNR Trainee Days took place in St Anne’s College, Oxford on the 24th & 25th June 2019, and this year the topics were neuro-oncology on the first day and ENT and skull base on the second. Below is a summary to give a flavour of the topics covered on the days and a few learning points and references that I took away. As ever, any glaring errors are mine rather than the lecturers!

Day 1 – Neuro-Oncology

Pieter Pretorius kicked off the day with a discussion of the implications of the 2016 WHO classification of brain tumours for neuroradiologists, highlighting the key areas where we need to develop our reporting and looking at where there is evidence to align radiological and molecular findings (for example here). He discussed the problem of referring to ‘low-grade’ gliomas as a group, suggesting this is an unhelpful term as it is usually used in the setting of grade 2 diffuse astrocytomas, which are difficult to distinguish from grade 3 tumours. The areas of imaging where we can potentially add prognostic information were also highlighted (see here).

Adam Waldman gave two complementary talks, first taking a guided tour through brain regions and which tumours to expect in different anatomical locations, and in the second talk looking into molecular stratification and drilling down into how radiologists can add value in the era of molecular diagnosis. The relative contribution of perfusion imaging and spectroscopic imaging (including the future application of 2-HG spectroscopy) were discussed, along with potential pitfalls, and also the issues of treatment response and pseudoprogression and the danger of relying on contrast enhancement to assess response with new treatment agents such as the anti-angiogenics.

fMRI and DTI physics are a challenging topic even in a room full of radiology trainees, but Stephen Wastling addressed them in a clear and practical way , highlighting how they are used in preoperative planning and how an awareness of the underlying mechanisms allows the user to account for other pathologies that might affect the imaging results. Samantha Mills took this into the operating theatre, showing how the Walton Centre makes use of its intraoperative MRI and the challenges of running an intraoperative MRI service, as well as sharing her clinical experience of using fMRI and DTI.

Glioma imaging across Europe is very heterogeneous in its application (as seen here), and Gerry Thompson looked at how to make sure your centre is using its advanced imaging appropriately, starting with a thorough understanding of the techniques and software used in MR perfusion and spectroscopy. He stressed the importance of not accepting outputs from scanner software without interrogating the data yourself and understanding where the potential problems could arise. In his tutorial he recommended the ASFNR guidance on performing DSC-perfusion MRI as a starting point for standardised physiological imaging and a way to evaluate your own institutional processes.

The afternoon workshops took us through a fascinating selection of difficult and interesting cases, from tumour follow-up and post-treatment changes with Robin Joseph, tumour mimics with Priya Bhatnagar, perfusion applications with Gerry Thompson, pediatric tumours with Rob Dineen, and some representative cases from the neuro-oncology MDT with Samantha Mills.

Overall it was an excellent and informative day; the common themes emerging were the importance of having a fundamental understanding of the advanced imaging techniques and where they can be useful before applying them, as they are a useful adjunct rather than a cure-all, and that radiomics/radiogenomics are in their early stages but will have more and more of an impact on the traditional imaging approach to brain tumours so we need to stay up to date and on our toes!

Day 2 – ENT & Skull Base

The second day began with a clinically orientated, practical lecture from Fintan Sheerin on infective pathologies of the neck. His rules and myths were particularly useful: for example, that the origin and current site of an infection are more important than where it is going (and hence the ‘danger space’ is not a particularly useful concept), and that infection rarely enters the tonsil from outside so if involved is usually the point of origin.

Reena Dwivedi pointed out that the majority of our scans as neuroradiologists included the nasopharynx and as such it was crucial for us to have an appreciation of common and significant pathology even for (perhaps especially for) those who do not report head and neck imaging, and her talk gave an excellent overview of the pathologies to suspect and how to investigate them.

Ata Siddiqui gave the first of his two talks on the orbit, highlighting important and unusual pathologies and focusing on optic neuropathy, with useful clinical suggestions for differentiating demyelinating aetiologies (see here for differences between multiple sclerosis and neuromyelitis optica, here for those between NMO and MOG, and here for a protocol for the investigation of optic neuritis) and touching on imaging for papilloedema (see here for a suggested review).

Sinuses were next up and Jagrit Shah gave an overview of how to approach sinus reporting systematically, using the CLOSE checklist system as a structure (outlined here) to ensure that surgically important anatomical variants are flagged up preoperatively.

The importance of understanding the surgical perspective also ran through Gitta Madani’s excellent talk on the temporal bone, including surgical blind spots (for example the sinus tympani in the middle ear), and relevant variants (for example limited access to the oval window by a variant facial nerve canal) as well as important pathology to identify.

Rounding up the lectures was Ata Siddiqui talking on paediatric head and neck, covering a wide range of paediatric pathology. Particular highlights were the clear discussion of vascular anomalies which can be difficult to classify appropriately (good resources are the ISSVA classification document here and a concise commentary here) and the spectrum of branchial cleft anomalies (see a useful review here).

The tutorials included general head and neck and neuroradiology interesting cases from Reena Dwivedi and Fintan Sheerin, an introduction to the skull base MDT from Jagrit Shah and skull base surgeon Sanjeeva Jeyaratna, temporal bone lesions with Gitta Madani and orbital and sinonasal cases with Ata Siddiqui.

Common themes emerging from the second day were the importance of having a good understanding of important head and neck imaging pathologies even if this is not an area you would normally report as a neuroradiologist, and how crucial a thorough understanding of the surgical perspective and a good working relationship with the surgeons is to head and neck imaging.

Overall, the two days were a fantastic educational experience, and thanks go to Gerardine Quaghebeur and the BSNR trainee day working group who organised the event as well as all of the excellent speakers and tutors on the days. I look forward to seeing you at the next trainee day in Cardiff in October!



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