BIR UK MRI course

4–7 NOVEMBER 2014

BIR UK MRI COURSE 2014 Venue: Events Centre, Stewart House, London CPD: 24 Credits

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BIR ANNUAL CONGRESS 2015 4–5 NOVEMBER LONDON

Day 1 • Room 1

Primers for the nonspecialists Session organised by Dr David Wilson, Consultant Interventional MSK radiologist, Oxford University Hospitals NHS Trust

• Room 2

Radiation protection

Session organised by Mr Andy Rogers, Head of Radiation Physics, Nottingham University Hospitals NHS Trust

More information available soon at www.bir.org.uk

Day 2 Clinical hybrid imaging in oncology • Room 1

Session organised by Dr Gopinath Gnanasegaran, Consultant Physician in Nuclear Medicine, St Thomas’ Hospital

• Room 2

Musculoskeletal imaging

Session organised by Dr Richard Wakefield, Consultant in Rheumatology, St James’s University Hospital

Essentials for the radiology trainee Session organised by Dr Hardi Madani, Radiology Registrar, Royal Free London Hospital and Dr Ausami Abbas, Cardiothoracic Radiology Post CCT Fellow, University Hospital Alberta

Welcome and thank you for coming to the British Institute of Radiology UK MRI course 2014.

This booklet contains the abstracts and biographies for each speaker (where supplied) This meeting has been awarded 24 RCR category I CPD credits (6 per day).

The BIR MRI course organising committee and the BIR wish you a very enjoyable and educational experience.

Certificate of attendance Your certificate of attendance will be emailed to you within the next two weeks once you have completed the online event survey at: https://www.surveymonkey.com/s/MRIcourse2014 BIR Annual Congress 2015: 4–5 November, London

We are most grateful to

for supporting this conference

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Programme

Tuesday 4 November

DAY 1: PHYSICS 09:00 Registration and refreshments Chair: Dr Martin Graves, Consultant Clinical Scientist,

Cambridge University Hospitals NHS Foundation Trust 09:40 Welcome and introduction 09:45 Basic physics refresher

Dr Ian Cavin, MRI Physicist, NHS Tayside 10:15 Principles of gradient echo imaging

Mr Lukasz Priba, Clinical Scientist,

Royal Infirmary Edinburgh, NHS Lothian 10:45 Principles of fast/turbo spin echo imaging

Dr Martin Graves, Consultant Clinical Scientist,

Cambridge University Hospitals NHS Foundation Trust 11:15 Refreshments 11:45 Principles of diffusion weighted imaging

Mr Lukasz Priba, Clinical Scientist,

Royal Infirmary Edinburgh, NHS Lothian 12:15 Imaging options: what do they mean?

Dr Ian Cavin, MRI Physicist, NHS Tayside 12:45 Fat/water imaging

Dr Martin Graves, Consultant Clinical Scientist,

Cambridge University Hospitals NHS Foundation Trust 13:15 Lunch 14:00 Osirix - the top 10 tricks

Dr John Curtis, Consultant Radiologist, University Hospital Aintree 14:30 Paediatric MRI = GA

Dr Owen Arthurs, Consultant Paediatric Radiologist,

Great Ormond Street Hospital 15:00 Why is my image quality poor?

Dr Geoff Charles-Edwards, Principal Clinical Scientist,

Guy’s & St Thomas’ NHS Foundation Trust

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15:30 Incidental findings

Professor David Lomas, Professor of Clinical MRI,

University of Cambridge 16:00 Refreshments 16:15 Advanced pulse sequences

Dr Geoff Charles-Edwards, Principal Clinical Scientist,

Guy’s & St Thomas’ NHS Foundation Trust 16:45 Question and answer 17:15 Close of day ________________________________________________________________________

Certificate of attendance Your certificate of attendance will be emailed to you within the next two weeks once you have completed the online event survey at: https://www.surveymonkey.com/s/MRIcourse2014 BIR Annual Congress 2015: 4–5 November, London

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Speaker profiles (where supplied) Dr Owen Arthurs Consultant Paediatric Radiologist, Great Ormond Street Hospital Owen Arthurs is the Clinical Lead for Paediatric and Perinatal Post Mortem Imaging at Great Ormond Street Hospital in London, funded by an NIHR Clinician Scientist Fellowship. He trained in paediatrics and academic radiology in Cambridge, developing new paediatric MR techniques for which he won several national and international prizes. He was a clinical lecturer in Cambridge, ESOR/ESPR fellow in Paris, and latterly a fellow at Great Ormond Street Hospital in London. His main interests are non-accidental injury and post mortem imaging in children, and he has co-authored over 45 peer reviewed papers, review articles and book chapters.

Dr Ian Cavin MRI Physicist, NHS Tayside Dr Ian Cavin is an MRI physicist with NHS Tayside providing both clinical and research support to MRI Radiology as well as clinical and academic researchers from the Universities of Dundee and St Andrews. Prior to his current position, Ian has carried out research at the University of Nottingham Sir Peter Mansfield MRI Centre investigating the biological effects of MRI magnetic fields associated with whole body clinical 1.5, 3 and 7 Tesla MRI scanners.

Dr Geoff Charles-Edwards Principal Clinical Scientist, Guy’s & St Thomas’ NHS Foundation Trust After training as a clinical physicist, Geoff Charles-Edwards obtained a PhD in magnetic resonance from the Institute of Cancer Research, before moving to Guy’s & St Thomas’ Hospitals in 2003 where he is now Principal Clinical Scientist.

He is also a HEFCE-NIHR Senior Clinical Lecturer and an Honorary Senior Lecturer at King’s College London.

Dr John Curtis Consultant Radiologist, University Hospital Aintree Dr John Curtis has been a consultant radiologist at University Hospital Aintree since 1997. He has an interest in chest radiology and medical education. He has organised the Aintree FRCR courses since 2002 and in the last 5 years has had extensive experience using OsiriX on courses and for teaching.

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Dr Martin Graves Consultant Clinical Scientist Cambridge University Hospitals NHS Foundation trust Martin Graves is a Consultant Clinical Scientist at Cambridge University Hospitals NHS Trust where he is Head of MR physics and radiology IT; he is also an Affiliated Lecturer within the University of Cambridge Clinical School. He has a BSc in physics and an MSc in medical electronics from the University of London and a PhD in MRI from the University of Cambridge. He has over 30 years of experience working in clinical and research MRI in London and Cambridge. He is a fellow of the Institute of Physics and Engineering in Medicine and the Higher Education Academy. He is active on a number of national and international committees including the Clinical Imaging Board and the ISMRM Education and Annual Meeting Programme Committees. He has authored over 140 journal articles/book chapters as well as the award winning MRI text book MRI: from Picture to Proton, Physics MCQs for the Part 1 FRCR, and co-editor of Carotid Disease: the Role of Imaging in Diagnosis and Management.

He teaches on a number of MRI courses both nationally and internationally and has received ISMRM Outstanding Teacher awards in 2006 and 2011.

Professor David Lomas Professor of Clinical MRI, University of Cambridge David J Lomas is qualified in engineering, medicine and radiology and has been Professor of Clinical MRI in Cambridge since 2001. He has worked closely with Addenbrooke’s Hepatology and Liver transplantation services over the last 25 years and leads the clinical MRI service. His research interests include novel developments in Body MRI including the hepatobiliary and GI tract and he helped develop MR elastography with colleagues at the Mayo Clinic. He has published over 100 peer reviewed papers and lectured extensively in these areas. Previously secretary of ISMRM, he is currently Chair of the BIR MRI committee and a member of the PHE AGNIR group.

Mr Lukasz Priba Clinical Scientist, Royal Infirmary Edinburgh, NHS Lothian After graduating with an MSc in medical physics from University of Aberdeen, Lukasz started his training as a clinical scientist in Ninewells Hospital, Dundee, NHS Tayside.

After successfully completing his training in MRI and diagnostic radiology, he joined the medical physics department in Edinburgh where he works now as a senior clinical scientist. In his current post, he focuses on support and development of MRI service across Lothian.

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Abstracts (where supplied) Basic physics refresher Dr Ian Cavin This 30 minute basic MRI physics refresher will recap the essential physics needed to gain a working knowledge of MRI. Principles of gradient echo imaging Mr Lukasz Priba Educational aim: A basic understanding of image formation using gradient echo pulse sequence.

Learning outcomes: Gradient echo is one of the bases of magnetic resonance imaging. The major advantage of a gradient echo sequence is significant reduction in scan time. To achieve that, small flip angles are used, which, in turn, allow very short repetition times to be used. After this talk, delegates will be familiar with basic physics principles behind the pulse sequence and will gain knowledge on how altering sequence parameters will influence resultant image contrast. Finally, this presentation will discuss advantages and disadvantages of using gradient echo pulse sequences as well as give some examples of fast imaging sequences.

Principles of fast/turbo spin echo imaging Dr Martin Graves The fast or turbo spin echo (FSE/TSE) pulse sequence was originally developed by Hennig et al as a method to reduce acquisition times in T2-weighted imaging. The implementation is a modification of a multiple-echo spin echo sequence in that each echo is now individually phased encoded and contributes to the raw data, or k-space, for a single image. For example an FSE sequence may create 16 echoes through the use of 16 refocusing pulses in a single repetition period (TR). Since each echo is individually phase encoded the time to complete the full k-space is 16 times quicker. This does however have implications for image contrast. Since each echo is acquired at an increasing time from the initial excitation pulse the time of the echo that is encoded nearest the centre of k-space dictates the “effective echo time” TEeff, since the centre of k-space has the greatest influence on image contrast.

Furthermore, since the signal is decaying due to T2 relaxation during the acquisition there is an inevitable image blurring associated with FSE acquisitions. The use of multiple refocusing pulses also increases the power deposition (SAR) of the sequence, which may require careful optimisation of the sequence.

At the end of this lecture the participants will be expected to: • Understand the basic principles of FSE imaging.

• Appreciate some of the artifacts and limitations of FSE. • Explain how FSE sequences can be optimised.

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Further reading: McRobbie DW, Moore EA, Graves MJ and Prince MR. MRI: from Picture to Proton 2nd Ed. Cambridge University Press. ISBN 9780521683845

Principles of diffusion weighted imaging Mr Lukasz Priba Educational aim: A basic understanding of physics principles behind functional imaging based on molecular motion of water in body tissues.

Learning outcomes: Diffusion weighted imaging (DWI) has been established as a powerful tool in neurodiagnostics, mainly in detection of acute ischemic stroke. Further, it has been implemented to study neural fiber tract anatomy and brain connectivity. Nowadays, use of DWI has been extended to imaging in abdomen and pelvis and it is heavily utilised in oncology imaging for diagnosis and monitoring treatment response. This lecture will explain the molecular diffusion of water in body tissues and physical principles that underline diffusion contrast encoding. This will allow the delegates to understand the relationship between MR signal intensity and diffusion. With the basic principles in mind, a range of more sophisticated techniques and applications will be reviewed, discussing advantages and potential issues.

Imaging options: what do they mean?

Dr Ian Cavin This presentation will be split into three sections. Section 1 will cover the physics principles, followed by the construction of a basic pulse sequence used in imaging in Section 2. Section 3 will describe how the timings of radiofrequency (rf) and gradient pulses can be used to generate images with different contrast.

Educational aims: To provide delegates with a useful and concise overview of the MRI principles so that they will be able to apply this knowledge to gain an understanding of the imaging sequences used in routine diagnostic MRI. Learning outcomes: By the end of the presentation delegates will be able to explain the basic principles of how: • An MR signal is generated and detected.

• An MR image is formed.

• A gradient echo image is formed.

• A spin echo image is formed.

• An inversion recovery sequence is formed.

• T1, T2, T2* and proton density (PD) images are generated with the appropriate selection of echo (TE) and repetition time (TR).

• Apply the basic principles to understand the other types of advance MR imaging sequences.

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Fat/water imaging Dr Martin Graves In vivo MR images usually contain signals from protons in both water and fat.

Human fat is stored as triglycerides which are a subgroup of lipid molecules.

Triglycerides comprise multiple groups of protons (CH3, CH2, CH=CH etc) with the nuclear shielding effect resulting in a range of chemical shifts. The most abundant resonance comes from the methylene (CH2) groups, which precess approximately 3.4ppm lower than water. In terms of relaxation times, fat has the shortest T1, approximately 270ms at 1.5T, of any body tissue.

In this lecture we will consider techniques that can allow us to either suppress the signal from fat or provide qualitative or quantitative measurements of fat content in order to aid diagnosis. Fat suppression techniques can either be used to improve the contrast in an image by removing the high signal from lipids, or to reduce the artefacts that arise from the chemical shift between water and fat. Fat sensitive techniques can also be used to help characterise fat-containing lesions and provide quantitative measurements of organ fat such as in the liver.

At the end of this lecture the participants will be expected to: • Describe the effects of the chemical shift between water and fat.

• Compare various methods of fat suppression.

• Explain the principles and applications of chemical-shift-based imaging techniques.

Further reading: McRobbie DW, Moore EA, Graves MJ and Prince MR. MRI: from Picture to Proton 2nd Ed. Cambridge University Press. ISBN 9780521683845 Horger W. Fat Suppression in the Abdomen. Siemens Magnetom Flash 2007:3; 114-119

OsiriX - the top 10 tricks Dr John Curtis OsiriX is a free source software using Apple computers and is now widely used by radiologists to display DICOM images for reporting, teaching and examining.

There are numerous actions possible with OsiriX but in this lecture the top ten tricks will be covered that will get the novice up and running and the experienced user able to perform advanced actions to augment teaching and archiving.

Paediatric MRI = GA Dr Owen Arthurs This presentation will focus on the current challenges in performing MRI examinations in small children. To achieve diagnostic images this often needs them to lie still to reduce patient motion. Therefore, to obtain high-quality images, paediatric MRI is frequently carried out under sedation or general anaesthesia, but this is not without risk and expense. This presentation will focus on the current advantages and disadvantage of sedation and anaesthesia for paediatric MRI, the current alternatives that are available (including neonatal comforting techniques, sleep manipulation, and appropriate adaptation of the physical environment), as well as general issues in paediatric MRI such as RF 8

heating. There is an increasing understanding on what can be achieved with sub-anaesthetic doses of traditional anaesthetic drugs, as well as what can be achieved without access to anaesthetic drugs at all. The risk–benefit analysis must ultimately be taken on a patient-by-patient basis, and to this end should determine service provision and training requirements. The choice of approach to appropriate paediatric MRI is multifactorial, with limited scientific evidence for many of the current approaches.

Educational aims: To highlight the limitations of the different options available for paediatric MRI. Learning outcomes: To appreciate the challenges faced in delivering paediatric MRI examinations and to “broaden the mind” with possible solutions.

References • Arthurs OJ, Sury M. Anaesthesia or sedation for pediatric MRI: advantages and disadvantages. Current Opinion in Anesthesiology (2013) 26: 489-494 • Arthurs OJ, Edwards AD, Austin TA, Graves MJ, Lomas DJ. The challenges of neonatal magnetic resonance imaging. Pediatric Radiology (2012) 42: 1183– 1194 • Edwards AD, Arthurs OJ. Paediatric MR imaging under sedation: is it necessary? What is the evidence for the alternatives? Pediatric Radiology (2011) 41: 1353 – 1364 • Sury MRJ, Harker H, Begent J et al. The management of infants and children for painless imaging. Clin Radiol (2005) 60:731–741

Why is my image quality poor?

Dr Geoff Charles-Edwards Educational aims: To highlight the various issues relating to MR image quality.

Learning outcomes: An understanding of the reasons for a poor quality MR image.

Although it is typically straight forward to identify that the quality of an MR image is poor, the reasons for this are sometimes less obvious and not well understood.

This talk will cover issues such as SNR, acquired versus reconstructed spatial resolution, distortions, T2-blurring, and MR artefacts showing examples and highlighting approaches to resolve common issues.

Incidental findings Professor David Lomas The detection of “incidental” findings by diagnostic tests is an increasingly complex problem. This applies not just to imaging but to other diagnostic tests and in particular gene sequencing. The problem is compounded by using diagnostic tests designed for symptomatic patients to study “healthy” individuals by either “screening” procedures or as a part of research studies. There are now multiple large population based studies being undertaken to link the genetics of an individual to their phenotype and disease risk, several of which involve imaging- usually with MRI (eg UK Biobank).

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Incidental findings may be categorised according to their significance and the incidence varies widely depending on the nature of the test and the population.

Examples of significant findings include unexpected asymptomatic brain, lung, renal or colon cancers, gallstones in the common bile duct, and a cerebral AVM. Recent studies suggest incidental findings in as many as 20% of studies although “significant” findings that may adversely affect health are usually less than 5%.

In research studies the detection and management of incidental findings should now be explicitly addressed during the Ethical Review process and participants should be informed of the risks and consequences of such findings. These might include the anxiety, cost and risks related to further investigation (eg, brain or liver biopsy) to achieve a definitive diagnosis. In many cases the risks of false negative and false positives are poorly understood and may not be known. Unexpected complications of an incidental finding such as refusal for life insurance or a mortgage application are often not considered or appreciated in advance.

Recent public consultation studies by the Wellcome Trust have made clear that the general population are largely unaware of these issues and have a simplistic view of benefit related to detecting and diagnosing an unexpected disease process. This lack of understanding and public education has recently been highlighted by the recent COMARE report firmly advocating against self-referral CT and other imaging screening services being offered by the private sector.

In the past many MRI sites would use their staff and students as volunteers for MRI research studies with only minimal understanding and oversight of these issues. This is no longer considered acceptable and MRI sites now require ethical approval and written informed consent for volunteer studies, even to test out new sequence variations, protocols or new applications. Information has to be given to the participant outlining the risks and management of incidental findings. There is not yet complete consensus on these issues but there is largely agreement that for participants in screening and research studies there should be “no surprises”.

Advanced pulse sequences Dr Geoff Charles-Edwards Educational aims: To describe the basic principles and key benefits of some of the more advanced pulse sequences available on clinical MRI scanners.

Learning outcomes: An understanding of the aims and limitations of some of the more advanced pulse sequences.

There is a continuing expansion of pulse sequences and techniques available on clinical MRI systems. This talk will introduce the basic concepts of some of these and highlight areas where they appears to have significant utility. Topics will include PROPELLER/BLADE/multi-vane for reduced motion artefact, SPACE/ CUBE/VISTA for spin-echo based 3D acquisitions, temporal sharing for dynamic contrast-enhanced MRI, susceptibility-weighted imaging for enhanced sensitivity to microbleeds and new metal artefact reduction sequences.

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Programme

Wednesday 5 November

DAY 2: BODY - GI/HPB 08:45 Registration and refreshments Chair: Professor David Lomas, Professor of Clinical MRI,

University of Cambridge 09:00

Lecture A - a scientific lecture given by the ‘physicist of the day’ to cover the physics aspects of the subsequent lectures Dr Geoff Charles-Edwards, Principal Clinical Scientist, Guy’s & St Thomas’ NHS Foundation Trust

09:30 Lecture B - Diffuse liver

Professor David Lomas, Professor of Clinical MRI,

University of Cambridge 10:00 Lecture C - Focal liver

Dr Sofia Gourtsoyianni, Consultant Radiologist,

Guy’s and St Thomas’ NHS Foundation Trust 10:30 Lecture D - MRCP/pancreas

Dr Helen Bungay, Consultant Gastrointestinal Radiologist,

Oxford University Hospitals NHS Trust 11:00 Refreshments 11:30 Workshop session 1 - topics A&B and C&D 12:15 Workshop session 2 - topics C&D and A&B 13:00 Lunch 14:00 Lecture E - Upper GI

Dr Angela Riddell, Consultant Diagnostic Radiologist,

The Royal Marsden Hospital 14:30 Lecture F - Lower GI

Dr Sofia Gourtsoyianni,Consultant Radiologist,

Guy’s and St Thomas’ NHS Foundation Trust 15:00 Workshop session 3 - topics E&F 15:45 Refreshments 16:15 Panel discussion reviewing complex cases 17:00 Close of day 11

Speaker profiles (where supplied) Dr Geoff Charles-Edwards Principal Clinical Scientist, Guy’s & St Thomas’ NHS Foundation Trust See page 4 Professor David Lomas Professor of Clinical MRI, University of Cambridge See page 5 Dr Sofia Gourtsoyianni Consultant Radiologist, Guy’s and St Thomas’ NHS Foundation Trust April 2012 - March 2013 - Clinical Research Fellow, Division of Imaging Sciences, King’s College London, Guy’s and St Thomas’ NHS Foundation Trust, London, UK February 2011 - February 2012 - Locum Consultant Radiologist, Konstantopouleion General Hospital, Athens, Greece January 2010 - January 2011- Research Fellow in CT Applications, Department of Computed Tomography, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA January 2006 - November 2009 - Resident in Radiology, Department of Radiology, University Hospital of Heraklion, Crete, Greece May 2004 - November 2005 - Institute of Clinical Radiology, Ludwig Maximilian University, Campus Innenstadt and Campus Grosshadern, Munich, Germany Dr Helen Bungay Consultant Gastrointestinal Radiologist, Oxford University Hospitals NHS Trust Helen is a consultant gastrointestinal radiologist, specialising in hepatobiliary and pancreatic imaging, at the Oxford University Hospitals NHS Trust. Having studied at St John’s College, Cambridge, and Green College, Oxford, she did her radiology training in Oxford. Helen is, indeed, big sister to Peter Bungay, Consultant Radiologist, Derby! But also mum to two gorgeous daughters. She has spoken at RSNA, BSGAR, RCR and BIR study days, but also enjoys face painting at school fetes. She is very happy to discuss interesting cases with people from different hospitals, and wish a little more of that cooperation were possible in the time strapped NHS.

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Dr Angela Riddell Consultant Diagnostic Radiologist, The Royal Marsden Hospital Dr Angela Riddell works as a consultant diagnostic radiologist at the Royal Marsden Hospital. Her work is in oncology imaging with specialist interests in upper GI and hepatobiliary cancer. She initially trained in radiology in Oxford & undertook an abdominal imaging Fellowship in Toronto before undertaking a radiology research post at the Royal Marsden Hospital. She was awarded an MD in 2007 for her research developing an MRI technique for assessing operability in oesophago-gastric cancer. She is currently the lead investigator for a UK multi-centre trial investigating the technique. She is the lead radiology representative on the London Cancer Alliance for upper GI & hepatobiliary cancers.

Abstracts (where supplied) Lecture B - Diffuse liver Professor David Lomas MRI is of value in the detection and, increasingly, quantification of a range of diffuse liver diseases.

Hepatic steatosis or “fatty liver” The epidemic of obesity affecting the western world has led to the recognition that “fatty liver” is no longer a “normal variant” but a marker of potentially important disease, in particular non-alcoholic steato-hepatitis (NASH) which is expected to become the major cause of liver fibrosis/cirrhosis and hepatocellular carcinoma in the next decade. Regional variation of hepatic fat (focal deposition and sparing) is also an increasing diagnostic problem in radiology. MRI provides both confident diagnosis and quantification of global and regional hepatic steatosis through both in and out of phase imaging and 3 point Dixon techniques. In the future these will be widely available and are likely to useful for the monitoring of hepatic steatosis as new therapies emerge.

Hepatic iron – haemochromatosis/haemosiderosis It was recognised very early in the development of MRI that accumulation of iron in the liver results in T2 and T2* shortening–reducing the liver signal relative to other tissues. More recently reliable methods to accurately evaluate T2 values and correlate these with hepatic iron concentration have been developed. These include a commercial FDA approved offering developed in Australia as well as several “DIY” methods published in the literature. The organ pattern of iron deposition may also useful to help characterise the underlying aetiology.

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Liver fibrosis Traditionally, imaging tests have been relatively insensitive to mild and moderate liver fibrosis and only of real value in established cirrhosis when morphological changes have developed. Increasingly this view is being challenged by newer functional imaging approaches which include elastography (using both MRI and US) and measurements of the extra-cellular matrix using T1 methods.

Whilst these are still being validated, several are now available commercially.

These techniques are already reducing the number of diagnostic liver biopsies performed for suspected liver disease.

Lecture C - Focal liver Dr Sofia Gourtsoyianni Most commonly encountered focal liver lesions in non-cirrhotic patients and their typical MRI characteristics will be reviewed.

Different available MRI contrast mechanisms including hepatocyte specific contrast agents and DWI acquisition protocols (optimal b values, optimal sequences) will be discussed.

Focus will be placed on how DWI and hepatocyte specific contrast agents can aid in characterisation of focal liver lesions and differentiation between benign and malignant lesions (mainly liver metastases).

Lecture D - MRCP/pancreas Dr Helen Bungay Educational aims: This session is aimed at consultant radiologists who report MRCP/MRI pancreas, but do not hold a specialist HPB post, and radiology trainees.

The lecture, and the accompanying workshops, will discuss: MRCP: including: • Normal anatomy and variants of clinical importance (especially biliary variants relevant to cholecystectomy); • Artefacts and mimicks; • pathology: calculi; tumour; primary sclerosing cholangitis.

MRI of the pancreas: including: • Pancreatitis; cystic lesions; IgG4 related disease.

The session will include when to use MRI, utility of different sequences, tips on technique and common pitfalls, as well as an overview of common and important pathologies.

Learning outcomes: Delegates should know the relevant anatomy and sequences, understand when to choose MRI to image certain groups of patients, apply technique modifications for optimal images, analyse the images in light of the possible artefacts, and synthesise a report, knowing likely common diagnoses.

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Lecture E - Upper GI Dr Angela Riddell With advances in surface coil technology and the development of faster sequences it is now possible to achieve good quality imaging of the upper GI tract. There is an emerging role for MRI in both morphological and functional imaging of the upper GI tract.

The lecture will describe how functional MRI has been evaluated as an alternative to video fluoroscopy for the assessment of motility disorders within the oesophagus for several years. Small group studies have shown that it shows potential to diagnose motility disorders, such as gastro-oesophageal reflux and achalasia.

Research studies have also demonstrated the utility of the technique to locally stage oesophagogastric cancer and to assess response following neoadjuvant therapy. The lecture will offer guidance on sequence selection and optimisation to achieve diagnostic quality images in this challenging area; highlight the strengths and weaknesses of the technique and demonstrate where the technique could potentially fit into the staging algorithm for patients with oesophago-gastric cancer. It will also show how the introduction of diffusion weighted imaging has enabled the technique to be used in response assessment following neoadjuvant chemotherapy and chemoradiotherapy. It will also describe how the technique is being utilised for radiotherapy planning.

Lecture F - Lower GI Dr Sofia Gourtsoyianni Pre-operative MRI of the rectum, using mainly high resolution T2 weighted sequences, has gained significant accreditation, especially after the introduction of total mesorectal excision (TME) surgery and neoadjuvant therapy in the treatment regimen of rectal cancer. MR imaging is so far the only method that can preoperatively identify patients most likely to benefit from neoadjuvant therapy as well as demonstrate high risk patients for local recurrence/metastatic disease.

State of the art MR imaging protocols tailored to allow radiologists to obtain all necessary information for appropriate treatment decision making, will be described. MR signal changes encountered in pelvic structures/tissues involved by primary rectal cancer at baseline staging as well as after completion of neoadjuvant treatment will be illustrated. Influence of imaging findings on initial therapeutic approach will be discussed.

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Programme

Thursday 6 November

DAY 3: NEURO - BRAIN 08:45 Registration and refreshments Chair: Dr Mark Radon, Consultant Neuroradiologist, The Walton Centre 09:00 Lecture A - a scientific lecture to cover the physics aspects

of the subsequent lectures

Dr Jonathan Ashmore, MRI Physicist, King’s College Hospital 09:30 Lecture B - Demyelination and inflammation

Dr Brynmor Jones, Consultant Neuroradiologist,

Imperial College London 10:00 Lecture C - Stroke and mimics

Dr Tufail Patankar, Consultant Neuroradiologist,

Leeds General Infirmary 10:30 Lecture D - Epilepsy

Dr Ian Craven, Consultant Neuroradiologist,

Sheffield Teaching Hospitals NHS Foundation Trust 11:00 Refreshments 11:30 Workshop session 1 - topics A&B and C&D 12:15 Workshop session 2 - topics C&D and A&B 13:00 Lunch 14:00 Lecture E - Tumours

Dr Mark Radon, Consultant Neuroradiologist, The Walton Centre 14:30

Lecture F - Congenital brain and spine abnormalities in children Dr Stavros Stivaros, Head of Paediatric Neuroradiology, Royal Manchester Children’s Hospital and National Institute for Health Research (NIHR) Clinician Scientist, University of Manchester

15:00 Workshop session 3 - topics E&F 15:45 Refreshments 16:15 Panel discussion reviewing complex cases 17:00 Close of day

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Speaker profiles (where supplied) Dr Jonathan Ashmore MRI Physicist, King’s College Hospital Jonathan Ashmore is an MRI physicist specialising in neuroimaging at King’s College Hospital, London. He did his clinical scientist training at University College London Hospital and the National Hospital for Neurology and Neurosurgery, Queens Square, London. His areas of interest include advanced MRI techniques for brain tumour imaging and pre-surgical planning.

Dr Ian Craven Consultant Neuroradiologist Sheffield Teaching Hospitals NHS Foundation Trust Dr Craven is a Consultant Neuroradiologist with a sub-specialty interest in paediatric and neonatal imaging at Leeds General Infirmary. He is an Educational Lead for radiology in the Leeds Teaching Hospital Trust and Specialist Interest Lead for Neuroradiology.

He is currently undertaking a PhD at Sheffield University in MR brain imaging in young adults and children. During his fellowship, he undertook several research projects in epilepsy imaging at 3.0T and has recently set up a 3.0T service for imaging refractory focal epilepsy in Leeds.

Dr Brynmor Jones Consultant Neuroradiologist, Imperial College London 2004-2008: Diagnostic radiology training at Hammersmith Hospital NHS Trust.

2008-2010: Pan London Diagnostic Neuroradiology Fellowship.

2010 – present : Consultant Diagnostic Neuroradiologist, Imperial College Healthcare NHS Trust with an interest in paediatric neuroimaging.

Dr Tufail Patankar Consultant Neuroradiologist, Leeds General Infirmary Dr Patankar trained in Manchester in diagnostic and interventional neuroradiology and got PhD in medicine from University of Manchester mainly in MR perfusion in brain tumours. He has been a consultant neuroradiologist in the UK for the last 9 years. He started the interventional service in Preston and moved to Leeds 4 years ago.

Dr Patankar has expertise in endovascular treatment of neurovascular diseases especially in brain aneurysms and emerging technologies in flow divertors and flow disruptors.

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He has a special interest in imaging in stroke particularly in advanced imaging of stroke and its role in treatment of stroke.He has over 100 publications in peerreviewed journals and has been involved with various research projects in brain tumour and biomarker imaging and treatment of neurovascular diseases (mainly brain aneurysms and stroke).

He has been involved with teaching and training medical students, radiology trainees and neurology and neurosurgical trainees at University of Leeds and University of Manchester and has been involved with supervising PhD, MD and MSc students at University of Manchester and Leeds.

He has been a proctor for web treatment of brain aneurysms and been training neurointerventionsist in UK and Europe and in addition, have trained, supported and assisted complex neurointerventional cases in a number of UK and European centres.

He is an Associate Editor for BJR and member of the training and standards subcommittee and academic subcommittee and research subcommittee of BSNR and reviewer for number of national and international journals.

Dr Mark Radon Consultant Neuroradiologist, The Walton Centre Dr Radon qualified from the University of Cambridge medical school, and subsequently trained in radiology in Sheffield. He took a fellowship in diagnostic neuroradiology at the National Hospital for Neurology and Neurosurgery in London and now works as a consultant neuroradiologist at The Walton Centre in Liverpool.

Dr Stavros Stivaros Head of Paediatric Neuroradiology, Royal Manchester Children’s Hospital and National Institute for Health Research (NIHR) Clinician Scientist, University of Manchester Stavros Stivaros is Head of Paediatric Neuroradiology at the Royal Manchester Children’s Hospital, one of the largest specialist children’s hospitals in Europe and is also a National Institute for Health Research (NIHR) Clinician Scientist at the University of Manchester. He specialises in paediatric neuroradiology with a special interest in imaging hydrocephalus and the imaging of blood flow and cerebrospinal fluid throughout the head and spine and leads the paediatric multi-parametric imaging research group which combines anatomical, physiological and functional imaging analysis in specific disease groups including neurofibromatosis, autism, epilepsy and children’s brain tumours.

Dr Stivaros holds a degree in medical physics from University College London as well as a medical degree from the University of Manchester from where he obtained his joint computer science/medical imaging PhD. He frequently provides evidence and reports to the court and coroner on issues related to brain imaging in children.

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Abstracts (where supplied) Lecture A - a scientific lecture to cover the physics aspects of the subsequent lectures Dr Jonathan Ashmore There are a number of advanced MRI techniques which can significantly aid in neuroradiological diagnosis and treatment planning.

These include: • Magnetic resonance spectroscopy (MRS) • Diffusion weighted (and tensor) imaging • Dynamic susceptibility contrast (DSC) perfusion imaging • Arterial spin labelling (ASL) perfusion imaging • Susceptibility weighted imaging (SWI) • Volumetric imaging (including CUBE/SPACE/VISTA) Many of these techniques have, however, had limited uptake into routine clinical use potentially due to difficulties in their implementation and interpretation.

MRS measures the proton NMR signal for hydrogen atoms attached to various metabolites rather than those attached to the water molecule. These protons resonate at slightly different frequencies to those in the water molecule allowing them to be displayed in a “spectra” of metabolites rather than an image. Their clinical applications include brain tumour diagnosis and the identification exotic metabolic species in paediatric neurological disorders.

DWI weights the image to the diffusive random motion of water molecules from which maps of the apparent diffusion coefficient (average diffusion along each direction) and the fractional anisotropy (the relative restriction of diffusion along one direction compared to the other) can be created.

DSC and ASL are techniques which measure perfusion through endogenous and exogenous based contrast methods respectively. The use of gadolinium in DSC results in increased SNR and therefore shorter imaging times but with the associated risks of injecting gadolinium. In ASL spins are labelled within major feeding arteries and produce suppression of signal from the tissue into which they perfuse. These methods have found use in diagnosis of oncological and vascular pathologies.

SWI is a T2* based image sequence which utilises the phase shift associated with susceptibility differences in tissue to enhance the contrast in the resultant T2* weighted image. Its major use is to enhance the identification of bleed.

The volumetric fast spin echo sequences CUBE (GE), SPACE (Siemens), VISTA (Philips) utilize a standard 3D fast spin echo technique but with a modified refocusing pulse to allow for the use of long echo trains. These methods replace standard T1W, FLAIR and T2W imaging for certain applications such as surgical planning where true 3D imaging is beneficial.

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Lecture B - Demyelination and inflammation Dr Brynmor Jones Both conventional and advanced MRI techniques give a valuable insight into a diverse and often devastating group of disorders affecting the central nervous system (CNS). This talk will concentrate on the common CNS demyelinating disorders looking at conventional MRI imaging features which in combination with clinical findings will help to provide an appropriate differential diagnosis.

Particular attention will be given to clinically isolated syndromes (CIS) and multiple sclerosis (MS) with discussion of the specificity of imaging findings required for diagnosis. Other primary demyelinating pathologies such as neuromyelitis optica (NMO) will be covered emphasising the differential diagnosis of long intramedullary spinal cord lesions.

Disease modifying therapies are now frequently employed in MS. JC virus related progressive multifocal leucoencephalophy is a disorder which was previously only seen in severely immunocompromised HIV patients. It is, however, a rare but well recognised complication of some of these disease modifying treatments.

We will review some of the secondary demyelinating disorders such as acute disseminated encephalomyelitis (ADEM) and briefly discuss other CNS inflammatory conditions such as neurosarcoid, Behcet’s and system lupus erythromatosis (SLE).

Lecture C - Stroke and mimics Dr Tufail Patankar The interest in MRI as a tool for acute stroke management lies not only in the capability of this technique to detect early ischemic lesions with high sensitivity, but also in the breadth of the cerebrovascular pathology revealed by such imaging. Multimodal MRI can delineate the presence, size, location, extent and effects of acute brain ischemia, identify the hypoperfused tissue that is at risk of infarction, and show additional features of the cerebrovascular pathology.

MRI can also detect or exclude hemorrhage with accuracy comparable to CT. The additional diagnostic information obtained with MRI could result in improvements in patient outcomes and cost-effectiveness.

The presentation will cover typical acute stroke MRI imaging and the benefits of various MR sequences and magnetic resonance angiography and perfusionweighted which has transformed the diagnosis of ischemic stroke imaging.

It aims to discuss MR appearances of stroke, the difficulties that can be encountered by the radiologists and the various other pathologies that can mimic stroke.

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Lecture D - Epilepsy Dr Ian Craven Imaging patients with epilepsy can be a contentious topic as often we are given limited information yet expected to exclude a multitude of pathologies.

In a time pressured clinical environment, the utilisation of multiple sequences is undesirable. This session will cover how to identify patients that require in-depth examination using dedicated epilepsy protocols. The common pathologies will be discussed in detail with multiple examples illustrating why certain sequences are so important. The rare aetiologies will also be covered, allowing the audience to see examples that they may not have come across in their own practice.

Advanced imaging techniques will be discussed to give the audience insight into what can be achieved and what may become routine practice in the future.

The cases provided for the workshop will help consolidate the lecture material and also allow informed discussion of everyday problems encountered in clinical practice.

Lecture E - Tumours Dr Mark Radon MRI is the core modality for the diagnosis and follow-up of brain tumours. This lecture reviews the most important types of primary brain tumour and their imaging characteristics and features that distinguish them from metastatic tumours.

The importance of anatomical localisation for differential diagnosis and surgical planning is highlighted, with emphasis on the differences between intra-axial and extra-axial tumours, and between supra- and infra-tentorial regions. The features of a various low-and high-grade tumours are compared, and indications for advanced MRI techniques discussed. Treatment effects are also illustrated.

Common pitfalls in both diagnosis and follow-up are highlighted, and the indications for the use of techniques such as MR spectroscopy and perfusion are reviewed.

This talk aims to illustrate the application of these principles with several cases, and highlight the findings which assist in diagnosis and follow-up.

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Programme

Friday 7 November

DAY 4: MSK - FUNDAMENTALS 08:45 Registration and refreshments Chair: Dr David Wilson, Consultant Interventional MSK Radiologist,

Oxford University Hospitals NHS Trust 09:00

Lecture A - a scientific lecture to cover the physics aspects of the subsequent lectures Dr Peter Wright, Principal MRI Physicist, Sheffield Teaching Hospitals NHS Foundation Trust

09:30 Lecture B - Cartilage

Dr Bernhard Tins, Consultant Musculoskeletal Radiologist,

The Robert Jones and Agnes Hunt Orthopaedic and District Hospital 10:00 Lecture C - Bone

Dr David Wilson, Consultant Interventional MSK Radiologist,

Oxford University Hospitals NHS Trust

10:30 Lecture D - Soft tissue tumours

Dr Geoff Hide, Consultant Musculoskeletal Radiologist,

Freeman Hospital 11:00 Refreshments 11:30 Workshop session 1 - topics A&B and C&D 12:15 Workshop session 2 - topics C&D and A&B 13:00 Lunch Chair: Dr Sarah Burnett, Consultant Musculoskeletal Radiologist,

King Edward VII Hospital 14:00 Lecture E - Spine

Dr Winston Rennie, Consultant Musculoskeletal Radiologist and

Honorary Senior Lecturer, University Hospitals of Leicester NHS Trust 14:30 Lecture F - Rib lesions

Dr Sarah Burnett, Consultant Musculoskeletal Radiologist,

King Edward VII Hospital 15:00 Workshop session 3 - topics E&F 15:45 Refreshments 16:15 Panel discussion reviewing complex cases 17:00 Close of event 22

Speaker profiles (where supplied) Dr Sarah Burnett Consultant Musculoskeletal Radiologist, King Edward VII

Hospital

Sarah Burnett is a Consultant Musculoskeletal Radiologist, formerly at St Mary’s and the Royal National Orthopaedic Hospital, she has been in independent practice since 2001. She qualified in medicine in 1985, and started her radiology training at St Bartholomew’s in 1998, becoming a consultant in 1993. She is the Clinical Lead for Quality at 4Ways Healthcare, and has vast experience of teleradiology and audit. She also has a large medicolegal practice.

Dr Geoff Hide Consultant Musculoskeletal Radiologist, Freeman Hospital Dr Hide qualified in medicine from the University of Newcastle upon Tyne in 1990 and was appointed as a consultant radiologist at Newcastle Upon Tyne Hospitals in 2002, with a special interest in musculoskeletal imaging. He is the lead radiologist for the bone and soft tissue tumour service. He is a member of the International Skeletal Society, currently the treasurer of the British Society of Skeletal Radiologists and has acted as an advisor to NICE and the Department of Health.

Dr Winston Rennie Consultant Musculoskeletal Radiologist and Honorary Senior Lecturer, University Hospitals of Leicester NHS Trust Dr Rennie is a Consultant Musculoskeletal and Trauma Interventional Radiologist with an academic interest at the Leicester Royal Infirmary. He has set up pioneering palliative interventional procedures like spinal tumour coablation and cementoplasty in Leicester. He was Involved in collaborative research projects with Loughborough University and is a supervisor of two PhD fellows in Biomechanics and in Physical sciences. He has a special interest in the spine and spinal intervention, having set up the RF Kyphoplasty service in Leicester for spinal fractures with standardised QoL outcome measures.

His special diagnostic interest is spine MR imaging in SpA, having caught the bug working as a musculoskeletal radiology fellow, in the prestigious Canadian University of Alberta with Professors W Maksymowych and R Lambert. He has provided advice to the National Ankylosing Spondylitis Society, with guidance on setting up services in the United Kingdom. He has developed standardised protocols in SpA MR imaging and am invited international faculty teaching both Nationally and Internationally on hands on MRI in SpA courses for rheumatologist and radiologists. He was recently appointed onto the NICE Guidelines Development Group for SpA in the UK. He is a reviewer for peer reviewed journals in a wide range of specialities ranging from orthopaedics, trauma, sports medicine, Rheumatology and radiology based in the UK, North America and Europe. He attempt to stimulate an interest in research, high quality reporting and journal publications amongst his trainees.

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He has been invited to contribute to an SpA think tank held at Portcullis House (House of Commons). In the little time he has to spare, he enjoys playing the guitar (very badly) to the women who care to listen (his wife and young daughters!).

Dr Bernhard Tins Consultant Musculoskeletal Radiologist, The Robert Jones and Agnes Hunt Orthopaedic and District Hospital Dr Tins studied physics and medicine in MĂźnster, Germany and initially wanted to become a scientist. However he changed his mind and began work as a doctor, eventually training as a radiology registrar in Stoke-on-Trent. During this time he spent six months in Munich, Germany, in MR imaging and 1 year in Oswestry as a musculoskeletal fellow. He took a job as MSK Radiologist in Oswestry and has developed in interest in cartilage imaging and spinal imaging and intervention.

Dr David Wilson Consultant Interventional MSK Radiologist, Oxford University Hospitals NHS Trust and President, BIR Dr Wilson’s primary interest is in the application of modern imaging techniques to disorders of the locomotor system and spine intervention. He has undertaken original work in the application of diagnostic ultrasound to joint, muscle, and soft tissue disease with particular attention to joint effusion and congenital dysplasia of the hip. He has over 20 years of experience in vertebroplasty and is the author of publications on multicentre controlled trials on the treatment of insufficiency fractures. He has established innovative training courses in the UK in musculoskeletal ultrasound in Oxford and Bath. He teaches internationally and is a leader in the development of ultrasound in musculoskeletal disease and injection techniques in the spine. He has considerable experience in all aspects of musculoskeletal imaging and is the Editor of the principle textbook on MSK imaging. As a former President of the British Society of Skeletal Radiologist and a previous Medical Director of the Nuffield Orthopaedic Centre he has wide clinical and research experience.

He has been a member of the BIR since 1982. He was Commissioning Editor of the BJR (2011-12) and then Deputy Editor (2012-2013). He was Vice President (External Affairs) from 2012-2014. He is currently President of the BIR (2014-16).

Dr Peter Wright Principal MRI Physicist, Sheffield Teaching Hospitals NHS Foundation Trust After being awarded a PhD in MRI Physics at the University of Nottingham, Dr Wright started training towards becoming a clinical scientist at the University Hospital North Staffordshire (UHNS). Dr Wright continued his training at Leeds Teaching Hospital, where he was resident MRI Physicist to the NIHR Leeds Musculoskeletal and Biomedical Research Unit (LMBRU) for 3 years. Since then, Dr Wright returned to UHNS to establish and develop an MR Physics team and is now Principal MRI Physicist at Sheffield Teaching Hospitals NHS Foundation Trust.

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Abstracts (where supplied) Lecture A - a scientific lecture to cover the physics aspects of the subsequent lectures Dr Peter Wright Education aims • Introduction to fat saturation techniques • Advantages and disadvantages of STIR, SPIR and SPAIR • Importance of shimming • Tips and tricks to reduce artefact caused by metal implants • To understand the physics behind the magic angle effect By the end of the lecture delegates should be familiar with fat suppression techniques, including short tau inversion recovery (STIR), spectral pre-saturation with inversion recovery (SPIR) and spectral adiabatic inversion recovery (SPAIR) and the advantages and disadvantages of these techniques. The role of shimming will be introduced and the importance it plays in fat suppression.

Metal implants can cause severe artefact in MR imaging to the point that images can be non-diagnostic. The second part of the lecture will discuss tips and tricks to reducing metal artefact using modified standard MR sequences.

The magic angle effect can cause the T2 of tissues to lengthen. In the case of tendons and other short T2 tissues this can result in signal appearing where none is expected, leading to the potential for mis-diagnosis. Here we will look at the physics behind the magic angle effect and how to identify it.

Lecture B - Cartilage Dr Bernhard Tins Cartilage damage due to trauma or degeneration is a cause for joint degeneration. This is associated with pain, lifestyle limitations and morbidity and ultimately cost.The interest in cartilage imaging has arisen from the need to better understand degenerative joint disease.

Cartilage has a complex microscopic structure. In normal cartilage its nutrition is purely by diffusion and its metabolic rate and repair capacity is therefore limited.

The normal anatomy and imaging appearance of cartilage will be discussed.

In recent years imaging techniques have been developed that allow to assess cartilage metabolism and infer some information on its microstructure.

Conventional and advanced imaging techniques and their relevance to routine practice and research will be reviewed. This includes contrast medium enhancement and T1 rho and T2 weighted imaging.

Scoring systems for joint degeneration are sometimes used by surgeons but are mainly relevant for research, they will briefly be introduced.

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Cartilage has a limited repair capacity. Surgical repair techniques, their problems and complications and the relevant imaging appearances will be discussed.

In particular microfracture, chondrocyte implantation and mosaic plasty will be explained and the imaging appearances outlined.

While a number of topics will be covered, the main aim of this presentation is to enable a general radiologist to understand which aspects of cartilage imaging are relevant for routine practice and which areas are mainly the domains of research. After this presentation a radiologist should be able to understand their orthopaedic surgeons and offer guidance to our orthopaedic colleagues.

Lecture C - Bone Dr David Wilson Bones may be affected by disease that is:• Lytic • Sclerotic • Mixed lytic and sclerotic • Periosteal reaction • Expanded • Deformed • Fractured Diseases may be grouped as:• Congenital • Trauma • Infection • Malignant • Metabolic Imaging is in order of use:• Conventional Radiographs • CT • MRI • Nuclear medicine • Ultrasound (these methods are complimentary – MR is not the panacea) Common pitfalls are:• Miss the lytic lesion • Miss the diffuse marrow disease • Miss the periostea l reaction • Miss the undisplaced fracture • Miss the subperiosteal erosion • Confuse insufficiency fracture with malignancy • Forget to think of infection.

Examples of the above will be presented in a quiz format.

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Lecture D - Soft tissue tumours Dr Geoff Hide This presentation will focus on the use of MRI and other imaging modalities in the diagnosis and staging of soft tissue tumours. A systematic approach to determining a diagnosis, where possible, will be discussed as will the advantages and limitations of MRI. Lecture E - Spine Dr Winston Rennie Educational aims: • To understand the principles of spine MR and the essential nuances and critical difference to all other radiological imaging - why spine MR is left at the bottom of the pile!

• To plan an imaging protocol to deliver a smooth patient throughput yet not compromise on diagnostic image quality - quantity not at the expense of quality!

• To develop standardised clinically relevant nomenclature and appreciate the diagnostic process - stop the tower of babel!

• To gain an insight into specialised spine imaging pathways tailored to the clinical pathology - clinical standardised protocols not standard protocols Learning outcomes: • To be able to construct a protocol/pathway for spine MRI • To have a standardised approach to spine reporting • To be able to streamline services and patient flow through the MR department • To gain an insight into SpA MRI Imaging.

Lecture F - Rib lesions Dr Sarah Burnett The talk will cover diverse aspects of rib pathology. Learning outcomes include the benefits and limitations of MRI as a method of diagnosing rib, sternal and chest wall pathology. By the end of the session, delegates should expect to know the best method to image certain types of rib pathology, and learn some of the classical appearances. These will be revised in the interactive and panel sessions. __________________________________________________________________

Certificate of attendance Your certificate of attendance will be emailed to you within the next two weeks once you have completed the online event survey at: https://www.surveymonkey.com/s/MRIcourse2014

BIR Annual Congress 2015: 4–5 November, London 27

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FORTHCOMING EVENTS WELSH BRANCH MEETING: TO REPORT OR NOT TO REPORT....WHAT IS THE ANSWER? 11 NOVEMBER 2014 SOUTH WALES THE JOURNEY FROM RESEARCH TO PUBLICATION 20 NOVEMBER 2014 LONDON THE FUTURE OF RADIOLOGY IN THE NHS: TOP TOPICS FOR INTERVIEWS 21 NOVEMBER 2014 LONDON DIAGNOSTIC RADIOLOGY FOR ADVANCED HEAD AND NECK CANCER PLANNING 26 NOVEMBER 2014 LONDON STATE OF THE ART RADIOTHERAPY EDUCATION DAY 10 DECEMBER 2014 LONDON WESSEX BRANCH EVENT 10 DECEMBER 2014 SOUTHAMPTON ADVANCES IN RADIOTHERAPY FOR PROSTATE CANCER: FROM THEORY TO PRACTICE 12 DECEMBER 2014 CARDIFF THE SPINE IN HEALTH AND DISEASE 21 JANUARY 2015 LONDON CONTRAST STUDY DAY AND ESSENTIAL PHYSICS FOR FRCR 29 - 30 JANUARY 2015 SHEFFIELD RADIOLOGY ERRORS 6 FEBRUARY 2015 LONDON EMERGENCY INTERVENTIONAL RADIOLOGY 13 FEBRUARY 2015 LONDON 4TH ANNUAL SPECT/CT SYMPOSIUM: CURRENT STATUS AND FUTURE DIRECTIONS OF SPECT/CT IMAGING 23 FEBRUARY 2015 LONDON THE TECHNOLOGY AND USES OF ON-TREATMENT IMAGING IN RADIOTHERAPY 24 MARCH 2015 LONDON RELATIVE BIOLOGICAL EFFECT IN RADIOTHERAPY 14-15 APRIL 2015 OXFORD VISIT: WWW.BIR.ORG.UK FOR MORE INFORMATION AND TO REGISTER! 29

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