Understanding the relevance of neutropenic sepsis as a radiologist and who is at risk.

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1 What to do next above the diaphragm 08:30 09:00 Investigating suspected chest infection in febrile neutropaenia Dr Anna Sharman, Manchester University NHS Foundation Trust Understanding the relevance of neutropenic sepsis as a radiologist and who is at risk. To appreciate the possible ways to investigate patients with neutropenic sepsis looking at the role the chest X-ray and computed tomography (CT) play in the potentially life threatening condition. There are many different pathogens to be considered in this group of patients but invasive pulmonary aspergillosis is hugely under recognised and the imaging features are often nonspecific making diagnosis challenging. Similarly, pneumocystis jirovecii also needs to be considered in this group of patients, particularly if the CT shows diffuse ground glass opacification. Estacio O, Loh Z, Grigg A et al. Limited utility of routine CXR in initial evaluation of febrile neutropenia in patients with haematological diseases undergoing chemotherapy. Blood 2016; 128: Orlowski H, McWilliams S, Mellncik V et al. Imaging spectrum of invasive fungal and fungallike infections. Radiographics 2017; 37: Patsios D, Maimon N, Chung T et al. Chest low dose computed tomography in neutropenic acute myeloid leukaemia patients. Respiratory Medicine 2010; 104:

2 What to do next above the diaphragm 09:30 10:00 Management of subsolid pulmonary nodules Dr Arjun Nair, Guys & St Thomas NHS Foundation Trust, London Subsolid nodules (SSNs) are an umbrella term for ground-glass (GGN) and part-solid (PSN) nodules. Persistent SSNs are much more likely to represent a primary malignant lesion (usually pulmonary adenocarcinoma) than solid nodules; however, the spectrum of neoplastic behaviour represented by these nodules is wide, encompassing atypical adenomatous hyperplasia to invasive adenocarcinoma. Guidelines for pulmonary nodule management have been updated to reflect increasing awareness that SSNs without a measurable solid component can be managed conservatively as, even if malignant, they represent lesions that will not impact on a patient s health and mortality in other words, they may represent overdiagnosed cancers. Current risk models for predicting the likelihood of a nodule being malignant (for example, the Brock risk calculator) may underestimate the risk of malignancy in SSNs. Besides a new or enlarging solid component, morphological factors (such as the presence of pleural indentation, bubble-like luncencies and air bronchograms) also herald the presence of an invasive component in SSNs, but recent evidence suggests inter-observer agreement for both the classification of nodule composition and morphology is only moderate. Callister ME, Baldwin DR, Akram AR et al. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax 2015; 70(Suppl 2): ii1 ii54. Travis WD, Asamura H, Bankier AA et al. The IASLC lung cancer staging project: proposals for coding T categories for subsolid nodules and assessment of tumor size in part-solid tumors in the forthcoming eighth edition of the TNM classification of lung cancer. J Thorac Oncol 2016; 11: MacMahon H, Naidich DP, Goo JM et al. Guidelines for management of incidental pulmonary nodules detected on CT images: From the Fleischner Society Radiology 2017; 284:

3 11:00 11:30 White-matter disease in adults: a pragmatic approach Professor Daniel Birchall, Newcastle Upon Tyne Hospitals NHS Foundation Trust Interpretation of white-matter disease in adults can be complex and requires a pragmatic approach. Unusual disease manifestations can occur in common white-matter disorders. Advanced imaging techniques are important in discriminating between white-matter disorders. Surveillance is often key to the understanding of uncertain aetiology white-matter disease.

4 11:30 12:00 How I approach the thyroid nodule Dr Sarah La Porte, Milton Keynes Hospital NHS Foundation Trust There has been a significant increase in the diagnosis of thyroid cancer, without impact on patient survival. To attempt to combat this overdiagnosis, there have been publications of grading systems to stratify the risk of thyroid cancer in nodules, based on ultrasound features. They also provide guidance on further investigation and management. The ultrasound features will be explained and illustrated with cases, along with an overview of how to grade nodules based on the British Thyroid Association guidance. Perros P, Boelaert K, Colley S et al. Guidelines for the management of thyroid cancer. Clinical Endocrinology 2014; 81(Suppl 1): Tessler FN, Middleton WD, Grant EG et al. ACR thyroid imaging, reporting and data system (ti-rads): white paper of the ACR TI-RADS Committee. J Am Coll Radiol 2017; 14(5): Russ G, Bonnema SJ, Erdogan MF et al. European Thyroid Association guidelines for ultrasound malignancy risk stratification of thyroid nodules in adults: The EU-TIRADS. Eur Thyroid J 2017; 6:

5 12:00 12:30 How I approach the opacified middle ear Dr Steve Connor, King's College Hospital NHS Foundation Trust, London Computed tomography (CT) appearances of an opacified middle ear need to be correlated with clinical findings and otoscopic apparances to determine aetiology and significance (for example, features of acute otitis media or chronic suppurative otits media). Uncomplicated acute otitis media does not require imaging but clinical mastoiditis does require imaging in order to exclude intracranial, skull-base and extracranial complications. A standard (bone protocol) CT petrous temporal bones will not suffice and contrast-enhanced studies are required which are able to image the intra- and extra-cranial soft tissues. Cholestetaoma generally requires surgical management and is a key diagnosis in the context of chronic suppurative otitis media (CSOM), there are multiple potential middle-ear substrates in CSOM which have similar appearances on CT. However a systematic approach to the analysis of CT in this context allows the radiological suspicion of cholesteatoma to be stratified. CT remains the imaging workhorse for primary cholesteatoma diagnosis and surgical planning. Non-echo planar diffusion-weighted magnetic resonance imaging is now established in the clinical pathway for the follow-up of cholesteatoma post surgery, and particularly after canal wall up mastoidectomy. It also plays a limited more role in primary diagnosis. Be on the look out for rarer but clinically significant pathologies that may present with an opacified middle ear such as cephaloceles/cerebrospinal fluid (CSF) leak and tumours. There may be clues in the clinical history (for example, previous trauma, bloody otorrhea) or in unusual patterns of bone/ossicular erosion on CT. Dubrulle F, Souillard R, Chechin D et al. Diffusion-weighted MR imaging sequence in the detection of postoperative recurrent cholesteatoma. Radiology 2006; 238: De foer B, Vercruysse JP, Bernaerts A et al. Middle ear cholesteatoma: non-echo-planar diffusion-weighted MR imaging versus delayed gadolinium-enhanced T1-weighted MR imaging--value in detection. Radiology 2010; 255: Lingam RK, Connor SEJ, Casselman JW, Beale T. MRI in otology: applications in cholesteatoma and Ménière's disease. Clin Radiol 2018; 73: