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preface
The RAP HEX 2010 Exam Answers book provides a short explanation of why each answer is correct, along
with worked calculations where appropriate. An in-depth review of the exam with the physics instructor is
encouraged.
In cases where more than one answer might be considered correct, the most appropriate answer is used.
Although one exam cannot cover every topic in the syllabus, a review ofRAPHEX exams/answers from three
consecutive years should cover most topics.
We hope that residents will find these exams useful in reviewillg their radiological physics course.
RAPHEX 2010 Committee
Copyright 2010 by RAMPS, Inc., the New York chapter of the AAPM. All rights reserved. No part
of this book may be used or reproduced in any manner whatsoever without written permission from the
publisher or the copyright holder.
Published in cooperation with RAMPS by:
Medical Physics Publishing
4513 Vernon Boulevard
Madison, WI 53705-4964
l-800-442-5778
E-mail: mpp@medicalphysics.org
Web: www.medicalphysics.org
Tl. E
T2. B
TJ. D
T4. A
TS. C
T6. D
T7. B
T8. E
T9. A
TIO. C
Til. C
Tl2. D
Til. B
Raphex 2010
therapy answers
Although most odd-numbered nuclei have a magnetic moment, only hydrogen nuclei,
consisting of a single proton, are detected in most MR imaging.
Neutrinos have no charge and almost no mass,_ and rarely interact with matter.
Beta rays emitted in negative beta decay are electrons.
Ratio of neutrons and protons in heavy nuclei is about 1.4 to 1.6.
Isotopes of an element have the same Z (number of protons or electrons) but different
numbers of neutrons and, hence, different A (mass number). Chemically, all isotopes of
the same element are identical.
The nucleus of a hydrogen atom is a proton.
Electrons fired at a high-Z target create bremsstrahlung and characteristic x-rays.
When a positron and an electron combine in an annihilation interaction, their rest masses
(0.51 MeV each) are converted into two 0.51 MeV photons emitted in opposite directions.
This is the basis of the PET scanner.
Tritium (H-3) has one proton and two neutrons in the nucleus.
Increasing the kV increases the kinetic energy of the electrons colliding with the target.
This leads to greater x-ray production as well as additional heat load for the target.
Contrast is reduced at higher kV settings, as is quantum noise, which is inversely
related to the number of photons produced.
With the exception of the K edges, photoelectric interactions are more likely at low energy
than at high energy. After passing through a filter, the total beam intensity is reduced, but
the beam contains a relatively greater number of high-energy photons than before filtration.
therapy answers
Tl4. A
TIS. D
Tl6. C
Tl7. C
TIS. A
Tl9. C
T20. D
T21. B
T22. C
T23. C
Laser accuracy should be checked daily before using the CT Simulator. AAPM TG-66
report
1
requires that constancy of CT-to-density conversion for treatment planning software
be verified annually.
Ultrasound is high-frequency sound waves; it is not part of the electromagnetic spectrum.
The monitor chamber remains in position to monitor the beam output, but the target and
flattening filter are replaced with a scattering foil. The electron applicator is usually inter-
locked so that the electron beam cannot be turned on unless it is attached.
Flattening filters are only used in photon beams. Electrons use scattering foils.
In high-energy linear accelerators the accelerator tube (wave guide) is generally mounted
parallel to the floor, and the bending magnet bends the beam of electrons exiting from the
accelerator through 270 to point at the isocenter. For low-energy linacs the wave-guide is
short enough to be mounted vertically, perpendicular to the gantry axis of rotation, so that
the beam always points to the isocenter and no bending magnet is needed.
The target is used only in the photon mode.
For photon beams, neutron contamination increases rapidly between 1 0 and 20 MY, and
then remains approximately constant. The neutron dose in photon beams is about an order
of magnitude higher than that in electron beams.
Fast neutrons dissipate energy in tissue by the four main reactions in A, B, C, and D. The
most important reaction is elastic collisions with protons.
Directly ionizing radiation refers exclusively to charged particles. Indirectly ionizing
radiation refers to uncharged particles such as neutrons, or photons such as x-rays and
gamma rays. Ultrasound is not ionizing radiation.
Only charged particles are deflected by a magnetic field, not electromagnetic radiation.
1
AAPM Report No. 83. Quality Assurance for Computed-Tomography Simulators and the Computed-Tomography-
Simulation Process: Report of the AAPM Radiation Therapy Committee Task Group No. 66. Reprinted from
Med Phys 30(10):2762-2792 (2003).
2 Raphex 2010
T24. A
T25. B
T26. B
T27. C
T28. B
T29. A
TJO. D
Tll. B
T32. B
Tll. D
Raphex 2010
therapy answers
In the interaction of radiation with matter, energy is generally transferred to electrons and
photons. The energy transferred to electrons is then dissipated locally in collisions with
atoms and results in absorbed dose.
CT number (in Hounsfield units)= 1000 X [(!lmaterial- ~ t e r / ~ t e r l where ll is the linear
attenuation coefficient.
The probability of Compton interactions in a material depends upon the number of
electrons per unit mass in that material. The mass attenuation coefficient is similar for
most low atomic number materials in the Compton region, except those containing
hydrogen. This is because most low atomic number materials have approximately one
electron per two nucleons (one proton and one neutron), while the most abundant isotope
of hydrogen has one electron per nucleon, or twice the number of electrons per unit mass
as most other elements.
In a photoelectric interaction the photon is completely absorbed. An electron is then
emitted from the atom with kinetic energy equal to the difference between the incident
photon energy and the binding energy of the electron. The vacancy in the shell is then filled
by an electron from a higher energy level, causing a characteristic x-ray to be emitted.
The minimum energy for a backscattered photon always occurs at 180 to its original
direction. When this happens, due to conservation of momentum, the Compton electron
must go off in the direction exactly opposite to the backscattered photon: 0 relative to
the direction of the initial photon.
ll x HVL = 0.693 ( = In 2.0) where 11 is the attenuation coefficient.
This is a measure of exposure in air. To convert to absorbed dose in a small mass of
material, e.g., tissue, exposure is multiplied by the "f factor."
10 MeV represents the electron energy as it impacts on the target, and hence the maximum
bremsstrahlung energy. The average photon energy is about one-third of the maximum. The
characteristic peaks, which have the same energy as those in a diagnostic x-ray spectrum,
are relatively too low in energy to be of any significance in a linac spectrum.
Dose rate increases proportionately with rnA. The other factors will all reduce the dose rate.
It is greater for bone due to the Z dependence of the photoelectric effect.
3
therapy answers
T34. C
TJS. D
T36. C
T37. E
T38. A
T39. C
T40. E
T41. B
T42. B
T43. A
T44. D
T45. C
The ffactor (roentgen-to-cGy factor) for muscle tissue ranges from 0.921 at 10 keV to
0.960 at 150 keV. 1 cGy is equal to 10 mGy.
Proton beams are accelerated in a cyclotron at energies up to 250 MeV. Gamma Knife
uses Co-60 sources, which have an average energy of 1.25 MeV. Linacs are generally
available with energies up to 25 MeV. TomoTherapy and CyberKnife employ a
6 MV wave guide.
For electrons TG-51 protocoF allows the use of plane-parallel chambers in a high
high-energy electron beam, calibrated against a cylindrical chamber having an ADCL
calibration.
Full calibration of all beams with a water tank is required annually, to verify the TG-51
parameters.
2
Bone density is about 1.6 times the density of soft tissue. Therefore 3 em bone is
equivalent to an additional3 x 0.6 = 1.8 em tissue. The attenuation at 6 MV is about
3.5% per centimeter. Therefore the bone attenuates 1.8 x 3.5 = 6.3% more, causing the
dose to be about 6.3% less beyond the bone.
Maximum tissue dose (at dmaJ =(dose at depth)/(PDD/ 100) = 250/0.871 = 287 cGy.
2
AAPM Report No. 67, Protocol for Clinical Reference Dosimetry of High-Energy Photon and Electron Beams,
Report of AAPM Task Group 51. Reprinted from Med Phys 26(9):1847-1870 (1999).
4 Raphex 2010
T46. D
T47. B
T48. C
T49. D
TSO. A
TSI. D
TS2. C
TS3. A
TS4. A
TSS. D
TS6. C
TS7. C
Raphex 2010
therapy answers
Conventional tangents with a separate, angled electron field usually give a better dose
distribution.
By the inverse square law:
Dose mte 1 - [ dist 2 r
Dose mte 2 - [ dist 1]
2

The inverse square correction to the output is: (130 + d?/(100 + d)
2
.
This is approx. (130/100)
2
= 1.69.
The POD increases with increasing SSD, according to Mayneord's f-factor, because the
inverse square factor becomes relatively less important at greater SSD. The depth dose
curve increases between the surface and dmax then decreases approximately exponentially.
POD increases with increasing field size because the proportion of dose due to scatter
increases with depth and does so more quickly as field size increases.
Attenuation in a 6 MV photon beam is about 3.5% per centimeter.
As SSD increases, POD increases, because of the difference in the inverse square
component of the POD. The correction factor is (SSD + d/SSD + dmax? X (SSDext
+ dmax/SSDext + d)
2
. In this case: (106/101.6)
2
X (136.6/141)
2
= 1.022.
The formula is inverted.
TMRs are used for isocentric MU calculations.
For parallel opposed fields the higher the photon energy, the more homogeneous the dose
profile below dmax, and the lower the skin dose. A possible disadvantage is that dmax is
deeper, so tissue in the build-up region can be underdosed. If tissue between the surface
and dmax needs to be treated, the actual dose profile should be examined. The depth at
which 95% of the mid-plane dose occurs, for parallel opposed fields, is generally much
less than the depth of dmax but this depends on field size and separation, and should be
calculated for each case.
s
therapy answers
TS8. D
TS9. A
T60. D
T61. D
T62. E
T63. B
T64. B
T65. D
T66. B
T67. A
T68. C
T69. B
6
The effect on the TMR of a small corner block can be ignored, but the tray factor (TF)
must be included.
MU = dose at depth/ (output x TF x TMR).
The flattening filter "overfl.attens" at shallow depths, and "underfl.attens" at greater depths.
The dose profile at dmax exhibits "horns," which increase with field size, and are generally
greater in lower energy beams.
The total dose at dmax must be greater than the midplane dose. D and E are 8% and 20%
greater, respectively. For 10 MV x-rays Dis the only reasonable answer. (A separation of
34 em would be required for a value of 20%.)
As the prescription point moves further away from the source, the MU must be increased.
Increasing the SSD slightly increases the PDD (due to a smaller inverse square factor),
making the total dose at dmax slightly smaller.
TMR represents the attenuation of d-cm of tissue, while FDD represents attenuation and
inverse square falloff between dmax and depth d.
Although the wedge blocks some scatter from the treatment head, the wedge itself produces
more low-energy scatter. As the result, the contralateral breast receives more dose.
"Half-blocked" wedged fields can be treated with dynamic wedges and are useful for breast
tangents. An advantage of dynamic wedges is the increased field size and choice of wedge
angles, compared with conventional wedges.
The extra dose is due to scatter from the surrounding tissue.
Note, Cis not exact, but would give a wedge angle very close to 15.
The wedge angle is the angle through which the isodose at 10 em depth is rotated from its
position in the open beam.
TomoTherapy units have only a 6 MV wave guide, and a MLC (a digital system similar
to the MIMiC originally implemented by CORVUS) mounted in the CT doughnut. The
system rotates around the patient and delivers only a 6 MV photon beam with intensity
distribution modulated as per its treatment planning software.
Raphex 2010
T70. D
T71. C
T72. B
T73. D
T74. A
T75. C
T76. C
T77. E
T78. A
therapy answers
The maximum distance an electron can travel in tissue can be approximated by the value of
its energy (in Me V)/2 em. Therefore, the dose at depth of 5 em is due to bremsstrahlung.
As a rule for electron treatments, 1.0 em margin is added to each side of the volume to be
treated. This is because of the penumbra width, and because the 90% isodose "curves in"
with depth.
Thus the range of an electron beam is approximately= MeV/2 em.
For electrons, output can be corrected by the inverse square law only when the virtual SSD
(generally not 100 em) is used in the equation. For very small inserts, it is best to measure
the output for the actual cut-out and SSD to be used.
The surface dose as a percent of Dmax is influenced by the spread of electron energies in
the beam and their incident angles. Electrons scattered from the collimator and the foil(s)
affect the surface dose. A 6 MeV electron beam typically has surface dose of about
75% to 90%. A 6 MV photon beam has a much smaller surface dose, typically
20% to 40%, depending on the field size. Orthovoltage beams have surface doses of
approximately 100%. Surface dose increases as electron beam energy increases.
As a general rule of thumb, small air gap changes on electron beams need a correction
proportional to the Inverse Square Law, which amounts to 2%/cm. The cone is generally
at 95 em from the source for treatment at 100 em SSD, giving a nominal air gap of 5 em to
facilitate setup.
Commercial daily QA systems that are frequently used have an array of chambers that
monitor output. Some also check beam symmetry and energy constancy, although these
checks are not part of the TG-40
3
recommendation for daily QA.
The tolerance stated in TG-40
3
for daily output checks is 3%. This test is usually performed
daily by the technologists. If the value exceeds tolerance, it must be checked by a physicist,
who will decide on the course of action to be taken.
3
AAPM Report No. 46, Comprehensive QA for Radiation Oncology, Report of the AAPM Radiation Therapy
Committee Task Group 40. Reprinted from Med Phys 21(4):581-618 (1994).
Raphex 2010 7
therapy answers
T79. B
T80. B
T81. B
T82. D
T83. C
T84. B
T85. D
T86. B
T87. D
T88. A
DICOM (Digital Imaging and Communications in Medicine) is the industry standard for
transferring radiologic images and other medical information between computers. It defines
file formats and network communication.
Treatment planning systems model dose for patient treatment planning.
HL-7 interfaces are not defined in DICOM standard.
HIPAA (Health Insurance Portability and Accountability Act) provides security and
privacy of health data.
U is the Use factor.
Out of a total of about 1.6 mSv, nuclear medicine contributes about 0.14 mSv, and
the others all contribute about 0.3 to 0.4 mSv each.
The dose rate at some distance from a single
125
1 seed is small, so a sensitive detector is
needed. The Geiger-Mueller (GM) counter uses gas amplification to convert the small
signal into a measurable one. TLDs are too insensitive and do not give an instant reading,
and the other detectors are less sensitive than the GM counter.
Using concrete for primary shielding will also shield for neutrons. Lead is not a good
attenuator for neutrons because of its high-Z value, and must be supplemented by
additional neutron shielding, typically borated polyethylene.
The ovaries would receive about 0.5% of the dose to the tangents, or about 25 cGy. The
portion due to internal scatter cannot be shielded against. To shield against head leakage
and collimator scatter would.require a substantial amount of lead on a sturdy bridge over
the patient. These bridges are sometimes fabricated for pregnant patients, but are not used
routinely.
4
4
AAPM Report No. 50, "Fetal Dose from Radiotherapy with Photon Beams," AAPM Radiation Therapy Committee
Task Group 36. Reprinted from Med Phys 22:63-82 (1995).
8
Raphex 2010
T89. B
T90. D
T91. C
T92. A
T93. B
T94. D
T95. C
T96. D
T97. C
T98. B
therapy answers
In a 120-to-140 kVp x-ray beam the photons mostly undergo Compton scattering.
However, there are a sufficient number of photoelectric interactions to achieve differential
attenuation in bone.
Although the isocenter of a plan can be related to internal structures, it must also be
related to surface landmarks (preferably triangulation points) in order to position the
patient correctly for treatment.
The long scan times associated with PET scans mean that the tumor will be imaged over
the entire respiratory cycle, which can increase apparent tumor size. Gating can be used to
capture CT and PET images over the same part of the respiratory cycle, improving local-
ization. The same gating must then be used for treatment.
Ultrasound does not penetrate dense bone.
The MU must be increased by the inverse square law: (160/ 130)
2
= 1.5.
The physical buildup in front of an amorphous silicon EPID consists of a metal plate
(typically 1 mm copper) to convert incident x-rays into electrons, followed by a phosphor
screen to convert the electron ionization into visible light. The photosensitive diode array in
the amorphous silicon EPID converts the visible light into electron-ion pairs; the charges
are collected by application of a bias voltage onto a storage capacitor for subsequent
transfer to the readout electronics.
The average x-ray energy is 2 MeV and maximum energy is 6 MeV. The dominant type
of interaction is Compton scattering with very small amounts (few percent) of pair
production.
Radiographic film with cassettes can provide better resolution than any digital system.
Digital systems, however, are more convenient for archival and viewing of portal images.
The calculation volume needs to encompass only the PTV and OARs required for the DVH.
See ICRU report 62.
5
lTV = internal target volume, encompassing the CTV and the internal
margin, IM, which is added for variations in position and/or shape and size of the CTV.
5
International Commission on Radiation Units and Measurements (ICRU) Report 62, Prescribing, Recording and
Reporting Photon Beam Therapy (1999) (Supplement to ICRU Report 50 (1993).
Raphex 2010
9
therapy answers
T99. A
TIOO. B
TIOI. B
TI02. D
TIOl. A
TI04. B
TIOS. E
Tl06. E
TI07. B
TI08. D
10
The skull can be aligned by simple rotation and translation; deformable fusion is not
required.
Bony anatomy is not a good surrogate to be used in patient setup because it does not follow
the motion of the prostate, which can be influenced by adjacent bladder and rectal filling. A
system of markers which can be followed during treatment would be the best surrogate for
prostate position assessment.
Megavoltage CT-based imaging of patients for setup verification.
This can be true, but it is not always the case.
In IMRT a portion of the field is blocked at any one time, in order to produce dose
modulation. Since the effective field size is always smaller than the total field size
defined by the collimators, the total number of MUs must increase.
All the three techniques of modulated arc require less monitor units and less time for dose
delivery, mostly due to the fact that the dose rate is greatly increased during arc delivery,
and only one initial field setup is needed.
Hot spots in the PTV may be higher than for 3-D conformal plans, although this is not
always the case.
IMRT plans can require 3 to 5 times the monitor units for a conventional plan, so the
neutron leakage dose is a consideration. At 18 MV, the neutron leakage is 0.15%, versus
0.04% at 10 MV However, a higher photon energy will deliver less dose to normal tissue
outside the PTV 10 MV is therefore a good compromise: a good dose distribution and a
low neutron dose.
"Step-and-Shoot" IMRT is delivered using a fixed number of MLC-shaped sub-fields, each
with a fixed number of delivered monitor units, or dose. After each sub-field is treated, the
beam is turned off, the MLC field shape reset, the beam turned on again, and so on.
Because there are a fixed number of sub-fields, the number of intensity levels possible must
be finite. Both methods require more monitor units than conventional treatment, with
"Sliding Window" usually requiring slightly more MUs than "Step-and-Shoot."
Raphex 2010
TI09. B
TIIO. C
Till. E
Tll2. C
Till. A
Tll4. A.
TIIS. E
Tll6. D
Tll7. E
therapy answers
The Winston-Lutz test consists of registering (on radiographic film) the position of the
isocenter under multiple gantry and couch rotations. Verifying that the lasers are aligned with
the isocenter is also very important as lasers are used to position the patient for treatment.
Total uncertainty=

= )4 (0.5)
2
= 1.0.
CyberK.nife is a robotic radiation therapy unit which acquires images of the target to
be treated (in real time) and delivers radiation from multiple directions using a system of
multiple cones which are selected automatically to match the target volume to be treated.
Radiosurgery procedures can be performed with the CyberK.nife.
Some radiation oncologists prefer low dose rate due to the historical data on LDR
treatment of cervical cancer; it is for this reason that "pulsed dose rate" systems were
developed, although they have not enjoyed wide popularity in the United States, partially
due to regulatory issues.
However, with LDR, there is more of a chance that packing will move during an
extended irradiation time, possibly delivering higher doses than expected to the rectum
and bladder. HDR suites are well-shielded and exposure is only to the patient, whereas
LDR patients need monitoring over the span of several days, causing exposure to nursing
and other staff. DVT is more likely when patients are confined to bed for several days. For
HDR, a Schmidt sleeve can be placed following dilation of the cervix, thereby requiring
only one visit to the OR.
The Syed/Neblett or MUPIT applicator allows the use of interstitial needles to treat the
tissues near the cervix, which are too far away from the colpostats or ring applicators to
receive sufficient dose from these applicators alone.
Tll8. B. The half-life of
192
Ir is 74 days. The activity decays by about I% per day. In 14 days it
decays to 35.5 x exp-(0.693 x 14/74) = 35.5 x 0.877 = 31.1 mCi.
Raphex 2010 II
therapy answers
Tll9. C
Tl20. D
Tl21. E
Tl22. C
Tl23. D
Tl24. B
Tl25. C
Tl26. E
Tl27. A
Tl28. B
Tl29. C
12
A/A
0
= 0.420/0.455 = exp-(0.693 x t/60). This gives t = 7 days.
[As a good approximation: the daily decay is exp-(0.693/60), or about 1%.
0.420/0.455 = 0.922, so 7% = 7 days is the best answer.]
It is (112)
5
, i.e., 1132.
Iodine-125 decays by electron capture to an excited state of
125
Te. From this it decays
to the ground state by emission of 35.5 keV gammas. Internal conversion gives rise to
characteristic x-rays that have energies in the range of 27-35 keV.
Average energy= 350 keV.
1251.
Points AR and AL. These points were selected because they are anatomically comparable
from patient to patient, and are in a region of limiting radiosensitivity (at or near the point
where the uterine artery crosses the ureter). The other points are created for dose distribu-
tion evaluation and reporting.
Studies are ongoing to determine the effectiveness and toxicity associated with APBI
versus conventional treatment to the whole breast.
Positrons annihilate with electrons in the patient's body, emitting anti-parallel
0.511 MeV photons.
The Poisson distribution expresses the probability of a number of events occurring in a
fixed period of time if these events occur with a known average rate and independently of
the time since the last event, i.e., the events are truly random. The Poisson distribution
becomes a Gaussian distribution when the mean of the distribution (the mean number of
events within the time period) exceeds 10. However, the Poisson distribution is valid for a
small mean count value. -
Raphex 2010
TllO. C
Till. D
Till. C
Till. D
therapy answers
AAPM has published QA protocols
6
for hyperthermia equipment and planning. The others
still remain a problem.
Air is 800 times less dense than tissue, so a 2-cm air gap will shift the Bragg peak of a
proton beam 2 em further into the underlying tissue. Corrections for 2-crn air are only
a few percent for photon and neutron beams.
6
AAPM Report No. 26, Performance Evaluation of Hyperthermia Equipment, AAPM Hyperthermia Task Group 1
(1989) and AAPM Report No. 27, Hyperthermia Treatment Planning, AAPM Hyperthermia Committee Task Group 2
(1989).
Raphex 2010
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