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diagnostic answers

Just as electrons are held in their orbits by an electron binding energy, the nucleons (protons
and neutrons) are held together in the nucleus by a nuclear binding energy. I n a carbon atom,
the nuclear binding energy can be accounted for by the apparent discrepancy between the true
mass o f an intact carbon atom (12.0000000) and the mass o f the sum o f the components o f a
carbon atom (12.099006). To express the mass deficit i n terms o f energy, multiply by the
energy equivalent o f I amu (931 M e V ) :

B.

D3.

This situation is similar to the scenario described i n Question D l , except instead o f the
production o f a characteristic x-ray, there is the release o f an Auger electron from the M shell.
Emissions o f characteristic x-rays and Auger electrons result from vacancies in inner electron
orbits. Either a characteristic x-ray OR Auger electron (but not both) can be emitted. The
fluorescent yield describes the ratio o f the frequencies o f characteristic x-ray emission relative
to ejection o f an Auger electron. For the specific problem, we begin w i t h the accounting o f
energy described i n D l (above) 69.5 k e V - 11 keV = 58.5 keV. In the case o f Auger electrons,
we must also account for the energy required to liberate the M shell electron (2.5 keV for
tungsten). Hence the energy o f the Auger electron is 58.5 k e V - 2.5 k e V = 56.0 keV.

C.

D2.

C.

Dl.

The energy o f characteristic x-rays is directly linked to the electronic binding energy o f the
electron shells involved i n the transition. Since electron binding energies are unique to each
atom, the corresponding energy o f the produced x-ray is characteristic o f the atom. In our
case, tungsten (chemical symbol = W ) has electron binding energies o f 69.5 k e V ( K ) , 11 keV
( L ) , and 2.5 k e V ( M ) . The energy o f a characteristic energy resulting frorh a L - t o - K electron
transition would therefore be: 69.5 k e V - 11 k e V = 58.5 keV.

0.099006 X 931 M e V = 92.2 M e V


The nuclear binding energy is often characterized by the average energy per nucleon (carbon
has 12 nucleons):
92.2 M e V / 12 = 7.28 M e V / nucleon

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diagnostic answers

D4.

C.

Ionizing radiation can be divided into two broad categoriesparticulate and electromagnetic.
Particulate radiation transfers energy by means of fast-moving atomic or subatomic particles
(electrons, proton, positrons, neutrons). Electromagnetic radiation propagates energy in
discrete (photons) with zero rest mass. The electromagnetic spectrum is illustrated below.
Penetrates Eanh's
Atmosphere?

Radfation Type
Wavelength (m)

Radio
itf

Approximate Scale
of Wavelength
Buildings

Humans

Butterflies

Needle Point Protozoans

f^lolecules

Atoms

Atomic Nuclei

Frequency {H2}
10"
Temperature of
ot)]ects at which
this radiation is the
most intense
wavelength emitted

IK
-272 -C

100 K
-173'C

10,000 K
9,727 X

10"

10"

Itf'

10.000,000 K
-10.000,000 - c

D5.

D.

Linear energy transfer (LET) is a measure of ionization density of a charged particle as it


moves through matter. Massive particles with large net charges deposit energy more
effectively than lighter or lower-charge particles. High-LET particles are more biologically
damaging per unit absorbed dose due to their greater efficiency in producing double-strand
breaks, which are inefficiently repaired by mammalian cells and, thus, more likely than singlestrand breaks to produce demonstrable biological damage.

D6.

A.

The Bragg ionization peak reflects the heightened LET associated with charged particles as
they near the slower velocities at the end of their path length. This peak occurs because the
interaction probability increases as the charged particle's energy decreases. The phenomenon
is observed for all heavy charged particles.

D7.

A.

The bremsstrahlung interaction is the result of energy loss by a charged particle in the vicinity
of the nucleus. High-energy electrons (such as those emitted by Y-90), by virtue of their
smaller mass and negative charge are more likely to approach the nucleus and lose energy via
bremsstrahlung.

R a p h e x 2014

diagnostic answers

D8.

B.

The mass attenuation coefficient of Compton scattering in soft tissue increases with photon
energy from 10 to 35 keV, and then decreases very slowly with photon energy increasing from
35 to 150 keV. Conversely, as photon energy increases from 10 to 150 keV, the mass
attenuation coefficient of the photo-electric effect decreases rapidly. This is illustrated in the
graph below in which the mass attenuation coefficients for photon interactions is plotted
versus photon energy. The crossover point in human tissue (identified by red circle) occurs
around 30 keV (-60 kV depending upon x-ray beam quality). For diagnostic x-rays, Compton
scattering is the more probable interaction above 60 kV and is the dominant interaction for 140
keV and 511 keV photons (corresponding to Tc99m and annihilation gamma-rays associated
with positron emitters such as '^F) in nuclear imaging.
Mass Attenuation Coefficients for Soft Tissue
10
3
1

^Total
/

0.3
0.1

hotoelectric
0.03
0.01

Rayleigh

0.003
0.001

Con pton

10

100

Pair
production >

1,000
Energy (keV)

10,000

D9.

A.

Photoelectric effect is the primary interaction determining contrast between soft tissue and
bone in diagnostic x-ray images. The absorption in bone is greater than that of surrounding
soft tissue since the mass attenuation coefficient of photoelectric effect is proportional to T?
where Z is the effective atomic number of absorbing medium. Because of its calcium content,
the atomic number of bone is approximately twice as much as that of soft tissue.

D10.

D.

The probability of Compton scattering is dependent upon the number of electrons in the
absorbing material which, in turn, depends upon the density of the absorber and the number of
electrons per unit mass. For most elements except hydrogen, the number of electrons per unit
mass is approximately the same; hence, the probability of Compton scattering is independent
of the atomic number of the absorbing material.

DM.

D.

In coherent (or Rayleigh) scattering, the incident photon changes direction but does not
deposit energy. Photoelectric effect, Compton scattering, and pair production all produce
photons and electrons as a result of their energy-depositing interactions with matter.

R a p h e x 2014

diagnostic answers

Diagnostic Reference Levels ( D R L ) are investigafional levels used to identify unusually high
radiation doses for common diagnostic medical x-ray imaging procedures. DRLs are
suggested action levels above which a facility should review its methods and determine i f
acceptable image quality can be achieved at lower doses. DRLs are based on standard
phantom or patient measurements under specific conditions at a number o f representative
clinical facilities. D R L s have been set at approximately the 75th percentile o f measured patient
or phantom data. This means that procedures performed at 75% o f the institutions surveyed
have exposure levels at or below the D R L .

B.

DI4,

By definition, only 50% o f incident photons penetrate a half-value layer ( H V L ) o f an absorber.


A thickness o f 30 cm corresponds to 4 H V L s . Therefore, Vz x
x Vi x '/2 = I / I 6 , or 6.25%, o f
incident fluorine-18 annihilation photons penetrate a soft-tissue thickness o f 30 cm.

A.

D13.

C.

D12.

Regulatory agencies set a m i n i m u m half-value layer for radiographic x-ray tubes for the
purpose o f minimizing the incidence o f non-penetrating (and therefore non-imageable) soft
x-rays upon the patient (see table below). The required m i n i m u m filtration is dependent upon
tube voltage. I n radiography, the H V L should not be too high, since this would decrease the
x-ray output at all energies, requiring a longer exposure time and more opportunity for patient
motion blur. However, interventional fluoroscopy typically can use H V L values significantly
higher than in the table in order to reduce skin dose for long procedures. The first column o f
"Other X-ray Systems" refers to systems grandfathered in by being manufactured before June
10, 2006. The second column o f "Other X-ray Systems" refers to m i n i m u m H V L for all
systems manufactured after June 10, 2006. For 80 k V general radiography systems
manufactured currently, the m i n i m u m H V L required by law is at least 2.9 m m A l . Hence, C is
the answer.
X-Ray Tube Voltage(kilovolt peak)
Designed Operating
Range

Measured Operating
Potential

Below 51

Minimum HVL(mm of aluminum)


Specified Dental
Systems'

30|

1.5
1.5

50|

1.5

401
51 to 70

1.5

Above 70

I-Other X-Ray
Systems^

Il-Other X-Ray
Systems'
0.4

0.4

0.3

0.3
0.5

0.5

1.2

1.3

4.1

150 j

3.8

140|

3.5

130|

3.2

1201

3.0

3.0

110{

2.7

2.7

looj

3.2

2.5

2.5

2.9

2.3

2.3

801
901

2.1

711

1.5

701

1.5

60{

1.3

1.5

1.5

1.8

2.1

2.5

3.6
3.9

3.2

4.3

3.5

4.7

3.8

5.0

4.1

5.4

1 Dental x-ray systems designed for use with intraoral image receptors and manufactured atter December 1, 1980.
S O U R C E : 21CFR1020.30
2 Dental x-ray systems designed for use with intraoral image receptors and manufactured before or on December I .
1980. and all other x-ray systems subject to this section and manufactured before June 10. 2006.
3 All x-ray systems, except dental x-ray systems designed for use with intraoral image receptors, subject to this section
and manufactured on or after June 10. 2006.

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diagnostic answers

I n 2006, the N C R P estimated a typical U.S. resident received an annual effective dose o f 6.2
millisieverts (mSv). The chart below describes the principle contributors.

D.

D16.

Reference air kerma (K^j) is the air kerma accumulated at a specific point in space relative to
the fluoroscopic gantry (the interventional reference point) during a procedure. For an
interventional fluoroscope, the reference point is defined as a point in space 15 cm o f f isocenter on the x-ray tube side o f the imaging chain.
^ does not include scatter from the
patient. It is measured in Gy.
^ is also called reference point air kerma and was formerly
called cumulative dose or cumulative air kerma.

C.

D15.

Internal

Space
(background)
(5 %)

Computed tomography
(medical) (24 %)

(medical) (12 %)

Interventional fluoroscopy
(medical) (7 %)

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diagnostic answers

Molybdenum anode tubes used for mammography produce two relatively intense
characteristic x-ray energies: K-alpha radiation, at 17.9 keV, and K-beta, at 19.5 keV. The
optimum spectrum to produce the best balance between contrast sensitivity and radiation dose
for an average-sized breast is one w i t h most photon energies below about 20 keV. In a typical
mammography machine, a molybdenum filter is used to remove that undesirable part o f the
spectrum. This is an application o f a filter that works on the " K edge" principle. It absorbs
radiation that is above the K-edge energy that corresponds to the binding energy o f the
electrons in the K shell o f the molybdenum atom (20 k e V ) and also lower-energy photons
below about 10 keV.

B.

D21.

The "heel effect" refers to a reduction i n the x-ray beam intensity toward the anode side o f the
x-ray field. Photons directed toward the anode side o f the field travel through a greater
thickness o f the anode, resulfing i n greater attenuation. The heel effect is less prominent for
long source-to-image distance (SID), and it is best to position the cathode end o f the x-ray tube
over the thickest part o f the patient.

A.

D20.

From the line focus principle, the dimension o f the projected focal spot is greatly
foreshortened in the anode-cathode direction at the anode side o f the x-ray field.

B.

D19.

Unlike reference point air kerma, the peak skin dose does account for the contribution o f
backscatter and is reported i n units o f mGy. Peak skin dose is NOT the total amount o f energy
imparted to a patient's skin during the procedurethat is the Dose Area Product ( D A P ) .

C.

DIB.

B.

D17,

Ionization chambers, as the name implies, measure electric charge (or ionizations) produced
by radiation as it passes through bone. Ionization chambers are capable o f directly measuring
exposure i n AIR. The conversion to dose in bone requires application o f a factor (the f-factor)
that is dependent on tube potential i n the range o f diagnostic x-rays (see graph below).

Mutcia

-1
20

1
40

1
60
Photon

1
80
Entfgy

1
1
100
120
(koV)

T 140

Raphex 2014

diagnostic answers

A l l other parameters remaining constant, radiation output o f an x-ray tube increases


approximately w i t h the square o f the kV. In this instance, the radiation output w i l l increase by
about 802 / 602 = 1.78.

C.

D31.

General-purpose and C T tubes are all capable o f being operated at close to 150 kV. The anode
rotation speeds are typically the same for both. The CT tube housing may be somewhat larger
than that o f the general tube. The CT tube must have very high heat capacity (mega heat units)
because the CT scanner may be operated continuously at both high k V and high m A for many
seconds, in contrast to general-purpose systems.

D.

D30.

The components o f the tube housing cannot be removed and, therefore, always provide
intrinsic filtration. Various copper filters can be added to the total filtration in order to harden
(i.e., increase the energy of) the x-ray beam for certain patients.

B.

D29.

The heel effect causes a lower intensity toward the anode side o f the anode-cathode axis, so
the anode should be closer to the upper thorax and the cathode toward the diaphragm to (at
least partially) compensate for the differential attenuation o f the x-ray beam between these two
body regions.

C.

D28.

O f the choices given, bremsstrahlung x-rays higher than 90 keV CANNOT he produced, but
bremsstrahlung x-rays up to 90 keV can be produced. The possible characteristic x-ray
energies69 - 12 = 57 keV, 69 - 2 = 67 keV, and 12 - 2 = 10 keVare determined by the
differences in binding energies between the electron shells.

A.

D27.

The step-up transformer in an x-ray system is required to provide the necessary high voltage
for acceleration o f electrons impinging on the focal spot in order to produce sufficiently
penetrating x-rays. For example, a 220 V line voltage, after being stepped up by an x-ray
transformer w i t h a turns ratio o f 500:1, w i l l produce the resultant peak applied voltage
equivalent to 220 x 1.414 x 500 = 155 kV.

C.

D26.

The maximum permissible exposure rate is stipulated by federal regulation.

B.

D25.

In contrast to a fixed-anode system, by rotating the anode the x-ray beam effectively covers,
and dissipates heat, over a much larger area and volume o f the anode for a given nominal focal
spot, thereby allowing a smaller focal spot size.

A.

D24.

By reducing the physical penumbra, w h i c h is directly proportional to the size o f the focal spot,
image blurring is decreased.

C.

D23.

Characteristic x-rays reflect the atomic structure o f the target material, which is not affected by
parameters such as the k V and mAs.

C.

D22.

Raphex 2014

diagnostic answers

The threshold dose for erythema is in the range o f 2 to 6 Gy. The apparent threshold is wide
due to individual variation in radiosensitivity among patients. There are no scientific studies
documenting skin damage at acute radiation doses below 2 Gy.

C.

D36.

For sparsely ionizing (or l o w - L E T ) radiations such as x-, gamma-, and beta-rays, most cellular
damage is caused indirectly through the creadon o f chemically reactive free radicals o f water
which are " f i x e d " (i.e., prevented from being eliminated). Fixation o f such radiogenic free
radicals is far more pronounced under normal oxygen tensions than under hypoxic conditions.
In fact, the dose o f l o w - L E T radiafions to produce the same biological damage under hypoxic
conditions is 2 to 3 dmes higher than that required under normal oxygenated conditions,
yielding an oxygen enhancement ratio (or OER) o f 2 to 3 for l o w - L E T radiations.

B.

D35.

Relative biological effectiveness ( R B E ) generally increases w i t h increasing ionization density


(or L E T ) because o f the greater efficiency in producing double-strand D N A breaks, as
illustrated i n the figure below. A m o n g the choices, alpha particles have the highest L E T and
the highest RBE.

D.

D34.

B y definition, 1 Bq = 1 dps. Extrapolating to one minute, 3.7 x 10^ dps = 222,000 dpm. The
system yielded a net count rate o f 199,800 cpm for the sample, so the approximate efficiency
o f the detector is 199,800 / 222,000 = 0.9 (90%). 90% efficiency is a common value for lowenergy photons from technefium-99m (140 k e V ) and cobalt-57 (122 k e V ) in a well-calibrated
well counter. As photon energy increases, the intrinsic efficiency o f the detector decreases
dropping below 40% for higher-energy photons like cesium-137 (662 k e V ) .

D.

D33.

A.

D32.

The power rating o f the tube is directly related to the system's ability to handle and disperse
heat. Increasing the focal spot size w i l l increase the dimension o f the accelerated electron
beam and serve to spread the heat load over a wider area o f the anode. Compared to stationary
anodes, the purpose o f a rotating anode is to dissipate heat over a larger target area. Increasing
anode speed w i l l more efficiently dissipate heat compared to a slower anode rotation speed
(see table below). The angle o f the anode determines the area impacted by the accelerated
electrons. A small anode angle concentrates the electron beam on a smaller area o f the anode
and increases heat load. Increasing the anode angle spreads the heat load over a larger area.
Single-phase
700 (0.7 mm)

Three-phase
1050 (0.7 mm)

3600 rpm

1700 (0.7 mm)

1100 (0.7 mm)

3400(1.5 mm)

2300(1.5 mm)

10,800 rpm
3900(1.5 mm)

5800(1.5 mm)

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diagnostic answers

Evidence o f radiation-induced cancer i n human populations has been documented in atomic


bomb survivors, patients undergoing fluoroscopy for tuberculosis, and radium dial painters.

A.

D46.

Although B E I R V I I cites evidence o f radiation-induced genetic effects in studies o f rodents


and fruit flies, to date there is no evidence o f genetic effects i n human study groups.

E.

D45.

Radiation risks for gross malformations are most significant during organogenesis and i n the
early fetal period, somewhat less so i n the 2nd trimester, and the least i n the third trimester.

B.

D44.

Statistically the risk is the same w i t h or without radiation.

E.

D43.

The number o f excess cancer death due to radiation exposure is equal to the (number o f people
irradiated) x (average effective dose received) x (risk factor for the cancer development) or (2
X 10^ people) x (3 X 10~^ Sv) x (5 x 10"^ fatal cancers/Sv) = 300 excess cancer cases.

D.

D42.

I n contrast to single-base damage and single-strand breaks, double-strand D N A breaks are not
efficiently repaired i n mammalian cells, so they tend to persist until the damaged D N A is next
replicated or transcribed. Thus, structurally and perhaps functionally abnormal D N A and R N A
and then proteins, respectively, w i l l likely result. This, in turn, may result i n the death o f the
cell or other biological damage. Pyrimidine dimers are typically associated w i t h ultraviolet,
not ionizing, radiation.

C.

D41.

The most authoritative current estimate o f the lifetime excess cancer risk associated with
exposure to ionizing radiation is 5% per Sv.

D.

D40.

Based on mouse data, the doubling dose for radiation-induced germ cell mutations i n humans
is 1 Gy.

B.

D39.

A m o n g the most exposed population associated w i t h the Chernobyl nuclear reactor accident,
the most notable effect was a substantial increase i n pediatric thyroid cancer. This was most
likely the result o f internal thyroidal exposure associated w i t h ingestion o f iodine-131contaminated m i l k , water, and other foodstuffs.

C.

D38.

The hematopoietic syndrome is one o f three classic acute radiation dose syndromes described
in the literature. The bone marrow is the most radiosensitive organ system due to the presence
o f the hematopoietic stem cells. The majority o f active bone marrow is located i n the spine and
the posterior aspects o f the ribs and pelvis. The hematopoietic syndrome is the primary clinical
consequence o f acute doses between 0.5 and 10 Gy. Healthy adults usually survive doses <2
Gy (with therapy.) Doses >8 Gy are almost always fatal unless aggressive therapy, such as
bone marrow transplantation, is successful. Doses >12 Gy are almost always fatal regardless
o f the therapeutic regimen. LD50/60 is estimated to be 3 to 4 Gy.

A.

D37.

Raphex 2014

diagnostic answers

D47.

LD50 is the dose required to k i l l half the members o f a tested population. When written as
LD50/30 it specifies 50% o f the exposed population w i l l be killed in 30 days.

Scattered radiation levels are typically in the range o f 0 . 1 % (0.001) o f primary entrance skin
dose rate for a collimated beam o f 400 cm^ at 1 meter from the patient. I n this instance:

B.

D49.

The dose to an embryo/fetus during the entire pregnancy due to the occupational exposure o f a
declared pregnant woman must not exceed 5 mSv.

B.

D48.

20 mGy/minute x 0.001 = 0.02 mOy/minute


D50.

The nuclear medicine dose calibrator is an example o f a gas detector operating in the
ionization region. Geiger-Mueller counters are also gas detectors but operate at higher
operating voltages.

1 ^

2: I

/i
Vottage applied-linear scale

A.

D53.

B.

D52.

C.

D 5 I.

A Geiger-Mueller counter operates in the Geiger-Mueller region.

Photon Energy ( l o V )

For chest examinations, an A P radiograph imparts a higher effective dose compared to a PA


radiograph. This is a result o f breast tissue receiving a higher dose for an A P projection.
Effective dose is the product o f equivalent dose and tissue weighting factors. The breast tissue
weighting factor and the higher dose to the breast w i l l result in a higher overall effective dose.

Raphex 2014

10

diagnostic answers

A.

D53.

B.

D52.

C.

D51.

A.

D50.

Scattered radiation levels are typically in the range o f 0.1 % (0.001) o f primary entrance skin
dose rate for a collimated beam o f 400 cm^ at 1 meter from the patient. In this instance:

B.

D49.

The dose to an embryo/fetus during the entire pregnancy due to the occupational exposure o f a
declared pregnant woman must not exceed 5 mSv.

B.

D48.

LD50 is the dose required to k i l l half the members o f a tested population. When written as
LD50/30 it specifies 50% o f the exposed population w i l l be killed in 30 days.

A.

D47.

20 mGy/minute x 0.001 = 0.02 mGy/minute


The nuclear medicine dose calibrator is an example o f a gas detector operating in the
ionization region. Geiger-Mueller counters are also gas detectors but operate at higher
operating voltages.

Vottage applied- linear scale

A Geiger-Mueller counter operates in the Geiger-Mijeller region.

PKoton Energy (HoV)

For chest examinations, an A P radiograph imparts a higher effective dose compared to a PA


radiograph. This is a result o f breast tissue receiving a higher dose for an A P projection.
Effective dose is the product o f equivalent dose and tissue weighting factors. The breast tissue
weighting factor and the higher dose to the breast w i l l result in a higher overall effective dose.

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10

diagnostic answers

B.

D60.

X-ray beams w i t h a higher degree o f filtration are referred to as "higher quality" beams. In the
example above, plot iv has the highest average energy and the greatest filtration o f soft x-rays,
giving it the highest beam quality.

C.

D59.
^

Beam hardening refers to the selective filtering o f lower-energy or "softer" x-rays from a polyenergetic beam. As lower-energy photons are filtered out o f the beam, the average energy o f
the beam increases and the beam is said to "harden."

D.

D58.

Fetal dose estimates from other common diagnostic x-ray procedures are shown in a table at
the Health Physics Society website at https://hps.org/physicians/
radiology_pregnant_patient_qa.html.

C.

D57.

There is no regulatory limit for radiation dose for a patient undergoing a bone scan, but all
imaging procedures should be justified and optimized for dose.

D.

D56.

The total effective dose equivalent to individual members o f the public may not exceed 1 mSv
in a year, exclusive o f the dose contributions from background radiation. A n exception exists
in the case o f individuals administered radioactive material where the annual dose limit may
be increased to 5 mSv in certain situations.

B.

D55.

B.

D54.

Organ and whole body absorbed dose information is available from several sources, including
the radiopharmaceutical package insert (see image below). In nuclear medicine procedures,
patients may reduce absorbed dose to certain organs by drinking fluids and voiding frequenUy.
T a b l e 5. Radiation Absorbed Dose From 1110 MBq {30 mCi) of Technetium Tc99m Bicisate
Estimated Absorbed Radiation Dose^
2.0 Hour Void
4.8 Hour Void
rads/10 mCi
mGy/370 MBq
rads/10 mCi
mGy/370 MBq
Organ
3.77
0.39
4.22
0.42
Bone Surface
Brain
6.11
0.61
6.11
0.61
Gallbladder Wall
27.75
2.73
27.75
2.76
1.41
Intestine Wall (Lower Large)
14.43
16.65
1.65
1.14
10.43
1.06
11.10
Intestine Wall (Small)
18.87
17.76
1.83
1.89
Intestine Wall (Upper Large)
8.21
0.81
0.81
Kidneys
8.10
5.99
0.60
Liver
0.60
5.88
2.22
0.23
0.23
Lungs
2.22
0.66
8.88
0.90
Ovaries
5.99
Red Marrow
0.26
3.00
0.29
2.66
0.24
0.39
Testes
2.44
4.0
3.89
0.39
Thyroid
0.39
3.89
8.10
Urinary Bladder Wall
33.33
3.33
81.03
0.27
2.66
3.22
0.33
Total Body
Dosimetry calculated using the MIRD software program at Oak Ridge Associated Universities, P. 0 . Box
117, Oakridge, TN, 29 July 1988.

II

Raphex 2014

diagnostic answers

Dose rates are usually determined by image noise. Flat-panel detectors require more electronic
gain at the digital video stage than do image intensifiers. The extra electronic noise may be
comparable to fluoroscopic quantum noise at fluoroscopic dose rates. A slightly higher FP
detector dose rate is usually needed to offset this effect for fluoroscopy. This is not a problem
with the higher dose rates used for "spot film" digital imaging. Reducing the "spot film" dose
rate by 75% may increase image noise unacceptably.

D.

D68.

Current N C R P recommendafions l i m i t fetal exposure to 0.5 mSv per month to the fetus for a
declared pregnancy. The radiologist's body badge provides a preliminary estimate o f expected
fetal dose. Her reading o f 3 mSv per year is well below the recommended limit. Additionally,
the dose to the fetus w i l l be reduced by at least o f fact o f two to three due to the attenuafion o f
the radiologist's body.

A.

D67.

For image quality reasons, fluoroscopic systems are usually configured such that the same
image receptor dose is required for 100 fluoro frames, 1 D S A frame, or 10 cine frames.

B.

D66.

The F D A requires the measurement or calculation o f the total air kerma accumulated at a
reference point during a procedure. This point differs for different fluoroscopic geometries,
but it is intended to approximate the locafion o f the patient's skin. Because neither the actual
skin position nor the beam motion during the procedure is known, this value is not skin dose.
Effective dose estimates require a great deal o f additional information that is neither required
by the F D A nor available to the x-ray system.

D.

D65.

When properly performed, the total dose for the tomosynthesis series is about the same as for a
standard digital mammogram. Only the x-ray tube moves, not the flat-panel detector, which is
an area detector different from C T detectors. The typical projection angles for tomosynthesis
are 3 0 degrees.

B.

D64.

The m i n i m u m contrast ratio should be at least 350:1, the m i n i m u m luminance should be 450
cd/mm^ (and preferably 600 cd/mm^), and the monitors must be approved by the F D A .

B.

D63.

The image shown in the question is an "ideal" radiographic image o f the American College o f
Radiology ( A C R ) mammography accreditation phantom.

C.

D62.

B.

D61.

The left-hand spectrum w o u l d be used for mammography o f women w i t h smaller/thinner


breasts while the right-hand spectrum would be used for mammography o f women with larger/
thicker breasts. Both x-ray spectra are used for mammography, their lower energies providing
higher tissue contrast while still being sufficiently high for adequate penetrafion through
breasts. However, the right-hand spectrum is better suited for mammography o f women with
larger/thicker breast because o f its slightly higher energies and tissue penetrability.

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Raphex 2014

diagnostic answers

C T has inferior spafial resolution and superior image contrast when compared to x-ray
radiography. The contrast resolution o f film screen radiography is 5%. The contrast resolufion
o f C T is 0.5%. CT's superior contrast resolution can be traced to its high signal-to-noise ratio
(SNR). SNR is directly tied to dose levels. I f one attempts to improve C T spatial resolution by
decreasii!g the pixel size, the SNR w i l l decrease.

D.

D74.

Increasing the slice thickness w i l l decrease image noise as well as spatial resolution.
Increasing slice thickness w i l l also increase the effect o f partial volume averaging. Partial
volume averaging is an imaging artifact. The C T number is proportional to the average
attenuation within a voxel. I f a voxel contains only one type o f tissue, the attenuation
coefficient (and hence the C T number) w i l l represent the tissue fairly well. I f the voxel
contains a mixture o f tissues (i.e., bone and soft tissue) the linear attenuation represents more
o f a weighted average. The probability o f partial volume averaging increases w i t h slice
thickness and is more profound for softly rounded anatomical structures parallel to the CT
slice.

C.

D73.

In mulfi-detector helical C T imaging, the detector pitch is defined as table movement (mm)
per 360 rotation divided by detector w i d t h ( m m ) . Table movement ( m m ) per 360 rotation
divided by collimator width at isocenter ( m m ) is collimator pitch. Pitch is typically in the
range o f 0.5-1.5 for clinical imaging protocols. Pitch values less than 1.0 result in overscanning o f the patient, which can improve image quality but w i l l also result in higher patient
dose. Pitch values greater than 1.0 result in partial scanning o f the patient and are associated
w i t h lower patient doseprovided the kV, the m A , and rotation time (or effective mAs)
remain constant. In automatic exposure modes using m A modulation, changing only the pitch
does not change the patient dose.

A.

D72.

Many newer fluoroscopic systems add Cu to the beam while adjusting the k V and mAs to
maximize the fraction o f photons just above the iodine K absorption edge (37 kEv). Increasing
k V w i l l reduce patient dose at the expense o f decreasing iodine contrast. Reducing k V w i l l
increase iodine contrast (to a point) at the expense o f greatly increasing patient dose.

B.

D71.

A low dose image w i l l be noisier but still maintain spatial resolution.The x-ray tube focal spot
size and examination magnification factor combine to produce penumbra unsharpness which
w i l l limit high-contrast resolution. The active field size at the image receptor and matrix size
combine to produce an effective pixel size which w i l l also limit high-contrast resolution.

C.

D70.

The active detector in fluoroscopic systems is usually a layer o f Csl that is similar in thickness
to the input layer in a modem image intensifier. Dose rates and image noise w i l l be similar in
the case where quantum mottle dominates the image. A g B r is found in radiographic film, N a l
in gamma cameras, and ZnCds in first-generation image intensifiers.

B.

D69.

Raphex 2014

13

diagnostic answers

C.

D78.

B.

D77.

B.

D76.

C.

D75.

C T D I ^ o i is an estimate o f dose in air measured w i t h i n a cylindrical acrylic phantom (which is


much different than an actual patient) and is not a direct measure o f patient dose. C T D I ^ Q I is
measured by placing a calibrated ionization chamber in either a 16 or 32 cm diameter phantom
and exposing the chamber to a single scan. CTDIypi is the result o f a chain o f C T dose metrics,
beginning w i t h the measurement o f a parameter called the C T D I , Q O . C T D I I Q O is measured by
placing a 100 m m ionization chamber in an appropriate phantom. Since CTDIjoo values are
influenced by the position o f the ion chamber within the phantom (peripheral vs. central
location) the values measured must be modified to derive a weighted C T D I w . Finally, the
CTDIyoi is estimated by dividing C T D I ^ by the pitch.
The Dose Linear Product ( D L P ) is another dose metric employed in CT. The D L P is related to
an estimate o f the total amount o f energy delivered by the x-ray tube during the entire study.
The D L P is calclated by m u l t i p l y i n g the CTDIy^i by the scan length and is reported in units o f
mGy X cm^. Both C T D I ^ Q I and D L P are indicators o f radiation exposure and are N O T
calculations o f patient dose.

CTDIVO1 = C T D I W / p i t c h

CTDIyQi is directly proportional to tube rotation time and tube current.

The relationship between variable C T acquisition parameters and dose quantity estimates is
detailed i n the chart below:
Relationship between Variable Paraineters and Dose Quantities
Increasing

Raphex 2014

14

D79.

C.

diagnostic answers

Automatic Exposure Control ( A E C ) describes a family o f features capable o f modifying


patient dose while maintaining image quality. A E C features include:

angular tube current modulation


longitudinal tube current modulation
EKG-based tube current modulation
organ-based tube current modulation
automatic tube potential selection
Organ-based tube current modulation is an A E C feature that allows for the tube current to be
decreased or turned o f f over radiosensitive organs on the patient periphery, such as the breasts or
eye lenses. To maintain image quality, tube current may need to be increased at other view angles.
The use o f organ-based tube current modulation may reduce the absorbed dose to organs at the
surface o f the body, but i t may increase the absorbed dose to other organs.

B.

D83.

C.

D82.

B.

D8I.

A.

D80.

'.y
'

j*^

Both images are from the same scan. The image on the left was obtained with a window/level
setting o f W = 600, L = - 1 0 0 to give a view o f all the different tissues, while the one on the
right had W = 700, L = - 6 5 0 mainly showing the difference between the low-densify lungs and
the higher-density soft tissue and bone.

Lateral resolution is dependent on beam width. For both linear and curvilinear transducers, the
beam width changes w i t h depth in the near and far fields. Therefore, lateral resolution is
directly dependent on depth. The frequency should be adjusted accordingly when imaging in
order to focus directly on the organ o f interest.

A.

D88.

The half value thickness is defined at the tissue thickness that reduces the intensity o f the
ultrasound beam by 50%. Using the relationship attenuafion (dB) = -101og(Iin/Iout) and
setting the intensity ratio to 0.5, the decibel reduction is equal to 3 dB.

B.

D87.

C.

D86.

D.

D85.

B.

D84.

R a p h e x 20 i 4

15

diagnostic answers

C.

D92.

In 1992, the F D A set the limit for all ultrasound imaging to 0.72 W/cm^. However, most
modem ultrasound units operate under O.I W/cm~. As indicated above, there are some special
procedures that exceed 0.1 and subsequently have time restraints. It is mandated that for
higher intensity outputs, manufacturers are required to indicate both thermal and mechanical
indexes to ensure safety.

A.

D91,

The calculation o f blood velocity shows that velocity is inversely proportional to the cosine o f
the angle. A n angle o f 90 degrees w i t h respect to flow w i l l not produce and image. A n angle o f
60 degrees w i l l give and error close to 10%, and 45 degrees w i l l give an error close to 5%.
Ideally, the transducer w i l l be placed in parallel, 0 degrees, w i t h the direction o f flow giving an
error o f less than 0.2%. In clinical practice, the angle ranges from 15 to 25 degrees to keep the
error w i t h i n 3%.

D.

D90.

The thyroid is a superficial organ and thus requires less depth o f penetration. Because there is
an inversely proportional relationship between frequency and depth ( f = v/A.), the thyroid
w o u l d require a much higher frequency (between 12 to 15 M H z ) and smaller wavelength in
order to be imaged. Conversely, the abdomen w i l l require greater penetration, so the frequency
is closer to 4 M H z w i t h a longer wavelength.

A.

D89.

<

The RF power needed to achieve a given flip-angle increases w i t h the field strength o f the
magnet. Therefore the power deposited i n the pafient w i l l increase i f a given pulse sequence is
simply used with identical parameter settings on a 3T scanner. The RF pulse amplitudes and
durations, as well as the T R values, may need to be adjusted in going from a 1.5 T to a 3.0 T
scanner. The field-of-view achievable does not depend on magnetic field strength; it depends
on gradient field strength. T l values increase w i t h magnetic field strength and, therefore, T l
contrast properties w i l l change at 3.0 T.

Navigator techniques use a rapid projecfion image to track a moving part o f the body such as
the diaphragm and prospecfively trigger or retrospectively reconstruct the data to reduce
motion artifacts. Diffusion weighfing and inversion recovery are techniques used to obtain
certain types o f contrast. Cardiac gating reduces cardiac motion.

D.

D96.

A n increase i n T R is not needed for parallel imaging. Data about the coil geometry and
sensitivity profiles provided by the calibration scan are incorporated in the data reconstmction.
This reduces the number o f phase encoding steps needed. B y reducing the number o f phase
encode steps i n a fast spin-echo sequence, parallel imaging permits shorter effective echo
times.

A.

D95.

B.

D94,

D.

D93.

A device which is MR-safe at 1.5 Tesla is not necessarily safe at 3.0 Tesla. Written
documentation should be obtained from the manufacturer or implanting physician that the
device has been tested and found safe at 3.0 T. Being undetected by a metal-detector does not
ensure a device's safety.

16

Raphex 2014

diagnostic answers

Nephrogenic systemic fibrosis is a rare condition characterized by the formation o f connective


tissue in the skin, which becomes thickened, coarse, and hard, sometimes leading to
contractures and j o i n t immobility. There is much evidence to suggest that it is associated with
gadolinium-based M R I contrast agents and occurs only in patients w i t h advanced kidney
dysfunction.

B.

D103.

The artifact shown above is phase wrap around or aliasing artifact and occurs mainly in phase
encoding direction. Aliasing in M R l occurs when the field o f view ( F O V ) is smaller than the
body part being imaged. The part o f the body that lies beyond the edge o f the FOV is projected
onto the other side o f the image. To remedy this artifact, phase F O V needs to be increased
beyond the anatomy-producing signal or fold over suppression techniques in phase encoding
direction should be used.

D.

D102.

F L A I R images are T2 weighted images w i t h CSF suppression. T l o f CSF is long


(approximately 3300 ms). B y carefully choosing the inversion time ( T l ) , the signal from any
particular tissue can be nulled. The appropriate T l depends on the tissue via the formula
T l = ln(2) x T l o f tissue to be nulled (approximately 70% o f T l o f tissue to be nulled).

E.

D101.

The phase contrast (PC) image provides a method o f quantifying flowing blood through
vessels. B y measuring the phase shift that occurs as protons in the blood move through a
magnetic field, the velocity and direction o f the blood can be obtained. In PC imaging,
stationary tissue appears gray, w i t h tissue moving through the plane appearing as shades o f
either white or black, depending on the direction.

D.

D100.

Matrix = 256 x 128 w i l l increase SNR by factor o f V2 or 1.41 times original SNR, and
increasing number o f acquisitions from 2 to 4 w i l l increase SNR by an additional V2 Net
SNR increase w i l l be 2 times original SNR. A ) would reduce voxel size and thus SNR. B )
would reduce voxel size by a factor o f 4 and thus SNR by a factor o f 4, while increasing
acquisitions from 2 to 4 would only increase SNR by V2, so there would be a net SNR
decrease. C) would halve the number o f acquisitions and thus reduce SNR by a factor o f V2
or 0.707 times original SNR.

D.

D99.

Short T E minimizes T2 contrast and long T R minimizes T l contrast, resulting in a proton


density weighted image. A ) w i l l be T2-weighted due to long T E . C) w i l l be T l weighted due
to short TR. D ) w i l l be T l and T2 weighted.

B.

D98.

SS-EPI is motion insensitive because the image is acquired in a millisecond. Therefore it is


effective for diffusion-weighted imaging which images the diffusion o f water. Acquisition o f
all echoes in one shot results in a long effective echo time and limits the number o f phase
encode steps, resulting in relatively coarse spatial resolution. {Source: Yoon, Y. C , H . W.
Chung, and J. H . A h n . " M R Imaging o f Stable Posterior Cruciate Ligament Grafts in 21
Arthroscopically Proven Cases." Korean J. Radiol. 8:403-9, 2007.)

C.

D97.

Raphex 2014

17

diagnostic answers

A radioactive material administered to a patient is eliminated from a tissue or organ o f the


patient by the simultaneous processes o f radioactive decay (with physical half-life T^) and
metabolism, secretion, excretion, etc. (with biological half-life 7\,). The overall elimination o f
the radioactivity is more rapid than i f it were eliminated only by radioactive decay or only by
biological processes, and the resulting effective half-life (Tg) is given by the following
formula:

B.

D108.

Yttrium-90 is used in the form o f microspheres for radioembolic therapy o f liver tumors. It is
highly energetic and, therefore, penetrating beta rays make it well suited for internal
irradiation o f bulky liver tumors. A commonly used rule o f thumb is that for a beta rayemitting radionuclide, the average emitted beta ray energy is 1/3 o f the maximum emitted beta
ray energy. For yttrium-90, therefore, w i t h a m a x i m u m emitted beta ray energy o f ?????, its
average beta ray energy is (1/3) (2.3 M e V ) = 0.77 MeV.

C.

D107.

Malignant lesions are more vascular and, as a result, enhance more rapidly than benign
lesions. In general, fast contrast uptake and fast washout is a characteristic o f malignant breast
lesions.

B.

D106.

Magnetic field inhomogeneity and aliasing. Superposition o f signals from different phases
causes alternate adding and canceling o f signal to produce the banding pattern. This is seen
mostly in gradient echo.

C.

D105.

Susceptibility weighted image ( S W I ) contrast utilizes the fact that magnetic susceptibility
differences between venous and arterial blood w i l l cause differences in phase image. The
susceptibility weighted image is created by combining the magnitude and filtered phase
images to highlight this susceptibility difference.

C.

D104.

TT,
T =
'
T+T
p b
For iodine-131 i n the body w i t h T^ = 8.04 days and T^ = 2.0 days, 7; is:

(8.04) (2.0) , _ ,
r =
= 1.60 days
'
8.04 + 2.0

18

R a p h e x 2014

E.

D I 10.

A.

D109.

diagnostic answers

A l l radioactive shipments must be identified as such w i t h the appropriate Department o f


Transportation ( D O T ) label. I n order o f increasing exposure rate measured at 1 meter from a
radioactive package, the appropriate labels are k n o w n as "White I , " "Yellow 1," and "Yellow
I I . " " W h i t e - I " packages actually produce an immeasurably low exposure rate at 1 meter. This
is the case for a pure beta-emitter such as Sr, and so a " W h i t e - I " label would be appropriate
for Metastron. The other radioactive shipments specified are all relatively high activities o f xand gamma-ray-emitting radionuclides, and this would yield a non-zero exposure rate at 1 m ;
they would, therefore, require either a " Y e l l o w - I I " or " Y e l l o w - I I I " label.
yellow
backgrounds

1
V

Integral uniformity ( l U ) is a commonly used parameter to characterize the uniformity o f


gamma-camera response based on a flood image. Integral uniformity ( l U ) is defined as
follows:
_ Maximum

counts per pixel-Minimum

Maximum counts per pixel-\-Minimum

counts per pixel


counts per

|QQ^

pixel

For the image matrix shown, the m a x i m u m and m i n i m u m counts per pixel are 1,140 and 870,
respectively. The integral uniformity is therefore:
-

1140-870 ^ j ^ ^

-^r^

1140 + 870
= 13%
A n l U o f 13% is actually much too large for clinical imaging. Gamma camera lUs should be
less than 5%.
DIM.

E.

The M T F gives a rich description o f spatial resolution, and it is the accepted standard for the
rigorous characterization o f spatial resolution. It is often useful to have a single number value
that characterizes the approximate resolution limit o f an imaging system. This number is
called the limiting spatial resolution The limiting spatial resolution is often considered to be
the frequency at which the M T F crosses the 10% level. I n the figure above the limiting spatial
resolution is 4.25 cycles/mm.

Raphex 2014

19

diagnostic answers

In mammography, compression is essential as it reduces thickness o f breast in x-ray beam,


producing less scatter and reduced pafient dose. It also decreases magnificafion as the breast is
closer to the detector. Immobilizing the breast minimizes any mofion.

E.

DM9.

Breast tomosynthesis is a 3 D imaging technique which acquires projecfions o f stafionary


compressed breast in a short scan time and doses similar to conventional mammography.
High-resolution images are reconstructed from these projection images at different depths in
the breast. Breast tomosynthesis is extremely helpful in detecting low-contrast lesions
(masses) missed in dense breast due to overlapping o f tissues structures in conventional
mammography.

B.

DM8.

To pass M Q S A image quality standards for screen-film mammography, at least 4 fibers, 3


calcification groups, and 3 masses must be clearly visible at an average glandular dose o f less
than 3 mGy.

E.

DM7.

M Q S A limits the average glandular breast dose to 3.0 m G y per exposure for phantom
simulating a standard breast (compressed breast w i t h thickness o f 4.2 cm w i t h 50% adipose
and 50% glandular tissue). Typical average glandular dose per view is 1.5 to 2.2 mGy.

D.

DM6.

Risk o f carcinogenesis from radiation dose is a concern in screening mammography. I n the


breast, the glandular tissue is the principal site o f carcinogenesis, so dose to glandular tissue is
dose that is legally required to be measured. Average glandular dose is the dose index used in
mammography which approximates dose to glandular fissue. It is given by A G D = D g ^ x
Xgsys^^l^ where D g ^ (in units m G y average glandular dose per m G y incident air kerma) is the
A G D conversion fraction and Xggys^]^ is the entrance skin air kerma in mGy.

D.

DM5.

The transport index ( T l ) o f a radioactive package is defined as the exposure rate in


milliroentgen per hour (mR/hr) measured at 1 meter from the surface o f the package. For a
package yielding an exposure rate o f 0.006 R/hr, or 6 mR/hr, at 1 m , the transport index is
therefore 6.

D.

DM4.

For a controlled (or restricted) area, such as a radiopharmacy, radiation surveys ( o f ambient
radiation levels) must be performed daily. For unrestricted areas, such as a waiting room,
radiations surveys are required weekly.

A.

DM3.

For an intrinsic gamma camera uniformity ("daily flood") measurement, the collimator is off
the detector. To approximate a "point" source, the volume o f Tc99m solution used as the
source should be -0.5 m l or less. The activity o f the Tc99m source should be 0.5 to 1.0 m C i .
To adequately simulate a uniform " f l o o d " source, that is achieve a uniform radiation flux over
the entire field o f view, the m i n i m u m source-to-detector distance is 3x detector diameter (or
the maximum detector dimension).

D.

DM2.

20

Raphex 2014