RADIOLOGICAL PHYSICS Raphex~ Preface “% The RAPHEX 2001 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 of RAPHEX exams/answers from three consecutive years should cover most topics. We hope that residents will find these exams useful in reviewing their radiological physics course. RAPHEX 2001 Committee Copyright © 2001 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 1-800-442-5778General <- Answers Gl. G2. G3. G4. GS. G6. G7. G8. G9. G10. GIl. G12. G13. Gl4. The f factor, also known as the “roentgen-to-rad” conversion factor is 0.871 in air, under conditions of electronic equilibrium. For media other than air, it varies with photon energy and effective Z. For water at 1 MeV, f= 0.970. Exposure, the ability of photons to ionize a mass of air, is only defined for photons below 3 Mev, and not for particulate radiation. The absorbed dose resulting from an exposure of 100R depends on the photon energy, and the effective Z of the absorbing material, which is higher for bone than muscle. The SI unit is C/kg. 1 Gy = 1 J/kg. 1 Bq = 1 disintegration/sec C/kg is the SI unit. 1R = 2.58 x 10 C/kg in air. 1 Sv = 1 Gy x Q where Q is a quality factor which depends on the type and energy of the radiation, and its RBE. LET, linear energy transfer, depends on both mass and energy. Isobars have equal A, but different numbers of protons and neutrons. In beta minus, n > p + 6” In beta plus, p > n + B*. Thus A is constant, but Z differs between the daughters. Raphex 2001General +* Answers * GI5. C The number of neutrons in the nucleus is the mass number A (238) — the atomic number Z (92). GIi6é. A This is the definition of electron binding energy. GI7. C The difference in mass between a deuteron (2.01355 amu) and its components, a proton (1.00727 amu), and a neutron (1.00866 amu) is 0.00238 amu. This is equivalent to 0.00238 x 931.2 MeV = 2.22 MeV. GIs. B The nth shell can contain a maximum of 2n’ electrons, but no shell can contain more than 8 if it is the outer shell. The shell filling is as follows: Z K shell L shell M shell N shell Sulphur 16 2 8 6 Chlorine 17 2 8 7 Argon 18 2 8 8 Potassium 19 2 8 8 1 G1I9. D The number of decays per unit time is the activity. G20. B 1/Teff = 1/Tp + 1/Tb = (1/6 + 1/12.5) = 0.247. Teff = 4.05 hrs. Note: Teff is shorter than Tp or Tb alone. G21. B At = Ao exp — (0.693 x T / T,,2) 0.001 = exp — (0.693 x T / 60) T = 598 days (approx. 10 half-lives). G22. A Activity 3 days earlier = 4.0 exp (0.693 x 3 / 14) =4.64 mCi G23. D After 4 half-lives the source decays to (1/2) times its original activity. (1/2) = 1/16 = 0.0625 G24. A In alpha decay, the mass number decreases by 4. In the other decays listed, a proton changes to a neutron, or vice versa, so A remains constant. G25. B The neutron changes to a proton plus an electron, and the electron is ejected as B-. 2 Raphex 2001General < Answers “ G26. D In beta decay the energy is shared between the electron and the anti-neutrino. The sum of their energies is the same, but each may have any energy from zero to the maximum energy available. Alphas and gammas are emitted with discrete energies. G27. E Both electron capture and beta plus decay (which can compete in the same nuclide) reduce Z by 1 and increase the neutron number by 1. G28. E In beta decay and electron capture the daughter nucleus can be created in an excited state. Decay to the ground state is then accompanied by emission of the excitation energy in the form of one or more gammas. If the daughter has a measurable lifetime, (e.g., Tc-99m), this is called an isomeric transition. G29. D Internal conversion is an isomeric transition. Energy can be emitted as a gamma, or transferred directly to an inner shell electron. In the latter case, the electron is emitted leaving a vacancy, which is filled by an outer electron. This is accompanied by characteristic radiation and auger electrons. G30. A Radionuclides decay in order to gain greater stability, and increase the BE per nucleon. The value is highest for intermediate values of Z. G3l. D Positrons combine with electrons in the patient and emit two annihilation photons of 0.511 MeV, in opposite directions. These are detected by coincidence counters. G32. B Adding neutrons to the nucleus results in too many neutrons for stability. The neutron changes to a proton and a 8’, which is emitted. The daughter nuclide may be in an excited state, and emit gammas. An example of this is Co-60. G33. C Too many protons in the nucleus favors beta plus decay, in which a proton decays to a neutron and a positively charged electron. G34. C Cs-137 is one of the many radioisotopes produced when uranium reactor fuel rods undergo fission. G35. A An example is Ra-226 — Rn-222. The half-lives are 1620 years and 3.8 days respectively. G36. B An example is Mo-99 — Tc-99m. The half-lives are 67 hours and 6 hours respectively. G37. B 1 Ci =3.7 x 10!° Bq. Thus 10 mCi = 3.7 x 108 Bq = 3.7 x 10? MBq. Raphex 2001 3General °, ° + Answers G38. E Amu stand for atomic mass unit. G39. Exposure rate = Exp. Rate const. x Activity x 1/d? = 3.3 R.cm?/mCi.h x 10 mCi x (1/1007) cm = 3.3 mR/hr G40. The process whereby a filament is heated to a sufficient temperature to emit electrons is called “thermionic emission”. G4l. G42. G43. G44. G45. A, B, and E all affect the shape of the spectrum, but the maximum photon energy is equal to the kVp applied across the tube. G46. For a monochromatic beam two HVLs would reduce the intensity to 25%. However, for a broad spectrum the beam becomes hardened as it passes through the filtration, making the 2nd HVL greater than the Ist. G47. Filtration changes the shape of the spectrum, tending to filter out more low- than high-energy photons. G48. The first HVL reduces output from 200 to 100, and is 2.5 mm. The second HVL reduces output from 100 to 50, and is 6.0 — 2.5 = 3.5 mm Al. G49. If 1 mm Al is added to the beam, the initial output is 142. To reduce this to 70 requires an additional 3 mm Al. G50. For HVL measurement, only the primary beam should be measured. With a broad beam the detector will record scattered radiation also, which will give an incorrect HVL value. 4 Raphex 2001General <- Answers “ GSI. G52. G53. G54. G55. G56. G57. G58. G59. G60. G6l. G62. G63. X-rays have the highest energy of the components of the electromagnetic spectrum listed. Note: Ultrasound is a sound wave, and not part of the EM spectrum. Radiowaves have the lowest energy and frequency, hence the longest wavelength. The radiation must have sufficient energy to ionize atoms in the film emulsion. The only difference between x-rays and gamma rays is their origin. After emission, they are indistinguishable. By the inverse square law: Ij; / Isp = 50? / 75° Thus I,; = 4.4 R/min. The mass energy absorption coefficient is the linear attenuation coefficient divided by the density (i.e., attenuation per unit mass rather than per cm.) The mean attenuation length is the linear attenuation coefficient x 1.44. In this case the HVL is x cm. pt = 0.693/HVL. The probability is proportional to Z’. (60/6) = 1000. The photon is most likely to undergo a photoelectric interaction when its energy is just above the binding energy of the electron. The energy of the photon is totally absorbed by the electron, which uses 4.4 keV to overcome its binding energy, leaving 3.6 keV as the energy of the emitted photoelectron. In Compton interactions, interaction at any angle other than grazing incidence leads to a significant transfer of energy to the electron. That is why the energy of scattered radiation from a megavoltage beam is significantly lower than that of the primary beam. Electrons cannot be backscattered. They can only be scattered at angles between 0 and 90° to the direction of the incident photon. The threshold energy for pair production is 2 m,c? = 1.02 MeV. The electron and the positron share the photon energy less 1.02 MeV. When the positron loses its kinetic energy and annihilates with an electron, two 0.51MeV photons are emitted in opposite directions. Raphex 2001General “+* Answers *? G64. G65. G66. G67. G68. G69. G70. G7l. G72. G73. G74. G75. G76. Compton scattered photons decrease the contrast by increasing the level of background fog. Compton is actually most probable for monoenergetic photon energies between 25 kV and 25 MV. Coherent scatter (also known as Raleigh or unmodified scatter) occurs only at very low photon energy, and is of little concern in radiology. The probability of a Compton interaction depends on the number of electrons per gram, which is roughly the same for all elements except hydrogen. Alphas have the highest linear energy transfer (LET) because of their larger mass and charge. A neutron is most likely to interact with hydrogen, which has a similar mass. Optical density (OD) = log (incident intensity / transmitted intensity) = log (1/0.1) = log10 = 1.0. If a large number of measurements are made, approximately 67% will fall between +o, and 96% between +26 of the mean. The standard deviation o = VN, or 50 in this case. 2500 + (2 x 6) = 2400 — 2600. 100 mrem = | mSv Dose equivalent (H) = Dose (D) x Quality factor (Q) Q for neutrons is 20 Out of a total of about 3.6 mSv, nuclear medicine contributes about 0.14 mSv, and the others all contribute about 0.3 to 0.4 mSv each. Radon contributes about 2 mSv to the average annual effective dose equivalent. Raphex 2001General < Answers G77. G78. G79. G80. G8l. G82. G83. G84. G85. G86, G87. G88. G89. The current value is 5 x 10 per Sv. (See BEIR V: Biological Effects of Ionizing Radiation Committee of the National Academy of Science.) The latent period is 20 to 30 years. In early organogenesis the organ buds consist of a few cells, and the loss of some of these can result in a major defect which may not be apparent during gestation, but after birth is too severe to permit independent life. It is questionable whether the fetus is in a hyperoxygenated state. Even if it is, there is little evidence that hyperoxygenation increases radiation damage. Film badges cannot measure exposures below about 20 mR. Placing filters over parts of the film allows one to estimate the proportion of dose due to x-rays in different energy ranges. Heat, e.g., exposure to intense sunlight, can cause film blackening. See NCRP report 116 (1993). See NCRP report 116 (1993). 0.5 mSv per month, or approximately 5 mSv (0.5 rem) for the whole period of gestation is the dose limit recommended by NCRP report 116. 2 HVLs will reduce the dose by a factor of 2? = 4. The use factor can be difficult to calculate, so standard fractions can be used for the walls and floor. Workers can receive up to 100 mrem/week. The acceptable level for continuous or frequent exposure of members of the public is 100 mrem/yr = 2 mrem/wk = 0.05 mrem/hr, assuming a 40-hr work week. To reduce 2 to 0.05 requires 2 TVLs, i.e., a factor of 1/107. The temperature-pressure factor correction factor is: [(273 + T)/295] x [760/P] In this case: [(273 + 18)/295] x [760/750] = 1.0 Raphex 2001General ~* Answers * G90. D The advantage of a geiger counter is its sensitivity. The ionization of a single event is magnified, due to gas multiplication, into a measurable signal. Its disadvantage is that it can read zero in a high-intensity field. The high Z of iodine makes it highly sensitive to low-energy radiation. This is because of the Z dependence of photoelectric interactions. To locate a dropped seed, one needs a portable detector with an instantaneous readout. The scintillation probe will give a much higher reading (as would a geiger counter) than an ionization chamber, due to its greater sensitivity. Very low concentrations of radioactive materials, if ingested, can produce high localized radiation doses to internal organs. If the packaging material reads background, it can be disposed of as regular trash, provided all radioactive warning labels have been removed or obliterated. G9l. D G92. EF G93. A G94. B 8 Raphex 2001Diagnostic “ Answers‘ DiI. C The probability of an incoherent scattering interaction (Compton) is essentially independent of the photon energy. The actual ratio is 1.08. D2. E Mammograms and chest X-rays are typically performed at 25 kVp and 100 kVp respectively. The mass attenuation coefficient of Ca decreases rapidly over this energy range due to the decline in its photoelectric component. The mass attenuation coefficient of soft tissue does not change dramatically over this range. D3. D The linear attenuation coefficient of CO, is significantly lower than tissue because the physical density is much less. The mass absorption coefficients (attenuation per gram) and K edges are very similar. D4. B D5. A D6. E D7. E Virtually all of the electrical energy heats the anode at diagnostic x-ray energies. D8. A Penumbra, caused by a finite focal spot, increases with magnification. Eventually this dominates the image. The grid, H&D curve, and size have no effect on magnification. The receptor’s MTF becomes less important as magnification increases. D9. B An example is microcalcifications on mammography. DIO. A Flood replenishment uses timed replenishment to stabilize the processor in low film volume situations. It requires the addition of starter to the developer replenishment tank, which may not result in optimum processing of film. It does not involve daily draining. DIl. C A high base+fog (normal is <0.25) can be from contaminated developer, high developer temperature or film fogged during storage or handling. DI2. B The blue sensitive film is effectively slower than the proper green-sensitive film, so the net result will be lowered noise and higher patient dose. MTF is not affected. Raphex 2001 9Diagnostic + Answers “ DI3. D14. DI5. DI6. DI7. DI8. DI9. D20. D2I. D2z2. D23. A Focal spot size is unimportant in a contact radiograph. A hand will not generally have motion blur due to short exposure time. Film grain size is much smaller than the spread of light in a thick screen like a 400 speed system. The fastest film will give the highest noise (smallest number of x-ray photons used) while the thinnest screen will give the highest resolution (smallest light spread in phosphor). 30% is absorbed in the first screen, 70% passes through. The second screen absorbs 30% of that 70% (or 21%). Total stopped is 30% + 21%. 70 mrem is generally too low for an AGD, meaning a fast (noisy) screen-film system is being used. It would also imply a short exposure time and possibly an underexposed film. A-D are advantages of good compression, but magnification decreases since patient to image receptor distance decreases. Although the AGD is decreased by raising the kVp, the main resaon for increasing kVp is to reduce exposure time, and hence motion blurring. The rule of thumb is to try to keep the exposure time between 1 and 2 sec. Placing the AEC sensor under the densest portion will reduce problems with underpenetration. All portions of the image should have an OD above 1.0. Reviewing previous films helps to position the sensor. Only changes in x-ray beam and scatter affect subject contrast. The other items affect film contrast. Focal spot size has no effect on contrast All these items can cause artifacts on the film, but white specks are due to either dust on the screen or processor roller pick-off. The table-top exposure of a properly operated fluoroscopic unit is between 1 and 5 R/min. For protection purposes an R is equivalent to a rem (for x-rays). The 5 rem limit will be reached in less than 5 min. Conversion gain is related to brightness gain, which is the product of minification gain and flux gain. In the 6” mode, the minification gain decreases. Quantum mottle remains about the same. The automatic brightness control boosts the radiation level in magnification mode, to maintain brightness, and in doing so boosts patient dose. Spatial resolution improves because of apparent magnification. Raphex 2001Diagnostic ¢ Answers‘? D24. B D25. B D26. A D27. D D28. A D29. D D30. A D3!I. D D32. B D33. A D34. D D35. D Raphex 2001 I represents x-ray photons transmitted through the patient, and includes a large number of scattered photons. II represents x-ray photons transmitted through the grid, with much of the scatter removed. III represents light photons produced in the image intensifier phosphor. IV represents electrons produced in the image intensifier photocathode. V represents light photons produced in the output phosphor. Vertical resolution = (Kell factor x #lines) / (2 x FoV) in mm. The FoV is decreased and the patient dose is increased. Overframing has no clinical effect on shape or framing rate. Measured slice width is always greater than nominal for 5 mm slices, and helical slice width is greater than axial for pitch 1 due to the interpolation algorithm which averages in data from more than 1 collimation width. The big advantage for multiple slice units is the collection of more than 1 slice of data per rotation, thus reducing total study time and total heat produced by the factor of the number of slices collected per rotation. Thin slices reduce volume averaging in the slice thickness direction. Since a thin slice increases noise, usually dose and possibly scan time have to be increased. Although the effective dose is lower for a pitch greater than 1, it will be higher for a pitch of less than 1, since this represents an overlapped x-ray beam on the patient surface. The reconstruction algorithm affects both noise and resolution, but has no affect on dose. A smooth algorithm decreases noise and resolution. A sharp algorithm increases noise and resolution.Diagnostic “+ Answers * D36. D37. D38. D39. D40. D4I. D42. D43. D44. D45. Increasing kVp or slice width will decrease noise because of higher voxel dose. Increasing the pitch will also decrease noise, as the slice width effectively becomes larger. The smoothing algorithm will decrease noise. A body scan technique usually uses about half the mAs of a head scan, so this will result in a noisy head image. The x-ray image is captured in a high resolution II with a CsI input phosphor. Because the difference signal contains noise determined by the sum of the noise in the mask and the angiogram, a very low noise TV camera is normally employed (SNR 500:1 or higher) in order to prevent additional noise from being added to the image. The analog video signals go to an analog-to-digital converter (ADC). Image manipulation and enhancement is best achieved with systems which store the mask and angiogram separately in digital form. The resolution is limited by the II (4 !p/mm), which has lower resolution than screen-film systems (6 to 10 lp/mm). However, contrast enhancement (window / level) is easily achieved. Digital systems usually require an entrance exposure into the II of 1.0 mR/frame, whereas cine requires only 20 to 40 .R/frame. However, many more frames are used for cine (30 to 60 per sec) than for digital (about 1 per sec). The frequency used in MRI depends on the product of the magnetic field strength and the gyromagnetic ratio of the element being imaged. Since most MRI is of hydrogen atoms, the frequency depends only on the magnetic field strength. Fluids take a long time to realign, and have longer T1 and T2 than soft tissue. T1 increases with field strength; T2 does not change with field strength. Superconducting magnets have field strengths of 0.3 to 5.0 tesla (T), while resistive magnets have strengths below 0.2 T. Superconducting magnets use no electrical power after the magnetic coils and the surrounding insulating region of liquid helium is cooled with liquid nitrogen (or helium). The superconducting magnets have no coil resistance and remain “on” as long as they are cooled. Raphex 2001Diagnostic “< Answers‘? D46. D47. D48. D49. D50. DS51. D52. D53. D54. D55. D56. D57. Gradient fields are used to modify the magnetic field so that resonance will be slightly different at different points in the volume of interest. It is then possible to localize these points. A T1 weighted image has a minimal T2 effect. This requires a short TE. T1 is well demonstrated by using a medium TR. A T2 image has a minimal T1 effect. This requires a long TR so that all the nuclei relax longitudinally. The T2 effect is emphasized by using a long TE which allows for differential dephasing. A proton density image has minimal T1 effects (long TR) and minimal T2 effects (short TE). Frequency encoding steps are determined only by the resolution setting of the ADC. The largest reflections (echoes) will occur when there is the greatest difference in acoustic impedance (Z) since R = (Z, — Z,)* / (Z) + Z,)’. Ll, = (Zp — Zi? (Zo + Zi)? = (1.65 — 1.55)? / (1.65 + 1.55)? = 1/1024. Acoustical impedance (Z) is equal to the density of the material times the velocity of sound in the material. Z = p c. Both are independent of frequency. The attenuation in dB is given by: Attenuation (dB) = 1 dB/MHz-cm x 5 MHz x 4 cm = 20 dB. But: dB = 10 log (J/I,) = 20 log (1/I,) = 2 I/I, = 10? Aliasing occurs when there are too few scan lines. In general, one must use twice as many scan lines as expected to eliminate aliasing. Raphex 2001Diagnostic °, °, + Answers D58. A Coded aperture is a method of imaging with scintillation cameras without using standard pinhole collimators. DS59. E The doppler shift Af = (2f, v/c)cos®@ where f, is the incident frequency, v is the velocity of the object, 6 is the angle between the sound beam and the moving object, and c is the speed of sound in the medium. D60. C The half-life is 73.1 hours. The activity 2.5 hours before noon is: A(noon) x exp [0.693 x (2.5/73.1)] = 2.2 x 1.024 = 2.25 mCi. Dél. E Although Tc-99m decays by gamma decay, approximately 10% of the photons undergo internal conversion, producing internal conversion electrons. The vacancy in the K shell then causes emission of characteristic x-rays and Auger electrons. D62. C I-123 invariably contains about 5% of I-124 due to the production method. The concentration of I-124 increases with time because of its longer half-life. D63. A Tc-99m contains small amounts of Mo-99 from the generator. D6é4. B I-131 hipuran often has I-131 iodide as a contaminant. It should not exceed 2% for clinical use. D65. E Ga-67 is essentially carrier-free. It contains negligible amounts of other radionuclides. D66. D TI-201 contains about 1% to 9% of TI-202 and less than 0.3% of Pb-203 as contaminants D67. C D68. E All the answers are true. Resolution and sensitivity are degraded when the PHA window is decentered from the photopeak. D69. B A second peak is seen at twice the energy of the main peak. 14 Raphex 2001Diagnostic «+ Answers’ D70. D71. D72. D73. D74. D75. D76. D77. Raphex 2001 A 95% confidence interval means the counts must fall within two standard deviations (SD) of the mean (N). Error limit = 1% = 2 SD/N, but SD = N!”. Thus 0.01 = 2(N!?)/N = 2/N!”. [0.01]? = 4/N. N = 40,000. The relative standard deviation (RSD) of the net counts of a sample is given by: RSD = (G + B)'2 / (G — B) where G = gross counts and B = background counts. Thus RSD = (122 + 22)!” / 122 — 22) =0.12. In nuclear medicine it is usual to state the MTF of the system. Temporal resolution is known as the “dead time.” Sensitivity is a function of crustal thickness and collimator septa size. Energy resolution is related to the FWHM of the photopeak. The FWHM of the line spread function is related to the MTF of the crystal (intrinsic spatial resolution) or the crystal plus collimator (extrinsic resolution). The full width at half maximum (FWHM) is typically of the order of 11 mm. A wider window collects more counts at the expense of degraded resolution, since the photopeak is less clearly delineated from background. The wrong collimator would increase septal penetration and increase or decrease camera sensitivity, but it could not produce a cold spot in the image. An off-peak camera is equivalent to the application of an incorrect uniformity correction table. The resolution of an object acquired as a stationary spot view is typically about 10 to 11 mm versus 12 to 13 mm when acquired in SPECT mode. The collimator causes the prevalent loss of image resolution. However, when the camera is rotating, there are imperfections in the orbit. The additional blurring due to the process of image reconstruction further degrades image resolution. The resolution expressed as the FWHM of a modern whole body PET camera is approximately 4.3 mm. The mean range of the positrons produced by F-18 is <2 mm. The mean uncertainty is the line of response from two coincident annihilation photons is about 3.5 mm. Adding the two errors in quadrature would yield 4 mm. It is for this reason that a dedicated brain scanner, with a much smaller bore size, can achieve resolutions of close to 2 mm.Diagnostic “* Answers ¢ D78. D79. D80. D8!. D82. D83. D84. D85. D86. D87. D88. D89. Although the F-18 has a 110 minute half-life, even the presence of 1% F-18 relative to the Tc-99m activity will significantly interfere with the bone scan image (so answers A and B are incorrect). This is because the F-18 is barely attenuated by the low energy collimators used for Tc-99m imaging. Energy discrimination does not work, because of the large scatter and partial absorption tail for F-18 in the Nal crystal. There are no long-lived daughters of F-18. Step wedges are used to create a gray scale which can be used to evaluate the contrast of the image receptor system. Hysteresis refers to the retention of previous history as a cycle is reversed (e.g., ferromagnetism). Some chromosome effects occur at doses as low as 5 rem. The eyes have a threshold of 200 to 400 rem for cataract formation. 700 rem or more are required to destroy bone marrow. GI death occurs in the 1000 to 5000 rem range, while CNS death requires more than 5000 rem. In general the HVL of a typical x-ray beam used for abdominal radiography is 2 to 4 cm of tissue. A 24 cm thick abdomen would be Equivalent to 6 HVLs (using the higher value), and the transmission would be 1/2° or 1.6%. 4 to 6 R are typical values for a head scan series. A lateral chest ESE is typically 50 to 80 mR. The thyroid activity reaches its maximum activity 24 hours after administration. Since T= 5.2 days, the thyroid reaches half its maximum activity after 6.2 days. Using a high ratio grid increases patient dose. The mature gametes are less radiosensitive than the immature precursor cells. The most conservative approach would be to wait 6 months before attempting conception. a a Raphex 2001Diagnostic «“- Answers D90. E D9I. A D92. B D93. D D94. B D95. E D96. A D97. C D98. C D99. B Raphex 2001 Published data indicate that 0.5 mm Pb will stop 92% to 96% of the scattered photons for 100 kVp x-rays. (Murphy, P. H., Y. Wu, and S. A Glaze, “Attenuation properties of lead composition aprons.” Radiology 1993, 186: 269-272). Typical resolutions are: CT = 0.6 to 1.0 Ip/mm 525 line TV with 6” II = 1.8 to 2.0 lp/mm DVI is always less than TV Screen-film is typically 4 to 10 Ip/mm Direct film exposures are limited by geometric unsharpness, but the resolution of the film itself can exceed 50 Ip/mm. MRI uses 2-D Fourier Transforms for reconstruction. All the others use filtered back projection. (Historically, it was used in MRI, but 2-D FTs gave a better signal-to-noise ratio. More pixels of a smaller size means better resolution. This also means increased pixel noise, because there are less x-ray photons per pixel, but this may not necessarily mean increased noise for an area of interest, because the eye integrates pixels. However, the increased resolution will make the noise appear more prominent. Storage requirements increase from 256x256 to 512x512, i.e., 4 times greater. 128 colors (or shades of gray) require 2’ numbers (or 7 bits) to keep track of the color for each pixel. Thus 1 byte (8 bits) is needed for each pixel, as it is generally very difficult to break up a byte. Thus the total number of bytes required is the number of pixels, or 256 x 256 = 65,536 bytes (64 KB).Therapy “¢ Answers “ TI. T2. T3. T4. TS5. T6. T7. T8. T9. TIO. TIt. PDD increases with increasing SSD because it has two components, attenuation and inverse square. The inverse square component decreases as distance increases. TMRs are a measure of attenuation only, whereas PDDs comprise attenuation and inverse square components. Dose at depth 180 MU= = ————_ = 212 MU (Output at dmax, SSD) x (7 (0.985 x 0.862) 100 Dose at d2 = (PDD2 / PDD1) x Dose at dl = (66.4 / 86.2) x 180 = 139 cGy. _ Dose at depth 125 = 130 MU (Output at dmax, SAD) x TMR ~ (1.089 x 0.880) The dose at dmax = the dose at depth / PDD = 150/ 0.65 = 231 cGy. Dneck = Daxis x (TMR d5 /TMR d8) = 4000 x (0.945 / 0.879) = 4300 cGy. The mid point of the neck is at 98 cm (AP) and 102 cm (PA). However, the inverse square corrections from ant and post cancel each other out, so they can be omitted. The maximum dose occurs at dmax. This effect is field size dependent; for example, it would be 22 cm for 8x8 cm fields. Dose at dmax, expressed as a percent of dose at midplane for parallel opposed fields decreases with increasing energy and increasing SSD. PDDs increase with increasing SSD, because the inverse square component decreases. The correction (known as Maynard’s F factor) in this case is: PDD(150 SSD) = PDD (100 SSD) x [(110/(100 + dmax)]? x [(150 + dmax)/160]? Dmax is a small factor, and can be ignored. Thus, the factor is 1.063, i.e., a 6.3% increase. The equivalent square of a rectangular field has the same PDD and TMR as the rectangle. It is smaller in area than the rectangle (i.e., CxC < 6x30 in this case), since it is the field with the same scatter contribution on the beam axis. A useful rule of thumb is that C = 4x (area / perimeter). The use of “equivalent square” enables PDD and TMR tables to be simplified to only square fields rather than tabulating the many rectangular fields in use. Raphex 2001Therapy << Answers ¢ T12. TI3. T14. TIS. TI6. TI7. T18. TI9. T20. T2I. 722. Dose per field = 180/3 = 60 cGy. _ Doseatisocenter _ 60 = 147 MU (OutputxTMRXxWF) (0.9 0.782 x0.58) This is also the angle between the isodose curve at 10 cm depth and the line perpendicular to the beam axis. Omitting the wedge increases the dose at all points. The isocenter dose is increased by 1/(wedge transmission factor), B more than this, and A less than this. A 180° posterior arc gives a distribution with a hot spot posteriorly, and doses which fall off across the volume. Wedges are needed for homogeneity. Skin dose decreases as photon energy increases. If only high-energy photons are available and superficial structures would be underdosed, spoilers may be used. The ideal is to maintain a low skin dose and increase dose in the build-up region, to emulate a lower energy beam. However, while it is impossible to exactly mimic a lower energy beam with a spoiler, the build-up characteristics may be preferable to using bolus. Adding bolus to a patient’s surface to correct for “missing tissue” eliminates skin sparing in megavoltage photon beams. Tissue compensators, by moving the absorber away from the skin, preserve skin sparing. Wedges are sometimes used as crude tissue compensators. A thru D are all techniques used to improve homogeneity at photon field junctions. Overlapping fields on the skin will always give a hot spot. By similar triangle geometry: gap = d x (C/2)/SAD for each beam = (9x10/100) + (9x12/100) = 2.0 cm. The divergence of the spine field is tan"! (25/2 x 100) = tan! 0.125 = 7°. The depth to midline changes from 10 cm to 8 cm. The attenuation in a 6 MV beam is about 3% per cm. Thus, a change of 2 cm will cause an overdose of 6%, if no MU correction is made. em Raphex 2001Therapy + Answers T23. T24. T25. T26. 27. T28. T29. T30. T31. T32. The PDD is 92.0/136.0 = 0.676. This is the PDD at 10 cm depth for 6 MV photons. Geometric penumbra increases with increasing source size or effective focal spot size, with increasing SSD, and with decreasing source-collimator distance. By the inverse square law: Doserate1 _ [dist 2) Dose rate2 [dist iy Thus, dist 27 = 100? x (250/100) = 25000 and dist 2 = 158 cm. The effective TMR will not change, and the collimator output (Sc) will change minimally, so this is essentially an inverse square problem. MU at 140 SSD,d5 = 320 x (145/125)? = 431 MU. For a skin dose, PDDs are not required. Heterogeneity corrections, which may or may not be used at the planner’s discretion, are based on the electron density of the tissues traversed. The CT number is related to the linear attenuation coefficient of the CT scanner beam (about 140 kV). The path length is 6 cm tissue + 6 cm lung. Assuming a density of 0.3g/cm? 6 cm of lung is equivalent to 2 cm of tissue, giving a total effective path length of 6+2 = 8 cm. This is 4 cm less than 12 cm. At 10 MV the attenuation is about 2.5% per cm. Thus, not using lung corrections will lead to an overdose of about 4x2.5 = 10%. The increased transmission through lung will create higher doses at the chest wall, and thus a slightly thinner wedge will give a more homogeneous dose distribution. SAR (scatter-air ratio) represents the portion of the dose deposited due to scatter. The dose under the cord block is made up of primary dose (attenuated to about 3% by the block), and scatter from the unblocked portion of the beam. This is represented by the difference in the SARs for the whole field and the blocked area. 20 Raphex 2001Therapy ~ Answers T33. T34. T35. T36. T37. T38. T39. T40. T4l. T42. T43. T44, 7.5 cm is 5 HVLs. The transmission is (1/2)° = 0.03 or 3%. By similar triangle geometry the collimator setting C is: C = 15 x (100/140) = 10.7 cm. The dose is due to internal scatter, head leakage, and scatter from the collimators and wedge. Using the inverse square law, the MU will be: 100 x (400/100) = 1600 MU. Only CT provides a map of electron densities. MRI can map hydrogen density. While newer units with 0.5 cm leaves are being developed, currently 1.0 cm is the most common. Stepping is most dramatic at the 50% isodose in the penumbra, and becomes somewhat less defined at the 80% and 20% levels. However, over a course of treatment the stepping becomes blurred out by patient motion and set-up variation, so a beam film presents the “worst case” scenario. In plan A 80% of the lung receives about 45% of the prescribed dose. See ICRU Report 50 (1993), Prescribing, Recording and Reporting Photon Beam Therapy. Microscopic disease is included in the CTV. This can be done with most 2-D systems also. The collimator setting will decrease. The PDD and exit dose will increase slightly. The range of 6 MeV electrons is 3 cm in tissue, or 1 cm tissue + 2 cm tissue equivalent lung. Since lung density is 1/4 that of soft tissue, 2 cm tissue is equivalent to 4x2 = 8 cm in lung. Thus, the total range is 1+8 = 9 cm. nl Raphex 2001 21Therapy + Answers T45. D When electrons interact with high Z components in the head of the linac, bremsstrahlung and a smaller number of characteristic x-rays are produced. This bremsstrahlung “tail” increases with increasing energy, but is usually between 2% and 5%. T46. A The opposite is true for 2 and 4. T47. A The most noticeable effect of increased SSD is increased penumbra width. PDD and beam energy are unaffected, and output decreases. T48. C MU = Dose / Output x PDD = 200 / (1.02 x 0.9) = 218 MU. T49. D 200 cGy is delivered to a depth of 4 cm (1 cm bolus + 3 cm tissue). The PDD is 80% at d=4 cm. Thus, the maximum tissue dose (100%) is 200 x 100/80 = 250 cGy. The skin dose (now at 1 cm depth under the bolus) is 95% of the maximum, i.e., 250 x 0.95 = 238 cGy. T50. A The reason for placing field shaping on the skin is to achieve a sharper penumbra. The output factor may not be the same as for the same effective field size with an insert in the applicator. TSI. D Hot and cold spots are inevitable when adjacent electron fields are abutted. Moving the junction as many times as practical during treatment will reduce the hot and cold spots accordingly. T52. E All the items noted are used to get as homogeneous a dose as possible over the skin surface. T53. B The dose rate will be lower by the ratio of the exposure rate constants, i.e., 3.26/8.25 = 0.40. Also, whereas 160 mCi (64 mg Ra equ) is a reasonable loading for a Fletcher type applicator, 160 mg Ra equ would be unusually high. TS4. C The time interval is 6.5 years. A, = Agexp — (0.693 x t / T,2) = 15.5 exp — (0.693 x 6.5 / 30) = 13.3 mg Ra equ. 22 Raphex 2001Therapy «& Answers % TS55. T56. T57. T58. T59. T60. T6l. T62. T63. Exposure rate =T x A x 1/R? x n. where T = exposure rate constant = 8.25 R. cm? / mg.hr A = activity = 60 mg R = distance from source = 4m = 400 cm n = fraction emitted (i.e., not attenuated) by patient = 0.7 Exp. Rate = 8.25 x 60 x 1/(400)? x 0.7 = 0.002 R/hr = 2 mR/hr. For Ra-226, Cs-137, and Ir-192, scatter and attenuation approximately cancel each other at distances up to about 5 cm, so that the inverse square law predominates. Total dose = Initial dose rate x mean life. Mean life = Half-life x 1.44. Total dose = 50 cGy/hr x 2.7 days x 24 hr/day x 1.44 = 4666 cGy. “Point A” was originally defined as a point 2 cm superior to the mucosa of the lateral fornices, in the plane of the tandem, (i.e ., 2 cm superior to the ovoids) and 2 cm lateral to the tandem. The sup/inf distance is often taken to be 2 cm superior to the flange on the tandem (which abuts the cervix). However, as the relative positions of the tandem and ovoids vary from case to case, care should be taken to ensure that point A measured from the flange does not lie too close to the colpostats, as this will tend to increase the dose rate and possibly result in under-treatment. A better way to prescribe dose is to the isodose surface encompassing the tumor volume, although this is technically more difficult to define. To reduce 64 to 2 requires a reduction factor of 2/64 = 1/32. This is achieved with n HVLs, where 1/2" = 1/32. Thus, n= 5. Dose rate at 2 m = 40 mSv/hr x 1/2? = 10 mSv/hr. Time to receive 1 mSv = 1/10 hr = 6 min. Cs-137 decays by beta minus with subsequent gamma emission, but the beta emissions are absorbed in the source and its encapsulation. ee Raphex 2001 23Therapy “+ Answers ¢ T64. T65. T66. This allowed rules developed for Ra sources (e.g., Patterson-Parker) to be used for Cs sources, provided the activity was expressed in mg Ra equ. T67. Because it has a shorter half-life, the clinically relevant initial dose rate (and initial activity) of Pd-103 is higher, and the total dose is delivered in a shorter time. T68. T69. Due to the inverse square law, a point near the end of the cylinder is further away from most of the sources than a point at an equal radius near the center. Thus, longer dwell times are required at the ends to compensate for this effect. T70. Time, = Timey exp(0.693 x d /T1/2) = 366 x exp(0.693 x 7 / 74) = 391 sec. T7I. Without a flattening filter the dose rate along the central axis would be substantially greater than that at the edge of a clinically useful (40x40 cm) beam. 772. A monitor unit (MU) represents the amount of charge collected by the monitor ionization chamber (located in the path of the beam, in the head), when a specific dose has been delivered at a reference point in a phantom. The beam terminates after the set number of MUs have been delivered. As the dose rate on a linac is not absolutely constant, dose cannot be monitored by time alone. However, linacs have a backup timer in case the monitor (and backup) chambers fail to terminate the beam. T73. The length of the accelerator waveguide increases as photon energy increases. When it becomes greater than about 30 cm, it is mounted horizontally, and the electron beam is turned through 90° or 270° to point down at the isocenter. Linacs with dual photon energies and electron beams also require bending magnets for energy selection. 774. Most neutrons are generated by interactions between high-energy photons and high Z components in the head of the linac. a a il 24 Raphex 2001Therapy < Answers “% T75. T76. T77. T78. TT79. T80. T8I. T82. T83. T84. Polyethylene scatters the high-energy neutrons generated by high-energy linacs. Scattering reduces the neutron energy to thermal levels, and these thermal neutrons can then be absorbed by the polyethylene and boron. Boron is more efficient at capturing thermal neutrons than polyethylene, and also emits capture gammas of much lower energy. The door must contain sufficient lead to attenuate these gammas. A thicker filter will reduce output, and hence skin dose. Because a thicker filter hardens the beam by removing more low-energy photons, the PDD, as a percent of the skin dose, will increase. The output should be spot checked daily by the therapists, and if outside the range specified by the physicist, should be checked by the physicist before treatment. A calibration is part of the monthly physics Q/A. Additionally, a calibration in water is part of the annual Q/A. The light field coincides with the 50% isodose line, i.e., the line joining all points which are 50% of the dose on the axis in the plane of the film. Light/radiation coincidence is part of the monthly Q/A. The charge collected is proportional to the mass of gas in the chamber. As temperature increases, or presssure decreases, the mass of gas in the chamber decreases. Chambers are calibrated at standard temperature and pressure (22°C and 760 mm Hg), and the chamber reading must be corrected to the value that would have been obtained at 22°C, 760 mm. For photon shielding, 1 cGy is equivalent to 1 rem. The dose rate at 1 m = 500 rem/min = 500 x 60 rem/hr = 30 x 10° mrem/hr. The dose rate at 4 m = 30/42 x 10° mrem/hr = 1.9 x 10° mrem/hr. To reduce the dose rate by a factor of 10° requires 6 TVLs. SAR (scatter-air ratio) is used in Clarkson dose calculations for irregular fields. The annual dose limit to a radiation worker’s hands is 500 mSv (50 rem). (See NCRP report 116). The ring badge is an additional badge used to measure the dose to the hands. The whole body dose, which will generally be lower, is still recorded by the film badge. a ———=—————— Raphex 2001 25Therapy «+ Answers “+ T85. T86. T87. T88. T89. T90. T9I. T92. The dose rate at some distance from a single Ir-192 seed is small, so a sensitive detector is needed. The Geiger counter uses gas amplification to convert the small signal into a measureable one. TDLs are too insensitive and do not give an instant reading, and the other detectors are less sensitive than the Geiger counter. Annual calibration is required. The detector must be checked before each use to see that its batteries are operational, and that the expected reading is obtained from a check source. However, the check source does not need to be the same type of source that is being removed from the patient. These detector checks are important because getting a zero reading from a detector with dead batteries would give the impression that no sources were present, when in fact a source could have been left behind. Increasing mAs will make the film darker, but have no effect on contrast. Contrast is improved by reducing scatter. Reducing the collimator setting to the minimum necessary field of view usually has the greatest effect. If different grids are available, the one with the greatest grid ratio will “clean up” the most scatter. If these two techniques still don’t work, for patients with very large lateral separations one solution is to take orthogonal R and L ant obliques, making use of the somewhat reduced separation. At diagnostic energies the probability of photoelectric interactions increases as Z*, which magnifies the difference in attenuation between bone and tissue. In megavoltage beams the Compton effect predominates, with virtually no photoelectric effect, and shows differences in electron density rather than Z. CSF appears dark on a T1 image, and bright on a T2 image. Findings of interest such as transependymal edema or intraventricular tumor can be obscured by the brightness of the CSF on a T2 image. FLAIR allows the CSF to appear dark, and thus make T2 changes more conspicuous. Gadolinium is a ferromagnetic agent which is useful in the imaging of a variety of lesions. It is always important to verify that adequate gadolinium was delivered and looking at the intensity of uptake (i.e., brightness) of the nasal mucosa can help confirm this. Compton interactions are most likely over the range of (monoenergetic) photon energies from 25 keV to 25 MeV. Even in diagnostic beams, there are generally more Compton than photoelectric interactions. 26 Raphex 2001Therapy ¢< Answers “ T93. B T94. +E T95. A T96. B T97,. A T98. D See NCRP report 94. The average annual dose to members of the public is about 1.6 mSv, excluding the dose from radon. Medical x-rays, cosmic, internal, and terrestrial radiation each contribute 0.3 to 0.4 mSv, and nuclear medicine contributes about 0.14 mSv. (See NCRP report 116.) The maximum permissible whole body dose for a radiation worker is 5 rem or 50 mSv per year. Most radiation workers receive only a fraction of this, due to the principle of ALARA (as low as reasonably achievable) used when designing shielding. ee Raphex 2001 27