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RADIOLOGICAL PHYSICS Raphex “+ Preface The RAPHEX 2003 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 2003 Committee Copyright © 2003 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 www.inedicalphysics.org a General < Answers “% Gl. G2. G3. G4. GS. G6. G7. G8, G9. G10. GIl. G12. G13. Gli4. “A” is absorbed dose (Gy); it is only defined for photons below 3 MeV; “D” is dose equiv- alent (Sv). The dose equivalent for x-rays, gamma-rays and electrons is the same as the absorbed dose. For neutrons, however, it is between 5 and 20 times as great, depending on neutron energy, because of the higher LET and greater potential for biological damage per Gy. 1.0 Sv = 100 rem. Thus 100 uSv = 0.0001 Sv = 0.01 rem = 10 mrem. The rest mass of an electron is 0.51 MeV. Thus, the mass of the muon is 0.51 x 207 = 106 MeV. 10 MeV is the kinetic energy of the particle. The lightest particle travels fastest. An element is defined by the number of protons in its nucleus. Protons and electrons must be equal in number in a neutral atom, so it is the number of neutrons that differs between isotopes of the same element. In the symbol, the subscript is the atomic number, Z, which is the number of electrons. The number of protons must be equal to Z to balance positive and negative charges. The super- script is the mass number, A, which is the total number of protons and neutrons, N, in the nucleus. Thus N=A —-Z= 14-6=8. a Raphex 2003 General + Answers GI5. Glé. GI7. G18. GI9. G20. G2l. G22. G23. G24. G25. G26. Cc Binding energy is the energy needed to remove an electron from its orbit, and increases with both Z and proximity to the nucleus (i.e., K > L > M, etc.). As the mass number increases, more neutrons are needed to balance the attraction of all masses (nucleons) with the repulsion between positively charged protons. The maximum number of electrons allowed in any shell is 2n’, but the maximum in the outer shell is 8. All isotopes of a given element always have the same electron configura- tion. Inert gases have the maximum number of electrons in the outer shell. Activity after time t = Initial Activity x exp-t(0.693/half-life) = 10 x 24(0.693/6) = 0.625 mCi. Alternatively, since the time is 4 half-lives, the activity can be found by multiplying the ini- tial activity by 1/(2*). The average life is 1.44 x half-life. The half-life is inversely proportional to A, and is unaf- fected by temperature and pressure. Tin x nN = 0.693. tet + t If Tp << Tb, this is approximately equal to T,. eff rp lb Since The mass number decreases by 4 (226 to 222), so this must be alpha decay. Since Z increases by 1, this is an example of beta minus decay, which always emits a spec- trum of betas. In this case, they are accompanied by two gammas. The rest masses of the two particles combine to yield two 0.51 MeV gammas, emitted in opposite directions. In a PET scanner, they are detected by coincidence counters. °mT¢ decays to Tc, emitting a 140 keV gamma, so its mass equivalent is greater by this amount. nn a Raphex 2003 General ¢< Answers “ G27. B The 140 keV x-rays could interact with lead to emit lead characteristic x-rays. No photons of energy greater than 140 keV are present. There is no such thing as an Auger x-ray. Annihilation radiation is emitted when a positron and electron combine. Cerenkov radiation is emitted when charged particles travel very fast in a medium such as water. G28. D As Z decreases by 1, it must be either beta plus or electron capture. However, no positron is created, so beta plus is ruled out. G29. A Energy is transferred directly to an inner shell electron, which is then ejected. G30. E '8F is a cyclotron produced positron emitter used in PET. G3l. B An example is ?°Ra decaying to radon gas. G32. D 1.0 Ci = 3.7 x 10'°Bgq. Thus 5.0 x 10° Bq = (5.0 x 10°)/(3.7 x 10!°) = 0.135 Ci or 135 mCi. G33. A Exposure rate = Activity x Exposure rate const. x 1/d* = 4.0 x 4.6 x 1/(100)* = 1.84 x 10-3 R/hr = 1.84 mR/hr. G34. D Thermionic emission is the emission of electrons from the heated filament. G35. D Resolution is improved by the use of the small focal spot. However, if a high kVp/mA set- ting is required, this might overheat a smail area of the target; a larger focal spot helps with heat dissipation. G36. C G37. B Bremsstrahlung is emitted in a continuous spectrum up to a maximum energy equal to that of the incident electron. G38. C In order to emit characteristic x-rays, the incident electron must have an energy equal to or greater than that of an electron shell, so that an orbital electron is ejected. The shell is then filled with an electron from a shell farther out, and the characteristic x-ray is emitted with energy equal to the difference between the two shells. The characteristic x-ray energies possible from this atom are: 29.3, 26.0, and 3.3 kV. a Raphex 2003 3 General 2, 2, + Answers * G39. D This is greater than the incident energy. G40. E The effective energy of an x-ray beam is about 1/2 to 1/3 of the kVp, depending on filtration. It can be increased by adding additional filtration. Z does not affect the bremsstrahlung spectrum, and mAs has no effect. G4l. E G42. C For polyenergetic beams, passing through the first HVL hardens the beam, making the second HVL larger than the first. G43. B Frequency is proportional to energy. Ultrasound is not electromagnetic radiation. G44. A See answer G43 above. G45. C See answer G43 above. G46. B Using the inverse square law: I75/Isy = (50/75). G47. A G48. E c= A. c = speed of light = 3 x 108 m/s. v= 100 x 10° s’. G49. C The fraction transmitted = I/lo= e™. uw = 0.0693 cem™!. x=10cm. Vlo =e =0.5. G50. B The mass attenuation coefficient is similar for most materials in the Compton region, except those containing hydrogen. This is because most materials have approximately one electron pet two nucleons (one proton and one neutron), while hydrogen has one electron per nucleon, or twice the number of electrons per unit mass as most other elements. GSI. D The probability increases as Z>, and decreases approximately as 1/E’. EE E Raphex 2003 General <- Answers “ G52. B G53. C G54. D G55. C G56. C G57. B G58. E G59. C G60. C In the interaction of radiation with matter, energy is generally transferred to electrons and photons. The energy reemitted as photons is called “scatter”. The energy transferred to electrons is called “absorbed dose”, and is dissipated locally in collisions with atoms. The probability is greatest when the photon energy is just greater than the electron binding energy. This is an example of photoelectric absorption since the product is a 65 keV photoelectron. Characteristic radiation will be emitted as a result of an electron from an outer shell falling into the K-shell vacancy. Electrons interact because of their charge and mass by ionization and excitation along their paths. In general, the path of an electron in any medium, except air, is very short. The energy of the incident photon is divided between the scattered photon and the recoil electron. The scattered photon may travel in any direction. The minimum scattered photon energy occurs when the photon is scattered at 180° (backwards). In this case, the electron acquires its maximum kinetic energy and travels in the forward direction. The electron acquires the least energy when it is emitted at 90°. Even at low KV, coherent scatter contributes only a small part of the total scatter. The characteristic x-rays created by photoelectric interactions within the patient are of very low energy (because of the low Z of tissue) and have an extremely small range. Compton and photoelectrons also have a short range and are unlikely to leave the patient’s body. The energy lost by the incident photon is used to eject the electron (binding energy), with the remainder given as kinetic energy to the electron. The maximum energy transfer occurs when the photon is backscattered. Nuclear recoil accounts for a very small amount of energy. Compton interactions, per unit mass, are approximately independent of Z, and decrease with increasing energy. Compton is the most probable interaction in soft tissue between 25 keV and 25 MeV. It takes 2 x 0.51 MeV to create the electron-positron pair. The remaining 1.28 MeV is divided between the two particles as kinetic energy. This kinetic energy is deposited locally, and when the positron and an electron combine and annihilate, two 0.51 MeV photons are emitted. Neen nnn eee ee Raphex 2003 General ° 2, «+ Answers “¢ Gél. See answer G60 above. G62. See answer G60 above. G63. With the exception of the K edges, photoelectric interactions are more likely at low energy than at high energy. After passing through a filter, the total beam intensity is reduced, but the beam contains a relatively greater number of high-energy photons than before filtration. G64. CT number = 1000 X [(Umateriat — Hwater)/Hwater! Where [1 is the linear attenuation coefficient. G65. Energy loss is greatest for the particle with the greatest mass and charge. G66. Neutrons are not charged particles; they generally interact by transferring their energy to protons or other light nuclei, which then produce dense ionization tracks. G67. The electron’s rest mass is low compared to its kinetic energy so it must be traveling at nearly the speed of light. The alpha particle has the greatest total energy. G68. Protons, like all charged particles, have a finite range; photons are attenuated exponentially. G69. Depending on their energy, neutrons cause up to 20 times as much damage as x-rays. For radiation protection purposes, a factor of 20 is used for all neutrons. G70. The probability of a photoelectric interaction is proportional to Z°, so small differences in Z between, say, bone and muscle result in a large difference in the number of x-rays trans- mitted to the image receptor. G7l. The direct beam interacts with the patient’s body, and generates Compton scattered photons. G72. Collimating the beam decreases the area of exposure. Using screens and a high kV tech- nique both reduce patient dose. Grids improve contrast by cleaning up scatter, but require a somewhat higher dose to compensate for attenuation by the grid. 6 Raphex 2003 General “< Answers *% G73. E G74. D The net count rate is: [(N,/t,) — (N,/t,)] = [(900/1) — (100/10)] = 890 counts/min. The net standard deviation, 6, = [(N,/t,”) + (Np/t,”)]!” = [(900) + (1)]!? = 30. G75. C The “p-value” represents the probability of error in accepting the conclusion of the statisti- cal analysis; i.e., there is a 1% chance that the two results are not different. G76. E Each number in the binary system represents 2 to some power. The first number to the right represents 2° = 1. The second number from the right represents 2! = 2; the third is 2? = 4, and so on. The ones and zeros indicate whether a number is present or not. E.g., 101 would be 4+ 0+ 1=5. The range of —1024 to 3096 Hounsfield numbers requires 12 bits. G77. B MIPS stands for Millions of Instructions Per Second. G78. B ROM stands for Read Only Memory. Programs and/or data once put into ROM may be used, but not revised. G79. B Parallel processors divide a task into pieces, with each piece being solved on a separate processor to increase speed. G80. E 1 byte = 8 bits. 1 Mbyte = 1024 x 1024 = 1,044,448,575 bytes = 8,388,608 bits. G8i. D See NCRP Report 116. G82. C Radon decays through a chain of daughter products that may be inhaled, some of which decay by alpha emission. G83. E The average natural background radiation is about 100 mrem/year (excluding radon). About 40 mrem/yr is contributed by radionuclides within the body, mostly “°K. (The other choices are artificially produced.) G84. A About 55% (2 mSv per year) is due to radon, 11% from internal radionuclides, 8% from cosmic radiation, 8% from terrestrial radiation, and 15% from medical procedures. re Raphex 2003 7 General ¢- Answers “ G85. A NCRP Report 116 gives a probability of fatal cancer of 0.05 per Sv x breast organ weight- ing factor of 0.05 for a total of 0.0025 per Sv. For x-rays 1 Sv = 1 Gy. Thus the probability is 0.0025 x 10-3 per mGy, or 0.00025% per mGy. For 4 mGy the probability is 0.001%. This is typical of the increased risk for many radiographic exams. G86. E In NCRP Report 116 the Effective Dose (E) attempts to weight the radiation dose to different organs by the relative cancer risk of each organ. G87. D Cancer is a probabilistic or stochastic effect; the chance of getting cancer depends on the dose, but the severity is not dose related. G88. C G89. D Prior to 1994 it was 25%, but since this date it has been set at 10%. G90. C G9l. A G92. A 2 TVLs = 1/10? = 0.01. 6 HVLs = 1/2° = 0.16. G93. D The shield is 3 HVLs thick, and therefore reduces the dose rate by a factor of 1/2? = 1/8 = 0.125. G94. D Sodium iodide is only used to protect the thyroid from the radioactive iodine released in a nuclear explosion. '3'I has a relatively short half-life, and would not be used ina “dirty bomb”. G95. B A Nal well counter is an efficient device for measuring low-level gammas. It can also pro- vide energy discrimination. G96. C A GM counter has a fast response and the ability to detect low levels of gamma rays. G97. E An ionization chamber survey meter is capable of accurate x-ray dose rate measurements with minimal energy dependence. 8 Raphex 2003 General «* Answers “ G98. D The small size and relative energy independence of TLD make it useful as a personnel monitoring device. G99. D Very low concentrations of radioactive materials, when ingested, can preduce high, local- ized radiation doses to internal organs. GI100. C ALARA is a basic tenet of radiation protection. Obviously, radiation levels could be reduced to negligible levels with huge amounts of shielding that would be prohibitively expensive and unwieldy. The ALARA concept seeks to strike a reasonable balance between safety and practicality. a SS Raphex 2003 9 Diagnostic ¢, “- Answers DI. *°mT¢ photons have an energy of 140 keV. D2. Depending on filtration type and thickness, a 30 kVp spectrum is dominated by relatively low energy photons, which interact predominantly by the photoelectric effect in breast tissue. D3. The main photon energy of 7°'T1 is 70 keV. The photoelectric effect accounts for less than 25% of the interactions at this energy in bone. D4. Increasing in the focal spot size increases the area over which the instantaneous heat is distributed. This increases the heat loading capacity of the anode track, and thus the avail- able exposure times for a given mA. Unsharpness and resolution are degraded. The dose remains the same, since the total mAs is unchanged. DS. This is the only answer that refers to properties of the image receptor. D6. Due to increased attenuation coefficients with reduced kVp, A and E will reduce subject contrast. Focal spot size affects resolution, not contrast. D7. Low contrast detectability represents the ability of a system to reproduce an object whose linear attenuation coefficient does not vary greatly from the surrounding material. D8. Increasing film speed reduces the need for primary x-ray photons and hence increases mottle (quantum noise). The vast majority of the x-ray photons that contribute to the image are absorbed in the intensifying screen(s), not in the film. D9. DIO. Increasing the mAs increases the number of x-rays, but the shape of the spectrum does not change. DI! Typically, 99% or more of the energy deposited by the electrons in the target of an x-ray tube is dissipated as heat. D12. Increasing filtration increases the HVL by removing more of the lower energy photons than the penetrating higher energy photons. This in turn reduces contrast. The more penetrating filtered beam will then require less exposure at the skin entrance to properly expose the film. However, since the filter reduces the overall number of photons (both high and low energy) in the beam, the exposure time must be increased to compensate. 10 Raphex 2003 Diagnostic “> Answers“ DI3. DI4. DIS. DI6. DI7. DI8. DIY, D20. D2I. D22. D23. High filtration is required to reduce the contrast of the spinal column compared to soft tissue. Al filters are used in routine radiography to selectively filter out the lower energy photons. In mammography low-energy photons are required to improve contrast. Filtration is used to increase latitude and reduce patient dose. These shaped filters are attached to the bottom of the collimators, and are used to compen- sate for density differences, thus providing a more uniform exposure over the film. The maximum wavelength corresponds to the lowest photon energy, which is determined by the filtration. OD2 — OD1 = y log(E2/E1) where E is exposure, proportional to mAs. —0.8 = 3.0 log (E2/E1) E2/E1 = 0.54 or 46% reduction Increasing exposure time increases motion unsharpness. For a fixed kVp and mAs, the film and patient exposures, latitude and speed are unaffected. No change in kVp means no change in system latitude. The screen/film system usually is not significantly affected by exposure time variations, though if the exposure time becomes quite long, the speed is reduced by the reciprocity failure effect. Reducing scatter improves contrast. As the grid ratio increases, the patient dose increases, as more radiation is required to replace the radiation absorbed in the grid. An upside-down grid will produce a film that is dark in the center and almost blank toward the edges.Patient motion produces a blurred image; lateral misalignment produces an over- all lighter image; poor screen-film contact produces a spotted image. MRI, CT, and ultrasound have resolutions of about 1 lp/mm or less. Stereo fluoroscopy is limited to the TV resolution of about 2 Ip/mm. Laminar section tomography is limited to the film-screen resolution of 4 to 8 Ip/mm. a Raphex 2003 Diagnostic *, + Answers % D24. D Double-emulsion films may produce higher contrast than single-emulsion films, and are faster, thus reducing patient dose. Using two screens reduces spatial resolution due to more light diffusion in the thicker screens, and some possible crossover of light from the far screens to the emulsions. D25. D Optical densities are additive, so the net OD of both films is 5.0. An OD of 3.0 looks black on a standard view box. OD = log;o(I/T), where I and T are the incident and transmitted light intensities. For OD = 3.0, T = 0.001, and for OD = 1.0, T = 0.1. D26. C Film density is a function of exposure. Decreasing exposure time does not affect the total exposure. (This assumes reciprocity law is valid.) D27. C Latitude is a function of kVp, which was not changed. D28. C Speed depends on the thickness and sensitivity of the screen material, which was not changed. D29. A B-E directly influence the density and speed of the various film/screen systems. Although bromine concentration in the developer affects both speed and contrast, nitrate depletion has no effect on the development of mammography films. D30. D To pass ACR at least 10 objects must be visible in the image of the phantom. These must include four fibers, three speck groups, and three masses. D3I. E Average dose to the glandular tissue is an indicator of the risk of carcinogenesis. The dose depends on the energy distribution in the incident x-ray beam (kVp, HVL), mAs, and com- pressed breast thickness. D32. A At the low x-ray energy used in mammography, the interactions are predominantly photo- electric. Thus attenuation (and hence contrast) is proportional to Z*. The Z of calcium is 20, while the effective Z of fat and breast tissue is between 6 and 8. D33. E Good compression moves the breast tissue closer to the film, reducing geometric unsharp- ness from the focal spot. It also reduces the breast thickness near the chest wall, resulting in less scatter and better contrast, and a lower radiation dose. Compression also prevents movement, reducing motion unsharpness. rn 12 Raphex 2003 Diagnostic “<- Answers“ D34. D35. D36. D37. D38. D39. D40. D4l. D42. D43. See NCRP Report 85: “Mammography — A User’s Guide”. IV represents electrons produced in the photocathode. I and II are x-ray photons, and III and V are light photons. Switching to the 6-in. mode spreads out 6-in. of input information over the entire output phosphor, resulting in a magnified image. This also reduces the light intensity at the output phosphor because only the x-ray photons from the center 6-in. portion of the input con- tribute to the light. Thus, the ABC system will usually drive the patient dose higher to maintain constant brightness. The TV system has a resolution of only about 1.8 lp/mm. The II has a resolution of about 4 Ip/mm. The grid and optical lenses do little to degrade the spatial resolution. Standard broadcast TV consists of 30 frames/sec with 525 lines/frame. It is actually made up of two interleaved half frames of 262.5 lines lasting 1/60" of a second. Time for one line = (1/30 sec)/525 lines = 63.5 sec. Dose is directly proportional to frame rate. Large f-number lenses are less efficient at gathering light. Larger apertures permit more light to reach the cine film. A higher conver- sion gain produces more light for less radiation. Larger SIDs utilize geometry to reduce the patient’s radiation dose. Vignetting is the brightness change from the center to the edge of the II. The center is brighter than the edge. Flare and veiling glare are related parameters that indicate a degra- dation in contrast due to light scattering in the image intensifier. Blooming is the excessive brightness that occurs at the outside edge of a highly attenuating object. Increased scan time results in a higher dose; therefore, more photons are detected resulting in less noise. A thinner patient causes less attenuation, resulting in more photons at the detector, and less noise. A thicker slice increases the total number of photons detected, reducing noise. Window width has no effect on the number of photons detected. Higher detector efficiency increases the number of photons detected, thus reducing noise. Increasing mA results in an increased number of photons, which will lower the noise (quantum mottle), and increase low contrast resolution For low CT numbers (—200 to 200) the percent contrast can be approximated by: % contrast = (CT number difference)/10 = (45-40)/10 = 0.5 EE SE SSS SSS SSS SS Raphex 2003 Diagnostic “- Answers D44. A D45. D D46. B D47. C D48. C D49. C Ds50. C DSI. C Partial volume effects depend on slice width. Helical CT scanning effectively gives thicker slices for a given beam width. The main advantage of helical scanning is better registration of organs; breathing between each slice, as in conventional CT scans, does not ensure that the organ will be in the same position on each slice, as the depth of inspiration may change. As the beam is on continuously, with no opportunity to cool the target between slices (as with axial scanning), a tube with a higher heat capacity is required. The center is at 500, and the width is 1000, i.e., 0-1000. CT numbers below 0 are outside the window, and are displayed as black. A 9-in. (or 229 mm) image receptor digitized to provide 3 Ip/mm requires (229 mm ~ 6 lines/mm), i.e., a 1370 square matrix. The total number of pixels is 13707 = 1.88 x 10°. Since 256 shades of gray are provided, each pixel includes 1 byte (=8 bits) of information. Thus, 1.88 x 10° bytes, or approximately 2 MB are required. Scanned projection radiography is a type of digital imaging system, not a type of software filter. Subtracting structural background improves the visualization of low contrast objects. On a frame-by-frame basis, digital subtraction angiography delivers about 50 times more radiation than cine, and therefore produces more scatter. Digital storage is an advantage, but is not the principle reason for using digital radiography. The digital system has lower resolution than a cine film. The image consists of 512 x 512 pixels with 12 bits per pixel = 4096 = 2’. Note that you would actually need to store each pixel in 2 bytes since you cannot use a fraction of a byte. Thus, in reality, you end up using 16 bits per pixel (a byte is 8 bits). The matrix height and width are each twice as large as the DICOM standard (1024 vs. 512); thus four times as many pixels are required. In addition, each pixel needs twice as many bits (16 vs. 8), so the total storage is 4 x 2 = 8 times as large. Digital radiographic (DR) detectors use a fixed number of pixels to image the entire field of view (2048 x 2048 for 20 x 20 cm in this example). Only some of the pixels are used when the image is coned down (1024 x 1024 for 10 x 10 cm in this example). Since the pixel size is fixed, spatial resolution does not change with collimation. el Raphex 2003 Diagnostic «- Answers D52. B D53. C D54. D D55. E D56. A D57. C D58. B D59. A D60. E Dél. A Dé62. B D63. C Continuous video implies continuous x-ray production during the entire acquisition of a fluoroscopic frame. Pulsed fluoroscopy typically uses the same kVp and about the same mAs, but the mAs is delivered in a short pulse. The resulting stroboscopic effect yields less motion blur than continuous fluoroscopy, thus improving the sharpness of a rapidly moving structure. Contrast is related to kVp, and is unchanged. Since the mAs can be programmed, the dose per second can be programmed. In some cases lower frame rates are programmed for dose reduction, while in other cases the dose rate may actually be increased. The frequency for hydrogen is 42 MHz x magnetic field strength in tesla. Unlike x-ray images, atomic number differences have no effect on MRI images. Gradient fields are required in three planes for localization. The RF is used to excite (or tip) the hydrogen nuclei out of equilibrium with the main field. Shim coils and sometimes small blocks of metal are used to improve the uniformity of the main magnetic field. Ultrasound velocity is inversely related to the compressibility of the conducting material. All body tissues have approximately the same compressibility and velocity (1540 m/s) except bone, which is much less compressible than the other tissues. The velocity in bone is about 4080 m/s. Reflected intensity = [(Z, — Z,)/(Z, + Z,)/’. Wavelength A = velocity v/frequency f. The average velocity in tissue is 1540 m/s. Frequency = 2 x 10° s-!. SS Sr SSS Raphex 2003 Diagnostic «+ Answers D64. B D65. B D66. E Dé67. B D68. D D69. A D70. A D7I. C D72. B D73. C Half the time is required for the pulse to go forward, and half for it to return. Distance = velocity x time. D = (1540 m/s) x (32 x 10 s) = 4.9 om. Transducer diameter affects only lateral resolution. The reflected intensity (I) is lower than the incident intensity (Ip). The relative power in decibels (dB) is: dB = 10 logyy Cp 1). 40 = logj, (20/1). (20/1)* = 10. [=20 x 10%. The spatial resolution of ultrasound units is similar to that of CT scanners, about 1 mm. A shadowing artifact is caused by a lack of reflection from an area. This can be caused by an incident beam being highly attenuated, or if the beam is strongly reflected from an overlying interface, such as between air or gas and tissue. Water has a low absorption coefficient, and acts as a window, generally producing no shadowing. The resonant frequency (f) is determined by the speed of sound in the medium (c) and the crystal thickness. f = c/(2 x thickness). A, = Ag exp-(0.693t/T j2) where Ag is the initial activity, and A, is the final activity after time t. Substituting A, = 10 mCi, t = 3.0 days, Tj. = 8.04 days, gives Ap = 12.95 mCi. Assuming the syringe to be a point source, Exposure rate = TA (1/d*) = 0.6 x 20 x (1/207) = 0.03 R/hr = 30 mR/hr. Raphex 2003 Diagnostic “¢ Answers* D74, D75. D76. D77. D78. D79. D80. D8l. D82. D83. D84. D8s. '8F is produced by a (p,n) reaction on '8O, Detector counts decrease with increasing energy. Although the fraction of photons escaping the patient is higher for '*'], the efficiency of the Nal crystal is about 25% for '°'l (364 keV) compared with about 80% for 9™Tc (140 keV). Two 140 keV photons entering a scintillation crystal simultaneously would create the same light pulse as a 280 keV photon. Scattered photons have less energy than the photopeak. They degrade the image contrast because most do not contribute to the accurate positional information of the activity distri- bution in the body. Energy discrimination allows most of these scattered photons to be eliminated. The standard deviation o = VN where N is the average number of counts per pixel. The minimum detectable count difference would occur when the counts are highest, Le., 256. 26 = 2V256 = 32. Expressed as a percent of 256 this is 32/256 x 100% = 12.5%. According to Poisson statis- tics, a pixel with a number of counts that differs by more than 12.5% from the average occurs less than 5% of the time. The net standard deviation is Ce O2ampt J =J(100+909 =316. The wrong collimator would increase septal penetration and increase or decrease camera sensitivity, but could not produce a cold spot in the image. 740 exp(-0.693 x 10/124) = 699 MBq. The detector photopeak must be centered around 512 keV, the energy of each annihilation photon. Positron emitters are proton rich, and are made in cyclotrons. The positrons are not detected directly, but rather the annihilation photons are detected in coincidence at 180° from each other. i Raphex 2003 17 Diagnostic + Answers D86. D87. D8s. D89. D90. D9. D92. D93. D94. D95. D9. Coincidence detection, i.e., detection of simultaneous anti-parallel photons, eliminates most noise. In nuclear medicine scintigrams, the measured values are representative of the radioisotope distribution. In the case of SPECT, where the reconstructed image is of a known slice thickness, each pixel in the image is associated with a unit volume; hence the values repre- sent isotope concentrations. However, they are affected by the attenuation of the radiation in the body. “Peaking” consists of tuning the energy window so that it is centered about the photopeak of the isotope used in the study. The bar phantom is used to check resolution. With manual control, where the operator sets the mA and kVp, and it remains at those settings, the federal performance standard limits table top exposure rate to 5 R/min for under-table x-ray tubes. With auto-brightness control systems, the table top exposure rate can be 10 R/min. The philosophy is that in this mode it is allowable to go to higher exposure rates for the thick patients. The absorbed dose depends on the patient specific clearance kinetics. The same activity administered to two different patients of the same weight could result in different absorbed doses, if they metabolized and cleared the '°'I at different rates. According to HEW (FDA) 76-8231 the embryo would receive about 0.002 to 0.004 of the primary beam. Since AP chest radiographs usually deliver less than 30 mR at the skin surface, and the LAT is about 2.5 times greater, the dose to the fetus would be less than 0.004 x (30 x 3.5) = 0.42 mR or 0.0042 mGy, which is about 0.0042 mSv. a Raphex 2003 | I Diagnostic “+ Answers“ D97. A D98. E D99. E There are no regulations limiting the radiation dose to patients undergoing radiological procedures. Physicians are expected to weigh the risks and benefits to determine whether a procedure should be performed. D100. B Patient exposure or x-ray output is approximately proportional to kVp” and the product of the tube current and exposure time (mAs). ———— Raphex 2003 19 Therapy 2, 4, + Answers Ti. T2. Over the normal clinical range of SSD, TMR is independent of SSD, since it represents the attenuation of a given thickness of tissue. (Percent depth PDD, on the other hand, has an inverse square component, and does depend on SSD.) T3. Dose equivalent, measured in Sv (formerly rem) takes into account the relative biological effectiveness (RBE) of different types of radiation. For example, 1 cGy of neutrons causes more biological damage than | cGy of photons, and thus has a higher value in Sv. 100 ergs/gm = 1 cGy, formerly 1 rad. T4. The formula is inverted. TS. This is a measure of exposure in air. To convert to absorbed dose in a small mass of material, eg tissue, exposure is multiplied by the “f factor”. T6. The equivalent square of 6 x 28, using 4A/P, is 9.9; use 10. MU = [dose/fx]/[(cGy/MU at SSD) x (PDD/100)] = 180 / (1.0 x 0.871) = 207 MU. T7. Dose at dl/dose at d2 = PDD1/PDD2. Dose at dj, = 180 x (100/87.1) = 207 cGy. T8. Dose at d20 = 180 x (39.2/87.1) = 81.0 cGy. T9. Equivalent square of 18 x 22 = 20. MU = [dose/fx]/[(cGy/MU at SAD) x TMR x TF] = 125/(1.089 x 0.869 x 0.96) = 138 MU. a EEE 20 Raphex 2003 Therapy “Answers TIO. TI. T12. TI3. T1l4. TIS. TI16. At 102% of the M/L dose, this is the only reasonable answer. The dose at djnax is always greater than the M/L dose, so A and B cannot be correct, and the other answers are too large for this energy and separation. To calculate the actual dose at this point: ' Depth to M/L = 8 cm. Depth to d,,,, = 1.6 cm. Depth to exit point (16 — dy) = 14.4 cm. Distance to M/L = 100 cm. Dist. to dina, = 93.6 cm. Dist. to exit point = 106.4 cm. For SAD: dose at dl/dose at d2 = [TMR1/TMR2] x [dist2/dist1]?. Entrance dose at dina, = 125 x [(1.0/.869) x (100/93.6)?] = 164.2 cGy. Exit dose = 125 x [(.711/.869) x (100/106.4)?] = 90.3 cGy. Total dose at this point = 164.2 + 90.3 = 254.5 cGy. The total dose at d,,,, for parallel opposed fields is always greater than the dose at the isocenter; the lower the energy, and the larger the thickness, the greater this difference will be. As photon energy increases, the increased dose at a depth of d,,,, for parallel opposed beams decreases. For a separation of 28 cm, it would typically be 115% for 6 MV, and 107% for 18 MV, for typical pelvic fields. Any factor that increases the PDD will decrease the total dose at d,,,,, compared with the total dose at midplane. Treating at SSD rather than SAD gives slightly higher PDDs. As the prescription point moves further away from the source, the MU must be increased. Increasing the SSD slightly increases the PDD (due to a smaller inverse square factor), making the total dose at d,,,, smaller. PDD increases with increasing SSD because of the change in the inverse square factor. PDD (130 cm SSD, d8) = PDD(100 cm SSD, d8) x [(100 + 8/100 + dina, X (130 + dya,)/130 + 8)P For 6 MV dina, iS 1.6 cm. The equivalent square CxC of a rectangular field has the same PDD and TMR as the rectangle. It is smaller in area than the rectangle (i.e., CxC < 5x25 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. The rule is: Wedge angle = 90 — (Hinge angle/2), where the hinge angle is the angle between the beam axes. This wedge will cause the isodose lines from each field to run par- allel to each other, so that the fall-off from one beam across the volume is matched by a fall-off in the opposite direction from the other beam. a Raphex 2003 21 Therapy ¢ Answers + TI7. TI8. TI9. T20. T2i. T22. T23. 724. T25. T26. en SSS SSS SSS SS 22 Cc The wedge angle is the angle through which the isodose at 10 cm depth is rotated from its position in the open beam. A larger wedge angle will reduce the dose at the anterior side of the volume, increase the dose at the opposite side, and thus create a more homogeneous distribution. Renormalization has no effect on dose homogeneity. The metal wedge delivers a greater scatter dose to the contralateral breast than a universal wedge (which is smaller, and situated higher up in the head), or a dynamic wedge (which is achieved with a closing collimator). The dose on the axis is increased by 1/0.75 = 1.33. The thick end of the wedge is increased by a greater amount, and the thin end by a smaller amount, relative to the beam axis, because of the shape of the wedge. Wedges are used to reduce the anterior hot spot in a larynx plan treated with lateral opposed fields. If a hot spot is required, the wedges may be omitted. Since the depth to the isocenter is less in the AP dimension than the lateral dimension, a greater dose is delivered per degree of arc anteriorly and posteriorly, creating an oval iso- dose. Lower isodose values may appear star-shaped on the plan if the treatment-planning system approximates continuous rotation with fixed beams every 10°. As photon energy increases, skin dose decreases. The surface dose is about 15% to 40%, depending on field size. Spoilers are designed to increase the dose in the build-up region (to simulate a lower ener- gy photon field) without raising the skin dose to 100%, as with bolus. Bolus can be used with an electron beam to achieve a desired isodose distribution at depth. Wedges are often used as simple compensators, (e.g., thick ends up in AP/PA treatment of the thorax, in tangential breast treatment, etc.) but have the disadvantage of having uniform thickness in height. Two-dimensional “missing tissue” compensators can be fabricated using a device that mills the shape in styrofoam (based on the patient’s surface contour), which is then filled with cerrobend. Dynamic MLC can be used to create any desired dose pattern; this is one technique used in IMRT. Raphex 2003 Therapy < Answers 727. T28. T29, T30. T31. T32. T33. T34. T35. T36. T37. T38, T39. T40. Divergence = tan“! (9/100) = 5° for each field. To eliminate divergence, the RPO gantry angle = 60° + 180° — (2 x divergence) = 230°. Gap = [(C] + C2)/2] x d/SAD = [(20 + 28)/2] x 5/100 = 1.2 cm. Attenuation in a 6 MV photon beam is about 3.5% per cm. This is why a Co unit has a wider penumbra than a linac. The flattening filter “overflattens” at shallow depths, and “underflattens” at greater depths. The dose at d,,,, is therefore greater towards the edges of the beam, and this effect increas- es with field size. The patient would be further away from the isocenter, and the dose would be lower by the inverse square factor of (100/101.5). Using the inverse square law, the MU will be: 100 x (400/ 100)? = 1600 MU. The plan is over-wedged. The thinner filter will increase dose rate, but will not harden the beam as much as the 2 mm filter, so the HVL and PDD will both decrease. Ee Raphex 2003 23 Therapy < Answers T4l. T42. T43. T44. T45. T46. T47. T48. T49. T50. The HVL (in Al or Cu) defines the penetrability of a low-energy x-ray beam. Different combinations of kVp and filtration can produce beams with the same HVL. The SSD also affects the PDD and is important for machines that treat at short SSDs. Although the isocenter of a plan can be related to internal structures, it must also be related to surface landmarks (preferably triangulation points) in order to position the patient cor- rectly for treatment. 10 cm of lung is approximately equivalent to 3 cm tissue, and 10 — 3 = 7 cm of “missing” tissue. Thus the dose beyond the lung is increased by approximately 24% (ignoring scatter effects). Transmission corrections are greater at lower energy, where the attenuation per cm of tissue is greater. TMR, is the primary component and SMR is the scatter component for the blocked field. TMR, is found by extrapolating TMR,,, to zero field radius. In the megavoltage range, the lower the energy, the greater the contribution of scatter. For this reason, irregular field calculations are more important for lower energy beams, since blocking reduces scatter dose from under the blocked area. By similar triangle geometry: w1/w2 = dist 1/dist 2. W(d7)/10 = 107/100. By similar triangle geometry: coll/40 = 100/130. By similar triangle geometry: coll/15 = 100/111. The field at 100 cm SSD must still project to 15 cm atd= 11 cm, i-e., at 111 cm. 2 Gy out of 40 Gy is 5%. This occurs at about 2 cm from the field edge. Inhomogeneity is mainly due to differences in thickness (e.g., forearms vs. trunk). B, C, and D tend to improve dose homogeneity. en 24 Raphex 2003 Therapy + Answers “% TSI. D Multileaf collimators (MLC) have leaf widths on the order of 3 to 10 mm, meaning that field edges have checkerboard shapes. Cerrobend blocks can be cut to precisely match the desired shape of the treatment field. MLC field sizes may be limited, whereas cerrobend can be used with the largest field available. There is some radiation leakage between leaves, and for most MLCs the ends of the leaves do not exactly match beam divergence. In fact, other than for IMRT, MLCs have no dosimetric advantages over cerrobend blocks. Their main advantage is ease of use. T52. E The “tongue-and-groove” effect may decrease (not increase) interleaf dose, is present in all current MLC models, and has no effect on output. TS53. B The graph shown is a cumulative dose volume histogram (as opposed to a differential dose volume histogram), It depicts the fraction of the volume (y-axis) that receives more than the dose values given on the x-axis. For example, 100% of the volume receives at least 30% of the prescribed dose; 75% of the volume receives less than 50% of the dose; 25% of the volume receives at least 75% of the dose. T54. C Setup margin is included in creation of the PTV from the CTV. T55. A Intensity distribution is the only fundamental difference between IMRT and 3-DCRT. The number and direction of beams are not affected by the planning method, nor is the delin- eation of targets or critical organs. T56. D “ Step and Shoot” IMRT is delivered using a fixed number of MLC shaped sub-fields, each with a fixed number of delivered monitor units, or dose. After each sub-field is treat- ed, the beam is turned off, the MLC field shape reset, the beam turned on again, and so on. Because there are a fixed number of sub-fields, the number of intensity levels possible must be finite. Both methods require more monitor units than conventional treatment, with “Sliding Window” usually requiring slightly more MU than “Step and Shoot.” T57. D Monte Carlo dose calculations are still too time consuming to be used for most individual patient treatment planning, although they are used as a basis of comparison to determine the accuracy of analytical type dose calculations which are still used in virtually all treat- ment planning systems including IMRT. T58. B The MU need to be increased by the inverse square law: (160/130)? = 1.5. T59. A The DRR has noticeably worse resolution. A smaller slice separation will improve resolu- tion, but the data file will be larger. However, DRRs have the advantage in that the data can be manipulated to emphasize different features such as bone, lung, etc., which may yield a more useful image for treatment planning in spite of poorer resolution. Se Raphex 2003 25 Therapy %, 2, + Answers + T60. A See remarks following answer T62. Tél. A See remarks following answer T62. T62. C Both CT and MRI have pixel sizes less than 1 mm. PET scan resolution is limited to a few millimeters mainly because of the finite range of the positrons, and also because the 511 keV annihilation gammas are not exactly anti-parallel. T63. A Most EPIDs have on the order of 256—512 rows of pixels, and 256-512 pixels per row, giving them a spatial resolution no better than about | mm, which is vastly inferior to radiographic film. T64. £E T65. C Electrons lose 2 MeV per cm in tissue. T66. B Rule of thumb: 90% depth dose = Energy(MeV)/3. T67. A T68. D Electron interactions with high Z materials in the head of the linac generate bremsstrahlung X-rays. T69. B Surface dose will generally increase, due to scatter from the insert. T70. B 6 MeV electrons are stopped in 3 cm of water, or approximately 3 mm of lead. T7i. D Oblique incidence tends to increase skin dose and decrease depth dose. In general, the more oblique fields used, the higher the x-ray dose to the patient’s whole body but the greater the dose uniformity. T72. +A 10 mins = 600 sec. The treatment time will double when the activity has dropped to one half, i.e., after one half-life, or 74 days. a, 26 Raphex 2003 Therapy + Answers T73. TT74. T75. T76. T77. T78. T79. T80. T8I. The MPD 1s 5000 mrem/yr or 100 mrem/wk. For protection purposes this is taken to be equal to 100 mR/wk. The exposure rate is: Activity x Exposure rate constant x 1/d?. = 110 mCi x 4.6 R.cm?/mCi-hr x 1/(30)? = 0.562 R/hr. or 562/60 = 9.4 mR/min. 100/9.4 = 10.6 minutes. In practice, portable lead shields at the bedside would decrease the whole body dose to personnel. 90% of the dose will have been delivered when the initial dose rate drops to 10% of its value, i.e., when I,/Ip =10/100 = exp-(0.693 t/60). Thus t = 199 days, or 6.5 months. (For a more intuitive answer: 50% of the dose is delivered after | half-life, 75% after 2 half-lives, 87.5% after 3, and 93.75% after 4 half-lives.) A greater activity of '”*I is required because it has a lower exposure rate constant than !%Ir, Paterson-Parker tables can only be used for isotopes with energies comparable to 725Ra, such as 'Ir, and '°’Cs; not low-energy isotopes such as !”51. Paterson-Parker also requires a non-uniform distribution of sources to achieve a uniform dose distribution. With uniform source distribution the center of the implant will always be hotter than the periphery, with the degree of non-uniformity increasing with increasing isotope energy (less attenuation of high energy photons). Non-Agreement states follow NRC regulations, and Agreement states, which make their own regulations, must have rules which are at least as stringent. The photon energy is about 35 keV. The patient’s body provides substantial attenuation, and the exposure rate at | m from the patient is around background. However, by the ALARA principle, seeds should always be handled with tweezers to reduce exposure. After a minimum of 10 half-lives (20 months for 1) the seeds must be surveyed with an appropriate instrument to ensure that the dose rate is not above background. They can then be discarded in regular trash, provided documentation is kept. The total dose to point A average is fixed at 2000 cGy—only the relative doses to other points, and the time taken to deliver 2000 cGy will change. The initial plan delivers 41/61 = 67.2% to the rectum. After the change, the dose rates at A are 56 (R) and 58 (L). The rectal dose rate is 36 cGy/hr. Thus, the new plan delivers 36/57 = 63.2% to the rectum, or 6% less. x SSS Ss Raphex 2003 27 Therapy «<- Answers ¥ T82. C T83. C T84. D T85. B T86. B T87. §E T88. D T89. E T90. D T9I. B (1) 10 Ci Ir expressed in mgRaEq = 10,000 mCi. 10,000 mCi = 10,000 x 4.61/8.25 = 5588 mgRaEq. (2) Treatment distance = Cylinder diam/2 + 0.5 cm = 2.0 cm. (3) Per Patterson-Parker tables: 898 mg-hr per 10 Gy at 2 cm = 449 mg-hr per 5 Gy = (449/5588 hr) x (60 min/hr) = 4.82 min. Betas have a range of 0.5 cm per MeV in water, so 2 Mev betas would travel 1 cm. Air has a density of approx. 1/1000 that of water, so 2 MeV betas will travel about 10 m. %Sr decays to °°Y, which emits 2.2 MeV betas. IVBT beta sources (°°Sr and °?P) have a very short range and are completely stopped by the source holder (prior to insertion), and by the patient (after insertion). The only exposure is due to a small amount of bremsstrahlung radiation from the holder or the patient. During transit, however, the operator is exposed directly to the unshielded betas. For photons, the dose falls off more slowly between the inner and outer arterial walls, than for betas. In the x-ray mode the electron beam strikes the target to produce x-rays. This narrow, for- ward peaked beam is broadened and flattened by the flattening filter. Scattering foils are used only in the electron beam mode, and the other components are used for both. The flattening filter is used only in the photon mode, is thicker in the center than at the edges, and is designed to create a flat photon beam (+3%) at a depth of 10 cm. Neutrons are indirectly ionizing. They are therefore measured by detecting the products of their interactions, such as protons or alphas, or by foil activation. The temperature/pressure correction is used to correct the ion chamber reading to that which would be obtained at Standard Temperature and Pressure (STP), i.e., 22°C and 760 mm Hg. The correction is [(273 + C)/295] x [760/P]. In this case, 760/770 = 0.987. Lead is inefficient as a moderator, but it is placed in the door after the borated polyethylene to attenuate the capture gammas. The neutron dose is about 10 times higher for photons than for electrons. The threshold for neutron production is 8 MeV. SS Sn 28 Raphex 2003 Therapy “<- Answers T92. C 250 x (1/27) = 1.95. T93. A MU, workload, and leakage (hence whole body dose) increase with IMRT. However, the PTV receives the same dose per fraction as conventional RT, so the primary beam exiting the patient, and requiring a primary barrier is the same. T94. A The maximum permissible dose is 5000 mrem/yr (50 mSv), or 100 mrem/wk (1 mSv). In practice, however, 0.1 mSv/week is generally used to comply with the ALARA principle. T95. D T96. E The flow meter is not a radiation detection device. It is used to measure the flow of air in a fume hood or flow of air in a stack monitoring system in a Cyclotron Facility. T97. A Rooms containing sealed radioactive sources, such as '°’Cs sources, !*5I seeds, etc., must be surveyed quarterly. Records must be kept showing inventory and use of the sources. v——— SS SSS Se Syst Raphex 2003 29

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