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preface
The RAPHEX Therapy exam 2009 was prepared by members of the Radiological and Medical Physics
Society of New York (RAMPS, Inc.), the New York chapter of the American Association of Physicists in
Medicine (AAPM).
The exam format has been changed this year to match the syllabi for teaching Diagnostic Radiology and
Radiation Oncology residents published by the AAPM's Subcommittee for Review of Radiation Physics
Syllabi for Residents (RRPSR). The numbers of questions for each subject are approximately related to the
number of teaching hours allocated to each subject.
There are now two exams, Diagnostic and Therapy, each with about 140 questions, including general physics
questions appropriate to the specialty.
Exam committee:
Susan Brownie, M.Sc., Editor
Howard Amols, Ph.D.
Richard Riley, Ph.D.
Eugene Lief, Ph.D.
Doracy Fontenla, Ph.D.
Additional questions contributed by:
Mark Belanich, M.S.
Gabor Jozsef, Ph.D.
If you are taking RAP HEX under exam conditions, your proctor will give you instructions on how to fill out
your examinee and site IDs on the answer sheet.
You have 2 HOURS to complete the exam.
Non-programmable calculators may be used.
Choose the most complete and appropriate answer to each question.
We urge residents to review the exam with their physics instructors.
Any comments or corrections are appreciated and should be sent to:
Susan Brownie, M.Sc.
Maimonides Cancer Center
Radiation Oncology Department
6300 8th Avenue
Brooklyn, NY 11220
E-mail: sbrownie@maimonidesmed.org
Copyright 2009 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
E-mail: mpp@medicalphysics.org
Web: www.medicalphysics.org
therapy questions
Tl. A particle with a rest mass equivalent of938 MeV and a charge of +1 is a(an):
A. Electron.
B. Positron.
C. Neutrino.
D. Photon.
E. Proton.
T2. Different isotopes of the same element will have equal numbers of __ _
A. Electrons
B. Protons and electrons
C. Neutrons
D. Electrons and neutrons
E. Protons and neutrons
TJ. The atom
1
: C contains electrons, protons, and neutrons.
A. 6 6 8
B. 6 8 8
C. 14 6 8
D. 14 8 20
E. 8 6 14
T4. The radioisotope used in brachytherapy that decays by electron capture, emitting 35.5 keV
gammas, and 27 to 35 keV characteristic x-rays from internal conversion, is:
A.
137
Cs
B. 192Ir
c. 1o3Pd
D. 12s1
E. 1311
TS. After 10 half-lives, the fraction of activity remaining in a source is:
A. (1/10)
2
.
B. 1110.
C. Dependent on the initial activity.
D. (l/2)'o.
E. 9/ 10.
T6. An HDR treatment has a total treatment time of282 seconds on May 1. Assuming the
192
Ir source has not been changed, the treatment will take __ seconds on May 15.
(T
112
is 74 days.)
A. 322
B. 302
C. 296
D. 264
E. 247
Raphex 2009
therapy questions
T7. Tungsten has the following binding energies: K = 69 keY, L = 12 keY, M = 2 keV.
100 keV electrons striking a tungsten target can cause emission of characteristic x-rays,
including which three of the following energies (keV)?
A. 100, 69, 31
B. 98, 88, 31
c. 95, 63, 15
D. 57, 67, 10
T8. To produce a bremsstrahlung x-ray:
A. An orbital electron is removed.
B. An electron is slowed down by the field of the nucleus.
C. An electron is absorbed by the nucleus.
D. An electron will change shells, emitting the excess binding energy as an x-ray.
T9. Regarding x-ray tubes, all of the following are true except:
A. The cathode emits electrons by thermionic emission.
B. Electrons travel from the anode to the cathode.
C. The kVp is the peak voltage applied between the anode and the cathode.
D. When electrons strike the target, characteristic x-rays and bremsstrahlung can be emitted.
E. The target is angled and rotated to increase its heat capacity.
T I 0. If the filtration of a diagnostic x-ray beam is increased, the resulting beam will have:
A. A lower dose rate and greater HVL.
B. A higher dose rate and higher effective energy.
C. A lower dose rate, but the same HVL.
D. The same dose rate, but a lower HVL.
E. The same dose rate, but a greater HVL.
T I I. Regarding the radiation emitted by the Gamma Knife, all of the following are true, except:
A. The spectrum consists of gammas of discrete energies 1.17 and 1.33 MeV.
B. The treatment time will double every 5.26 years.
C. The HVL is about 5 em in lead.
D. The beta minus emission contributes to the dose rate at the isocenter.
T 12. With regard to the production of electron beams by linear accelerators, which of the following
is true?
A. The beam current is much higher in the "electron mode" than in the "photon mode."
B. Electron beam flatness depends on the design of the cone or applicator.
C. The bending magnet is rotated out of the beam when "electrons" are selected.
D. Thick scattering foils can be used to reduce bremsstrahlung.
E. All of the above.
2 Raphex 2009
therapy questions
T 13. On a linac with a nominal dose rate of 300 MU/min, a treatment requires a monitor unit setting
of 150 MU. This means that:
A. The timer will terminate the beam after exactly 30 seconds.
B. The timer constantly monitors the true dose rate and terminates the beam after the time
calculated to deliver 150 MU.
C. The monitor chamber collects charge as the beam passes through it and terminates the
beam after a charge equivalent to 150 MU has been collected.
D. The beam is terminated after 150 R have been collected in the chamber.
T 14. According to the AAPM's TG-40 report on QA, the light field on a linac corresponds to
_ _ _ % of the dose on the axis at <1roax, and should match the digital field size indicator
with a tolerance of mm for a 1 OxlO em field.
A. 50, 2
B. 80, 2
C. 50, 5
D. 90, 3
TIS. Cerro bend blocks of thickness 7.5 em, when compared with a multileaf collimator, have all of
the following features, except:
A. Less primary transmission.
B. Edges which exactly follow beam divergence.
C. The ability to conform to any arbitrary shape.
D. Sharper geometric penumbra due to larger source-blocking tray distance.
T 16. The "picket fence" test is used in MLC QA to detect:
A. Changes in inter leaf leakage, compared with the value used in the treatment planning
system.
B. Changes in leaf transmission, compared with the value used in the treatment planning
system.
C. Leaf positions that are out of calibration.
D. Changes in leaf speed, for dynamic IMRT.
T 17. In modern simulators flat-panel imagers have replaced film cassettes. Advantages include all of
the following, except:
Raphex 2009
A. Reduced time for simulation (no films to develop).
B. No need for a processor or a darkroom.
C. Convenient access to archived digital images (no bulky film storage).
D. Ability to optimally adjust window/leveling of images (no retakes for under- or
overexposed films).
E. Size of imager.
3
therapy questions
T 18. For CT simulators, all of the following are useful features used for radiation therapy
simulation, except:
A. Alignment lasers, similar to those in the treatment room.
B. Large bore to accommodate patient setup devices and to visualize the surface of
large patients.
C. Gating.
D. Gantry tilt, to obtain CT slices parallel to the base of skull.
E. Flat tabletop, similar to the linac tabletop.
T 19. If a technologist were to stand 2 m away from a patient during fluoroscopy (outside the primary
beam), the dose received by the technologist would be mainly due to:
A. Compton electrons.
B. Photoelectrons.
C. Compton-scattered photons.
D. Characteristic x-rays generated in the patient.
E. Coherent scatter.
T20. The most probable interaction in soft tissue for a 3.0 MeV photon is ___ .
A. Coherent scatter.
B. Photoelectric.
C. Compton scatter.
D. Pair production.
E. Photonuclear disintegration.
T21. The photon interaction most responsible for the difference in Hounsfield units between barium
and soft tissue on aCT image is:
A. Coherent scatter.
B. Photoelectric.
C. Compton scatter.
D. Pair production.
E. Photonuclear disintegration.
T22. A linac has a maximum field size of 40 x 40 em at the isocenter, at 100 em SAD, and a nomi-
nal dose rate of 600 cGy/min. To cover a TBI (total body irradiation) field measuring 180 em,
the treatment distance would be - em, and the dose rate would be cGy/min.
A. 450, 133
B. 450, 30
c. 203, 133
D. 203, 30
E. 325, 333
4 Raphex 2009
therapy questions
Tll.
The linear attenuation coefficient, !l, is 0.0693 cm-
1
The half-value layer (HVL) is em.
A. 69.3
B. 15.0
c. 10.0
D. 6.9
E. Not enough information given.
T24. Hounsfield numbers in a CT image are linearly related to the:
A. Mass attenuation coefficient.
B. Linear attenuation coefficient.
C. Electron density of the patient.
D. Number of photoelectric interactions per centimeter.
TlS. In soft tissue, a beam of 9 MeV electrons loses most of its energy by:
A. Bremsstrahlung radiation.
B. Ionization.
C. Compton interactions.
D. Collisions with nuclei.
E. Pair production.
T26. All of the following are directly ionizing radiation except:
A. Protons.
B. Alpha particles.
C. Beta particles.
D. Neutrons.
E. Positrons.
T27. Neutrons have a higher Quality Factor than electrons because:
A. They transfer energy to protons, which have a high LET.
B. They slow down in tissue, and deposit a lot of energy at the ends of their tracks.
C. They have a large mass and charge.
D. They are directly ionizing.
T28. A linac photon beam has a nominal energy of 6 MY. All of the following are true regarding the
energy spectrum of the beam, except:
A. The AAPM's TG-51 report (on calibration) specifies beam energy by the measured
Raphex 2009
PDD at 10 em depth.
B. The average energy of the beam is about 6 MeV.
C. There are photons of 6 MV in the beam.
D. 6 MeV is the maximum energy of the electrons striking the target.
E. The effective energy varies slightly with off-axis distance because of the hardening
effect of the flattening filter.
s
therapy questions
T29. One roentgen:
A. Results in the same absorbed dose to muscle, bone, or fat.
B. Is a measure of the ability of a photon beam to ionize air.
C. Applies to photons and particulate radiation.
D. Is a unit used in the SI system.
TJO. Which of the following is not equal to one gray (Gy)?
A. 1.0 joule/kg
B. 100 rads
C. 1.0 Sv x Quality Factor
D. 1000 mGy
TJI. For the diagram below, which kerma curve ( 1 through 4) corresponds with the depth dose
curve (thick black line)?
A. Curve 1
B. Curve 2
C. Curve 3
D. Curve 4
E. None of the above.
""
e

Depth
T32. The f-factor is all of the following except:
A. The roentgen-to-rad conversion factor.
B. Generally greater for high-Z materials.
C. Generally greater for low energy.
D. Has the value 0.876 in air for Co-60 photons.
E. Is 1.0 for water at 1 MeV.
TJJ. The quality factor is 1.0 for all of the following, except:
A. Diagnostic x-rays.
B. A 6 MeV photon beam.
C. A 20 MeV electron beam.
D. 200 ke V neutrons.
E. A 100 kV superficial x-ray beam.
6 Raphex 2009
therapy questions
T34. Kenna is the:
A. Energy per unit mass absorbed or retained along the path of a charged particle.
B. Energy per unit mass transferred from charged particles.
C. Energy per unit mass transferred from photons to charged particles.
D. Charge released by photons as they pass through a specified amount of air.
TJS. When measuring photon depth dose curves in a water tank with a Farmer-type ion chamber,
the "effective point of measurement" is:
A. At the center of the chamber.
B. On the surface of the chamber.
C. Displaced downstream from the chamber center, by an amount that depends on the
photon energy.
D. Displaced upstream from the chamber center, by an amount that depends on the
photon energy.
E. Displaced upstream from the chamber center, by an amount that depends on the radius
of the chamber.
T36. The AAPM recommends the TG-51 protocol for photon beam calibration. This protocol
requires calibrations to be performed in:
A. Acrylic.
B. Solid Water.
C. Water.
D. Any medium similar to muscle tissue of known composition.
T37. A physicist measures the output of a linac and finds it to be 2.5% low. The usual action taken
by the physicist is:
A. To change the tables of output factors (cGy/MU for all collimator settings) to the new
measured values.
B. If the calibration is within 5%, nothing is changed.
C. All patients treated since the last monthly calibration spot check must be notified.
D. A potentiometer is adjusted so that one monitor chamber unit is equal to 1 cGy
measured at the reference point.
E. None of the above.
T38. Regarding an ion chamber and electrometer used for photon beam calibration, which of the
following is false?
A. The chamber and electrometer must be calibrated annually by an Accredited Dosimetry
Calibration Lab (ADCL).
B. The reading must be corrected for difference in temperature from that specified in the
calibration.
C. The reading must be corrected for difference in pressure from that specified in the
calibration.
D. The chamber is calibrated in a Co-60 beam.
Raphex 2009
7
therapy questions
T39. 6 MeV and 20 MeV electron beams are calibrated using an ion chamber in a water tank at d.nax
for each energy. For the same dose, the electric charge is greater for 20 MeV The reason for
this is:
A. The charge is proportional to dose to the air in the chamber. To calculate the dose to
water, one must multiply by the water/air stopping power ratio, which decreases with
increasing electron energy in this range.
B. The difference in the depths of du,ax for the two energies. The charges would be the
same if measured at the same depth.
C. The beams temporarily raise the temperature in the chamber, more so for higher
energy. A greater temperature correction is required for 20 MeV
D. The beams temporarily raise the voltage in the chamber, more so for higher energy.
This causes more charge to be collected for 20 MeV
T 40. For clinical measurement of the dose to a patient's pacemaker, diodes have the following
advantage over TLDs:
A. Smaller size.
B. Greater accuracy.
C. Instant reading.
D. More tissue equivalent.
T 41. The advantages of radiochromic film, as compared to radiographic film, for purposes of x-ray
and electron dosimetry include all of the following, except:
A. It is nearly tissue equivalent.
B. It does not require post irradiation processing.
C. It is relatively insensitive to visible light.
D. Its response (optical density vs. absorbed dose) is more linear.
E. It requires a lower dose.
T42. All of the following are true regarding percentage depth dose (PDD) in megavoltage photon
beams, except:
A. Increases with increasing SSD.
B. Increases with increasing field size.
C. Increases with increasing beam energy.
D. Decreases exponentially from the surface.
E. Has an inverse square and an attenuation component.
8 Raphex 2009
therapy questions
T 43. A patient's spine is treated with 6 MV photons at extended distance in order to obtain a large
enough field. The total length is 52 em on the skin, and the SSD is 135 em. PDD at 6 em depth
will compared to that at 100 em SSD.
A. Increase by about 2%
B. Increase by about 10%
C. Remain the same
D. Decrease by about 10%
E. Decrease by about 2%
T 44. Which of the following is false? The equivalent square of a rectangular field:
A. Has the same PDD as the rectangular field.
B. Is approximately four times the area divided by the perimeter.
C. Has the same TMR as the rectangular field.
D. Has the same area as the rectangle.
T45. Tissue-Maximum Ratio (TMR) depends on:
A. Energy, SAD, depth, and field size.
B. Energy, SAD, and field size.
C. SAD, depth, and field size.
D. Energy, depth, and field size.
E. SSD only.
T 46. The fraction of dose due to scatter is greatest for which of the following 6 MV fields?
A. 5 em X 5 em field at dmax
B. 10 em X 10 em field at dmax
C. 5 em x 5 em field at 10 em depth.
D. 10 em x 10 em field at 10 em depth.
E. All of the above have an equal fraction of scatter.
T47. An isodose plan is normalized to 100% at the isocenter; the hot spot is 107%, and
the 95% isodose covers the PTV. If the physician decides to prescribe 180 cGy/fraction
for 25 fractions to the 95% isodose, the total hot spot dose will be cGy.
A. 5165
B. 5068
C. 4815
D. 4737
E. 4500
Raphex 2009 9
therapy questions
Questions T48-50 refer to the following data tables for 6 MV photons. (PDD are for 100 em SSD)
Field Size { m ~ 5x5 10 X 10 15 X 15 20 X 20 25 X 25
5 85.6 87.1 87.6 87.9 88.2
8 72.0 75.0 76.3 77.3 77.9
PDD 10 64.2 67.6 69.2 70.3 71.1
15 47.7 51.6 53.7 55.4 56.4
20 36.7 39.2 41.5 43.4 44.5
5 0.912 0.928 0.934 0.937 0.941
8 0.809 0.842 0.857 0.869 0.877
TMR 10 0.745 0.784 0.804 0.818 0.828
15 0.602 0.647 0.675 0.697 0.713
20 0.487 0.530 0.560 0.586 0.605
Output (cGy/MU) at 0.950 1.000 1.038 1.055 1.069
depth= 1.6 em,
SSD = 100 em
Output ( cGy/MU) at 0.980 1.032 1.071 1.089 1.103
depth= 1.6 em,
SAD= 100 em
T 48. The Monitor Unit (MU) setting to deliver 180 cGy at 5 em depth to a 6 x 28 em field
at 100 em SSD is __ .
A. 180
B. 191
C. 199
D. 207
E. 215
T49. The maximum tissue dose in the previous question is cGy.
A. 180
B. 195
C. 207
D. 215
E. 233
TSO. Parallel-opposed 22 x 18 em whole-brain fields are treated isocentrically. The SSD is 92 em on
each side. A small corner block is added, and the tray factor is 0.96. The MU setting to deliver
a total of 250 cGy at midline is MU per field.
A. 138
B. 132
c. 129
D. 124
E. 119
I 0 Rap hex 2009
therapy questions
TSI. When treating a lung volume with off-cord parallel-opposed oblique fields, 10 MV photons
may be chosen by the physician over 6 MV photons because:
A. 6 MV would give inadequate dose in the build-up region.
B. Lung corrections are more accurate with higher energy.
C. The total dose at x is less with 10 MY.
D. The cord dose is less with 10 MY.
T52. Flattening filters in megavoltage photon beams are designed to achieve a flat beam at 10 em
depth. This means that at <Imax, the profile of a 30 x 30 em 6 MV beam is:
A. Higher toward the edges than the center.
B. Lower toward the edges than the center.
C. The same as at 10 em depth.
T53. Consider two 25 x 20 em fields one (left) with a midline block of area 3 x 20 em, the other
(right) with a corner block of the same area. At which Point, "A" or "B" would the depth dose
curve be more penetrating?
A B
A. "A" would have a more penetrating depth dose.
B. "B" would have a more penetrating depth dose.
C. The depth dose curves would be equal.
D. Cannot be determined from the information given.
T54. Regarding the use of bolus, all of the following are true, except:
Raphex 2009
A. It can be used to reduce the depth in tissue of the 90% isodose in an electron field.
B. It is used to increase the skin dose in megavoltage photon fields.
C. To achieve a surface dose of 90% of the midplane dose with parallel-opposed photon
beams, bolus of thickness equal to the depth of dmax is required.
D. Bolus is unnecessary for superficial x-ray beams.
I I
therapy questions
TSS. A single direct posterior field is planned to treat the T-spine to 300 cGy per fraction at 5.0 em
depth using 6 MV photons. The field is treated in error with 18 MV photons, using the same
MU. Which of the following is true?
A. The dose delivered at 5.0 em depth will be lower.
B. The exit dose will be lower.
C. The skin dose will be lower.
D. The variation in dose across the vertebral body will be greater.
E. The dose at ~ x will be lower.
T56. According to the "rule of thumb" for wedge angle vs. hinge angle, the wedge that would give
the most homogeneous dose distribution in the diagram below is degrees.
Hinge Angle = 60
A. 15
B. 30
c. 45
D. 60
T57. All of the following are advantages of a dynamic wedge (created with a moving jaw) over a
conventional physical wedge, except:
A. Same depth dose as the open beam.
B. Field is not limited in the non-wedge direction.
C. Therapists do not have to lift a heavy wedge.
D. Less dose outside the field (e.g., to contralateral breast).
E. Wedge transmission factor is independent of field width.
T58. Regarding inhomogeneity CO!:fections, all of the following are true, except:
A. At high energy, build-up and lack of scatter at lung-tissue interfaces could underdose
a tumor adjacent to normal lung.
B. 10 em of lung in a 6 MV beam will increase the dose beyond the lung by about 24%.
C. The density of lung is about 114 to 113 that of soft tissue.
D. Attenuation corrections for transmission are greater for 15 MV photons than for 6 MV
photons.
12 Raphex 2009
therapy questions
TS9. AAPM's Report No. 85 "Tissue Inhomogeneity Corrections For Megavoltage Photon Beams"
(2004) draws some general conclusions. Which of the following statements is false?
A. The widespread availability of CT and 3-D planning systems makes inhomogeneity
corrections more accurate than was previously possible.
B. Inhomogeneity corrections should account for changes in the electron densities of
tissues traversed.
C. Because different treatment planning systems use different inhomogeneity algorithms,
making such corrections will introduce even larger errors in dose reporting than were
previously made without them.
D. Monte Carlo dose calculations can calculate the effects of inhomogeneities on scatter
radiation, whereas analytical dose calculations only correct for changes in effective
depth.
E. Since most prescriptions and toxicity estimates are based on historical data calculated
without inhomogeneity corrections, use of these historical doses introduces consider-
able uncertainty to dose-response data.
T60. A wedged, tangential breast plan is calculated without heterogeneity corrections. The same plan
is then calculated with heterogeneity corrections, then adjusted to optimize dose homogeneity.
In general, the plan with heterogeneity:
A. Requires a smaller wedge angle.
B. Results in a greater maximum tissue dose.
C. Results in a higher skin dose.
D. Results in greater uncertainty in the reported lung dose.
T61. On a 100 em SAD linac, adjacent single direct spine fields with collimator heights of25 em
and 28 em are matched at 6.0 em depth. The gap to be left on the skin between the light field
edges is _ em.
A. 0.8
B. 1.0
C. 1.6
D. 2.4
E. 3.2
T62. On a 100 em SAD linac, the collimator rotation required to align 25 x 25 em cranial fields with
a direct spinal axis field of height 36 em is:
A. 3.5 degrees.
B. 5 degrees.
C. 7 degrees.
D. 10 degrees.
E. 17 degrees.
Raphex 2009 13
therapy questions
T63. It has been recommended that the dose to a pacemaker be kept below 2.0 Gy. In a lung
treatment of 40 Gy with 6 MV photons, the fields should be no closer than to the
pacemaker.
A. 0.5 em
B. 2cm
C. 7cm
D. 10 em
T64. A pregnant woman is treated for Hodgkin's disease with AP/PA 6-MV mantle fields, to a total
dose of 4000 cGy. The fetus is 15 em from the field edge. Without supplementary shielding,
the maximum dose to the fetus would be approximately cGy.
A. 300-400
B. 100--200
C. 20--80
D. 2-4
E. 0.05--0.1
T65. Compared with 6 MeV electrons, 16 MeV electrons have a:
A. Greater surface dose.
B. Lower bremsstrahlung tail.
C. Narrower plateau region around dmax
D. Sharper fall off between the 80% and the 20% isodose levels.
E. Narrower penumbra.
T66. X-ray contamination in electron beams is:
A. Highest for low-energy electrons.
B. About 2% to 5% for a 16 MeV beam.
C. Zero beyond depth RP.
D. Mostly due to electron interactions in tissue.
T67. To ensure adequate coverage of the treatment volume with an electron beam, it is important to
remember that:
A. All isodose curves decrease in width with depth.
B. All isodose curves increase in width with depth.
C. The 90% isodose increases and the 20% isodose decreases in width with depth.
D. The 90% isodose decreases and the 20% isodose increases in width with depth.
T68. A 12 MeV electron beam has a range of __ em, and a 90% depth dose at approximately
14
em.
A. 6, 4
B. 12, 4
c. 12, 6
D. 4, 3
E. 9, 6
Raphex 2009
therapy questions
T69. Which of the following is true regarding electron beams? The surface dose:
A. Is about the same as that of a photon beam of the same energy.
B. Is lower for a beam with a scattering foil than for a scanned beam.
C. Is about the same as that of a superficial x-ray beam (HVL 2.5 mm AI).
D. Increases as energy increases.
T70. As a rule ofthumb, rnm of lead is(are) reqqired per MeV to make an electron beam
cutout of adequate thickness to stop the electron beam.
A. 2.0
B. 1.0
C. 0.5
D. 0.2
E. 0.1
T71. When treating the buccal mucosa with an electron beam, a lead shield is inserted into the oral
cavity. The change in dose expected in the tissue next to the proximal and distal surfaces of the
shield, relative to the unblocked treatment, are:
A. Increased dose at both surfaces.
B. Increased dose at the back, no change at the front.
C. Increased dose at the front, decreased dose at the back.
D. Decreased dose at both surfaces.
T72. According to AAPM's TG-40 report on quality assurance, regarding linac photon output
checks, all of the following are true, except:
A. Daily output constancy should be within 3% tolerance.
B. Monthly output constancy should be within 2% tolerance.
C. Annual calibration constancy should be within 0.5% tolerance.
D. Annual calibration must be performed by a qualified medical physicist.
T73. On linacs, therapists perform daily pre-treatment QA. Regarding the items tested daily, all of
the following are true, except:
A. They include devices vital for accurate patient alignment.
B. They include devices that can drift, or have been observed to do so.
C. They are relatively quick and simple to test.
D. They include items that are subject to catastrophic failure, which would prevent further
treatment.
E. They include safety interlocks.
T7 4. Check sums are used in a Quality Assurance program for:
A. Testing the integrity of computer files.
B. Weekly confirmation of total dose delivered during a course of radiation therapy.
C. Calibration of ionization chamber dosimeters.
D. Testing the alignment of a cone beam imaging system.
Raphex 2009 IS
therapy questions
T75. When CT scans are used in treatment plans with heterogeneity corrections, QA should be
performed regularly to ensure constancy of all of the following, except:
A. Laser alignment.
B. CT number vs. electron density.
C. Absence of distortion over the field of view.
D. Patient dose.
T76. A 100-slice CT simulation for radiation therapy treatment planning requires approximately __
of computer (or disk) memory:
A. 100 kilobytes
B. 5 megabytes
C. 50 megabytes
D. 500 megabytes
E. 5 gigabytes
T77. The DICOM RT transfer protocol includes transmission of the:
A. Patient's outer contour only allowing homogeneous plan calculation.
B. CT image set with all pixel values only.
C. CT image set with the beam geometry information only, which allows calculation of
the dose distribution.
D. CT image set with beam information and dose distribution.
T78-80. Match the following annual dose-equivalent with the correct value.
A. 0.4 mSv
B. 1 mSv
C. 20 mSv
D. 50 mSv
E. 5000 mSv
T78. Average dose to a member of the U.S. population from natural background
radiation (excluding radon).
T79. Average dose to a member of the U.S. population from medical x-rays.
T80. Annual maximum recommended whole-body dose for a radiation worker.
T81. Which of the following would not be a factor used in calculating room shielding for
an HDR unit?
A. Energy of the source
B. Closest distance of the unit to the shielded wall
C. Wall material
D. Average source activity between installation and replacement
E. Estimated maximum workload
16 Raphex 2009
therapy questions
T82. The occupancy factor used to calculate wall thickness between a linac and the treatment console:
A. Is always 1.0.
B. Depends on the photon energy.
C. Depends on the workload.
D. Depends on the direction of the primary beam.
E. Depends on the use factor for that wall.
T83. Which of the following is true regarding neutron shielding for linacs?
A. The neutron dose is higher in an electron beam than a photon beam of the same energy.
B. When thermal neutrons are captured in boron, "capture gammas" of about I MeV are
emitted.
C. Lead is an efficient neutron moderator.
D. A 6 MV photon beam can generate neutrons.
T84. The main advantage of modern linac-based EPIDs, compared to conventional portal images
taken with radiographic film, is:
A. Greater spatial resolution.
B. Improved signal-to-noise ratio.
C. Significantly less dose required to achieve good images.
D. Images can be digitally enhanced.
E. All of the above.
T85. The artifacts caused by dental fillings in a simulation CT are mainly due to interactions.
A. Pair production
B. Coherent scatter
C. Compton
D. Photoelectric
E. Photonuclear
T86. Orthogonal films of a gynecological applicator are required for dosimetry planning. AP and
lateral films are taken, but the lateral film has very poor contrast. All of the following solutions
may provide films with acceptable contrast except:
A. Retake lateral, reducing the collimator setting to the minimum area possible.
B. Retake lateral using a higher ratio grid.
C. Retake lateral with increased mAs.
D. Take orthogonals at 45 and 315 instead of0 and 90.
T87. For head and neck IMRT planning, a simulation CT with slice thickness of 1.25 rnm, rather
than the standard 3 mm, is ordered by the physician. All of the following are true, except:
A. The DRR will have better resolution.
B. Small structures such as the optic chiasm are more accurately contoured.
C. Faster image acquisition time.
D. Contouring normal structures may take longer.
Raphex 2009 17
therapy questions
T88. PET scanners detect:
A. Positrons emitted from the region of uptake.
B. Annihilation photons.
C. Protons emitted from the region of uptake.
D. The paths of the positrons traveling through tissue.
T89. PET images have a spatial resolution of approximately __ mm in the axial plane:
A. 0.5-1.0
B. 1-2
C. 3-4
D. 5-6
T90. Advantages of MR vs. CT simulation for treatment planning of the prostate include:
A. Better delineation of soft tissue.
B. Less spatial image distortion.
C. Faster scanning times.
D. All of the above.
T91. Ultrasound-based treatment planning is most commonly used for the following treatment site:
A. Breast teletherapy.
B. Tandem and ovoid brachytherapy.
C. Prostate brachytherapy.
D. Colon teletherapy.
E. Whole-brain teletherapy.
T92. The purpose of image fusion in radiation oncology is to:
A. Reduce calculation errors inherent in using CT numbers that are based on photoelectric
interactions, not Compton interactions.
B. Calculate the uncertainty in volume localization, based on the amount of 3-D translation
(mm) and rotation (degrees), in order to calculate the expansion necessary for creating
PTVs from GTVs.
C. Utilize the increased resolution of PET and MR (512 x 512 and 1024 x 1024 pixels,
respectively), compared to CT (256 x 256 pixels).
D. Allow volumes of interest to be drawn on MR or PET images, and have them mapped
or translated onto a CT dataset for planning.
T93. Regarding virtual simulation, all of the following are true, except:
A. The time for simulation of the patient can be reduced.
B. The treatment isocenter can be related to arbitrary triangulation points marked on the
patient's skin and visible on the CT.
C. 3-D visualization of the patient is used to optimize beam placement.
D. Any beam that can be visualized in 3-D can be treated on the linac.
18 Raphex 2009
therapy questions
T94. When expanding a to create a , expansion into bone will typically be excluded.
A. GTV, CTV
B. CTV, PTV
C. GTV, IGTV
D. IM, PTV
T95. A volume measuring 5 x 5 em is drawn on aCT scan. The width (in the plane of the CT)
of parallel-opposed fields required to cover this volume with 95% of the dose at the volume
center:
A. Is 5 em.
B. Is less than 5 em.
C. Depends on the beam energy.
D. Depends on the depth to the volume center.
E. C and D.
T96. The choice of photon beam energy in a treatment plan is governed by all of the following,
except:
A. Depth to the isocenter.
B. Proximity of PTV to lung.
C. Depth of PTV below the surface.
D. Neutron leakage outside the beam.
E. PTV dimension in the longitudinal direction.
T97. The number of phases normally used for binning a 4D-CT study to be used for gated treatment
is ___ .
A. 25
B. 10
c. 5
D. 2
T98. For a photon treatment at 100 em SSD, the optical distance indicator (ODI) used for setup is in
error by 0.5 em. This means that the dose at <1max will be in error by %.
A. 0.25
B. 0.5
c. 0.75
D. 1.0
E. 2.0
T99. The typical residual positioning error after an image-guided setup is ___ .
A. 1-2 em
B. 0.5-l em
C. 1-5 mm
D. <0. 5 mm
Raphex 2009 19
therapy questions
TIOO.
TIOI.
TI02.
TIOJ.
TI04.
TIOS.
20
Comparing the advantages and disadvantages of cone beam CT (such as used on Elekta,
Siemens, or Varian linacs) with dual orthogonal kV fluoro systems (such as used on Accuray
CyberKnife or Brainlab Exactrak), for cone beam CT, all of the following are true, except:
A. Cannot be used in real time during treatment delivery, whereas orthogonal fluoro can.
B. Delivers a higher patient dose than orthogonal fluoro.
C. Can image soft-tissue differences, whereas orthogonal ftuoro cannot.
D. Has better spatial resolution than orthogonal ftuoro.
Which of the following methods of prostate localization can detect movement of the prostate
during the actual treatment delivery?
A. Implanted radiopaque fiducials and daily orthogonal kV portal images.
B. Daily cone beam CT.
C. Implanted RF beacons and a 3-D detection system (e.g., Calypso).
D. Ultrasound.
Compared to a conventional spiral CT, a linac-based cone beam CT has all of the following,
except:
A. Poorer soft-tissue contrast because of increased scatter dose.
B. Shorter image acquisition time.
C. Better spatial resolution in the craniocaudal direction.
D. Comparable patient dose.
The dose received at the isocenter by a patient undergoing cone beam CT (CBCT) for setup
prior to treatment is approximately cGy.
A. 20-40
B. 10- 20
C. 2-4
D. 0.2--0.4
Regarding ultrasound used to localize the prostate in treatment position before radiation
therapy, all of the following are true, except:
A. The patient must have a full bladder.
B. The patient must have an empty rectum.
C. The prostate cannot be imaged through the pelvic bone.
D. The operator must be trained to correctly interpret the images obtained.
E. The system must be calibrated to correctly align with the linac isocenter.
A TomoTherapy unit incorporates which modalities into a single machine?
A. Kilovoltage CT, megavoltage linear accelerator
B. PET scanner, megavoltage linear accelerator
C. MRI scanner, megavoltage linear accelerator
D. Megavoltage CT, megavoltage linear accelerator
E. Kilovoltage CT, proton accelerator
Raphex 2009
TI06.
TI07.
TI08.
TI09.
TIIO.
therapy questions
For prostate treatment, a TomoTherapy unit delivers dose by utilizing:
A. The Bragg peak.
B Axial kVp photons.
C. Intensity-modulated radiation therapy (IMRT) using fixed beams.
D. Helical delivery of IMRT.
E. Laser energy.
IMRT can create highly conformal plans, sparing organs at risk. However, potential problems
associated with IMRT include all of the following, except:
A. Steep dose gradients at the edges of PTV s or OARs, making setup accuracy more
critical.
B. Higher MUs, increasing leakage dose outside the treatment field.
C. The potential for the optimization algorithm to place hot spots outside the PTY.
D. The trade-off to sparing OARs is greater dose variation across the PTV.
When performing IMRT QA on a plan, a field is measured on a 2-D detector array. In the test,
50% of the points fail the criterion of3% dose or 3 mm DTA (distance to agreement). Possible
reasons for this poor match could be all of the following, except:
'\. In the TPS, converting from the ideal ftuence plan to the deliverable plan resulted in a
poor plan.
B. The measurement depth differs from the plan depth.
C. The measurement SAD differs from the plan SAD.
D. The wrong field was selected for the plan/measured field comparison.
All of the following dosimetry techniques could be used for checking the intensity-modulated
ftuence of an IMRT treatment plan prior to patient treatment, except:
A. Radiographic film.
B. Diode array.
C. EPID.
D. Ion chamber measurements on central beam axis.
Whtch of the following statements regarding TBI (total body irradiation) is false?
\.. 6 MeV, 10 MeV, or 15 MeV photons can be used.
B. In certain orientations, tissue compensators are unnecessary.
C. APIPA or lateral opposed fields can be used.
D. The dose to the lungs must be limited.
Raphex 2009 21
therapy questions
Till.
Till.
Till.
Tll4.
TIIS.
Tll6.
22
For cranial stereotactic radiosurgery, accuracy and reproducibility should generally be on the
order of mm.
A. 7
B. 5
c. 2
D. 0.5
Compared with linac-based stereotactic radiosurgery, treatment on the Gamma Knife is likely
to result in dose variation across the target volume.
A. Greater
B. Less
C. The same
In total skin electron beam therapy (TSET), using multiple treatment beams achieves all of the
following, except:
A. Improves the uniformity of the skin dose.
B. Decreases the effective depth of dmax
C. Increases dose uniformity in the target volume.
D. Eliminates overdosing fingers and toes.
When using the MarnmoSite, which of the following parameters are evaluated to determine
whether the patient can be treated?
A. Tissue-balloon conformance
B. Balloon diameter
C. Balloon symmetry
D. Balloon to skin distance
E. All of the above.
A prostate implant to be performed in 10 days requires 0.5 mCi seeds. Seeds of mCi in
the current inventory will have decayed to this activity in 10 days. (Half-life= 60 days.)
A. 0.93
B. 0.77
c. 0.56
D. 0.51
Which of the following is not a unit used to specify activity or source strength in brachytherapy?
A. mg Ra equivalent
B. mCi
C. Bq
D. Air-kerma strength
E. Joules/kg
Raphex 2009

Tl17.
Tll8.
Tll9.
TllO.
Till.
therapy questions
The air-kenna strength of an HDR
192
Ir source is 40,000 cGy h-
1
cm
2
The dose per minute in
air at 1 m from the unshielded source would be cGy.
A. 4.0
B. 2.4
c. 0.67
D. 0.24
E. 0.067
The prescribed dose for a prostate implant using
103
Pd is usually lower than for
125
1 implants
because
103
Pd:
A. Delivers the dose in a shorter time.
B. Requires less initial activity.
C. Has a lower initial dose rate in the prostate.
D. Poses a greater radiation hazard to staff and family members.
A patient has a temporary implant of the thigh containing 110 mCi of
192
Ir seeds. The exposure
rate at 30 em from the implant (ignoring tissue attenuation) is about mR/h.
(Exposure rate const for
192
Ir = 4.7 R cm
2
mCi-
1
-h-
1
.)
A. 570
B. 430
c. 280
D. 190
E. 56
If the exposure rate from a patient's temporary implant is 200 mRih at the bedside, the
maximum time a physician could spend at the bedside without exceedirlg the maximum
recommended weekly dose for a radiation worker would be hour(s).
A. 2.0
B. 1.0
c. 0.5
D. 0.25
A planar implant is planned using a uniform distribution of sources. The implant consists
of a 4 x 6 em plane of sources, with all sources 1 em apart, and all sources having the
same air-kerma strength. For the same initial dose rate, the required total activity of
125
1 will
be that needed if
192
Ir were to be used.
A. Greater than
B. Less than
C. The same as
D. Cannot tell from the information given.
Raphex 2009
23
therapy questions
Tl22.
Till.
Tl24.
Tl25.
Tl26.
24
The dose distribution in tissue up to 5 em from an
192
Ir seed closely follows the inverse square
law because:
A. No other factors are involved.
B. Up to 5 em, tissue attenuation is negligible.
C. Scatter dose buildup and attenuation approximately cancel out each other.
D. Dose from betas emitted by the source cancels the attenuation.
With regard to preferentially implanting seeds towards the periphery of the prostate vs. uniform
distribution of seeds within the prostate, which of the following statements is false?
A. The dose to the urethra will be lower.
B. The dose to the rectum will be lower.
C. The dose to the entire prostate will be more uniform.
D. This is more easily achieved with LDR ('
25
1 or
103
Pd seeds) than with HDR ('
92
Ir source).
For an "ideal" Fletcher tandem and ovoids, with the loading shown below (a total
of 65 mg Ra eq), the typical dose rate at point A is cGy/h.
Tandem: 15-10-10 mg Ra eq sources
Ovoids: 15 mg Ra eq each
A. 90
B. 75
C. 55
D. 35
E. 20
When selecting ovoids for a tandem and ovoid application, the optimal choice is the __ _
diameter, since this will ___ .
A. smallest, cause the least discomfort to the patient
B. smallest, spare the vaginal mucosa
C. smallest, reduce the bladder dose
D. largest, shorten the treatment time
E. largest, spare the vaginal mucosa
For the same source geometry and effective dose at point A, high dose-rate (HDR) afterloader
treatment of the cervix would be expected to give increased rectal complications, compared
with conventional low dose-rate (LDR) brachytherapy with
137
Cs sources. Rectal problems are
reduced in HDR treatment by:
A. Reducing the dwell times in the colpostats.
B. Reducing the number of fractions for the HDR treatment.
C. Reducing the dwell times in the tandem closest to the rectum.
D. Using a rectal retractor and/or more packing.
Raphex 2009
Tl27.
Tl28.
Tl29.
TIJO.
Till.
therapy questions
A 5 x 7 em two-plane implant of uniform activity
192
1 seeds is proposed. To calculate the
required activity to deliver 1000 cGy/day at 0.5 em from the upper surface, which of
the following calculation systems could be used?
A. Paterson-Parker tables
B. Quimby tables
C. A commercial computer treatment planning system
D. All of the above
E. B & Conly
A patient receives a permanent sealed-source implant. The isotope's half-life is T and the initial
dose rate is DRo. The total dose delivered when the sources have fully decayed is ___ .
A. ORo xT
B. ORo x T x 2
C. ORo X T X e0.693
D. ORo X T X 0.693
E. ORo X T X 1.44
When
192
Ir sources are sent from the manufacturer to a hospital, all of the following are true,
except:
A. The container must be DOT approved.
B. The "Transport Index" must be measured, and written on the label.
C. A radioactive source warning label must be attached to the container.
D. The maximum dose rate on the surface of the container must be stated on the label.
E. The activity and radionuclide must be stated on the label.
Post prostate implant dosimetry is performed using a CT scan several weeks after the implant.
All of the following are possible reasons why the dose distribution looks different from the
pre-plan, except:
A. The preplan was done with ultrasound images, and the prostate volume may appear to
be different on US and CT.
B. The implant was performed under ultrasound guidance, but the post-plan was done
with CT images.
C. The prostate swelled during the implant and shrank down again later.
D. The source strength of the seeds decayed since the implant.
QA tests that should be performed before MammoSite treatment include verification of the
constancy of all of the following, except:
A. The balloon dimensions.
B. The product of source activity and total dwell times.
C. The accuracy of the source position.
D. The minimum distance from the balloon to the skin.
Raphex 2009 25
therapy questions
Till.
Till.
Tll4.
TllS.
Tll6.
26
Which of the following is the correct expression for calculating Te, the effective half-life,
from Tb, the biological half-life, and Tp, the physical half-life of the isotope?
A. Te = Tp +Tb
B. Te = SQRT(Tp x Tb)
C. lffe = lffp + lffb
D. lffe = Tbffp
E. Te = 0.693 (Tp - Tb)
Which of the following isotopes is created in a cyclotron?
A.
137
Cs
B. 1sp
C. 192Ir
D. 40K
E. 131I
A patient is to receive
131
I therapy. Which of the following methods can be used to calculate
the effective half-life, Te, and the biological half-life, Tb, so that the correct activity can be
administered to the patient?
A. Once treatment has begun, collect all urine for each 24-hour period. Knowing the
volume and counting a urine sample will determine clearance (Tb ).
B. Several days prior to treatment, a small tracer dose is given to the patient. A whole-
body assay is performed the following day, and again a few days later.
C. Values ofTe and Tb are published in the MIRD tables, and are based on age, sex, and
weight.
D. Tb can be calculated by an assessment of kidney function based on blood chemistry,
e.g., BUN, and by dietary restriction of iodine during therapy, e.g., restriction of
seafood, iodized salt, etc.
Current release criteria for radionuclide therapy patients state that such patients can be released
from the hospital when the projected dose to individuals around the patient is less than or equal
to __ _
A. 5 mSv
B. 50 mSv
C. 500 mSv
D. None of the above.
In current hyperthermia treatments, the tumor and its vicinity are heated using:
A. Ionizing radiation.
B. Microwave radiation.
C. Infrared radiation.
D. Ultraviolet radiation.
E. Direct heat transfer from a heated object.
Raphex 2009
TJ37.
Tl38.
therapy questions
Which of the following statements is true regarding proton therapy?
A. Protons have a finite range that is proportional to their energy.
B. There is no neutron contamination in a proton beam.
C. The ratio of dose at depth of tumor to entrance dose increases with increasing tumor
siZe.
D. The lateral beam penumbra (perpendicular to the beam direction) is always narrower
for a passively scattered proton beam than for a megavoltage photon beam.
Comparing prostate treatment using a 5-field 15 MV IMRT photon treatment plan with a
proton plan using parallel-opposed lateral fields, the proton plan has:
A. A lower integral whole-body dose.
B. Better conformality to the PTV.
C. Lower rectal dose.
D. Lower bladder dose.
E. All of the above.
Raphex 2009 27