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preface
The RAPHEX 2011 Therapy 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 2011 Committee
Copyright 2011 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
Tl. C
Tl. c
Tl. B
T4. A
TS. c
T6. c
T7. E
T8. c
T9. B
TIO. A
Til. A
Raphex 2011
therapy answers
The end result, in beta-minus decay, is a neutron converted to a proton and an electron.
Thus, Z increases by 1, but the mass number, 60 in this case, remains the same.
60
Ni is
stable after the emission of 1.33 and 1.19 MeV gammas.
The total activity implanted must be the activity per seed will decay as:
A= Ao x 0.5<10160) or A= Aoe-<0.693/60)x!O = 0.891. -=b f\- -:o 0
1

Since the activity of each seed has decreased by 11%, the number of these seeds needed
is 60/0.891 = 67, to the nearest integer.
For a permanent implant, the total dose is equal to (1.44 x initial dose rate x T
112
). After
30 days, which is 2 half-lives, the activity (and hence the dose rate) remaining in the
patient is \4 of the original amount. So, from this point to eternity, the patient will only
receive 25% of the 100 Gy.
Therefore, the patient has already received 75 Gy.
Output changes with kVp
2
and linearly with mAs. kVp increases by a factor of
(120/80)
2
= 2.25, but mAs decreases by a factor of 2, resulting in an overall increase
of 1.125.
Contrast decreases with increasing kVp and is unaffected by mAs.
Characteristic x-rays always have energy equal to the difference between electron shell
energies.
"kV" refers to the voltage on the x-ray tube.
Waveguide is used in the linear accelerator.
In the case of traveling-wave accelerators, microwave power is fed to the structure via the
input waveguide at the proximal (electron gun) end. The residual power is absorbed at the
distal (target) end of the structure. In the standing-wave accelerator, the microwave power
can be fed anywhere along the length of the structure because the power proceeds in both
forward and backward directions from the input waveguide and is reflected at both ends.
therapy answers
Til. A
Til. D
Tl4. D
TIS. C
Tl6. D
Tl7. A
TIS. B
Tl9. C
TlO. C
Tll. B
Tll. C
Tll. A
T24. E
2
It would be appropriate to contour, and reassign the density of, any structures that do not
represent the actual density of the patient at the time of treatment.
Photoelectric interactions increase with the 3rd power of the atomic number. Bone, with a
significant amount of calcium, has a much higher photoelectric cross section than soft
tissue.
The probability of the photoelectric effect per unit mass is proportional to Z
3

There is no energy loss in coherent scatter.
The Compton photon can be scattered at any angle, but the Compton electron is emitted at
an angle limited to 0-90 with respect to the direction of the incident photon.
The kinetic energy of a photoelectron is equal to the photon energy-the binding energy
of the electron.
The threshold is 1.02 MeV, equal to the sum of energies of annihilation photons, each of
0.511 MeV. The incident photon energy is transferred to the rest mass energies of the
electron and positron plus their kinetic energies.
The probability is proportional to E-
3
except when photon energy is near the electron shell
binding energy.
Cerrobend blocks are both better focused and closer to the patient than MLC leaves, and
therefore reduce penumbra.
Raphex 2011
TlS. D
T26. B
T27. A
T28. B
T29. A
TJO. B
TJI. C
Tll. B
TJJ. B
T34. D
Raphex 2011
therapy answers
The attenuation coefficient in lead, for photon energies from 100 ke V to 20 MeV, initially
decreases with increased energy due to Compton interaction, then increases as pair
production becomes more prevalent at higher energies. As the attenuation coefficient
decreases, HVL increases.
For a 16 MV photon beam, 1 em depth is in the build-up region. Kerma (kinetic energy
released to charged particles per unit mass) is greater than the absorbed dose in the
build-up region.
HVL = 0.693/Jl.
Neutrons are indirectly ionizing. They transfer energy to protons, which have a large mass,
and are densely ionizing, especially at the ends of their tracks (the "Bragg peak" for
protons).
Coherent scattering does not change the beam energy. The pair production threshold is
above the energy of a typical diagnostic x-ray unit. The Compton effect may slightly
increase the effective beam energy but not nearly to the extent of the photoelectric effect,
which has Z
3
/E
3
dependence.
The uncertainty is given by the square root of the number of photons detected. There are
10,000 counts detected. The square root of 10,000 is 100, so the percent uncertainty is
(100/10,000) X 100% = 1%.
If the voltage is too low, less charge is collected because ion recombination increases, and
the reading will be low.
The AAPM recommends the use of a parallel-plate chamber for calibration of a 6 MeV
electron beam. The parallel-plate chamber perturbs the electron beam less than a
cylindrical chamber. Diodes, although small, are not used for direct calibration of any
beam.
3
therapy answers
TJS. A
T36. E
T37. D
T38. C
T39. D
T40. D
T41. E
T42. C
T43. D
4
The charge collected is proportional to the mass of air in the chamber. As temperature
increases, or pressure decreases, the air expands and the mass of air in the chamber
decreases. Chambers are calibrated at standard temperature and pressure (22 C and
760 mm Hg), and the chamber reading must be corrected to the value that would have
been obtained at 22 C, 760 mm.
A and C are commonly used for the calibration geometry, but there is no rule that states
that a particular geometry must be used to define 1 MU. It is vital, however, that all data
tables, treatment planning systems, and MU checking programs use data consistent with
each other, and with the department's definition of 1 MU.
This can be verified by calculating a simple plan, delivering it to a phantom, and
comparing the measured dose in the phantom with that prescribed in the plan and that
obtained with hand calculations.
Parallel-plate chambers can also be used.
The HVL (expressed as mm of 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, and hence the same depth dose characteristics. The SSD also affects the PDD and is
important for superficial x-ray units that typically treat at short SSD.
Although Monte Carlo is the most accurate, it also takes the most computer calculation
time and is therefore not yet universally used for treatment planning.
DVH plots show all statistical parameters about dose to a structure but provide no
information of spatial position of dose values.
For points that lie beyond the inhomogeneity, the predominant effect is the attenuation of
the primary beam. The changes in the secondary electron fluence affect the tissues within
the inhomogeneity and at the boundaries.
D
95
is typically used to evaluate target coverage, not hot spots which are often evaluated
using the 0
05
0
95
should therefore be high for targets and low for normal tissues. D
05
should ideally be no more than 110% of the D
95
, which means that there is good dose
homogeneity within the PTV. All doses in OARs should be as low as possible.
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T44. B
T45. D
T46. B
T47. B
T48. B
T49. C
TSO. B
TSI. B
TS2. D
TSJ. B
Raphex 2011
therapy answers
CSeq: 16x14 = 14.93, Sc = 1.015, FSeq 10x10, SP = 1.0
TMR (d = 8, 10.0) = 0.842
MU = 150/(1.0 X 1.015 X 1.0 X 0.842) = 176.
CSeq: 15x10 = 12, Sc = 1.006, SP = 1.007, PDD(5,12) = 0.873
Output= 0.971 cGy/MU
MU = 300/(0.971 X 1.006 X 1.007 X 0.873) = ~ 4 9
Typically, breasts with a separation over 25 em require higher energy photons to keep
the highest dose below 110%. However, this should be balanced against lack of dose in
the build-up region. The effective depth through lung at the chest wall will determine
the maximum dose.
At any interface between high- and low-density tissues, there are dose build-down and
build-up effects, which may result in lower dose to the surface of a lung tumor. This effect
is worse for higher energy beams and AAPM recommends using <12 MV for lung.
Gap= [d/SAD] x (Coll
1
+Coll
2
)/2 = 1.0 em.
Gap= [d/SAD] x (Coll
1
+Coll
2
)/2 = 0.75 em.
7 em of lung is approximately equivalent to 7 x 0.3 = 2.1 em tissue. The beam is therefore
not attenuated by 7 - 2 = 5 em tissue. This results in an overdose, compared to the
calculation at d = 11 em, of about 5 x 3.5 = 17.5%.
See, e.g., Klein EE, Esthappan J, LiZ. "Surface and buildup dose characteristics for 6, 10,
and 18 MV photons from an Elekta Precise linear accelerator." J Appl Clin Med Phys
4(1):1-7.
Higher energy beams deliver a lower surface dose.
Surface dose increases with field size due to increased electron emission from the
collimator and air and backscatter.
The use of a block tray produces secondary electrons, which increases the surface dose
unless the tray is far from the skin.
By the inverse square law, the dose at dmax will be reduced by (20/22?, or 17%. Inverse
square corrections can be quite large for short SSD units.
5
therapy answers
T54. D
TSS. B
T56. D
T57. D
T58. B
T59. C
T60. C
T61. D
T62. E
T63. B
T64. C
T65. A
6
By similar triangle geometry:
(size on wall/size at isocenter) = (source to wall dist./source to isocenter dist.)
= 500 cm/1 00 em.
Thus, size on wall = 40x5 em = 200 em.
(Note: The distance to the wall must be measured from the source, not the isocenter.)
The equivalent square is equal to 4 x area/perimeter = 2 x AxB/(A+B).
The surface dose will be slightly less at extended SSD.
All isodose values and MUs will be increased by 5%.
Attenuation is about 3.5% per em for a 20x20 em 611V photon beam at d = 12 em. An
increase of 4 em total, or 2 em per beam, will reduce the dose at the isocenter by about 7%.
The attenuation per centimeter at 6 MV is about 3.5% (B, D, and E). A is about 4%: 2%
for the change in TMR and 2% for the output. C involves an inverse square correction of
approximately (110/100? = 1.21.
The opposite is true. In a 3-field plan, the thick ends of the wedges point towards the
3rd field.
Because the wedging is achieved by closing a jaw, there is no limit to the collimator setting
in the non-wedge direction. This is an advantage over physical wedges, for which size and
weight can limit this dimension.
Divergence = tan-
1
(9/100) = 5 for each field. To eliminate divergence, the RPO gantry
angle= 60 + 180- (2 x divergence)= 230.
2 Gy out of 40 Gy is 5%. This occurs at about 2 em from the field edge.
Target and flattening filter are used in X-ray mode.
A pencil electron beam, after passing through scattering foils, is spread into a broad beam
that appears to diverge from a point that is closer to the patient than the photon beam
source.
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T66. c
T67. c
\
T68. c
T69. D
T70. B
T71. D
T72. D
T73. A
T74. c
T75. B
T76. D
T77. C
Raphex 2011
therapy answers
A typical 6 MeV beam delivers over 90% in the build-up region at d = 1 em, 100% at
d = 1.4 em, and 90% at d = 2 em. At d = 3 em, the depth dose is about 10%.
Theoretically, the range (6 em) would be the correct answer, but in practice its more like
5x5 before the 90% starts to decrease in depth.
The 90% depth dose occurs at about E(Me V)/3 em, except for very small fields.
Electron interactions with high-Z materials in the head of the linac generate bremsstrahlung
x-rays.
Electrons lose most of their energy in soft tissue by ionization and excitation of the tissue
atoms. Collisions with atomic nuclei resulting in radiative losses are also possible but less
likely in low-Z media.
This is an advantage of superficial x-rays over electrons.
Ref: Klein et al. "Task Group 142 report: Quality assurance of medical accelerators."
Med Phys 36(9):4197-4212, 2009.
However, the same report allows daily output measurements to be 3%.
Ref: Klein et al. "Task Group 142 report: Quality assurance of medical accelerators."
Med Phys 36(9):4197-4212, 2009.
Collision interlocks and positioning/repositioning are also listed as daily tests.
The amount of radiation that delivers 1 Gy to water will only deliver 0.99 Gy to muscle.
Therefore the beam-on-time needs to be increased by 1%.
The information in A, B, and Care sent with DICOM. DICOM-RT also sends the data
in D.
Radiation workers can get a maximum of 50 mSv per year (or about 1 mSv per week),
while the dose to the general public is restricted to 1 mSv per year (or 0.02 mSv/week).
Radiation shielding is usually designed using the ALARA (As Low As Reasonably
Achievable) principle, which suggests further reducing the dose to radiation workers by
a factor of 10, making it 0.1 mSv/wk.
7
therapy answers
T78. B
T79. D
T80. B
T81. D
T82. D
T83. B
T84. A
T85. A
T86. C
T87. A
T88. D
T89. C
8
Attenuation of x-rays in the MV range is almost independent of atomic number and is
determined mostly by equivalent path length (i.e., gm/cm
2
).
192
Ir has an average energy of approximately 340 keV, which is too high to be effectively
shielded by lead aprons, so they are not required for the patient. An advantage of remote
afterloaders is that staff are not exposed.
In current NRC regulations the definition of a medical event includes thresholds for both
an absolute dose error and a percentage difference from the prescribed dose. Total dose
errors of 0.5 Sv to an organ, tissue, or skin and 20% errors in total delivered dose (or 50%
in a single fraction) are reportable. (Errors of 10% are recordable.) See 10 CFR 35.3045:
Report and notification of a medical event.
In borated polyethylene the polyethylene moderates the neutrons to thermal energies, and
they are then captured by the boron, providing very effective neutron shielding. The
outside of the door must also contain lead or steel to attenuate the gammas produced by
this neutron capture event in boron.
The image resolution will degrade because of the blurring caused by lung motion.
Although treatment time may be increased, gating allows the beam to be turned on only
during a specific fraction of the breathing cycle, when tumor motion is limited. Without
gating, the lTV must include the full range of motion of the tumor.
X -rays produce electrons in the metal plate, and the electrons produce light in the phosphor
screen.
The scatter increases the signal, noise (square root of signal), and thus SNR (square root of
signal). The scatter degrades CNR because it increases the noise.
Raphex 2011
T90. A
(
T91. C
T92. B
T93. B
T94. B
T95. B
T96. B
T97. C
T98. C
Raphex 2011
therapy answers
Generally, CBCT is acquired in one single full or partial rotation of the kV tube. Because
it is a cone-beam acquisition, resolution in the cephalocaudad direction is superior or
similar to a regular multislice scanner, as is dose. On a linear accelerator, the length of
the scan volume is limited by the size of the kV detector and the single rotation
acquisition. Generally, CBCT over lengths greater than approximately 15 em is not
currently possible.
.
Small metallic fiducials are clearly visible with both 2D and 3D imaging techniques.
2D imaging techniques are not generally used to determine rotational errors. Only CBCT
can be used to visualize soft-tissue anatomy.
The reconstruction CBCT volume increases with the imager size. The half-fan CBCT scan
essentially increases imager size in the right-left direction and therefore increases the
reconstruction volume in the axial plane.
Only B can provide 3D information in real time. A single kV or MV source can only
provide real-time 2D information, while tomotherapy or CT units cannot provide real-time
information.
CyberK.nife uses real-time orthogonal x-ray imaging.
CT-on-Rails provides the best image quality but is arguably the most inconvenient
solution. kV image quality is always better than MV, and fan beam CT is always better
than MV because of decreased scatter dose.
The PTV is larger than the CTV, which is larger than the GTV. CTV includes microscopic
spread of tumor beyond GTV, and PTV must include setup uncertainties. PTV s need not be
connected. Margins may differ in different directions depending on patient and tumor
geometry and anatomy.
For certain treatment sites MR provides superior soft-tissue delineation as compared to CT,
and modem treatment couch top additions allow the patient to be set up accurately in the
treatment position. MRI images, however, still may have geometric distortions due to
magnetic field perturbations, and also do not provide information on electron density or
Hounsfield numbers needed to make inhomogeneity corrections in treatment planning.
9
therapy answers
T99. D
TIOO. D
TIOI. D
TIOl. C
TIOJ. B
TI04. B
TIOS. C
TI06. D
TI07. B
TI08. A
TI09. D
TIIO. E
10
The location of the RF beacons should be detected even if they move with breathing. In
fact, that is one of the advantages of this type of tracking: the patient can be monitored
during treatment, and the beam can be turned off if the beacons move outside a
predetermined range.
Each MV portal image will require 2 to 3 MU, for a total of 160 to 240 MU over the
course of treatment. Assuming 65% depth dose at 10 to 15 em, this will result in
approximately130 cGy total dose at the isocenter.
DRRs typically have poorer resolution in all directions than do conventional simulation
films, especially in the cranialcaudal direction because of CT slice thickness.
MV beams have greater penetrating power and thus deliver a higher midplane dose.
Within limited dose ranges, monitor unit settings for IMRT treatment can scale
proportionally with dose, just like MU for non-IMRT treatments.
For many treatment sites, single arc IMAT usually requires fewer MU than IMRT, but the
quality of the plans is highly variable.
Beam weighting is determined by the TPS based primarily on the treatment planning
objectives specified.
It is imperative that the dosimeter used for these measurements be smaller than the
radiation field. Otherwise the dosimeter will under-respond and patients will be overdosed.
A 0.6 cc Farmer chamber has a length of at least 1 em and is too large.
This definition of CI only takes the respective volumes into account, not the amount of
overlap between them.

Raphex 2011
Till. D
Till. A
TIIJ. D
Tll4. B
TIIS. A
Tll6. D
Tll7. E
Tll8. C
Raphex 2011
therapy answers
The projection of the largest jaw size must fall completely inside the circle, or radiation
will leak through the aluminum plate and irradiate the patient. Further, since the aluminum
plate blocks the light field but not the radiation field, it is possible to not notice this error.
2A
2
= 10
2
The 10 em thick cone will attenuate a 6 MV beam to 1%. The proximity of the cone to the
isocenter, 30 em, further reduces geometric penumbra.
About 80% of 6 MV radiation will be transmitted through 2 em of aluminum. The
Winston-Lutz test, although intended for determining target accuracy, will show areas of
leakage if the jaws are set too large, provided large enough film is used. Even with the
jaws set so that there is no leakage beyond the cone, output (dose/MU) will be affected if
the jaws are not set to the correct size. Once set and verified, jaw motion should be
disabled to prevent the therapist from inadvertently changing jaw size while using the
pendant to position the patient and gantry.
The conformality index in radiosurgery is defined as the tissue volume receiving the
given dose over the target volume encompassed by the same dose. The amount of target
volume receiving at least 14 Gy is 0.95 x 23.5 = 22.3 cc and hence the volume of brain
tissue receiving at least 14 Gy is 1.3 x 22.3 = 29.0 cc.
The dose to be delivered is the same, but the time to deliver the dose decreases because of
the higher activity.
Multi-lumen balloons allow for differential loading and therefore more control over the
dose distribution, including less dose to the skin if needed.
Because the wrong magnification is used, the balloon radius will be assumed to be too
small and lower dwell time will be prescribed, resulting in an underdose equal to
(1.29/1.4)
2

II
therapy answers
Tll9. A
TllO. C
Till. A
Till. D
Till. D
Tll4. A
TllS. A
Tll6. A
Tll7. E
Tll8. C
Tll9. E
ll
Titanium applicators are CT/MRI compatible and are available from several brachytherapy
equipment providers and, as such, allow both modalities of scans. Inhomogeneity
corrections are not usually done for T &0 planning.
The
131
1 gamma rays have a range of energies. The most prevalent (82%) is 364 keY.
125
1 decays via electron capture, and then emits a spectrum of characteristic x-rays in the
range 27 to 35 ke V.
Total dose= Initial dose rate x 1.44 x Half-life.
(1.44 x Half-life is called the Mean-life.)
Total dose= 0.1 Gy/h x 1.44 x 60 d x 24 h/d = 207 Gy.
A greater activity of
125
1 is required because it has a lower "U" (i.e., air kerma rate) than
192
Ir. In pre TG-43 terminology,
125
1 has a lower exposure rate constant than
192
Ir.
10 min= 600 s. The treatment time will double when the activity has dropped to one-half,
i.e., after one half-life, or 74 days.
On purely biological grounds, a higher dose rate for fewer fractions would be expected to
cause greater normal tissue complications.
Increasing the number of fractions would reduce the complication rate but would tend
to defeat the advantage of using HDR. In GYN, the rectal dose can be reduced to an
acceptable level by improved geometry.
Due to the inverse square law, larger diameter ovoids decrease the mucosal surface dose
but increase the depth dose. Since ovoids (except mini ovoids) have the same internal
shielding, doses to bladder and rectum are not affected.
Ingested radioiodine rapidly crosses the stomach wall, where it enters the blood stream.
Because the half-life of
131
1 in the blood is several hours, the whole marrow space is
continuously irradiated. Dose-limiting toxicity for whole marrow begins at doses in excess
of 2 Gy. Some patients can experience salivary gland complications, but these are usually
reversible and not life threatening.
Raphex lOll
TIJO. B
TIJI. C
Tl32. C
TIJJ. A
Tl34. C
TIJS. B
therapy answers
The dose in an unrestricted area must not exceed 0.02 mSv in any one hour according to
Subpart 380.5: Radiation Dose Limits for Individual Members of the Public.
1
To reduce
0.64 mSv/h to 0.02 mSv/h would require 5 half-value layers. 5 x 0.027 em= 0.135 em.
The average radiation dose from 37 mBq (1 0 mCi) administration of FDG in organs ranges
from approximately 1-4 cGy, the highest dose being received by the bladder wall, a
consequence of the fast excretion of FDG fron: the body.
1
Department of Environmental Conservation, Regulations, Chapter IV-Quality Services, Subpart 380.5.
Raphex 2011 13