ate] @)ats).4 N0AA0 ie to Vee I ) Answers Sean L. Berry, Ph.D., Therapy Editorpreface The RAPHEX Therapy Examination 2019 was prepared by members of the Radiological and Medical Physics Society of New York (RAMPS, In), the New York chapter ofthe American Association of Physicists in| Medicine (AAPM). ‘The exam content was updatd in 2016 to match the sylai for teaching Radiation Oncology residents published by the The American Society for Radiation Oncology (ASTRO) Physics Core Curriculum Subeommittee (PCCSC). The numbers of questions fo each subject re approximately related tothe number of teaching hours allocated to each subject Exam committee Sean L, Bery, P.D., Therapy Editor Howard L Amos, PRD. David Barbe, PhD. Eugene Lif, PRD. ‘Adam C. Riegel, PLD. Jussi Sillanpua, PhD. ‘Cheng-Shie Won, PhD, Chie Editor Additonal questions contbated by ‘Maria Chan, PhO. Martha Malin, Ph.D. Jeaghwa [Link]. Gregory Niyazow, MS, Ting Chen, PhD. Brian Wolthuis, MS. sian Li, PRD. ‘Yuanguang (Andy) Xv, Ph. Rongtao Ma, M3, $llen Yorke. PuD. Dennis Mab, PAD. I you are taking RAPHE, under exam conditions, your proctor wil give you insretions on how to fil | foul your examinee and site IDs onthe answer sheet. | + You have 3 HOURS to complete the exam, + Non programmable calculators may be sed + Choose the most complete and appropriate answer to each question, ‘We urge residents to review the exam with ther physics instructors Any comments or correction are appreciated snd shouldbe sent to (Cheng-Shie Wau, PRD. Chief altar esw6i@eume columbia edu Copyright © 2019 by RAMPS, In. the New York chapter ofthe APM. All igh reserved, No part of this ‘ook may be used or reproduced in any manner whatsoever without writen permission from the publisher oF the copyright holder.Published in coopes jon with RAMPS by: Modical Physi Publishing, Ine. 4555 Helgesen Drive Madison, WLS3718 1-800-482-5778 mppamedicalphysics. org vw medealphysics ong Print in te Ud Stes of Anercntherapy answers Tob. D. ae mc Tc. TB. A Te OB TB, Te. 8 TH eg. TB. Raphex 2019 2000 [Re 3.43 [Remi be = 583,09 [onCiem?) 583.09 [mC Jem] > (100 em) V8 [Ci] x 1/1000 [CVC = 66 ‘The joule isthe SI unit for energy, work, nd heat, The gray isthe ST unit fo radiation dose, and 1Gy= [kg = 1 kg mie The hai of Co i 5.26 yeas oF 6.12 months, Since A=? ty =n 2/63.12 months = 0.018 oF 1 per month In decay, a neuton decays to a proton, an electron, and an ant-neutrno, and possibly, ‘amma rays. With the ational proton, the alomic number is inreased by 1, but the sum of| projoas andneutons, A, remains unchanged, 40 MeV. The above nergy equivalent off amu ~931 MeV. Q=931 MeV 0.001 reaction is ecoergi; that i, 4 MeV of energy is released The energy ofa photon i inversely proportional tothe wavelength of the electromagnetic wave rpresnting that photon. Ex Tequeney = h(¢/ 3). Isotopes ar sable, ie. unlikely to deay, they havea neutronsprotons rato of I: for low atomic mass isotopes and 15:1 for heavy elements. This is refered to as the in, or band, of stabil. Above the Tine, where there are mote neuttns han protons, beta decay is Hkely, and below the line, where there are more protons than neutrons, positron decay is ikely. emission eguies an electron inthe K-sbell to be knocked out by incident electrons “Therefore, tke minimum energy of incident electtons required fr Ky emission 8 70 keV, ‘The ouput can x-ray tube increases as the square ofthe tbe voltage and linestly with tube ceument. CCharacterste x-rays are produced when an inne electron shel vacancy is filled by an auter sell electron However, sometimes the energy is not released as an x-ray, but transfered to an cleeton which gets ejected frm the atom. These electrons ae called Auger electwons There are to types of filtration in an xray tube. The frst is inherent Filtration, which comes fom the wirdow, housing, an olin the x-ray tube itself. Inherent fication i usually about 0.5 t 1.0 mm aluminum equivalent. The second is added filtration, which consists of metal shoots added tothe beam to remove low-energy xa) “The anode ofan x-ray tube is where the x-ray ae produced Since xrays are produced via bremstraling interactions, «high atomic mimber is desirable. high melting point is necessary athe vast majority ofthe energy ofthe electrons hing the anode is converted into hea. A heated Filaments component ofthe x-ray tubes cathodetherapy answers IB. C.__ Thelikelihood of photoelectric interaction goes as (2/5), so the lower-energy photons are ‘more likely to interact in the material resulting in an exit spoctrum with less intensity for lowerenergy photons than for higher-enery photons. rayon enue) TI4. A, Theclectron boa exiting the accelerating cavity typically hasan enengy spread of 1% 10 2% ‘The 270° bending magnet allows proper focusing of electro of slightly diferent energies td, therefre, a smaller spo size onthe target. There i also les loss oF electron beam “intensity with tae 270° bending magnet, albeit at inereased complexity and cost of bling the linge, When usingonly 3 90° bending magnet, lower-energy electrons would be bent slightly ‘more than high-energy electrons, thus resulting in large spot size onthe x-ray target. A larger spo size wal, in tua, result in light degradation of beam penumbra sharpness, which i undesirable 1B, ‘The xray beam or the eletron beam is inident on the dase monitoring chambers. The ‘monitoring syste: consists of several ion chambers ora single chamber with multiple plates. ‘Atnugh the chambers ae usually transmission type Ma parle plate chambers eover ‘he entire bet elindrcal hime chambers have aso been ied in some linac. The function ofthe ioe chambers to monitor dse rae, integrated dose, and fel symmetry. TH6, A. Because there willbe bot jaws and MLC in lige B, there wil be less space between the ‘gantry head and the patient ata piven SSD. However, there isn enginering reason why linge ‘A would have leaves that teavel faster or leat positions that canbe defined more precisely. Similarly, there isno engineering reason why only the MLC in linac A would be abe to move dynamically during beam-on, 2 occurs for sliding window IMRT and VMAT. TIT, —_D. Withouta fatonig iter to attenuate the beam, the dose rate wil be higher and the beam energy will be lower. Since the purpose of a atening fier isto make the photon intensity “faty" lack of attening filer wil result in higher photon intensities onthe bear central THB, B, Thefirst combined MR weatment units used Co because exposing the beam of electrons to an external magni ld i adficul enginecting problem, Even within the patient, the presence ofthe magnetic field affeots the delivered dose distribution duc to the interections of| the secondary electrons with the magnetic field. Metal implants may be subject to heating as well x magaetie lores, and many implants are nt safe fr use in any MR unit 2 aphex 2019therapy answers TI, A. mT. mA mA ™. vb. m4. 5. B. 8B. mA mB. mF Raphex 2019) Bremsstalng production is proportional to EZ, where isthe incident electron energy and Zs the atonic umber of the target. “The eel effet cocurs due to nonuniform sel-ttenuation within the angled anode wed in KV beam generation. MY beams utilize a uniform target and do not experience the hee effect According to AAPM TG.-0, mult-laf collimators (MLC) are usually made of tungsten alloy becaus itis hard, machinable,inexpeasive, and has one ofthe highest densities of any material, ‘As polyenergetie photon beam traverses a homoyencous material, the Tower-energy photons ae pefereall attenuated, so the average energy ofthe beam increases. Therefore, the fist THVL wil betho lest, and the HVL wil increase with increasing thickness ofthe material, ‘Reducing the intensity of the beam by 98% means that at most $% ofthe beam intensity remains. Malhematiclly: 1=1y(1/2)".1 will be between 4 and 5, For N=, his is 0.03125, 1g G.125% emai). For N= 4, this is 0.0825 Ig (6.25% remains) Hounsield number H)~ (01— t/a] * 1005 U2 Porat ~ Hater) / Hater) ¥ 1000 = 1000, \When a chaiged particle interacts with an atom, the influence ofthe particle's coulomb Force field affects tne atom asa whole, Mos of the interactions are “sol” collisions with outer shell, clectons rnstering only minaetractions ofthe incident particle's kinetic energy. his proces is ote referred toa the “continaousslowing-down proximation.” Fora mono-energeti beam, the HVL is constant. The narowest energy spectrum in the figure represen the situation where the frst and second HVLs will be the closest, [Bnergyspecrum A has the largest proportion of low-energy components that would be removed by a low-energy filter. The other eurves would be much less affected. Removal of this energy range would harden the beam and inerese the HVL. Gold is high atomic number and is high-density material, so photeletrc interactions are significant, sulting in high contrast na CT scan orn @ KV planar image betveen the fiducial andthe issue in which itis implanted. {Ina Compton scattering interaction, an incident photon interacts with ee clecton. Some of the photon exeray’is transfered to he electron, and the rest ofthe energy remains wit the Scattered photon. Due to conservation of energy and momentum, the electron canbe deflected between 190 and -90 degrees. The photon can be deflected by any angle. A deflection ange of 180 degresis that which the maximum energy was transfered by the photon to the eleeontherapy answers 133. 34, 35. 16. ao 38. jr production oscurs when a photon with energy above a threshold of 1022 MeV interacts with the Coulomb eld around nucleus, The photon dseppeats, and an electron-positon pair is produce. [KERMA is inte eneray released in mater and represen the nengy transfered from incident photons t electrons tat ae set in motion by a photon-lectron interaction. These clectrons transfer much oftheir energy locally, but not all atone. The energy is deposited ‘over the pathlength ofthe eletron, so KERMA, the energy initially ansferre, is higher in the region where tie electrons have not yet deposited ll their dose (the buildup region), This isthe definition ofthe uence, which is given in unis of Vn? ‘OSLDs provide a means for o-vino dose measurements. However, he response ofthese dosimeters fade ater iradiation. To accurately and reproducibly measure dose, OSLD. ‘measurement shold be made ater this fading period has ended (onthe order of ebout an hhour)OSLDs do exhibit linear dose response, energy independence for MV beams, as well ‘8 insensitivity to dose rate and temperature. [A parallel plate ox chambers the best instrument fr electron output measurements Is ative ‘volume size should he much smaller than the sizeof the euout Aeylndrcal chamber can also ‘be use for higher electon energies provided thatthe eutout is much larger in size than the collection area of he chamber. Opticsly stimulated luminescent dosimeters (OSLDs) or thermalumineseent dosimeters (TLDS) ae the mest common means of measuring the pacemaker dose ona patient. A neuton ‘meters bulky and would only capture the neutron dese Ton chambers use high voltage, which is dangerous forte patient. Film is inaceurate for small doses. ‘The fll corrected charge reading fom an io chamber is given in AAPM T-S1 as M= Pag Pp Pele Ppt Moan: Mr the raw chamber reading, and Pj ste factor that acenunts forthe fect that some of the ionization that occurs in the chamber ress in recombination betoeit is measured bythe chamber. Pq 8a function of dse rate and bias voltage and is meesured by acquiring measurements a v0 diferent chamber bas volte stings. “The dose recived the film can be related to the emount of light hat ean pass through the exposed, This known as the optical density. Given fy and fas the transmission values ‘measured before and after an exposure, the optical density ean be defined as: ND = logo (l/l) this example, OD = logo (5000/S00) = 1,000 Atd~ 1.5m, 100 SSD, 1 MU will deliver 0.97 cGy due to the inverse square law. Ihe data ‘ables improperly report that I eGy is being delivered under these condition, every MU ‘aletlation wil esl ina delivered dose that is 3% les than expected aphex 2019therapy answers TF 140, A, TH. Ta, TH, 8. Tas, 14s, Raphex 2019 Silicon diodes ate small enough to measure small fields. The parallel plate and farmer ‘camber are to large and would result in volume averaging effects, underreporting the ‘signal Af at ionization chamber is used for measuring exposure i ai, and a well chamber is used for ealbration of radiosctive sources. ‘TBI treatmeats ae often delivered at extended SSDs, upto 400 em, and in-vivo dosimetry can indicate whater the patient was positioned atthe correct distance from the source. In-vivo