Lw.UD)LOle therapy answers Oran CAL Ty allt cyg eR R COM Dem eT a= heda Eine RAMPS (Radiological and Medical Physics Society of New York)preface ‘The RAPHEX Therapy Examination 2018 was prepared by members ofthe Radiological and Medical Physics Society of New York (RAMPS, Ine) the New York chaper ofthe American Assocation of Physicss in Medicine (AAPM). ‘Tho exam content was updated in 2016 to match the syllabi for teaching Radiation Oncology residents published by the The American Society for Radiation Oneology (ASTRO) Phyrics Core Curriculum Subcommittee (PCCSC). The numbers of questions fr each subject ar approximately related othe number of teaching hours allocated to each subject. ‘Exam commits Sean L, Berry, PhD. Therapy Editor Howard Amols, PhD, Carl Elson, MS Eugene Lie, PhD. ‘Adam C. Riegel, PRD. Richard Riley, Ph.D. ‘Cheng-Shie Wau, PhD., Chief Editor ‘Additional questions conte by David Barbee, PhD. Dennis Mah, PP.D. Maria Chan, PhD. Matthew Williamson, MPH enghwa Chang, PhD. Gregory Niyazon, MLS. Karen Episcopia, MS. Juss illanpaa, PhD. Raphael Jakubovic, PhD. Yanisley Valenciaga, Ph.D. Rongtao Ma, MS. len York, PhD. Ifyou are taking RAPHEX under exam conditions, your proctor will give you instructions on how to fil tout your examine and site IDs onthe answer sheet + You have 3 HOURS to complete the exam. + Non-programmable calculators may be used + Choose the most complete and appropriate answer to exch question ‘We urge residents to review the exam with ther physiesinsrators. ‘Any comments or coretions are appreciated and shouldbe sent wo CCheng-Shie Wau, PhD. Chief Eitor ‘sw cume.columbineds Copyright © 2018 by RAMPS, Ine, the New York chapter of the AAPM. All rights reserve. No part ofthis book may be used oF repreucd in any manner whatsoever without writen peisson fom the publisher or the copyright holder.Poblished in cooperation with RAMPS by: ‘Medical Physes Publishing, Inc. 4555 Helgesen Drive Madison, WLS37I8 1-800-442-5778 pp medicalphysis ore ww.medicalphysics.ongtherapy answers ™ B mo mo TAA. oD. THe OA moa TB TRO Te. b. THe TA, TA, Raphex 2018 “The euie isa non-t unit of radioactivity that was based on the decay of Ro-226. The SL unit isthe bocauere, which is defined a the amount of radioactive material that experienees one lisintgration per socond. 1 C= 37 GB In inelastic collisions, some ofthe electron kinetic energy i los as its used in producing ionization and excitation (olision with tomie elections) or converted to other Forms of ‘nergy such as bremsstralung photons (collisions wit atomic nucle) amis defined a5 1/12 ofthe mass ofa "2€ atom, so amu~ 1.66% 10-7 kg, The halflife of b-192 is 74 days. Since 2 In2/ 9 =In2/74 d= 0.009 or 0.9% per day. ‘These are many atficilly produced isotopes with anatomic numbor greater than 92, but ‘because ofthe large number of protons inthe nucleus and the large repulsive frce between the ‘nuclear protons, they are al radioactive with ater shor hal ives, In alpha decay’ helium nucleus, which consists oF2 protons and 2 neurons, ejected, which ‘results inthe atomic number, Z, being reduced by 2, andthe atomie mass, A, by 4. The energy ofthe photoelectron, His the diference between the energy ofthe incoming ‘photon, and the binding energy, BE. Rearranging: BE= EE 20 keV = 40 keV ~20 keV 1WkeV= 40 keV -30 keV tei caleulated Of the three haltives, Fy wil be the shortest. The elective hal Wage WTy VT “Tho Z number increases by | and the A number remains the same. is therefore, a bet-minas decay, which i accompanied by an ant-neuttno For the calculation, the output wil be reduced by: BSF (cutout) /BSF(cone), “The frst HVL preferentially attenuates lower-energy xray, thereby hardening the beam. The second HIVL wil be thicker than the frst, The same logic holds for subsequent HIVLs, though the differences become small “The smaller the cal spt, the etter the spatial resolution ofthe image. A smaller focal spot pus the same amount of energy in a smaller volume of the anode, so using 8 method to Aisipate hat heat, using 2 rotating anode, i important. ‘The purpose ofthe automatic brightness contro isto oblain the best possible quality of the ‘Auoroscopy image by ehanging kV and mAs.therapy answers TH, THs. 116. Tia, 1 m0, m4, B A b, 12 (110 sox log 2= 0301 Ainge oletton gun produces eletron the same way a KV x-ray tube does, by heating a bigh-Z metal cathode to very high temperature, The lack of beam atemuaton through the atening filter allows the linac to diver beams with higher “dose rate” (MU: min), so the beamon part ofthe treatment is faster Most machines deliver 6X-FFF or 1OX-FFF, so neutrons, even for Natened beams, are not much of ‘consideration : rating tube needed to produce 6 MY x-ray is shor, only a couple of feet. Therefore, it ean be mounted in th head inline withthe beam. The long aoseleraing ‘tub requited to produce higher energies means that 100 em SAD machine could oly be placed ina treatment oom with both very high ceiling and also a teatment couch placed ‘very high above the ground. Both requirements are eater impractical, Ths, the need Tora bending magnet ‘The numberof neutrons produced por MU inereases rapidly with beam energy, bu he energy spectrum ofthe neutrons does nt have a song dependence on the beam energy, although the sigan neutron enerey des slightly increase The amount of MLC leaf tansmission depends onthe material composition ofthe MLC and the thickness othe leaf. MLC leakage can be minimized by having te jaw track along with the MLC. ‘The beam steering system compares the readings on two halves ofthe monitor chamber and csalizes them by deflecting the bear. In so doing it al maintains dose ate, quality, nd ‘utp, but these are simply results of maintaining the beam symmety, [MLCs with rounded laf ends are designed to maintain relatively constant geometric penumbra at different leaf positions in the beam, “Magnetrons generate RF, while Klystrons roqire an RF source (RF driver), which they then amplify. A thyratron i switch The Matening filler Martens the beam hat is ered inthe target. The monitor chamber ‘measures the dos, dose rate, tes, and symmetty of the beam fattened by the Matening, fer. The Xan ¥ jaws cllimat the beam a photon makes a grazing hit with the electron, the eleeton will be emitted at right anes, andthe scattered photon will go in the forward direction (9 = 0 degrees). Ifa photon makes a set hit with the electron, the elect wil travel Torward, and the scattered photon will travel backward (0 ~ 180 degrees) Raphex 2018therapy answers 25, B. This beam attenuator thickness i equal to the HVL as the dose rate increases by a factor of ‘vo after the beam attenuator i removed. HVL = 0.693/q = 0693/0.25 omy ~2.8 em. T26._D.__Foreither parce, twill ave the maximum energy in the forward dcecton, ie. O degrees The energy will decrease with increasing angle. Since there is conservation of ener, for any single interaction an increased angle for one particle implies decrease angle forthe othe, T27.—C.__ Photon attenuation can be caeulated using Beer-Lambert law: (0.85 » expf-0.0329 em’) x 1.20 (p'em?) > x (em)] X= -In(.88) 0.0329 /1.2= 4.1 em) 728, B. Directly ionizing particles havea charge and ean, therefore, ionize the atoms ofthe material via Coulom interactions. 729. E._Photodisintegraton isa nuclear process in which anatomic nucleus absorbs a high-nergy ‘gamma ay, enters an excited state, and immediatly decays by emiting a sbetomie parle. ‘Neutrons ae produced inthe (.) reactions by highenergy xray beams incident onthe various materials of target, latening filer and collimators. The neuzon contamination Increases rapidly as the energy ofthe beam is increase rom 10 to 20 MV andl then remains approximately constant above this T30. —_D.__ Since these two files are hoth 1 HV for this beam, they will each attenuate the same intensity of photons. Hovsever, the quality ofthe remaining photons wil be diferent TBI. _D,_Aninciden photon cannot undergo a pair production interaction unless its energy ist lest the sum ofthe rest masses ofthe tivo particles that ate produced, The rest mass ofan eletron {ad positon) is 0.S11 MeV, so the threshold for the interaction is 1,022 MeV. All ofthe incident energy, above and beyond the interaction threshold, willbe converted into Kinetic ener TRL DL Gy=dihg= (hems) hemes? 133. _D.__Thisisthe definition of fuence andthe units are m™™. The energy fences the radiant energy incident upom a sphere of cross-sectional area AA 34. A, _Theelecttometer measures the charge collected from the fonizationprodced in the material in the chamber. The temperature and pressure correction factors need a be applied separately Not only does each ionization chamber have a calibration Factor, but each electrometer has une aswell. Raphex 2018, 3therapy answers ms, 136. ce 18. T40, va. ra, Ta, «. A monitor unit represents the amount of charge recorded inthe ionization chamber mounted in ‘the head of the linear aceleratr, which correlates with a dose of | eGy delivered to water phantom under eeference conditions. When the dose rato (MU'min) changes, te treatment time will change aovordingly. I'he eorect MU are delivered during the treatment, the delivered dose wil be correct. The MUlmin atthe linge during a treatment delivery varies a ltl (for 300 Mimi, something ike 300 #3 MU). That’s why a lina tresiment is measured in MU, not with a timer For cobalt teletherapy, the dose rate (¢Gymin) is constant during a treatment session, which is why a timer can be used. Each radioactive isotope has its own decay scheme, Inthe decay scheme of Radium alpha and beta radiation cannot be detected outside of the safe. However, high-energy Dhotons—such the unigue gamma radiation of Po-2 at 609 keV —can be measured by @ Sesitivespectomete, even a low intensities outside ofthe safe “The comected ion chamber reading is given by M= Pan? rpPatecPpo! Maw The corrections are for temperature and pressure, incomplete ion collection efficeney polarity effects, and the lectromter calibration ctor Since the medium of nerest i water, it must be used for elinical reference dosimetry atleast ‘anally. Plastic terials, such as solid wale and plastic water, can be used for periodic ‘quality assurance checks OSLDs have some advantages inching: high semsivity and high pression, canbe reread mile times, the energy dependence is negligible inthe linae mepavelige range, and thet Fead-out i done at room temperature with laser (no need fr nitogen gas or high temperatures). OSLD fading fs severe in the fst L0 minutes afer radiation, and is insignificant aller that. Optical density sa mesure ofthe darkening of radiographic or radiochromic fl. Its icesured by taking the logarithm of the rato of the ight intensity poet and afer traversal ofa fil, Failing to divide the total dose by two doubles the MU foreach fed. The other mistakes also affect the MU caleulated, butt a lesser extent y= Dy x(PDDy/ PDD)), 50 300 Gy x (67887) = 231 cGy, “TMs the ratio of the dose rate ata given point in phantom to the dose rate atthe same souree-point distance and atthe reference depth of maxim dose Ie takes to account the Scattering contribution a the depth eative to that at and the primary bear attenuation forthe thickness (d-dq). The inverse square law his to Be applied when ealculting the dose at dy rom the dose ty aphex 2018,Tac. 145, D. 148. van. 48,8, TH. 50.8. Tc TA, 13. therapy answers ‘The spinal Y2jaw abuts the cranial Fields, The cranial elds would, therefore, reguite a collimator angle of arctan(13 cm 100 em) = 74° Skin gap = 0 «30 x (d/SAD) +08 30 «(Q/SAD)=30% 5/100 1.5 em, ‘The PDD increases with increasing SD, il size, and beam energy. The PDD decreases with depth Te increase in penumbra with energy is duc to the increased range ofthe secondary lectrons «created from the higher-energy photons. Penumbra actually decreases asthe energy increases ‘unt about 6 MV and then it starts increasing agai, The minimum penumira occurs a about SOM, Beam symmetry refers tothe beam profile Being the same on each side ofthe bear cena axis. Flatnes is measured by finding the maximum and minimum dose values on a beam profile within the central 80% of the beam. Penumbra isa measure ofthe fall-off between the ‘0% 10 20 dose shoulders of beam profile ‘Thesize ofthe buildup region is related to the range ofthe secondary charged particles released by the incident photons. As the photon energy increases, so does the secondary charged paticl range and, hence, the length ofthe buildup region Ths region is characterized by a lack of charged particle equilibrium, ‘The PDD incorporates changes in the inverse square lw, beam atteration, and sealtering so 15 the SSD increases, the PDD increases. However, the TMR is usta measure of bam tention and seattering, so asthe SSD increases, the TM remains the same ‘Small ields a the interface between two heterogenits isthe sition where model-based algorithms, suchas convoluon Superposition, are likely to reak down and Monte Caro will be beneficial Ina thre-feld beam arrangement, the wedges would be placed on the parallel opposed fields, and the thick ends ofthe wedges should be oriented toward the eam that is entering ecpendculart the parallel opposed fick ‘When doing an SAD treatment, itis easier to ealeulate dhe MU with he TMB. The equivalent sue fora collimator seiting of 13 8m? i 15 cm” and $,(15 15 om") = 1.015. ‘The field is blocked to 4 FS of 10> Lem othe 5y(10>10 cm?) = 1,000 and the TMR{d=8, 10% 10 em?) = 0842 MU = dose per field (outpt for SAD setup x "TMR) = (30002) (1.0% L015 100.802) = 176 Raphex 2018therapy answers 54, 55, 156, 157. 58. 59. 160. To. 62. 163. ‘When dengan SSD weatnent, its case tp cau the MU wih the PDD. The equivalent square fora collimator sting £8 13 em” Oem and S10 10cn?)~ L000 The ek Is blocked 10 FS of 88 em? so the S,(8% 8 cm?) ~ 0989 and the PDD(A-S, 8x 8 em?) = 86.2% MU ~ Dose per fed foupt for SD setup «S, x S, x (PDDI00%)] = (490!) (1971 % 1,000 % 0.989 0.862) = 483. The PDD is defined as (dose at depth / dose at yg) > 100%. In he previous question, the ose at depth was prescribed a 400 eGy, and the PDD(d=S,8 x 8em") = 86.2%. Therefore, the dose at dy = 400, 0862 ~ 464 eG. “The side ofthe equivalent square is caleuated 354 area/ perimeter = [4 (5% 20)] [2x (5 +20)] 80cm, Equivalent squares are used to convert an ireguary shaped photon field toa regularly shaped eld that has approximately an equivalent seater contribution to the point of interest This fs done to simplify lookup ables foe seater Factors, PDD, and TMS. Inonderto deliver a flat field at a depth of 10cm, 9 beam profile at dy, wil feature high Jose horns” lateral of the genta axis The dep of the distal side of the 909% isodose line can be approximated as E/3.2 of the fect energy. So, 9 MeV beam will eat to approximately 2.8 em. Use ofa higher energy ‘will necessarily expase move tissue. “The practical range of electrons in water (in cm) is approximately haf oftheir every Cin MeV), The thickness of lead necessary’ is approximately 10 times less than water “Theres litle change inthe ouput ofan electron beam ifthe eutou size is larger than or equal tothe practical ange, The practical range of 9 MeV bear is about 4 em (E22). The output will have significant changes only wie the minimum cutout dimension is less than 4S em The dose fall-off gradient becomes less seep with increasing enensy, as dos the bremssralung production radiative colistons) from the higherenergy electrons. A star shot is taken by exposing film from a number of different collimator, gantry, and couch postions inorder to determine the radiation socentr. An end-to-end test measures the ltncertainy fora given treatment technique by performing the technique ina phantom from ‘imation through panning, and treatment deliver. A picket fence fest is used for MLC QA. CTI isa measure of dose fom a CT scan, "AAPM Task Group 142 sets linge QA tolerances a function of intended treatment technique ‘on each linac withthe though ha thee son he an inereas in accuracy and precision when {you go fom non-IMIRT to IMRT to SRSVSBRT teats Raphex 2018therapy answers Te. Tes. b. To. Ter, 168. . Te. TH. A Tm. . ™ © Since madeen radiotherapy relies heavily on image guidance, iis essential verity thatthe imaging and weatment coordinate are coincident. ‘AAPNCTG=142 isa report that focuses on linear accelerator quality assurance I updates or prescribes QA tests both forthe linac and he ancillary systems that interact wih the fina Tor ptont setup and treatment, CT simulator QA is described in a separate ask group report AAPM Medical Physies Practice Guideline 8. iste that are deemed tobe ert for ‘are and effeative linac QA with the goa of ensuring that machine characteristics have not deviated from the baseline values determined during equipment installation, Ina picket fence test, film is radiated with opposing hanks of MLCS position close, but ‘ot touching. This is done at several postions across the Beam. The film is analyzed by looking for dater or lighter areas, which indicat wider or nartower gaps betwee the MLCS, Such areas would inieatemisposiioning ofa parculee MLC pair PACS stands for Picture Archiving and Communication Systm, Is advantages ar ess physical space necessary for storage, images can be reviewed remotely or simultaneously at Aiferent locations, and te data can he easly tansforred to ater digital systems byway of the ICOM standard (QA commiee minutes may contain private patient information and, therefore, they ean only be store on secure devices. ICOM is. standard use so that applications ean export and accept data from other applications. ln order for other DICOM applications connec o your application, you would need the IP address ofthe computer hosting the application, the port numb, and the AE ite, “AE" stands for application entity, and isthe unigue name used to iden your application to the other DICOM applications that wish to connect to it Wipe tests shouldbe performed after spill fa radiopharmaceutical has occured as wells iTthere is suspicion that contamination has occured. In the absence of either ofthese conditions, wipe tests performed periodically are necessary to identi any unsuspected For megavolage machines, the workloads specified as weekly dose dlverd at | meter rom the target Following the ners square lth workload fom this teatnet about 12 Gy (ni tm = 1926 Raphex 2018,therapy answers ™. vs, 176. 18. 19. 80. vai re, rea, Db As longa the physicians approved as an authorized user, pectic forthe Gamma Kaif by tithe the NRC oF te appropriate state regulatory agency, any licensed physician may prescribe adtion treatinents, Neurosurgeon, for example may be approved as an authorized {ser provided they have the proper taining. In practice, however, itis dificult for anyone tothe than aboard cetited radiation oncologist o obtain designation as an authorized see ‘See NCRP Repurt 151 section | 4.2. The design goal i 0.02 mSv week (0.02 mSv week) 2(S0lweek ye) = | mSv 94H, the annual dose limit fora member ofthe publi By aplying the faction of time the hear son and the use Tato, one determines that 25 mRirx0.5 x 5 minh! 60 min/he~ LO mR inany 1 hour. Althoug the circumstance that the location isan uncontrolled ares is not paramount tothe answer, noe tha the resultant tstimated dose to this location is ess than 2 mR in any br a public dose limit IMT increases the numberof MU and increases leakage, but doesnot increas the dose to [PMEA stands for “ile modes and effets analysis” and is applications to radiotherapy described in Hug ot al. “The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management” Med Plys 23:4209-62, 2016. RO“ILS stands for “radiation oncology incident learning system.” For more details see Evans and Ford, “Radiation Oncology Incident Learning System: A Call to Participation.” LROBP 99:249-0, 2014 As desried in Hug etl. “The report of Task Group 100 ofthe AAPM: Applicaton of tsk ‘analysis methods fo radiation therapy quality management,” Med Phys 23:4209-62, 2016, RPN OS xD where O, 5, and D are the likelihoods of occurence clinical harm, and detection, respectively. ‘Compared to performing deformable image regsiraton between image sels ofthe same ‘modality, intersidlity deformable image registration, such as CT to MR, i es elie, 40 CT allows determination ofthe tumor motion, Tumors near the diaphragm (ung iver, ete.) are most affected by respiratory motion. “The storage equitements, processing time, and patent dose are actully increased in onder to mainain the same level of nose ‘A larger focal spot fciitates better eat dissipation, which is equired when high AS (cillamp seconds) exposures are required. Otherwise the tube would overeat. In al ther respects, however lage focal spot image is inferior in image quality to a small focal spo aphex 2018,therapy answers Te. 8. Tes. C. 106, re, Ta, 8, Te, 190.4, THB. 1. &, Raphex 2018 ‘1 rclaxaton is related to relaxation inthe z-irection, and T2 relaxation i elated to relavaton inthe x- direction, ‘Xays in the KV range have intrations with tissue that are predominantly photoelectric lec, which is proportional 0 2°. The wavelength (9) i= cif where cs the velocity ofthe wave and fists frequency. The average velocity of ultrasound in sot issue fs 1830 ms. Therefore, = e/f= 1540 (m')/ 5 10° He= D003 m= 0.31 ram, The CT and PET portions of the diagnostic PET/CT share DICOM coordinates. In other ‘words, the images are acguied and automatically aligned based onthe coc postions, under the assumption that patient motion aecurted between scans. To corset fuse the sim lation CT and the diagnostic PET/CT, the CT from the diagnostic PET/CT scan is registered to the simulation CT. That repisteation mati isthe applied tothe PET om the diagnostic, PETICT so thatthe PET information can be shown overlaid ypon the simulation CT, “The width ofthe CT window is a measure ofthe range of CT number values displayed. When the window is nao ain piture a, the visual ranstion fom dark to light structures inthe image will happen quickly. Narrow windows ae used when rying to diferentate between tissues with similar attenuation properties, wheteas wide windows are used in areas where tissues wth very diferent atenuation properties are adjacent to one another. ‘The SNR increases as the number of photons absorbed by the detector increases creasing the mAs and the slice thickness will Both increase the numberof photons incident upon & particular detector. Hovever, increasing patient thickness will esl in greater attenuation of the xray’ beam, sulting in fewer photons reaching the detector. A.V20 of 25% mans 25% ofthe volume receives at leas 20 Gy, oF 75% of he volume receives at most 20 Gy, Since brachytherapy sources are implanted ito the patient, the patient motion errs are smallest, The proton range depends rtically on radiological pathlength, ad changes in patent poston could have alge effet onthe types of ssuesavesed by the beam, Although photons are less sensitive to radiological pa length than protons, IMRT xrays result in larger errors than 3D conformal x-ys because of the concave dose distributions ereated by IMRT. ‘The misalignment between the radiation and imaging isocenters i systematic ero that cannot be comected with image guidance,therapy answers therapy answers 193, 195. 196, 98. Tio0. Tio. ach image-guided treatment system performing patient positioning andlor repositioning tnscdonin-foom imaging system, ether 2D or 3D, relies upon vendor software that compares tnd rexiters on-board images end reference mages, Quality assurance ofthis process could be easily done bya phantom study with known shifts, and this i recommended foreach ‘system used clinically, The accuracy of his proces shouldbe tested on the dil bass, ‘expecially for SRS/SBRT Flatening filter fice beams are capable of higher dose rates, which counteract the low duty cycle mages should be acquired during the respirator gate in oder to vldate the coreaton between the extemal gating signal and the intemal anatomy. The setup alignment should be ‘ase on fil markers, high-contrast objects that move with the tums, Oshogonal Silovoltage images cannot reliably resolve sot issue. LV fluoroscopy canbe used ona ine gantry-mounted KY system in order to verify that an Jnerat fiducial or landmark, such as a ste sn the eorret place when the external marker sad for respiratory gating would trigger the MY beam on. Since uotoscopy uses the KV. ‘eam longer than a single radiograph, the doses greater. Ina linae-mounted kV imaging ‘System, the KV beam is oriogonal to che treatment ed, soit cant image the testment aperture, and the MV bear would e used for ths. Linae gansy-mounted KV imaging systems are capable of radiography, fluoroscopy. and cone- beam computed tomography (CBCT). An image is generate by te at pane area detectors mounted opposite the vay tbe and ean bo used for target localization before (radiography tind CBCT) and during (luoroseopy) treatment, However, uoroscopy-based tracking systems fre not commonly used due to the potential for excessive radiation exposure ‘Since an IMRT fluence pattem is designed tobe heterogeneous, the uniformity ofthe Beam incident upon the MLC is unimportant, ‘During the optimization, various luence patterns are checked to calculate the objective Function and minimize i The beam enerzy and VMAT ac length are usually manually {termined prior tan optimization, The PTV iste target defined bythe physician, whichis fn input tothe optimization, For the same patient geometry, more monitor unis usualy implies smaller average fed size uring teatment delivery and therefore more modulation ‘Such teatment would reuir atleast 10 steps with field wid for each step of 10.9, 8, 2yand I em, respectively. Even with 10 steps, the dose intensity variation would not be smooth “oto the fed bu rather would have discret steps of 3% every em. Thus more than 10 steps ‘would esl ina smioather dose gradient. ee Raphex 2018,therapy answers T02. Ti03. Toa, Tis, 106, Ti07, THo8, THs. Tho, Tun, 2, b. Increasing the numberof factions and the numberof teatment Fes or aes wll derease the liklinood of synchronization between the MLC motion and the target motion. Even if iis synchronized fo a particular faction or beam, the eect would get washed out ver the course ‘of many fractions or beams. The MU fora VMAT plan is generally lower than that fora static IMRT plan forthe sme Patient target and anatomy because VMAT teatments usually have larger beam apertures ad, thus, higher MU effcincy Contibution of each objective wo the ttl objective Fantion i proportional ots priory By allowing the target heterogeneity to increase, you can prescribe to an isedose line closer to ‘the penumbeaof exch beam, miniming the amount of nama issue exposed in the Bea's eye view projection ofeach weatment fil Assuming the teatment plan is propel ealulated, the range ofa proton beam ean be precisely controlled, thus minimizing the heat dose for proton therapy. ‘The spoiler needs tobe placed else tothe patient inorder o increase the surface dose. itis placed too far avay, an insufficient numberof electrons will each the patient. Lungs are atthe greatest risk for complication, and they are usally blocked. Patent separations are generally Simaller inthe anero-postrioe direction, so the dose homogeneity willbe beter with hat beam arrangement. Although te light and radiation fells maybe congruent at 100 cm SAD, this snot the ease for extended distances, “Treatment time i quite ong, which can be a disadvantage since tis population of patients isoten physically weak. However, some TBI treatment provocols actly rosommend lower dose ate. Extended SSDs ate use inorder to cover the patient na singe Held. A consequence of extended SSDs is increased dose unitormity de othe inverse square la. The se rate decreases with an increase in SSD, (Currently, the administered ativityis 1.49 pik. ¥.90 undergoes beta" decay with a decay energy of 2.28 MeV. 001% ofthe decays produce 17 MeV photons. ‘Radium-223 goes through a decay chain yieKling 4 alphas, 3 bets, and numerous gammmas About 98% oF the dose to the target cells from alpha particles. ‘Therapeutic election beams are typically of energies between 4 and 20 Mev, which translates to treatment depts beeen 13 emvand 7 em, Therefore, they are not piel used fr lesions ‘hat could potentially be deeper than tis. However, ol skin iadation is @ good site for an electron beam because i teas the entire skin while keeping the whole body dose lv, Raphex 201therapy answers TUB, C.__ Theale of Co-60 is 5.26 years, so assuming the same exact source and same pla caesrutt tines will have approximately doubled five years later. A 100 Gy teatment would a SO minutes. To detver 60 Gy the new treatment time will be (60/100) » 50 minutes 30 minutes. TINA, _D.__TheBeom energy and collimation system wil dre alfet the beam penumbra and the dose Ttt The seeequence of prescribing to a low isodose line (50% to 80%) wil result ina Fh hot spot but minimize the dose alo outside of the PTV. TINS, D._ The AAPM Practice Guideline for SRS/SRRT describes the minimum level of medica ‘ses spore neesary for SRS and SBRT, Table 1 ste guideline sammarzes equipment ‘Dd aoe ited tolerances. End-to-end testing, bth for localization assessment and Aosimere evaluation, i sted as an annual test ‘1116, _E. _The monthly radiation iocenrcity tet should cover the range of gantry, collimator, and couch postions used linically. ‘When sing separate isocenters for cach target, ach scent is usually placed within the aad of te target However, wien using a single isooenter or multiple metastases, the saa usally a some poin between the targets. The fer a particular targets frm the iaocenter th larger the eee of rotational setup error. TING BL _ Relative biological effectiveness (RBE) per unit mass tissue can be used to compare the aaa or harm caused by each interaction wih the variows masses of human issue, RBE: ara OF hosed on ICRP 60's 1990 Recommendation o the Intemational Comission on Routotoscal Protection. Neutrons havea range of RBE fom 59 20 depending o enerey+ ‘th the most damaging neutrons inthe range of 100 keV to.2 MeV! “TIN9. A. Titanium applicators are CT/MRI compatible and are available ftom several brachytherapy auipment providers ands sch, low both moat of scans. The crcent standard OF carrion of dose wound brachytherapy sources i based onthe AAPM TG-43 formalism, ‘Shieh goneats tbe dee ina homogeneous water medium. No inhomogeneity cometions are performed TI20, _D.__ KERMA stands for kinetic energy released pr unit mass. Dose i enerzy sorbed pet nit an fencer the unt Oy is the same fr both, For source strength, we are looking forthe ate ta specified distance. Here its pe hour atone meter TIA, E Thehalfiteisierolevant The activity specifies how many gammas are emit pe second, aid the energy allows calculation ofthe dose per decay 2 aphex 201therapy answers FIZ B, The halite of Pi-103 is only 17 days, whereas the hal: of -125 is 60 days, Thus, the {otal dose fr Pa is delivered over a shorter perio of time, meaning less issue repair and, therefore, higher effectiveness, even fora lower preseribed dose TIDB. A, SO mCi/90 seeds « 1U (0.787 mCi=0.7 U/ sed ‘TI24, D._Thereport of AAPM TG-128 on quality assurance tests for prostate brachytherapy ultrasound systems was released in 2008, The nee template alignment shouldbe within 3 mm, the axial and lateral resolution should be within I mm of baseline, and the grayscale visibility should be ‘within steps, of 10%, fom baseline, TIDS. D, The 2015 document describes the entire HDR process, including deals onthe appropriate ‘quality assurance program, of which the calibration of the sealed HDR source is par TH26.C. According to the joint ACR-AAPM technical standards, a qualified medical physicist can use ‘an autoradiograph or othe suitable method to make this measurement before the fist use of the remote aferouder on each given day ‘TI2T, D. The dose to be delivered is he same, but the time to deliver the dose decreases because ofthe higher asi TI2B, A. Well chambers calibrated by an Accredited Dosimetry Calibration Laboratory (ADCL) ean be used to measure LDR, HDR, and bela soures, ‘TI29. _D. _Wiell chamber measurements of source output are required annually or when a source is ‘exchanged. The source output shoul e verified daily in the treatment planning sytem versus a decay table, TH30, D. Fora ine source, the dose rate at a point near the source is approximately inversely proportional othe distance from the source. The prserpton pont fr patient Bis farther ‘om the source than the prescription point for patient A, hence it requires a longer raiment time. Since, fr patent B the distance feom the prescription point to the source i larger the ose fl fom the cylinder surface othe prescription point is less (ie, dose fal fom 1.75 em to2.25 em for patent Bis less than the dose Fillo from 1.25 em to 1.75 em for pilient A). Therefore, forthe same proscribed dose at 0.5 em depth fom the cylinder surface, the dose at the eylindr surface foe patent Bis lower TIBL, B. The total dose is calculated as initial dose rate times the mean life, The mean lif is 144 = half. Dose=0.1 Gyr» 24 hrday » 20 days» 144 69.1 Gy 7132, D. _Forthisisotope, 60 days is 3 halves, The remsining activity after 3 halves is: (0.5) 125% or e442 ~ 19 59, This means that 87.5% of the iia radioactive materi has decay, othe patient has already received 87.5% ofthe ftal dose TT Raphex 2018 Btherapy answers 1133, _D.__Artiation oncologist must he present, but not nevessarily be the preseiber. The qualified aerial pystat must be thee as well Depending on the istuion, a aation therapist may be there, but a radiation oncologist can operate the aftestoder. For ca, Au, and Co, over distance of about Sem fom te sures the rer uaticn ofthe primary photons very much compensited for bythe contribution of aaycd photons. For Pd, and 1, the atevation components larer than the seterng the to their low photon energies Ti34, 135. C.__ In TG-3, the anisotropy factor accounts for both photon absorption and scattering inthe reanes encapsulation athe medium, withthe inverse square correction factored ou “1136, A. _ Proton range depends on both the density and atomic umber (Z) of he tssue Single-enery ‘Crrecanniag doesnot allow accurate determination of atom mumber, but dual-energy CT cceosine hs the clear potential advantage o improving proton beam range peditions, Thus, “fadle-energy scanning is adequate for photon treatment planing, Dut may led to errs in Fron bea planting: Dual-energy seannets can acquire sans at bh nents eonmeonely. so they won't add information about setup uncertainties. Soft sss have aera nomic nanibers, so dual-energy CT won't enhance the ability 1 segment them over Single-enery CT. “TIBT, A. Typically pencil beam seaming has lower enrance dose since the plan can be iverse planned Ter entnal dose, Double scattering beams ae optimized for distal dose. RB i about the sare cs double scattering (1-1) and, ypiealy, the penumbra less sharp than double sifecng becawe of the sbsence ofan eprtre ear he patient Apertures ar slowly Being introduced into PBS. 138, A. _ Enofrange effects may be responsible for bigher RBE effets at he end of the readout Daze Pek Some proton centers aterpt to mitigate these effets by nt having al of the beams stop on the same eal streture TA9, _D._ The absence of exit dose allows proton beams to spate organs a sk downstream. Protons are Teac eepensive than aorays and ae more sensitive to uncertainties, sch as those nkewucet Ty tagan motion The chal RB is bighes, 1, bt hiss incorporated inthe reseiption ae rere an the equivalent dose tothe targets similar to that for photons. The stra {lenurara or proton is sharper a shallow depts, but larger at deeper depths -TI40, D. _ Proton sate causes ateal spread ofthe beam beyond the fel edges and the omount of restore dependent upon the depth in he patent, the energy ofthe beam, and the ir 82P etween the aperture andthe patient.