RADIOLOGICAL

PHYSICS
[ ~ ~ E X M
l- ~ --
Published for:
RAMPS
(Radiological and Medical Physics
Society of Nevv York)

tl "': -
"'
- .
The RAP HEX 2008 Exam Answers book provides a short explanation of why each answer is correct, along
with worked calculations where appropriate. An in-depth review ofthe 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 RAP HEX 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 2008 Committee
Copyright 2008 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.medicalpbysics.org
Gl. D
Gl. D
Gl. B
G4. B
GS. D
G6. D
G7. D
G8. B
G9. C
GIO. D
Gil. C
Gil. C
Gil. B
Gl4. C
GIS. A
Gl6. A
Raphex 2008
General
By definition, 1 gray is the dose of radiation that delivers 1 joule of energy to 1 kg
of material.
1 rad = 0.01 Gy = 10 mGy. Rad is an obsolete unit of radiation dose.
1 Sv = 1 Gy x wR, where wR is the radiation weighting factor, related to the previously
used "Quality Factor" Q. See NCRP Report 1 r6 (1993).
1 Sv = 100 rem.
Annihilation of an electron and a positron (with equal masses) produces two photons with
energies of 511 ke V each.
3
General
: Answers:
Gl7. D
GIS. B
Gl9. c
G20. E
G21. . B
G22. A
G23. c
G24. D
G25. D
G26. C
G27. A
G28. D
G29. E
GJO. C
Gll. E
4
The number of electrons in a neutral atom is equal to the number of protons in its nucleus.
Isobars are nuclides with the same mass number (A), but with different numbers of protons.
The energy of the y-quantum is equal to the difference in total rest mass before
and after the reaction, expressed in the units of MeV. The total mass before the
reaction is 1.00727 amu (proton) plus 1.00866 amu (neutron). It is more than the
deuteron mass (2.01355 amu) by 0.00238 amu. This is equivalent to 0.00238 amu
x 931.5 MeV/amu = 2.22 MeV.
The stability of the atomic nucleus is determined by the numbers of neutrons and protons
forming it.
The typical energy of alpha particles is 1 to 8 MeV.
Heavy nuclei tend to decay by alpha-particle emission. Z decreases by 2, and A decreases
by 4. An example is the decay of radium to radon.
Raphex 2008
G32. D
G33. D
G34. E
G35. B
G36. E
G37. E
G38. B.
G39. B
G40. C
G41. E
G42. D
Raphex 2008
General
! Answers !
The transition is decay, in which Z increases by 1. Beta particles are emitted with
a spectrum of energies; the available energy is divided between the beta particle and an
antineutrino.
Cyclotrons can accelerate only charged particles. Radioisotopes can also be created by
bombarding samples placed in the neutron flux of a reactor (e.g.,
60
Co,
192
Ir). Examples
of radionuclides prepared by methods A through D are:
A:
137
Cs,
90
Sr
B:
192
Ir,
60
Co
C: Various positron emitters with short half-lives; e.g.,
11
C,
13
N,
14
0, and
15
0
D: 99mTc
99
Mo decays to
99
mTc in a Technetium-99m generator.
Adding neutrons to the nucleus can result in an excessive number of neutrons for stability.
If energetically allowed, the neutron can change to a proton, emitting a particle and an
antineutrino. The daughter nuclide may be created in an excited state, and emit gammas.
An example of this is
60
Co.
Decay of
99
Mo to 99mTc is an example of transient equilibrium.
99
Mo decays to
99
mTc
in a Technetium-99m generator. After the elution of the
99
mTc, transient equilibrium is
re-established after 4 to 6 half-lives of the daughter. In practice, elution occurs
approximately every 24 hours, and the equilibrium is established by the next elution.
5
General
: Answers :
G43. C
G44. C
G45. C
G46. D.
G47. C
G48. A
G49. C
GSO. D
GSI. C
GSl. C
GSJ. D
Exposure rate= exp. rate const. x activity/d
2
= 3.3 R.cm
2
/(mCih) x 10 mCi x (11100
2
) cm-
2
= 3.3 mR/h.
Exposure rate= exp rate const. x activity/d
2
= 12.9 R.cm
2
/(mCih) x 19.5 mCi x (1/ 200)
2
cm-
2
= 0.00629 Rlh = 6.29 mR/h.
One HVL will reduce this to 3.15 mR!h. Two will reduce it to 1.57 mR/h, and
three, to 0.785 mR/h.
The smaller filament has smaller dimensions, producing a smaller geometric penumbra,
and hence Jess geometric blurring.
The electric power is a product of the voltage and current.
The constant potential circuit produces a tube voltage that is nearly constant over the
exposure time. Therefore the effective voltage is equal to the peak voltage. For the other
types of power supply, voltage variations reduce the effective voltage.
A Ka X-ray is characteristic radiation emitted due to an electron transition from the L-shell
to the K -shell. Its energy is equal to the energy difference of the respective electron shells.
Similar considerations apply for other characteristic X-ray energies.
Bremsstrahlung X-rays are emitted with a continuous spectrum, for which the maximum
is the applied kVp.
Unlike a polyenergetic beam produced by an X-ray tube, a monoenergetic beam does
not become harder due to filtration.
Their kVp (intersection witp the x-axis in high kV region) is the same, and the
characteristic peaks show that they have the same targets. The different positions of
the curves show that they have different HVL and different filtration.
6 Raphex 2008
G54. B
GSS. C
G56. E
G57. C
G58. D
G59. E
G60. D
G61. E
G62. D
G63. C
G64. C
G65. B
G66. C
Raphex 2008
General
Gamma rays are photons emitted in a nuclear reaction. The other rays mentioned are
particles.
This type of protection is often utilized in tile transparent doors of household microwave
ovens.
The Compton effect is the dominant photon interaction with muscle tissue in the
energy range of30 keV to 20 MeV.
HVL = 0.693/linear attenuation coefficient.
The probability of photoelectric interaction varies as Z
3
/E
3
.
The probability is greatest when the photon energy is just greater than the electron
binding energy.
Only photons can cause a photoelectric interaction; alphas and betas are particles.
In the photoelectric effect, the photon is absorbed as it knocks out an electron from
the atom.
The number of Compton interactions depends on the number of electrons present. Most
materials have the same number of electrons per gram, but hydrogen is an exception. It
has one electron per nucleon (proton), whereas all other atoms have approximately one
electron to every two nucleons (proton + neutron). Thus, hydrogen has approximately
twice as many electrons per gram as water.
7
General
! Answers !
G67. D
G68. B
G69. D
G70. C
G71. B
G72. D
G73. C
G74. D
G75. D
G76. C
G77. D
G78. A
G79. B
Although there is some energy and field size dependence influencing the quantity of
scattered radiation, answer D is used in shielding calculations as a conservative
approximation.
In pair production, the creation of the electron-positron pair requires 1.02 MeV The
difference between this and the original photon energy is shared between the two particles.
CT number= 1000 X [(llmaterial - J..lwater)lllw:nerL where ll is the linear attenuation
coefficient.
The units are cm
2
/g. Photon attenuation may be due to absorption, scatter or both,
depending on the type of interaction.
Because of their size and electric charge, alpha particles produce more ionization per
centimeter of travel. This is why they travel much shorter distances before their energy
is expended.
Protons, like all charged particles, have a finite range; therefore they are not attenuated
exponentially.
The photons that are detected are produced as a result of positron-electron annihilation
in tissue.
Fluorine-18 is a positron emitter used for PET; gadolinium is used as a contrast agent for
MRI. Iodine compounds are used for x-ray contrast. Due to the high atomic number, iodine
absorbs more diagnostic x-rays than soft tissue.
Attenuation is equal to 1 o--ooJ where OD is the optical density. The total OD is the sum of
the ODs of both components.
A logarithmic scale is used for theY-axis.
8 Raphex 2008
G80. B
G81. A
G82. C
G83. B
G84. D
G85. E
G86. C
G87. D
G88. B
G89. E
Raphex 2008
General
! Answers !
68% of the measurements fall within cr ofthe mean.
The standard deviation cr = N
112
In this example, cr = (1000)
112
= 32 counts.
The Poisson distribution is an approximation to the binomial distribution for large samples
and rare events, such as radioactive decay.
Radioactive decay depends only on whether the atoms disintegrate or not.
For measurements with large numbers of o u n t ~ N, the standard deviation, cr, is given
by cr = N
112
, but %cr = (N
112
/N)*100% (see answer to G80).
The "p-value" represents the probability of error in accepting the conclusion of the
statistical analysis; i.e., there is a 1% chance that the two results are not different.
16 bits is equal to 2 bytes (B). One image file takes approximately
2B x 512 x 512 = 524,288 bytes= 0.5 MB of the disk space.
1MB"" 1024 KB z 1024 * 1024 bytes.
Insufficient memory is one of the limiting factors in computer speed. Although insufficient
hard drive capacity can also slow a computer down, this limitation is less typical.
Millions of diagnostic x-ray procedures are performed each year. The next most significant
source of radiation dose to the population as a whole is from nuclear medicine exams.
There is a greater increase in thyroid cancer frequency per unit of X-ray dose in women
than in men. This parallels the natural occurrence of the disease. Both benign and malig-
nant thyroid tumors have increased in frequency after radiation exposure. The evidence
of increased susceptibility of infant thyroids to radiocarcinogenesis compared to adults
is not strong. In D, the reverse is true: the incidence increases for doses below 20 Gy. The
most likely reason that radiocarcinogenesis is reduced above 20 Gy is that cell killing
becomes a significant factor. About twice as many benign tumors as malignant tumors
appear in children irradiated for thymic enlargement.
Although there are valid arguments for the other models, the simpler and more
conservative linear, no-threshold model is currently used by the regulators.
9
General
G90. B
G91. E
G92. D
G93. E.
G94. C
G95. E
G96. B
G97. D
G98. C
10
In early organogenesis, the organ buds consist of a few cells, and the loss of some of these
can result in a major defect which may not be apparent during gestation, but after birth is
too severe to permit independent life.
Film badges cannot measure exposures below about 20 mR. Placing filters over parts of the
film allows one to estimate the proportion of dose due to x-rays in different energy ranges.
Heat, e.g., exposure to intense sunlight, can cause film blackening.
The lead apron attenuates 95%, and transmits 5% or 0.05. Two aprons will
transmit 0.05
2
= 0.0025 or 0.25%.
This is hard to estimate exactly, so standard fractions are generally used.
A Nal well counter is an efficient device for measuring low-level gammas. It can also
provide energy discrimination.
Very low concentrations of radioactive materials, when ingested, can produce high,
localized radiation doses to internal organs.
ALARA is a basic tenet of radiation protection. Obviously, radiation levels could be
reduced to negligible levels with huge amounts of shielding that would be prohibitively
expensive and unwieldy. The ALARA concept seeks to strike a reasonable balance
between safety and practicality.
Raphex 2008
01-4.
01. A
02. D
03. c
04. D
OS. C
06. A
Raphex 2008
Diagnostic
! Answers!
For questions Dl-D4; secondary radiation includes scatter radiation from the patient and
leakage radiation from the x-ray tube.
Radiographs of adult abdomens are typically done at 80 to 90 kVp, while chests are
typically done at 120 to 140 kVp. Thus there will be more transmission at the higher
chest energies.
Mammography uses low kVp x-rays (typically 24 to 32 kVp) which have very low
transmission. Most mammography rooms do not even need lead in the walls.
Radiographs of abdomens are typically done at 80 to 90 kVp, while angiography of the
extremities is typically done at 65 to 75 kVp. Thus there will be less transmission at
extremity energies.
99
mTc is monoenergetic at 140 ke V, so would generally have higher transmission than
even a 140 kVp chest beam, which contains a spectrum of lower energies. Being mono-
energetic, there is no beam hardening, and the transmission curve will be straight line
on a semi-log graph.
The effective focal spot size is the length and the width of the actual focal spot as
projected down the central ray in the x-ray field. The effective focal spot width is
equal to the actual focal spot width and therefore is not affected by the anode angle.
However, the anode angle causes the effective focal spot length to be smaller than
the actual focal spot length. The effective and actual focal spot lengths are related
as follows:
Effective focal length = actual focal length x Sine anode angle
= 4 mm x sin 15 degrees= 4 mm x 0.25 = 1 mm.
The projected focal spot size is 1 mm (length) by 1.2 mm (width).
A Butterworth filter is a mathematical kernel commonly used inSPECT image
reconstruction. Compensation filters are used to change the spatial pattern of the
x-ray intensity incident on the patient, so as to deliver a more uniform x-ray exposure
to the receiver/detector. They are placed close to the x-ray tube or just external to the
collimator assembly.
"Bow-tie" filters are used in x-ray CT to reduce dose to the periphery of the patient,
where x-ray paths are shorter and fewer x-rays are required.
A trough filter used in chest radiography has a centrally located vertical band
of reduced thickness that compensates for the high attenuation of the mediastinum
and reduces the exposure latitude incident on the receiver.
Wedge filters are useful for lateral projections in cervical-thoracic spine images.
They provide a low incident flux to the thin neck area and a high incident flux to the
thick shoulder.
II
Diagnostic
! Answers!
07. c
08. B
09. D
010. E
011. B
012. E
013. B
014. B
DIS. D
016. B
12
This is the only answer that refers to properties of the image receptor.
Due to increased attenuation coefficients with reduced kVp. A and E will reduce
subject contrast. Focal spot size affects resolution, not contrast.
Increasing the focal spot size increases the area over which the instantaneous heat is
distributed. This increases the heat loading capacity of the anode, and thus the available
exposure times for a given rnA.
Increasing the beam filtration removes more soft radiation, leaving a beam with higher
effective energy, hence higher HVL.
Mammography must visualize submillimeter calcifications; angiography must see
fine vessels of the order of a millimeter; chest radiography utilizes long target- image
receptor distances which allows somewhat larger focal spots; and CT scanners need
large focal spots- they have reduced high-contrast resolution while requiring greater heat
capacity for scanning sequences that may take several seconds at high kV and high rnA.
The single exposure rating is based on protecting the target track on the anode from
excessive heat.
A and D would result in decreased film density because the wrong AEC chamber is
selected. C should have no effect, unless the AEC malfunctions.
Contact radiography, with magnification equal to 1, means that the screen determines the
image sharpness. A single thin screen is sharper.
Geometric unsharpness =(focal spot size) x (magnification- 1). When the x-ray tube
of the C-arro is closer to the patient, the magnification increases causing more unsharpness.
Three-phase generators allow increased rnA and increased X-ray output per rnA, resulting
in shorter exposure times and less motion blurring.
Frame averaging in digital subtraction angiography (DSA) decreases noise by a factor of
N
112
, where N is the number of averaged frames. Increased conversion efficiency means
more light is produced from fewer x-rays, and hence more noise. A higher processor
temperature means faster film speed, requiring fewer x-rays, and hence more noise. A
bone algorithm is a sharpening filter, which increases noise.
B will generally require a decrease in current, which will require a longer exposure time.
A, C, and D will allow a reduction in exposure time.
Raphex 2008
017. E
018. B
019. A
020. E
021. E
022. B
023. B
024. B
Raphex 2008
Diagnostic
! Answers!
Magnification angiography can generally be done without a grid because the patient is far
enough from the film that the air gap reduces the scatter reaching the film. This is useful
for reducing patient exposure when the film is far from the focal spot in magnification
work.
A grid ratio of 8: l is usually used in radiography.
Because of the very low kVp and small field size and thickness, the scatter is small
(but significant in larger breasts). Thus, a very-low grid ratio is adequate.
The heel effect causes a lowered film density toward the anode side of the film that can be
dramatic near the edge of large films at shorter SID if the anode angle is small enough.
High-ratio parallel grids produce film density that decreases away from the center due to
grid cut-off. Inverted grids only have density in the central region. Worn screens produce
spots of low density in the worn regions. Phototimer drifts uniformly increase or decrease
the film density.
Estimated skin entrance exposures for an adult, average thickness patient are about:
10-20 mR for a PA chest, 60- 100 mR for a lateral skull, 200-300 mR for an AP
abdomen, and 500-700 mR for a lateral pelvis.
The fastest film will give the highest noise (smallest number of X-ray photons used)
while the thinnest screen will give the highest resolution (smallest light spread in
phosphor).
Use of the small focal spot requires a lower tube current, and thus higher exposure times,
likely to lead to more motion artifacts. Increased breast compression force should reduce
motion artifacts, but the type of grid and the rotation speed of the anode do not affect it.
A higher rnA should reduce exposure times, and thus would decrease the likelihood of
motion artifacts
This configuration is used because it minimizes blurring due to cross-over and
halation related to the finite thickness of the phosphor. In the double-emulsion
screen-film configuration, the average distance between absorption events in the
phosphor and the film would be greater, resulting in increased detector blur. MQSA
requires that the mean glandular dose to a phantom (simulating a 4.2 em breast of
50150 composition) for a single view be <3 mGy. Wider latitude reduces the slope
of the characteristic curve and this reduces film contrast. The anode-cathode axis is
positioned perpendicular to the chest wall to minimize the heel effect. Federal
regulations allow but do not require a system to use an Rh X-ray filter.
13
Diagnostic
! Answers !
025. B
026. A
027. B
028. E
029. c
030. A
031. B
032. B
033. D
14
Placing the AEC sensor under the densest portion will reduce problems with
underpenetration. All portions of the image should have an optical density (OD)
above 1.0. Reviewing previous films helps to position the sensor.
Typical full-field digital mammography units use detector element sizes of 50-100 microns
(0.05-{).1 mm).
All are regulated by MQSA, except stereotactic breast biopsy, which in 2008 is only
regulated by the state Departments of Health.
All full-field digital mammography, including CR mammography, must be interpreted
on 5 MP displays or laser hardcopy as per MQSA.
For full-field digital mammography, MQSA and ACR require the QC tasks and
frequencies to be those specified by the FFDM manufacturer.
Tomosynthesis provides thin slices that reduce superpositioning of structures
(i.e., volume averaging) and thus improves contrast of small lesions. Resolution may
decrease because of imperfect motion of the tube-receptor. Motion blurring in the
patient may increase because of the long scan time. Radiation dose will probably
increase because of the need to reduce noise in the thin slices.
Of the 1 024 lines in a standard TV only about 980 lines are used to actually form
the image. It takes two lines to make a line pair, so there are 980/2 = 490 line pairs.
However, small objects are generally not perfectly aligned between the TV lines, so
the effective resolution is obtained by multiplying by the Kell factor, which takes
into account the random positioning of small objects in the TV field. The Kell factor
is generally about 0.7, so the effective resolution is about 490 x 0.7 = 343 line pairs.
For a 23-cm (230-mm) input, the resolution would be 343/230 = 1.5 lp/mrn.
The focal spots for fluoroscopy are typically 0.3 or 0.6 mm; those for standard radiography
are usually 1.0 to 1.2 mm.Jhe spatial resolution for fluoroscopy is usually limited by
the TV system to 1.8 to 2.5 lp/mrn, while screen-film radiography has resolutions of
4 to 8 lp/mm. The tube current for fluoroscopy is usually 1 to 3 rnA in order to limit anode
heating for the long exposure times of 3 to 10 minutes; because of the short exposure
times of radiography (less than 1 second), tube currents of 200 to 800 rnA can be used.
Tube potentials are the same for both procedures in order to maintain subject contrast.
SSDs (source-to-surface distances) in fluoroscopy are usually 18 to 20 inches, while the
SSDs for radiographs are typically about 25 inches (except for chest radiographs).
Raphex 2008
034. c
035. D
036. A
037. A
038. B
039. E
040. B
041. D
042. c
Raphex 2008
Diagnostic
! Answers!
X-rays immediately vanish from the room. X-rays are produced only when a current flows
through the x-ray tube. Therefore, X-ray production stops immediately in the absence of
tube current. Scattered radiation is only produced when the primary beam interacts with
the patient; it stops immediately when primary X-rays are absent. Patients do not become
radioactive (or glow in the dark) when irradiated with diagnostic X-rays. Thus patient
scatter stops when the primary beam stops. There is no need for a lead shutter to stop
the beam.
Quantum noise in an image is inversely related to the radiation dose used to obtain the
image. The focal spot and patient motion will affect the sharpness of the patient's image.
The type of iodinated dye and the beam filters will affect the subject contrast of
the patient.
Geometric blur = Focal spot size x (geometric magnification - 1 ).
Geometric magnification = 1 when the object is in contact with the receiver.
For a given focus-to-receiver distance, geometric magnification increases with
increasing object-to-receiver distance.
This corresponds to the beam exiting from the x-ray tube at the collimator surface.
Entrance skin exposure over the area covered will not be affected by collimation.
When a larger area of the patient is irradiated, contrast degradation occurs due to the
increased amount of scatter reaching the receiver.
Radiation should not be the sole consideration for stopping an interventional procedure.
However, the physician performing the procedure should always consider keeping the
radiation doses "As Low As Reasonable Achievable" by following policies and procedures
on minimization of exposure from prolonged interventional studies. Patient dose from such
procedures can be monitored using established reference levels.
Covering more z-direction in a single rotation, 64 slice covers the heart in less time,
reducing motion artifacts. Most other image quality and dose issues are indistinguishable
between 16- and 64-slice scanners of the same model.
Reducing the beam width from 10 to 2 mm will actually increase patient dose in a
single-slice scanner because of penumbra and increased noise for the same mAs.
ln a multislice scanner, the noise will be increased, most likely resulting in the need to
increase patient dose to obtain acceptable image quality.
Noise is usually measured as the standard deviation of the CT numbers in a region
of interest.
IS
Diagnostic
! Answers !
043. A
044. B
045. B
046. c
047. A
048. A
049. E
16
Dose is directly proportional to mAs. However, the lower mAs may be too noisy for the
radiologist, and the algorithm may have to be changed to a slightly smoother one to reduce
the noise. Decreasing the scan time to 0.5 seconds is usually not recommended for brain
studies as this may lead to aliasing artifacts from too few views, and it would reduce the
dose by 4, leading to a too noisy image. Reducing slice width does not reduce dose. Pitch
would have to be increased to reduce dose.
A low kVp (80) is often used in CT with small pediatric patients to reduce radiation dose.
Low kVp is incompatible with large patient attenuation as the low penetration would lead
to unacceptably high quantum noise. For pediatric heads, 120 kVp is normally used to
maintain good penetration, and mAs is lowered to reduce dose. A high-resolution chest
scan requires thin slices (-I mm).
The PET (or SPECT) system and the CT scanner are adjacent to each other, which
then requires a longer table and greater length of travel so that the patient can be
imaged sequentially by both devices. Additionally, since the two devices are next to
each other, the CT gantry cannot have a tilt capability.
The Hounsfield unit is defined as HU = 1000 (!lmaterial - llwater)/J.lwa
1
er Bone has a
higher density (specific gravity) and higher effective atomic number (Z) than water,
and therefore the linear attenuation coefficient (J..L) at CT energies is much higher than
water. Fat has a slightly lower density than water and has a slightly lower effective
atomic number, so its J..l is slightly less than water. Muscle has a slightly higher density
and approximately the same Z as water, resulting in a slightly higher J..l than water. Lung
has a significantly lower density than water, with about the same Z, giving rise to a much
lower J..l than water.
CT number= IOOO(J..lmateriat-

By definition, aCT number is a ratio and has

no units. Window variations, matrix size, and mAs have no effect on the tissue CT number.
Beam hardening leads to reduced CT numbers in the center of the image. Ring artifacts are
caused by detector rniscalibration. Streak artifacts are due to metallic objects, barium, and
other heavy objects in the body.
The dynamic range is determined by the acquisition system. Post-processing cannot extend
data that were never recorded.
Raphex 2008
050. c
051. c
052. A
053. c
054. c
055. A
056. c
057. E
Raphex 2008
Diagnostic
: Answers:
RAID: redundant array of independent disks can be used to provide a large amount of
on-line storage.
DICOM: Digital Image and Communications in Medicine. A Standard developed by the
ACR and NEMA specifies standard formats to facil itate the transmission of medical
images and related data.
NEMA: National Electrical Manufacturers Association
ISDN: Integrated Service Digital Network. Permits the transfer of digital data over several
pairs of telephone lines at 128 kbps.
LAN: Local Area Network
T
. . . total bits per image x number' of images
ransrruss10n tune= ___ .___....:::::... _____ __.::::_
transmission rate x compression ratio
_ ( 2 images per study x 2000 x 2000 pixeliftmage x 2 bytes/pixel x 8 bits/byte)
- ( 128,000 bits/second x 15 compression)
= 66 seconds.
7 bits= 2
7
= 128 shades of gray. The pixel size in the image from a 10-inch image
intensifier displayed on a 512 x 512 matrix is 254 mm/512 pixels= 0.5 mm/pixel.
Line pairs/mm = (112) x (1/pixel size)= l.O.
In computer language K means 1024, not I 000, so 64 K = 65,536 = 256 x 256.
Computed radiography (CR) has a wide dynamic range, in effect wide latitude. It produces
acceptable films with suboptimal technique, such as those obtained with portable x-ray
units. It uses photostimulable phosphor (europium-activated barium fluoride) coated plates
as a receiver. Resolution with screen-film systems (5 to 10 lp/mm) is better than that
obtained with CR (2.5 to 5 lp/mm). The reject rate in CR is low due to post-processing
techniques available electronically. Unlike film, in CR image capture, storage, and display
are all performed by different components of the system.
Unlike the case with CT, where CT numbers measured in Hounsfield numbers represent
linear attenuation coefficient values relative to water, in general, radiography imaging pixel
values are not referenced to a value associated with any particular tissue or material.
256 shades of requires 2
8
numbers = 8 bits = 1 byte.
The central region ofk-space contains mostly contrast information. The missing outer
portions of the k-space contain the higher frequency spatial detail information.
Higher field strength = higher attraction, larger stray fields, more patient heating because
of higher frequency RF, and longer Tl. T2 does not change much.
17
Diagnostic
! Answers !
058. c
059. A
060. D
061. A
062. A
063. B
064. B
18
The main advantage of the 3T over thel.ST magnet is the higher signal-to-noise ratio
(SNR) obtained with the 3T magnet. Resolution depends on matrix size, FOV, gradient
field strength, receiver coil characteristics, and sampling band width. Scan time is not
necessarily shorter with 3T; but because of its higher SNR, scan time with the 3T can be
shortened for similar image quality. However, many sites use the same or a longer scan
time to increase image quality. Many artifacts are worse: susceptibility and chemical shift
artifacts and poor RF penetration of large abdomens lead to loss of information in the
center of the patient.
The BOLD (blood oxygen level dependent) sequence measures the signal influenced by
oxygen level depletion in the neurons as some thought process (e.g., visual stimulation)
is continuously repeated, and can map the region in the brain where this activity is taking
place.
Gradient fields are used to modify the magnetic field so that resonance will be slightly
different at different points in the volume of interest. It is then possible to localize these
points.
Frequency encoding steps are determined only by the resolution setting of the A DC.
Every imaging system, such as a SPECT or PET scanner, is characterized by the highest
spatial frequency (related to the size of the smallest structure) which the system can
reliably image. This is known as the Nyquist frequency.
A cold (i.e., less intense), circular (or otherwise) symmetric focal defect such as
that in the figure is most likely a photomultiplier tube (PMT) defect caused, for example,
by mistuning of the PMT (i.e., incorrect high voltage or gain applied to the PMT).
Whereas uncoupling of the PMT, i.e., physical detachment of the PMT from the back
of the scintillation crystal, would cause this artifact, this is not a common problem.
Radioactive contamination would cause a more intense (i.e., higher-count) defect.
Center-of-rotation misalignment would affect reconstructed tomographic in1ages,
producing a ring, or bull 's-eye, artifact, not planar images. Crystal cracks generally
appear as more focal, more irregular defects that are hypointense at the center and
hyperintense at the periphery of the defect.
The most likely cause for the appearance of a flood image like the one shown, with
the photomultiplier tube pattern visible over most of the crystal, is when the camera is
incorrectly peaked. The photopeak of the imaging radionuclide should be centered within
the camera's energy window. This QA test is required daily and whenever the study
isotope is changed, and requires only a few seconds to perform. If it is determined that
the isotope peak is correct within the energy window, then a new flood correction table
may need to be acquired. This procedure requires about one hour.
Raphex 2008
065. D
066. c
067. D
068. c
069. c
070. c
Raphex 2008
Diagnostic
! Answers!
A 2-D PET has septa (shields or walls) between contiguous detector rings. In this way,
detectors within a specific ring can only detect annihilation events within the plane of that
ring. Events occurring out of the plane of that detector ring are absorbed (stopped) by the
inter-detector ring septa. The advantage of such 2-D systems is that the contribution of
image quality-degrading random and scatter events in the data set is markedly reduced.
On the other hand, 3-D, or septa-less, PET has substantially higher sensitivity.
Two half-value layers reduce the exposure rate by a factor of 4.
For an intrinsic gamma camera uniformity ("daily flood") measurement, the collimator
is off the detector. To approximate a "point" source, the volume of the
99
mTc solution used
as the source should be about 0.5 ml or less. The activity of the
9
9mTc source should be
chosen to provide for a count rate of 20 to 50 kcps (0.2 to -0.5 mCi). To adequately
simulate a uniform "flood" source, that is, achieve a uniform radiation flux over the
entire field of view, the minimum source-to-detector distance is 3 x detector diameter
(or the maximum detector dimension).
For physical phenomena- such as counting or planar imaging- that follow
Poisson statistics, the standard deviation is proportional to the square root of the
measured signal. Thus, for a region of a planar gamma camera image with an
average of N counts per pixel, the standard deviation is .fN and the percent standard
deviation is therefore 100% x fN = O ~ o For N = 25 counts per pixel, the percent
N vN
standard deviation is lOO%-
100
%- 20m
.J25 -
5
- to.
The transport index (TI) of a radioactive package is defined as the exposure rate in
mR!h (milliroentgen per hour) measured at 1 meter from the surface of the package.
For a package yielding an exposure rate of 0.003 Rlh, or 3 rnR/h, at 1 m, the transport
index is therefore 3.
According to the applicable rules promulgated by the Nuclear Regulatory
Commission (NRC) or Agreement States, the maximum permissible effective
dose (essentially the mean total-body absorbed dose) for a radiation worker
is 50 mSv per year. For non-occupationally exposed individuals (e.g., a secretary
in a radiology department), the maximum permissible effective dose is one-tenth of
that for an occupationally exposed individual; that is, 5 mSv per year. From a regulatory
perspective, the fetus of a radiation worker is treated as non-occupationally exposed
individual, therefore limiting the exposure of a declared pregnant worker to 5 mSv for
the duration of the pregnancy.
19
Diagnostic
: Answers :
071. A
072. A
073. c
074. E
075. c
076. D
077. E
078. D
20
Historically, the Nuclear Regulatory Commission (NRC) and Agreement States required
patients receiving radionuclide therapy to remain hospitalized until the retained activity in
the patient was less than 1 ll 0 MBq (30 mCi) or the dose rate at 1 m from the patient was
less than 0.05 mSvlh (5 mremlh). However, in 1997 the NRC amended its regulations con-
cerning radionuclide therapy patients through the issuance of new rules that appeared
in the Federal Register on January 29, 1997. These NRC regulations, revised 10CFR 35.75
effective May 1997, allow for the release from medical confinement of patients if the
expected total effective dose to individuals exposed to the patient is not likely to
exceed 5 mSv.
For a controlled or restricted area, such as a radiopharmacy, surveys of ambient radiation
levels must be performed daily, and wipe tests for removable radioactive contamination
must be performed weekly. For unrestricted, uncontrolled areas, radiations surveys are
required weekly, and wipe tests are required monthly.
The FWHM is the distance between the two arms of the curve corresponding to half the
peak intensity.
The two gamma energies correspond to 419 - 24 7 ke V - 172 ke V and
247- 0 keY= 247 keV These two photon energies are emitted in cascade. The
question asked to identify the emission energies. If the question had requested
the peaks detected on a gamma camera, this would have included a third peak
corresponding to 172 + 24 7 = 419 ke V, the sum peak of the two gamma photons.
NET counts per minute is given by the total of the cpm - background = l 000 cpm
- 40 cpm = 960 cpm. Using the detector efficiency to convert from cpm to dpm
(disintegrations per minute) yields 960/0.8 = 1200 dpm. When 1200 dpm is
converted to disintegrations per second ( 1 dps = 1 Bq), then 1200 dpm /60 s/min
= 20 dps = 20 Bq.
Currently BGO is used by General Electric; LSO by Siemens; GSO by Philips; Nal was
used in the PENN PET system sold by GE and Philips earlier. Ceramics are used as CT
detectors only.
Axial (depth) resolution is the ability of the ultrasound beam to separate two objects lying
in tandem along the axis of the beam. The pulse length equals the wavelength of the beam
times the number of wavelengths used. The axial resolution is defined as
1
I
2
of the pulse
length. The highest frequency (10 MHz) has the shortest wavelength and a continuous
beam has an infinite pulse length.
The greatest doppler shift is at the highest frequency with the beam parallel to the direction
of blood flow.
Raphex 2008
079. A
080. B
081. A
082. D
083. A
084. E
085. B
086. c
087. E
Raphex 2008
Diagnostic
! Answers!
Attenuation (dB per em) is approximately proportional to frequency. Increased
frequency results in a decreased depth of penetration and results in a shorter
wavelength (frequency is inversely proportional to wavelength). Axial resolution
is improved with higher frequency due to the shorter spatial pulse length. Higher
ultrasound frequency has limited penetration depth, allowing higher pulse repetition
frequency. The speed of sound is constant in tissue. It is independent of the frequency.
The attenuation in dB is given by:
Attenuation (dB)= 0.5 dBIMHz-cm x 5 MHz x 4 em= 10 dB.
dB= 10 log (1;11
0
) = 10
log (I/ 1
0
) = 1
1/1
0
= 10
Coded aperture is a method of imaging with scintillation cameras without using standard
collimators.
Deterministic effects are characterized by a dose threshold and increase in severity with
dose. Cancer is a stochastic, not a deterministic effect, as it is thought that any dose of
radiation can induce a cancer and the severity of the cancer is not dependent upon dose.
Radiation-induced deterministic effects, such as skin erythema and desquamation, may
occur within several days or weeks following irradiation. Other than the rare cases of
skin damage resulting from prolonged fluoroscopy, the doses used in diagnostic radiology
seldom cause deterministic effects.
21
Diagnostic
! Answers !
088. c
089. E
090. D
091. B
092. E
22
The human doubling dose, which is the dose to double the incidence of mutations in the
offspring of irradiated people, has been estimated at l to 2 Gy. Radiation does not produce
unique mutations, but only increases the incidence of known mutations that appear in the
population. It is thought that any dose, however small, can induce mutations, including
the radiation emitted by radioisotopes in the earth's crust. The results of epidemiologic
studies are consistent with the conclusion that people are less sensitive than rodents for
the induction of mutations by radiation.
As tabulated and published by the Report of Biological Effects of Ionizing Radiation
(BEIR VII) and based on the linear, no-threshold dose-response model, current "best"
estimate (BEIR VII value) for the lifetime risk factor for radiogenic fatal cancer from
high radiation dose given over a short period of time (high dose rate) is approximately
800 excess cancers/million people/rem, rounded off to 1 000 excess cancers/million
people/rem, or 1 00,000 excess cancers/million people/Sv.
The results of epidemiologic studies indicate that the fetus is most sensitive to the
induction of mental retardation if the irradiation occurs during the 8th to the l5
1
h week
of gestation.
In a recent controversial review article [Brenner DJ and Hall EJ, (2007),
"Computed tomography- an increasing source of radiation exposure." N Eng/ J
Med 357(22):2277-2284] that addressed the increase in the use of CT, it was
estimated that based on the use of CT from 1991 through 1996, 0.4% of all cancers
in the United States may be attributable to the radiation from CT studies. However
the authors went on to state that "by adjusting this estimate for current CT use, this
estimate might now be in the range of 1.5 to 2.0%."
Individuals with potentially fatal wounds from the explosion should first be treated for
their injuries before efforts are made to decontaminate them since it is likely that their level
of exposure to radiation is not immediately life-threatening. If large numbers of people
appear at a hospital emergency room following the detonation of a "dirty bomb," it may
be best, so as not to overwhelm the facility, to only admit injured people into the hospital.
Individuals who were not injured should be washed down in outdoor showers and then
transported to a non-medical facility for further evaluation. The greatest concern for people
within 200 miles of the explosion of a radiation dispersal device would likely be an
increased risk for cancer and'genetic effects. It is unlikely that the dose associated with a
radiation-dispersal device would be great enough to cause death from an acute radiation
syndrome for most people i.n this range. Unless there is evidence that the bomb included
high-energy y-ray emitting radioisotopes, it is reasonable to handle the victims using
standard hospital gowns and gloves since the amount of isotope and the energy of the
emitted radiation are likely to be low. There should always be regulation of people entering
and exiting from the area where the victims of the accident are being treated so as not to
contaminate other areas in the hospital with radioisotopes.
Raphex 2008
093. B
094. A
095. E
096. D
Raphex 2008
Diagnostic
! Answers!
NCRP Report No. 116 recommends (but does not regulate) that the maximum permitted
effective dose (the dose to each organ multiplied by the tissue weighting factor) for a
radiation worker is 50 mSv per year. Infrequent exposure for a member of the general
public is 5 mSv per year. A minor is permitted exposure to radiation if it is received as
part of their education (e.g., a 15-year-old student performing research in a radiology lab
as part of a school project) and as long as the annual dose is held below 1 mSv. Continuous
exposure for members of the public is limited to 1 mSv per year. A radiation worker may
receive up to 500 mSv per year to the hands and feet.
"OH (hydroxyl radicals) are responsible for two--thirds to three-fourths of the damage
produced by the indirect action of radiation resulting from the radio lysis of water.
The GSD is the average gonadal dose adjusted for the child expectancy of people
who make up that population. The GSD for a radiology procedure performed only
with post-menopausal women would always be zero, regardless of the number of
people imaged, since none of these people is capable of conceiving a child. Radon
inhalation would not affect the GSD since the a-particles produced by the radon
daughter products located in the lungs would not irradiate the gonads. Although the
current GSD may be somewhat greater due to the increased use of CT, the most recent
survey estimated the average GSD associated with the performance of diagnostic
radiology procedures to be 0.3 mSv.
The annual estimated dose resulting from exposure to cosmic rays, radioisotopes in the
earth's crust, and inhaled/ingested radioisotopes, including radon, is approximately 3 mSv.
23
Therapy
: Answers:
Tl. C
T2. D
TJ. B
T4. C
TS. C
T6. D
T7. C
T8. C
T9. E
TIO. B
Til. D
Tl2. B
24
TMR at is 1.0 by definition for any photon energy, since it is the ratio of dose
at depth d to dose at dmax
PDD increases with increasing SSD because it has two components: attenuation and
inverse square. The inverse-square component decreases as distance increases.
MU = (doselfraction)I(SAD
0
utput X TMR) = 1501(1.086 x 0.867) = 159.
MU =(dose/fraction) I (SSDoutput X PDD/100)
= 150/(1.052 X 0.771) = 185.
The maximum tissue dose will be at depth dmax (1.6 em). The dose at this point is the
entrance+ exit dose:
150(PDDdmax I PDDmidptane) + 150(PDDexit I PDDmidplane)
= 150(100177.1) + 150(56.8177.1)
= 305 = 300 X 1.017.
Neck dose= axis dose x (TMR d5 I TMR d9) = 3600 x (0.937/0.844)
= 3997 cGy.
(Note: If neck point is not on the same plane as the isocenter, the inverse-square factors
will almost cancel out.)
The depth of dmax is greater for 18 MV photons.
The maximum dose occurs at dmax This effect is field size dependent; for example, it
would be 22 em for 8x8 em fields. It is also energy dependent: as energy increases, the
thickness increases.
Any factor that increases the POD will decrease the total dose at dmax compared with the
total dose at midplane. Treating at SSD rather than SAD gives a slightly higher POD.
POD increases with increasing SSD because of the change in the inverse-square factor.
POD (130 em SSD, d8) = PDD(lOO em SSD, d8) x [(100 + 8)/(100 + dmax)f
X [(130 + dmax)/(130 + 8)F.
For 6 MY, dmax is 1.6 em.
Percent depth dose is a combination of two factors: patient attenuation (which is
independent of distance but varies with depth) and inverse-square falloff between dmax
and depth. The longer the SSD, the smaller the inverse-square factor. Thus, POD increases
with increasing SSD.
A rule of thumb for calculating C, the side of the equivalent square, is:
C = 4 x area/perimeter= 4(a x b)/2(a +b). Equivalent squares enable the data for any
rectangular field (TMR, POD, etc.) to be obtained from one table of square-field data.
Raphex 2008
Til. C
Tl4. B
TIS. D
Tl6. D
Tl7. A
TIS. A
Tl9. B
T20. B
T21. A
T22. C
T23. C
Raphex 2008
Therapy
: Answers:
The equivalent square CxC of a rectangular field has the same PDD and TMR as the
rectangle. It is smaller in area than the rectangle (i.e., CxC < 8x30, in this case), since
it is the field with the same scatter contribution on the beam axis. A useful rule of thumb
is that C = 4 (area/perimeter). The use of"equivalent square" enables PDD and TMR
tables to be simplified to only square fields, rather than tabulating the many rectangular
fields in use.
A universal wedge acts as a beam hardener, resulting in a slightly more penetrating
depth dose. It also attenuates the beam along the central axis, which in turn requires
more monitor units to deliver the same dose. Since the universal wedge is high up in the
linac head, it does not increase scatter dose the way a conventional wedge does. The wedge
transmission factor is a function of field size for both dynamic and universal wedges.
The "hinge angle" (between the axes) is 90.
Wedge angle= (180- Hinge angle)/2 = (180- 90)/2 = 45.
The smaller the hinge angle, and the closer the fields, the larger the wedge angle required.
There is a hot spot of 11 0% in the anterior of the PTV indicating that the plan is
"underwedged." Increasing the wedge angle will reduce the hot spot anteriorly.
The lateral wedges compensate for the dose falloff across the volume from the open field.
The greater the weight of the open field, the greater the actual difference in dose across the
volume, and hence the greater the wedge angle required to compensate for this gradient.
The difference between the two plans would be seen in the exit dose of the open beam,
and the entrance doses of the wedged fields (i.e., femoral head vs. small bowel dose).
As SSD decreases, the patient will receive more scatter from the collimators. Skin dose
increases as field size increases. Bolus is generally used to remove skin sparing and to
bring the skin dose up to I 00%. Oblique incidence increases the skin dose.
Beam spoilers create electrons that scatter into the beam, and increase dose in the build-up
region without removing skin sparing, as bolus would do. They are used in situations where
the build-up characteristics of a lower photon energy are desirable, but a higher energy is
needed for greater dose homogeneity, e.g., breast tangents with a very large separation
(greater than 26 em).
The divergence of the spine field is tan-
1
[(25/2)/ 1 00] = tan-
1
0.125 = 7.
The formula for the gap (g) to be left on the skin between adjacent light fields of
collimator settings C 1 and C2, if the match depth is dcm, is:
g = (d/SAD) x (C
1
+ C
2
)/2 = (5.5/ 100) x (30 + 24)/2 = 1.5 em.
25
Therapy
! Answers !
T24. D
T25. C
T26. B
T27. C
T28. B
T29. E
TlO. A
Tll. C
T32. D
Tll. D
T34. A
TlS. B
26
Divergence= tan-
1
(9/100) =5 for each field. To eliminate divergence, the RPO gantry
angle = 60 + I 80 - (2 x divergence) = 230.
The attenuation of a 6 MV photon beam, for a lOxlO em field, is about 3.5% per em.
As photon energy increases, attenuation decreases, resulting in a greater POD at a
given depth.
Flattening filters cannot flatten the beam equally at all depths; they tend to produce "horns"
toward the edges of the beam at dmax and to underfiatten at d20.
Dmax for a single 18 MV beam occurs at 3.5 em, but the 95% isodose in the build-up region
is closer to the skin. With parallel-opposed beams, the exit dose from the opposite beam
brings the depth of the 95% dose even closer to the skin. Thus the depth of x is not a
reliable guide for the depth at which an adequate clinical dose is delivered.
The patient would be further away from the isocenter, and the dose would be lower by the
inverse-square factor of (100/ 101.5f
TMRs are a measure of attenuation only, whereas PODs comprise attenuation and inverse
square components.
The HVL (in Al or Cu) defines the penetrability of a low-energy X-ray beam. Different
combinations ofkVp and filtration can produce beams with the same HVL, and hence
the same depth dose characteristics. The SSD also affects the POD and is important for
superficial x-ray units that typically treat at short SSDs.
For A- C, the opposite is true.
Spatial resolution in the caudal direction for CT-generated digitally reconstructed
radiographs (DRRs) is compromised when scanning with large slice thicknesses. The
disadvantage of using a small slice thickness is the increased size of the dataset, and
hence possibly more work involved in contouring structures.
The greatest attenuation difference occurs for the lowest energy and the medium
with the greatest effective depth difference. 10 em lung is approximately equivalent to
3 em muscle tissue, or 7 em missing tissue. 5 em of dense bone is approximately
equivalent to 8 em muscle, or 3 em extra tissue.
In the other cases, the density on the CT is not representative of the density at the time of
treatment. However, the physicist may determine that the correction is not necessary if it
has a small effect on the dose distribution.
Raphex 2008
T36. C
T37. C
T38. D
T39. B
T40. C
T41. B
T42. D
T43. D
T44. D
T45. C
T46. B
T47. B
T48. A
T49. C
Raphex 2008
Therapy
! Answers !
The effect of blocking is greatest in a situation with the greatest scatter dose,
i.e., at lower energy and greater depth.
Five HVLs are equivalent to 3% transmission. The additional dose is due to scatter from
the surrounding tissue.
By similar triangle geometry: Field size at extended SSD =Extended SSD
Field size at l 00 em 1 00
Therefore: Extended SSD = (75/40) x 100 = 187.5 em.
B
..
1
.
1
Sizeonskin _ 88
y Simi ar tnang e geometry: s . - ] OO .
Ize at 1socenter
The dose is due to internal scatter, head leakage, and scatter from the collimators and
wedge.
2 Gy out of 40 Gy is 5%. This occurs at about 2 em from the field edge.
To a good approximation, the inverse-square law can be used to calculate the
output at extended distance. For 1.0 cGy/MU at 100 em SSD, the dose rate at
4.5 m is 1.0 x (1.0/4.5)
2
= 0.049 cGy/MU.
As SAD increases, PDD increases, thus increasing dose homogeneity for parallel-opposed
fields.
Gamma Knife SRS is generally prescribed to 50% of the maximum dose.
Average MLC transmission is generally Jess than 2%, with transmission between adjacent
leaves generally less than 3%. A 5 HVL block transmits about 3%.
The graph shown is a cumulative DVH (as opposed to a differential DVH). It depicts the
fraction of the volume (y-axis) that receives at least the dose values given on the x-axis.
For example, 100% of the volume receives at least 30% of the prescribed dose; 75% of
the volume receives at least 50% of the dose; 25% of the volume receives at least 75%
of the dose.
The lTV (internal target volume) is the expansion on the CTV (clinical target volume) due
to organ motion. The PTV (planning target volume) is an expansion around this to account
for setup error and gross patient motion.
With IMRT, 6 MV photons can give good results even for large depths (e.g., for a prostate).
However, the integral dose outside the PTV will generally be greater for lower energy.
27
Therapy
: Answers:
TSO. E
TSI. E
T52. C
TSJ. B
T54. A
TSS. A.
T56. B
T57. C
T58. D
T59. B
T60. A
The accuracy of leaf positioning affects the width of the gaps in an IMRT field. The dose
delivered is sensitive to small variations in gap width. Therefore, the dose is sensitive to
errors in leaf position. This is true for step-and-shoot IMRT as well as for sliding-window
IMRT.
Dose differences within 3% are bard to achieve in high-gradient regions due to spatial
uncertainties in dose calculation and measurement. The DTA criteria is designed to
compensate for small spatial errors in high-gradient regions.
At diagnostic energies, the probability of photoelectric interactions increases as Z
3
,
which magnifies the difference in attenuation between bone and tissue. In MV beams,
the Compton effect predominates, with virtually no photoelectric effect, and shows
differences in electron density rather than Z.
Because the beam area is larger, there is more scatter dose in a cone beam scan, which
reduces contrast and overall image quality. Blurring due to respiration and patient motion
can also decrease image quality in a cone beam scan. Motion artifacts are possible in a
spiral CT, but these do not lead to blurring.
Gadolinium is a ferromagnetic agent that is useful in the imaging of a variety of lesions.
It is always important to verify that adequate gadolinium was delivered, and looking at the
intensity of uptake (i.e., brightness) ofthe nasal mucosa can help confirm this.
CT and MRI resolution depend on field of view (FOV), but are usually I mm or less. PET
scan resolution is limited to a few millimeters, mainly because of the finite range of the
positrons, and also because the 511 ke V annihilation gammas are not exactly antiparallel.
Tumors and soft-tissue differences in the brain are usually more easily seen in MR images.
The range of 6 MeV electrons is 3 em in tissue, or 2 em tissue+ 1 em tissue-equivalent
lung. Since lung density is
1
I
4
that of soft tissue, 1 em in tissue is approximately equivalent
to 4 em in lung. Thus, the total range is 2 + 4 = 6 em.
When electrons interact with high Z components in the collimation system (scattering foils,
collimator jaws, etc.), bremsstrahlung, and a smaller number of characteristic x-rays, are
produced. Interactions with tissue also produce bremsstrahlung, but about one order of
magnitude less. The bremsstrahlung "tail" increases with increasing energy, but is usually
in the range of 1% to 5%. -
The rule of thumb is that the MeV /3 - MeV /4 is the approximate depth, in centimeters,
of the 90% isodose level. This depends on the linac manufacturer and the design of the
collimator system.
28 Raphex 2008
T61. D
T62. D.
T63. C
T64. D
T65. C
T66. A
T67. C
T68. C
T69. D
T70. D
T71. C
Raphex 2008
Therapy
: Answers:
All the isodose curves move up towards the skin.
Care should be taken when using small inserts in larger cones, especially for higher
energy. The depth of the 90% isodose can be significantly less due to lack of scatter from
the blocked area. If the depth is adequate, the output for the small insert will need to
be measured; and the skin dose and build-up characteristics should be expected to
change also.
MU = dose/(output x PDD/ 100) = 200/( 1.13 x 0.93).
The range of electrons in lead is approximately 2 MeV/mm. The range in Cerrobend is
20% greater; i.e., (12/2) x 1.2 = 7 mm.
Electrons alone would treat the volume adequately, and would deliver the least dose to the
cord and the contralateral parotid. The reason for adding photons is to reduce the skin dose,
and the trade-off is increased cord dose, which must still be kept below tolerance. Adding
photons does not increase the depth that can be covered homogeneously.
X-ray contamination in an electron beam is mostly along the central axis and angling the
beams reduces X-ray dose to the patient. Angling the beams also produces a more uniform
dose distribution over a larger area.
A= A
0
exp -(0.693 x 7/17) = 0.75 A
0
.
The measured dose rate will be lower by the ratio of the exposure rate constants,
i.e., 3.26/8.25 = 0.40. Also, whereas 160 mCi (64 mg Ra eq) is a reasonable loading
for a Fletcher-Suit type applicator, 160 mg Ra eq would be unusually high.
Units of Ci and Bq are related to the number of disintegrations per unit time. Air kerma
rate (AKR) has units of dose rate. Air kerma strength (AKS) = AKR x d
2

Assume a point source of 240 mg Ra eq at the center of the container.
Exposure rate at 10 em= [activity (mg Ra eq) X rR.] /d
2
= (240 X 8.25)/10
2
= 19.8 R/h.
4 TVLs will reduce this to 1.98 mR/h.
The dose distribution around a seed is "anisotropic," i.e., lower along the seed axis, due to
self-absorption, than perpendicular to the axis. Most treatment planning systems treat the
seed as a "point source," as the orientation is generally unknown. However, this would
overestimate the average dose rate at a given distance from the source, and is corrected by
using the anisotropy correction, to give the average dose rate around an actual seed.
29
Therapy
! Answers !
T72. B
T73. D
T74. D
T7S. A
T76. D
T77. B
T78. D
T79. C
TSO. B
T81. D
T82. A
T83. C
Total dose= Initial dose rate X Tmean = 1600 cGy, where Tmean = T
112
* 1.44. After
two half-lives, the dose rate has dropped to 0.25 x Initial dose rate. The total dose
delivered from this point on will therefore be 0.25 x 1600 cGy, and the dose delivered
during the first two half-lives will be (1 - 0.25) x 1600 = 1200 cGy.
In 3 years 25 mCi will decay to 25 x exp -(0.693 x 3 x 365/60) = 8 x 10-
5
mCi. The
dose rate at 1 ern, assuming a point dose, is: 1.45 x 8 x 10-
5
= 0.12 mR/h. This exposure
rate is so low that it poses no hazard to staff. Even films taken immediately after an implant
show no sign of fogging, since the dose rate at 1 m from the patient is generally close to
background.
The ovoid closest to the cassette will appear smaller. However, this is a small difference
and may not be helpful in distinguishing the ovoids.
The distanced is given by: d
2
= x
2
+ y
2
+ 2 2.
Thus d
2
= 3
2
+ 4
2
+5
2
= 50; d = 7.1
Radioactive materials must be correctly packaged and labeled according to DOT
regulations. They cannot be carried on public transportation.
A sensitive detector is the fastest and most reliable way to verifY that no sources have been
left in the patient or dropped in the bed during removal. This should be done as soon as the
sources have been removed because of the serious consequences to the patient if sources
are left in place longer than intended. The removed sources should be moved away from
the patient's immediate area during the measurement. The sources must be counted before
return to the manufacturer, but this does not have to be done immediately at the patient's
bedside.
Doubling the distance reduces the exposure by a factor of 4. A lead apron (typically
containing 0.5mrn Pb) is ineffective for
137
Cs photons (660 keV, HVL 5.5 mm Pb).
The transport index is the maximum dose rate (in mR/h) at 1 m.
The half-life of
103
Pd is 17 days, so
131
Cs delivers the dose faster, requiring a higher initial
air kerrna rate. The higher energy makes the dose distribution more homogeneous and is
more forgiving if the seed placement is not exactly as planned.
30 Raphex 2008
T84. A
T85. C
T86. A
T87. C
T88. A
T89. D
T90. D
T91. D
T92. B
T93. D
T94. E
T95. B
Raphex 2008
Therapy
! Answers!
Because ofthe inverse-square law, the PDD at a given depth from the surface of an
applicator increases as the diameter increases.
Some brachytherapy planning systems allow iiiteractive optimization, in which an
isodose distribution can be locally shaped by dragging an isodose line with the cursor,
hence altering dwell weights in real-time. This can be a useful tool; however, a small
displacement of the 1 00% isodose cloud can have a large effect on the dose at point A.
This is due to the inverse-square law, which has a powerful effect at the short distances
encountered in brachytherapy. Point A is 2 em from the tandem at the closest point. If
all the sources were at 2 em, the increase would be (2.2/2.0)
2
= 1.21; i.e., 21%. However,
the source distances range from 2 em to about 5 em, depending on the actual geometry,
so the actual difference is closer to 10%. One can use this optimization tool to shape
the isodose cloud, but it is usual to renormalize the plan to deliver the prescribed dose
to point A.
The product of activity x time (Ci x seconds) is constant. This product should be verified
before each treatment, as part of the QA.
When the new source strength is entered at the treatment unit, the times for stored plans
are automatically adjusted for the new source strength. Checking that the product of source
strength and time are constant for a plan is part of the pre-treatment QA.
An air pocket pushes the volume of tissue to be treated away from the balloon, thus
potentially underdosing it. The recommended maximum volume is 10% of the PTV
The scattering foil is used in the electron mode to create a large, flat beam.
Neutrons are created by high-energy photons (and to a lesser extent electrons) incident on
the high Z components in the head of the linac.
The chamber is calibrated at an accredited calibration lab at standard temperature and
pressure (22C and 760 mm Hg). The correction factor corrects the reading back to what
it would have been under calibration conditions. Dose is related to charge collected per
unit mass of gas in the chamber, and the mass changes as the gas expands or contracts,
assuming the chamber is not sealed.
31
Therapy
! Answers !
T96. C
T97. E
T98. C
T99. B
TIOO. A
32
Parallel-plate chambers can also be used.
Using concrete for primary shielding will also shield for neutrons. Lead is not a good
attenuator for neutrons because of its high Z value, and must be supplemented by
additional neutron shielding, typically borated polyethylene.
At 6 MY, Compton interactions predominate, and attenuation per unit thickness is
proportional to the mass density of the material. Thus, the equivalent thicknesses of
concrete and steel are in approximately the inverse ratio of their densities.
Lead is inefficient as a neutron moderator, but it is placed in the door downstream from the
borated polyethylene to attenuate the capture gammas. The neutron dose is about I 0 times
higher for photons than for electrons. The threshold for neutron production is 8 MeV, but
supplemental shielding is not required below I 0 MeV
1 0 HVLs attenuate by a factor of
1
I
2
10
= I I I 024. B is 5 HVLs, and C and D are both
2 TVLs = 11100 (regardless of the material used).
Raphex 2008