Professional Documents
Culture Documents
What total dose delivered with conventional fractionation would yield a 5% risk of
blindness 5 years after irradiation of the entire retina?
A. 25 Gy
B. 35 Gy
C. 45 Gy
D. 55 Gy
Correct answer is C. REFERENCES: Joiner and van der Kogel. Basic Clinical Radiobiology.
4th edition, 2009, Chapter 13. Hall and Giaccia. Radiobiology for the Radiologist. 6th edition.
2006. Chapter 19.
2. Which of the following types of thermoluminescent dosimeter is most commonly used for
dose measurements in radiation therapy?
A. Lithium fluoride
B. Lithium sulfate
C. Calcium fluoride
D. Sodium iodide
A. 1.05
B. 1.15
C. 1.25
D. 1.35
Correct answer is C. RATIONALE: There is a 1.27 relative risk (RR) factor of death from heart
disease for patients who received radiation therapy for breast cancer. REFERENCE: Effects of
radiation therapy and of differences in the extent of surgery for early breast cancer on local
recurrence and 15 year survival: an overview of the randomized trials. Early Breast Cancer
Trialists' Collaborative Group. Lancet. 2005;366:2087-2106.
5. Which of the following drugs was shown in a phase III trial to improve survival in patients
with symptomatic locally advanced or metastatic pancreatic cancer?
A. Gemcitabine
B. Capecitabine
C. Bevacizumab
D. Cisplatin
Correct answer is A. REFERENCE: Burris, et al. Pivotal trial on gemcitabine for pancreatic
cancer. Journal of Clinical Oncology (JCO). 1997.
6. According to the GOG (Homesley) study, which of the following survival outcomes was
demonstrated at 2 years for patients who have vulvar cancer with inguinal lymph node
metastases and received pelvic radiation in comparison to pelvic lymphadenectomy?
Correct answer is B. RATIONALE: In this GOG study, patients with vulvar cancer and positive
groin lymph nodes after radical vulvectomy and bilateral groin dissection were randomized to
receive pelvic-inguinal irradiation or pelvic lymphadenectomy. Patients who received irradiation
had a significantly improved survival compared to patients who had surgery alone (2-year
survival = 68% vs. 54%, p = 0.03). REFERENCE: Homesley, et al. Obstetrics & Gynecology.
1986;68:733-40.
7. What is the most appropriate treatment strategy for a patient who underwent a
lobectomy and mediastinal lymph node dissection with final pathology revealing a stage
T2N0 SCLC?
A. Close surveillance
B. Thoracic radiation therapy only
C. Thoracic radiation therapy, chemotherapy, and PCI
D. Chemotherapy and PCI only
Correct answer is D. RATIONALE: Stage I small cell lung cancer (SCLC) is diagnosed in less
than 5% of patients with SCLC. Patients who undergo complete resection (preferably by a
lobectomy with either mediastinal nodal dissection or sampling) should receive postoperative
chemotherapy, followed by PCI. REFERENCE: NCCN Practice Guidelines in Oncology. 2010.
8. A 2-year-old girl has had a complete resection of the right kidney for Wilms tumor
involving the kidney, perihilar lymph nodes, and renal sinus vessels. No tumor spillage
occurred during surgery, and chest radiograph is normal. Which of the following
treatments would be most appropriate?
Correct answer is A. RATIONALE: According to the current national Wilms tumor study group
staging system, this child has stage II disease and would be treated with vincristine and
dactinomycin alone. Stage III disease requires 10.8 Gy of local irradiation depending on the
extent of involvement and tumor spill.
9. Which of the following statements about the use of the linear-quadratic (LQ) isoeffect
formula in clinical practice is true?
Correct answer is C. RATIONALE: The linear-quadratic (LQ) model and formula is most useful
as a conceptual framework or guide for how to approach radiation treatment planning, and it
should not be used as a substitute for clinical judgment and experience. For example, the model
currently has no provision to take either consequential late effects or incomplete repair between
fractions into account. Further, there is much controversy over whether the model can or should
be applied in cases of extreme hypofractionation, as might be the case for stereotactic or
intraoperative radiation therapy. REFERENCE: Willers H and Held KD. Hematology/Oncology
Clinics of North America. 2006;20:1-24.
10. Which of the following types of cancer most commonly metastasizes to the eye in
women?
A. Lung
B. Breast
C. Colon
D. Thyroid
Correct answer is B. RATIONALE: The most common choroidal metastasis arises from breast
cancer in women and from lung cancer in men.
11. The number of electrons in a neutral atom equals the:
A. mass number.
B. atomic weight.
C. atomic number.
D. nucleon number.
Correct answer is C. RATIONALE: In a neutral atom, the number of electrons equals the
number of protons. The number of protons designates the atomic number for a given atom.
12. What is the expected 10-year overall survival rate for a 45-year-old man who had a
surgical resection with negative surgical margins for a grade 1 chondrosarcoma?
A. 90%
B. 80%
C. 70%
D. 50%
13. Approximately what percentage of patients with invasive bladder cancer will develop a
superficial local recurrence after bladder-preserving therapy consisting of TURBT,
radiation therapy, and chemotherapy?
A. 5%
B. 25%
C. 50%
D. 67%
Correct answer is B. RATIONALE: After bladder preservation, superficial local failure will occur
in approximately 17% to 30% of cases depending on the series. Understanding the appropriate
management and prognosis after local failure is a critical part of care for patients who undergo
this treatment. REFERENCE: Weiss, et al. International Journal of Radiation Oncology,
Biology, Physics (IJROBP). 2008;70(5):1502–1506.
14. Which of the following primary sites of stage T1 squamous cell carcinoma has a <20%
risk of bilateral lymph node involvement?
A. Base of tongue
B. Pyriform sinus
C. Glottic larynx
D. Nasopharynx
Correct answer is C. RATIONALE: There is a very high incidence of bilateral lymph node
involvement in many sites in the head and neck.
15. According to the International Prognostic Index, what is the expected 5-year survival rate
for a high-risk patient with diffuse large B-cell lymphoma?
A. 5%
B. 25%
C. 50%
D. 75%
Correct answer is B. RATIONALE: The 5-year survival rate ranges from 75% for low-risk
patients to 25% for high-risk patients with diffuse large B-cell lymphoma.
16. Which of the following groups provides the largest body of epidemiological data on
radiation-induced bone cancer?
A. Uranium miners
B. Young women employed as radium dial painters
C. Patients who received repeated fluoroscopies for pulmonary tuberculosis
D. Polynesian islanders exposed to atomic fallout
Correct answer is B. RATIONALE: Young women employed as watch dial painters during the
1910s and 1920s suffered a significant increase in fatal bone tumors and other health effects,
mostly due to the accidental ingestion of the radium-containing paint that allowed the hands and
numbers on the watch face to glow in the dark. This public health tragedy represented a classic
study in epidemiology and is acknowledged as the first mass experience with injuries (and
fatalities) caused by exposure to ionizing radiation. REFERENCE: Mettler and Upton. Medical
Effects of Ionizing Radiation. 3rd edition. 2008. Chapter 5.
17. A patient is treated with an abutting 9-MeV electron and a half-beam-blocked 6-MV
photon beam matched on the skin. The beam axes are parallel. What is expected of
the dose distribution at a depth of 3 cm?
Correct answer is D. RATIONALE: When photons and electrons abut, a hot spot develops on
the side of the photon field as the electrons scatter out of the electron field.
18. What is the endpoint of a phase I clinical trial?
A. Survival rates
B. Tumor response rate to treatment
C. Indication for treatment
D. Treatment toxicity rates
Correct answer is D. RATIONALE: Phase I trials provide information about the maximum-
tolerated dose(s) of treatment. These trials provide little or no information about anti-tumor
activity.
19. According to the NSABP-18 (preoperative versus postoperative chemotherapy) trial, the
9-year ipsilateral breast tumor recurrence rate in patients converted from mastectomy to
breast-conserving therapy was:
A. 4%.
B. 8%.
C. 16%.
D. 24%.
A. Only patients with pancreatic head tumors were included in the study.
B. The use of concurrent radiation therapy with 5-FU was compared to concurrent
radiation therapy with gemcitabine.
C. Compared to patients who received 5-FU, patients who received gemcitabine had a
significantly higher rate of grade 3 or higher toxicity.
D. Compared to patients who received 5-FU, patients who received gemcitabine had a
significantly higher rate of overall survival.
Correct answer is C. RATIONALE: Option A is incorrect, since tumors from all parts of the
pancreas were included. Option B is incorrect, since gemcitabine was not administered
concurrently. Option C is correct, since 58% of patients had a higher rate of toxicity. Option D
is incorrect, since only 9% of patients had a higher rate of overall survival. The survival
difference was not statistically significant between the two treatment arms. REFERENCE:
Regine, et al. JAMA. 2008.
21. Which of the following lymph nodes is the most common initial site of metastases in
patients with vulvar carcinoma?
A. Obturator
B. Internal iliac
C. External iliac
D. Superficial inguinal
Correct answer is D. RATIONALE: As the primary drainage site for vulvar carcinomas, the
superficial inguinal lymph nodes are the most commonly involved lymph node site in these
patients. The superficial inguinal lymph nodes subsequently drain into the deep femoral lymph
nodes and ultimately to the external iliac lymph nodes. Involvement of these sites without
involvement of the superficial inguinal nodes is extremely uncommon.
22. Which of the following characteristics is associated with patients who have SCLC?
Correct answer is C. RATIONALE: Small cell lung cancer (SCLC) accounts for 15% of all lung
cancers. Nearly all cases of SCLC are attributed to cigarette smoking. About one third of
patients present with limited disease confined to the chest. Less than 2% of patients with SCLC
present with a superior sulcus tumor.
23. Which of the following stages is most appropriate for a patient with bilateral Wilms
tumor?
A. Stage IIIb
B. Stage IV
C. Stage IVb
D. Stage V
Correct answer is D. RATIONALE: Patients with bilateral Wilms tumors have stage V disease.
Each kidney is considered separately as far as radiation therapy management; however, the
therapeutic approach emphasizes a renal-function-sparing approach.
24. For a tissue with an α/β ratio of 10 Gy, which of the following statements is true?
Correct answer is B. RATIONALE: A tissue dose response curve with a high α/β ratio would
be less "bendy" than one with a low α/β ratio. Tissues characterized by a high α/β ratio are less
responsive to changes in dose per fraction than tissues with low α/β ratios. Generally, although
not without exception, most late-responding normal tissues are characterized by low α/β ratios,
and most early-responding normal tissues and tumors are characterized by high α/β ratios.
A. 1.0 Bq.
B. 3.7 Bq.
C. 107 Bq.
D. 3.7 x 107 Bq.
Correct answer is D. RATIONALE: The definition of a Curie (Ci), also known as disintegrations
per second (dps), is 3.7 x1010 Bq. Therefore, 1 mCi is equal to 3.7 x 107 Bq.
26. According to a randomized, placebo-controlled (Kohno) trial, Japanese women who had
bone metastases from breast cancer and received monthly infusions of 4 mg of
zoledronic acid (Zometa) for 1 year had what percentage rate of reduced skeletal-related
events?
A. 20%
B. 40%
C. 50%
D. 60%
Correct answer is B. RATIONALE: This important trial indicated a substantial benefit for the
use of Zometa in women with metastatic breast cancer to the bone. Patients randomized to
Zometa were less likely to have skeletal events including pathologic fracture, spinal cord
compression, and the need for palliative radiation therapy. REFERENCES: Kohno N, Aogi K,
Minami H, et al. Zoledronic acid significantly reduces skeletal complications compared with
placebo in Japanese women with bone metastases from breast cancer: a randomized, placebo-
controlled trial. Journal of Clinical Oncology. 2005;23:3314.
27. Choroidal melanoma has the highest risk of metastasis to the:
A. liver.
B. lung.
C. brain.
D. bone.
Correct answer is A. RATIONALE: The COMS study for high-risk disease confirmed that >90%
of metastases from choroidal melanoma are found in the liver. Metastasis to the lung is 28%, to
the bone is 18%, and to the brain is 5%.
28. Which of the following margins around the iliac vessels is recommended when a pelvic
CTV is designed, according to the RTOG GU radiation oncology specialist consensus
statement on pelvic lymph node volumes for patients with high-risk prostate cancer?
A. 4 mm
B. 7 mm
C. 10 mm
D. 15 mm
A. Pyriform sinuses
B. Paranasal sinuses
C. Rosenmüller fossa
D. Tonsillar fossa
30. Which of the following studies reported a statistically significant improvement in overall
survival for patients receiving chemotherapy plus involved-field radiation therapy versus
chemotherapy alone for early-stage, aggressive non-Hodgkin lymphoma?
A. SWOG (Miller)
B. ECOG (Horning)
C. GELA (Bonnet)
D. EORTC (Gilman)
Correct answer is A. RATIONALE: Only the initial report from the SWOG study showed an
overall survival advantage for the addition of involved-field radiation therapy (RT) to
chemotherapy. The ECOG study demonstrated only a disease-free survival advantage. The
GELA study included patients older than 60 years with good IPI, and it showed no benefit from
the use of RT. REFERENCES: Miller, et al. SWOG study. New England Journal of Medicine
(NEJM). 1998. Horning, et al. ECOG study. Journal of Clinical Oncology (JCO). 2004. Bonnet,
et al. GELA study. Journal of Clinical Oncology (JCO). 2007.
31. A course of fractionated radiation therapy yields a tumor cell surviving fraction of n and a
tumor control probability of 0.49. If the tumor cell surviving fraction had been 0.5n
instead of n, the tumor control probability would be:
A. 0.50.
B. 0.70.
C. 0.85.
D. 0.98.
Correct answer is B. RATIONALE: Based on Poisson statistics, the tumor control probability
(TCP) can be determined using the equation TCP = e-n. Substituting 0.49 for the TCP and
solving for “n” gives a tumor cell surviving fraction of 0.71. If the cell surviving fraction had been
0.36 (i.e., “0.5n”), the new TCP would correspond to e-0.36 = 0.70.
32. The NCRP recommendation for annual occupational dose limits accounts for possible:
33. Which of the following defines the probability that the observed data occurred by
chance?
A. P value
B. Chi square
C. Odds ratio
D. T-test
Correct answer is A. RATIONALE: The P value gives the probability that the null hypothesis is
correct. Technically, it is the probability that the observed data or more extreme outcome would
have occurred by chance.
34. Which of the following characteristics is associated with the ESPAC-1 trial evaluating
treatment for patients with pancreatic cancer?
Correct answer is D. RATIONALE: Option A is incorrect, because the trial had a 2X2 factorial
design, but was really 3 separate trials. Option B is incorrect because only pancreatic cancer
was included. The EORTC trial included both. Option C is incorrect because survival was
worse in the chemoradiation group. Option D is correct because adjuvant chemoradiation
improved survival. REFERENCE: Neoptolemos, et al. New England Journal of Medicine
(NEJM). 2004.
35. According to the NSABP B-18 and B-27 trials, what were the 8-year locoregional breast
cancer recurrence rates for patients who had yPS 0 (T0N0) disease after preoperative
chemotherapy and mastectomy without radiation therapy?
Correct answer is A. RATIONALE: NSABP B-18 & B-27 studies addressed operable breast
cancers treated with preoperative or postoperative systemic therapy prior to mastectomy or
lumpectomy. Radiation therapy was not permitted to any regional lymphatics. In multivariate
analysis, predictors of locoregional recurrence (LRR) were: 1) Clinical tumor size and nodal
status (before preoperative chemotherapy) and 2) pathologic breast or nodal response (after
preoperative chemotherapy). By using these independent predictors, rates of LRR in different
patient subsets can be defined without the knowledge of pathologic axillary nodal status before
preoperative chemotherapy.
Table 60.7 Eight-Year Cumulative incidence Rates of Local-Regional Recurrence after Preoperative Chemotherapy
and Mastectomy in the NSABP B-18/B-27 Trials According to Pathologic Response in the Breast and Pathologic
Axillary Nodal Status at Surgery
Mastectomy/No Radiation+ Chest Wall Regional Chest Wall Regional Chest Wall Regional
1.5 4.4 5.0 3.0 11.2 3.7
NSABP, National Surgical Adjuvant Breast and Bowel Project; pCR, pathologic complete response. +No chest wall or
regional nodal radiation was allowed per protocol. From Mamounas E, et al. State of the Science Conference on
Preoperative Chemotherapy, Bethesda, MD, 2007
REFERENCE: Harris J., et al. (eds). Local regional therapy consideration in patients receiving
preoperative chemotherapy. Diseases of the Breast. 4th edition. Philadelphia: Lippincott Williams
& Wilkins Publishers. 2009;739-741.
36. What percent of patients diagnosed with SCLC present with superior vena caval
obstruction?
A. <5%
B. 10%
C. 20%
D. 30%
38. Proton radiation therapy has the greatest theoretical advantage over photon radiation
therapy for treatment of:
A. glioblastoma.
B. medulloblastoma.
C. non-small cell lung cancer.
D. adenocarcinoma of the prostate.
Correct answer is B. RATIONALE: The use of protons for craniospinal irradiation as part of
medulloblastoma treatment achieves superior target dose coverage and sparing of normal
tissue structures due to the lack of an exit dose. This may be especially important for children in
terms of reducing the likelihood of late complications. For the other tumors listed, the role and
possible advantages of protons have yet to be firmly established. REFERENCE: Lee, et al.
International Journal of Radiation Oncology, Biology, Physics (Int J Radiat Oncol Biol Phys).
2005;63:362-372.
39. Compared to the total PSA value, which of the following percent-free PSA values is most
likely to indicate that a patient has prostate cancer?
A. 10%
B. 25%
C. 40%
D. 55%
Correct answer is A. RATIONALE: The lower the free PSA, the higher the likelihood that a
patient has prostate cancer. A percent-free PSA of ≤15% is associated with a higher Gleason
grade and a poorer prognosis.
40. According to the AAPM TG40 report, treatments should be suspended if the morning
calibration check differs from the expected value by at least:
A. 2.0%.
B. 3.0%.
C. 5.0%.
D. 10.0%.
Correct answer is C. RATIONALE: AAPM TG40 report on Quality Assurance sets action levels
for morning calibration review. If the output is off by more than 5.0% of the expected value,
treatments should not continue until corrected.
41. A 70-year-old man with prostate cancer has a painful, solitary metastasis to the thoracic
spine that is not at risk for spinal cord compression or impending pathologic fracture.
What is the probability that the man will experience pain relief from administration of
12.5 to 25 Gy of stereotactic body radiation therapy in a single fraction?
A. 85%
B. 75%
C. 65%
D. 55%
Correct answer is A. RATIONALE: Stereotactic body radiation therapy (SBRT) has received
increasing attention recently for the treatment of painful bony metastatic disease. Using
accurate tumor localization with imaging and patient immobilization with body fixation,
hypofractionated doses can be delivered with increased safety. A prospective cohort of 393
patients who had bony metastatic disease and received SBRT doses between 12.5 to 25 Gy
achieved pain palliation and local control in 86% and 90%, respectively. REFERENCE:
Gerszten PC, Burton SA, Ozhasoglu C, Welch WC. Radiosurgery for spinal metastases: clinical
experience in 500 cases from a single institution. Spine. 2007;32:193.
42. Which of the following treatments is most appropriately performed first for a 4-year-old
patient who has an International Classification Group D (Reese-Ellsworth Group 5)
unilateral retinoblastoma?
A. Enucleation
B. Exenteration
C. Radiation therapy
D. Chemotherapy
Correct answer is C. RATIONALE: The depth of invasion correlates with the overall risk of
lymph node metastasis. Tumor sizes, tumor location, and depth of invasion as well as proximity
to midline are the predictors of the risk for contralateral lymph node involvement. This is
important in designing fields for treatment with nonsurgical approaches. The influence of
tobacco is not known to have an effect on lymph node involvement. REFERENCE: Perez,
Brady, et al. Oral Cavity Cancer. Perez and Brady’s: Principles and Practice of Radiation
Oncology. 5th edition Chapter 41. pp 896-897.
44. An otherwise healthy 50-year-old patient is diagnosed with stage IAE, extranodal
marginal zone lymphoma of the stomach. Which of the following treatments would be
most appropriate for this patient?
A. Total gastrectomy
B. R-CHOP x 3 and involved-field radiation therapy to 40 Gy
C. R-CHOP x 6 and involved-field radiation therapy to 30 Gy
D. Radiation therapy alone to 30 Gy
Correct answer is A. RATIONALE: The RBE is defined as a ratio of doses for low- versus high-
LET types of radiation that yield an equal level of effect in cells or tissues. The RBE is higher
when multiple, small radiation doses are used (e.g., conventional fractionation) compared to one
or a few large radiation doses (e.g., stereotactic or intraoperative radiation therapy). The
presence or absence of apoptosis as a mode of cell death and repopulation effects (that would
presumably be absent for overall treatment times less than 4 weeks) have little or no bearing on
the RBE. REFERENCE: Joiner and van der Kogel. Basic Clinical Radiobiology. 4th edition.
2009. Chapter 6.
46. For radiation-safety purposes, which of the following models has been adopted by
regulators to describe the risk of harmful effects from radiation doses?
A. Linear no threshold
B. Linear with threshold
C. Linear quadratic no threshold
D. Linear quadratic with threshold
47. The probability that a test will produce a significant difference at a given significance
level is called the:
A. risk ratio.
B. statistical power.
C. negative predictive value.
D. omnibus test.
Correct answer is B. RATIONALE: The probability that a test will produce a significant
difference at a given significance level is called the statistical power of a test (1 minus the
probability of a type II error).
48. A woman has ER/PR-negative, HER2/neu-positive metastatic breast cancer with tumor
progression after anthracycline, taxane, and trastuzumab (Herceptin) therapy. What is
the next most appropriate therapy?
Correct answer is C. RATIONALE: Lapatinib and capecitabine are recognized as the preferred
choice in this setting, according to the 2009 Practice Guidelines by the National Comprehensive
Cancer Network (NCCN). Based on a randomized phase III trial, the use of lapatinib and
capecitabine in these patients improved time to progression compared to the use of
capecitabine alone. The combination of lapatinib and trastuzumab is not used with cytotoxic
chemotherapy in this setting. REFERENCE: Cameron, et al. Breast Cancer Research and
Treatment. 2008;112:533-43.
49. A patient with liver fluke infestation has a higher risk for developing:
A. hepatoblastoma.
B. hepatocellular carcinoma.
C. fibrolamellar carcinoma.
D. cholangiocarcinoma.
Correct answer is D. RATIONALE: Liver fluke infestation has been associated with the
development of cholangiocarcinoma.
50. The majority of patients who have hereditary breast-ovarian cancer syndrome and
develop ovarian carcinoma have a mutation in which of the following genes?
A. BRCA1
B. BRCA2
C. HER2/neu
D. PTEN
Correct answer is A. RATIONALE: The majority of patients who have hereditary breast-ovarian
cancer (HBOC) syndrome and develop ovarian carcinomas have deletions in the BRCA1 gene,
with more than 100 mutations recognized to date. HBOC is less commonly associated with
mutations in the BRCA2 gene.
51. According to a prospective randomized study for patients who had limited-stage SCLC
and achieved a complete response to therapy, which of the following results was
associated with high-dose (36 Gy) versus standard-dose (25 Gy) PCI?
Correct answer is C. RATIONALE: The corresponding 2-year incidence rates of total brain
metastases in patients with small cell lung cancer (SCLC) are 29% (95% CI 24–35) in the
standard radiation dose group and 23% (18–29) in the higher radiation dose group. Comparison
of the cumulative incidence of total brain metastases curves by adjusted Gray’s test yields an
HR of 0.76 (0.54–1.05, p=0.10), with a 2-year difference of 6% (22% vs 16%) favoring the
higher radiation dose group. When brain metastasis is considered as an isolated first site of
failure, the HR is 0.48 (0.29–0.81, p=0.005), and the 2-year difference is also 6% (12% vs 6%)
favoring the higher radiation dose group. REFERENCE: Lancet Oncology. 2009;10:467–74.
52. Which of the following patients with Langerhans cell histiocytosis (LCH) has the highest
mortality rate?
Correct answer is A. RATIONALE: Mortality rates for patients with Langerhans cell
histiocytosis (LCH) are approximately as follows: An adult with isolated pulmonary LCH = 27%.
A 1-year-old boy with multisystem involvement = 60% to 70%. A 10-year-old girl with
multisystem involvement = 10% to 20%. A 6-year-old boy with multifocal bone disease = 5%.
REFERENCE: Satter, et al. Pediatric Dermatology. 2008;25:291-295.
53. Approximately how many DNA double-strand breaks per cell are produced after acute
exposure to 1 Gy of x-rays?
A. 1 to 4
B. 20 to 40
C. 200 to 400
D. 1000 to 4000
54. How do KERMA and absorbed dose quantities vary beyond the depth of maximum
dose?
A. Tumor size
B. Tumor histology
C. Extensive DCIS
D. Margin status
Correct answer is D. RATIONALE: Margin status appears to be the single most important
prognostic factor for the risk of local recurrence after breast-conserving surgery that includes
irradiation. Definitions of margin status vary between investigators. Most define a positive
margin as the presence of tumor in an inked surface. There is little evidence on how the exact
tumor-free margin width affects the risk of local recurrence. The amount of disease at the
margins may be important in determining the risk for local recurrence. In a Joint Center for
Radiation Therapy finding, the risk of recurrence with focal margin involvement (i.e., invasive or
DCIS cancer across all examined slides that could be encompassed by three or fewer low-
power microscopic fields) was 14%. For patients with extensive margin involvement, the rate
was 27%. In the same series, the respective rates of local recurrence were 7% and 18% for
patients who received systemic therapy. Experience from William Beaumont Hospital reports
the volume of disease near uninvolved margins affected the rate of local recurrence. With a
median follow-up of 103 months, the 12-year actuarial rates of recurrence were 6%, 18%, and
12% for increasing tumor burden at 2.1 mm from the surgical margin. REFERENCES: Recht A.
Breast cancer: stages T1 and T2. Gunderson LL and Tepper JE, eds. Clinical Radiation
Oncology. 2nd edition. Chapter 60. Philadelphia: Churchill Livingstone Publishers. 2007;1478-
1480. Park C, Mitsumori M, Nixon A, et al: Outcome at 8 years following breast-conserving
surgery and radiation therapy for invasive breast cancer: influence of margin status and
systemic therapy on local recurrences. Journal of Clinical Oncology. 2000;18:1668. Goldstein,
NS, Kestin L, Vicini F: Factors associated with ipsilateral breast failure and distant metastases
in patients with invasive breast carcinoma treated with breast conserving therapy. A
clinicopathologic study of 607 neoplasms from 583 patients. American Journal of Clinical
Pathology. 2003;120:500.
56. Which of the following treatments has improved overall survival in patients who have
advanced hepatocellular carcinoma with Child’s A cirrhosis?
A. Gemcitabine
B. Bevacizumab
C. 5-Fluorouracil
D. Sorafenib
57. The primary purpose of a phase II clinical trial of an experimental drug is to:
A. estimate the patient response rate to the drug with a 95% confidence interval.
B. determine the largest dose of the drug that can be administered safely to a patient.
C. determine if there is sufficient evidence of the drug’s safety and efficacy to justify
further testing.
D. compare the experimental drug therapy to the historical control group’s current
standard of care.
Correct answer is C. RATIONALE: Phase II trials are performed to determine whether there is
sufficient preliminary evidence for the safety and efficacy of a treatment to justify further testing.
The appropriate dose has been established in earlier trials, usually in a phase I trial. Response
is not always the desired outcome and may be poorly defined in some disease settings. Direct
comparison of two therapies is based on some evidence of efficacy for each one, and it is
generally the province of phase III trials.
58. Which of the following MRS findings is most consistent with prostate cancer?
Correct answer is B. RATIONALE: Normal prostate glandular tissue produces large amounts
of citrate. Cancer is associated with increased choline levels (secondary to cellular proliferation)
and decreased citrate levels.
59. Which of the following radiation treatment approaches is most appropriate for early-
stage squamous cell carcinoma of the glottic larynx?
Correct answer is C. RATIONALE: Stage T1N0 glottic larynx cancers can be treated very well
with a hypofractionated course of treatment with randomized data demonstrating better local
control. Complication rates are less than 1% for stage T1 tumors, as opposed to stage T2
tumors where the complication rates for severe laryngeal edema have been noted in 4% to 5%
of patients. These are all important factors for evaluating patients with larynx cancer. Stage T2
tumors have a 3% to 7% risk of lymph node involvement as opposed to 1% for stage T1 tumors.
60. Which of the following histologic subtypes of Hodgkin lymphoma has the best prognosis
after treatment with involved-field radiation therapy alone?
A. Lymphocyte-depleted
B. Nodular lymphocyte-predominant
C. Nodular sclerosis
D. Mixed cellularity
61. In mammalian cells, which of the following groups of proteins are positive regulators of
apoptosis?
Correct answer is C. RATIONALE: The p53, Bax, and Apaf-1 proteins are all positive
regulators of apoptosis. Further, the caspases facilitate the degradation of DNA and other
subcellular components during the actual process of apoptosis. Only Bcl-2 is a negative
regulator of apoptosis. REFERENCE: Tannock, Hill, Bristow, and Harrington. The Basic
Science of Oncology. 4th edition. 2005. Chapter 10 (Section 10.2).
62. What happens when a low-energy photon interacts with material via coherent
scattering?
A. The incident photon passes near the nucleus and spontaneously transforms into an
electron/positron pair.
B. The incident photon transfers a fraction of its energy to an electron and is scattered
in another direction.
C. The energy of the incident photon is radiated by the atom with only a slight change
in the direction of the emitted photon.
D. The energy of the incident photon is completely transferred to an atomic electron.
63. Which of the following three factors is most important in predicting the development of
distant metastases in patients who have a local recurrence after lumpectomy and
radiation therapy for stage T1-T2 breast cancer?
Correct answer is D. RATIONALE: After isolated local recurrence, the prognostic variables
across series that are consistently significant for distant recurrence and death are short interval
to recurrence, invasive local recurrence, and initial lymph node positive disease. Other
variables of less importance are local recurrence of the breast only versus regional lymph
nodes, age, hormone receptor status, and type of salvage treatment. REFERENCES: Wapnir,
et al. Journal of Clinical Oncology. 2006;24:2028-37. Shen, et al. Cancer. 2005;104:479-90.
Galper, et al. International Journal of Radiation Oncology, Biology, Physics. 2005;61:348-57.
64. Which of the following complications is LEAST likely to occur after a total gastrectomy?
Correct answer is A. RATIONALE: Dumping syndrome with loss of reservoir function needs to
be recognized after a patient has had a total gastrectomy, and the patient should be
encouraged to consume frequent small meals. REFERENCE:
http://www.netterimages.com/images/vpv/000/000/006/6684-0550x0475.jpg
65. Which of the following types of ovarian tumor is associated with virilization?
A. Granulosa cell
B. Sertoli-Leydig cell
C. Dysgerminoma
D. Choriocarcinoma
Correct answer is B. RATIONALE: Sertoli-Leydig cell tumors are commonly associated with
virilization. Young patients with granulosa cell tumors typically present with precocious puberty,
whereas older patients present with amenorrhea.
66. Thoracic radiation therapy improves the absolute local control rate in patients with
limited-stage SCLC by:
A. 10%.
B. 15%.
C. 20%.
D. 25%.
Correct answer is D. RATIONALE: Thoracic radiation therapy improves local control rates by
25% in patients with limited-stage small cell lung cancer (SCLC) and is associated with
improved survival. REFERENCES: Pignon, et al. New England Journal of Medicine (NEJM).
1992;327:1618-1624. Payne, et al. Journal of Clinical Oncology. 1992;10:890-896.
67. Which of the following staging classifications would apply for a 4-year-old girl with a
7-cm, unresectable, vaginal rhabdomyosarcoma with a 1-cm inguinal lymph node and
no distant metastasis?
Correct answer is A. RATIONALE: The cell cycle checkpoint activation and arrest response
induced by ionizing radiation exposure halts cell cycle progression to better coordinate with
DNA repair. The function of cell cycle checkpoints is to prevent genomic instability and promote
cell survival.
69. The photoelectric effect mass attenuation coefficient is proportional to:
A. ZE.
B. Z2E2.
C. Z3E3.
D. Z3/E3.
Correct answer is D. RATIONALE: The photon electric effect is heavily dependent on atomic
number (Z) and increases with Z. As the energy (E) increases, the probability of this effect
decreases significantly.
70. According to the 20-year follow-up report for the NSABP B06 (Fisher) trial, the
cumulative incidence of breast cancer recurrence in the ipsilateral breast after
breast-conserving surgery and radiation therapy is:
A. 8%.
B. 11%.
C. 14%.
D. 17%.
Correct answer is C. RATIONALE: The cumulative incidence of recurrent breast cancer in the
ipsilateral breast was 14.2% in the women who underwent lumpectomy and breast irradiation
compared with 39.2% in the women who underwent lumpectomy without irradiation. Study
design: Tumor size was 4 cm or less; patients who were lymph node positive and negative were
included; surgical margins at lumpectomy were negative (no tumor at ink), patients who had a
lumpectomy with tumor at the surgical margin received a total mastectomy but were followed for
subsequent events; patients with positive lymph nodes received melphalan and 5-FU; patients
who received 50 Gy of radiation therapy to the breast without boost; patients who had positive
nodes and did not receive radiation therapy to the regional lymphatics; no adjuvant tamoxifen
was used. REFERENCE: Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a
randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for
the treatment of invasive breast cancer. New England Journal of Medicine (NEJM).
2002;347:1233.
Correct answer is D. RATIONALE: Examples that were described in the question included two
early-stage larynx cancers (options A and B) that would be treated with radiation therapy alone
without the use of systemic therapy. Having a significant involvement of the base of tongue
were excluded from larynx preservation trials due to the poor outcomes on the VA larynx study,
and the tumor with thyroid cartilage invasion did not go through the cartilage so it still would be a
candidate for chemotherapy and radiation therapy, per RTOG 91-11.
73. Which of the following Ann Arbor stages is most appropriate for a patient who has
Hodgkin lymphoma with enlarged lymph nodes in the preauricular, cervical, and
supraclavicular regions, but no other adenopathy on workup?
A. IA
B. IAE
C. IIA
D. IIIA
Correct answer is A. RATIONALE: The preauricular, cervical, and supraclavicular lymph node
regions are considered as one region, based on the Ann Arbor staging system.
74. According to the International Germ Cell Cancer Collaborative Group Consensus
Classification System, a patient who has metastatic seminoma with elevated β-hCG and
LDH levels would be classified into which of the following prognostic groups?
A. Very good
B. Good
C. Intermediate
D. Poor
Correct answer is C. RATIONALE: In the International Germ Cell Cancer Collaborative Group
Consensus Classification System, the poor prognosis group includes only patients with non-
seminomatous germ cell tumors. REFERENCE. International Germ Cell Consensus
Classification: a prognostic factor-based staging system for metastatic germ cell cancers.
International Germ Cell Cancer Collaborative Group. Journal of Clinical Oncology. Feb 1997;
15(2):594-603.
75. What is the approximate risk of a local recurrence if salvage breast-conserving surgery
is attempted again after initial conservation therapy?
A. 5%
B. 15%
C. 30%
D. 50%
Correct answer is C. RATIONALE: The risk of second local recurrence has been reported to
be 19% (Salvadori, et al. British Journal of Surgery (Br J Surg). 1999;86:84-7), 32% (Kurtz, et al.
European Journal of Cancer (Eur J Cancer). 1991;27:240-4), and 38% (Voogd, et al. Cancer.
1999;85:437-46) in the three largest published series.
76. Which of the following DNA repair mechanisms has the highest activity during the S and
G2 phases of the cell cycle?
A. field size.
B. depth.
C. energy.
D. SSD.
Correct answer is D. RATIONALE: The tissue phantom ratio (TPR) is defined as the ratio of
the dose at a given point in a phantom relative to the dose at the same point at a fixed reference
depth. This ratio is nominally used for monitor unit calculations in isocentric geometries.
Although the source-to-surface distance (SSD) may vary depending on the contour of the
patient's surface, the source-to-axis distance (SAD) remains constant. Thus, the TPR is
independent of the SSD.
78. What is the leading cause of cancer death among women in developing countries
(American Cancer Society, 2007)?
A. Breast
B. Cervix
C. Colon
D. Lung
Correct answer is B. RATIONALE: The most common cause of cancer death worldwide (in
developing and developed countries) is breast cancer. Cervical cancer is the most common
cause of death in developing countries and the third most common cause of death in developed
countries (after lung cancer). REFERENCE: American Cancer Society (ACS), 2007 released
statistics. http://www.cancer.org/downloads/STT/Global_Facts_and_Figures_2007_rev2.pdf
79. The extent of SCLC metastases may be indicated by elevated serum levels of:
A. CA 19-9.
B. CEA.
C. LDH.
D. AFP.
Correct answer is C. RATIONALE: Lactate dehydrogenase (LDH) serum levels have been
shown to predict the extent of small cell lung cancer (SCLC) metastases.
80. Which of the following study designs would be most appropriate for investigating the
effectiveness of a radiation dose of 70 Gy versus 60 Gy in providing local disease
control for patients with prostate cancer?
81. Which of the following statements about potentially lethal damage recovery (PLDR) is
true?
A. It describes the increase in cell survival if a single radiation dose is split into two
fractions.
B. It describes the increase in cell survival when cells are prevented from proliferating
after irradiation.
C. Changing the postirradiation environmental conditions cannot modify PLD.
D. It is the manifestation of the repair of mismatched bases in DNA.
Correct answer is B. RATIONALE: Both sublethal and potentially lethal damage recovery are
operationally defined terms, as both were first described and characterized more than 40 years
ago, well before the DNA repair mechanisms of which they are a manifestation were elucidated.
PLDR is defined as an increase in cell survival noted under conditions where the cells were
prevented from proliferating for several hours after irradiation; such conditions may include, for
example, overcrowding, presence of drugs that directly or indirectly inhibit cell cycle
progression, or lack of sufficient nutrients and oxygen. Sublethal damage, on the other hand, is
defined as that increase in cell survival noted when a single radiation dose is split into two
fractions with a time interval inbetween. It is too simplistic to ascribe the biochemical repair of a
particular type of DNA lesion to one or both of these phenomena, although it probably is true
that both are manifestations of the rejoining of chromosome breaks, most of which arise from
radiation-induced DNA double-strand breaks.
82. Compared to a placebo, tamoxifen given for 5 years produced which of the following
outcomes for women with a history of LCIS, according to the NSABP P-1 (Fisher) study?
A. Reduced the hazard rate for subsequent invasive breast cancer by approximately
50%
B. Decreased the risk of subsequent invasive breast cancer to 10%, compared to 30%
with the placebo
C. Decreased the incidence of subsequent noninvasive but not invasive breast cancer
D. Lowered the risk of subsequent invasive breast cancer only for tumors that were
ER-positive
Correct answer is A. RATIONALE: The incidence of subsequent breast cancer for women with
lobular carcinoma in situ (LCIS) was approximately 6% at 5 years with the placebo, and the
relative risk for women randomized to tamoxifen was 0.54. Estrogen receptor (ER) status was
not tested for LCIS to meet eligibility for the study. The relative risk was seen for invasive
breast cancer as well as noninvasive breast cancer. REFERENCE: Fisher, et al. Journal of
National Cancer Institute. 2005;97:1652-62.
83. Which of the following statements about the treatment of gastric cancer is true?
A. A D2 lymph node dissection is defined by the removal of more than six lymph
nodes.
B. In the INT-0116 randomized intergroup (Macdonald) trial, adjuvant therapy improved
locoregional control and overall survival.
C. In the MAGIC (Cunningham) trial, perioperative chemotherapy improved the
pathologic complete response rate.
D. In the randomized Dutch Gastric Cancer trial, D2 versus D1 lymphadenectomy
increased overall survival.
84. According to randomized clinical trial data, which of the following statements about
chemoradiation for esophageal cancer is true?
A. Most of the patients in the RTOG 85-01 trial had esophageal squamous cell
carcinomas.
B. The CALGB 9781 trial established the equivalence of chemoradiation to surgery for
resectable tumors.
C. In the randomized German Esophageal Cancer Study Group (Stahl) trial, high-dose
chemoradiation had a lower local failure rate than standard-dose chemoradiation,
followed by surgery.
D. The INT 0123 (Minsky) trial showed that increasing the radiation dose for definitive
chemoradiation improved survival.
Correct answer is A. RATIONALE: Know current randomized clinical trial data [RTOG 85-01
trial, CALGB 9781 trial, German Esophageal Cancer Study Group (Stahl) trial, and INT 0123
(Minsky) trial data].
85. Which of the following histological types of carcinoma most commonly originates in the
fallopian tube?
A. Squamous cell
B. Adenosquamous
C. Adenocarcinoma
D. Papillary serous
Correct answer is D. RATIONALE: More than 95% of fallopian tube cancers are papillary
serous carcinomas. Other histologies including adenocarcinoma are very infrequently
diagnosed.
86. According to the ICRU, which of the following volumes is most appropriate when CT
images are used during radiation treatment planning for a patient with prostate cancer?
Correct answer is B. RATIONALE: Gross disease within the prostate capsule cannot be
discerned from normal prostate tissue based on CT images. Thus, the entire prostate is
typically contoured as the CTV. Per ICRU Report #50 and #62, the CTV consists of the gross
disease plus microscopic growth.
87. Which of the following characteristics of historical control patients is most accurate?
Correct answer is A. RATIONALE: A historical control is one whose outcomes are known
before patients receive the experimental treatment that is the subject of the trial. The historical
control patients are not only treated before the patients receiving the experimental protocol, but
their outcomes are known. This knowledge may affect the design and/or conduct of the
experimental part of the trial. The therapy received by a historical control is necessarily earlier
in time but may not be considered outdated. Registries and special purpose databases are
often used to identify historical control patients, but historical control data also may be collected
from among recently treated patients at a hospital or clinic.
88. According to the ANITA trial, which of the following stages of NSCLC is most likely to
have the best response to postoperative chemotherapy and radiation therapy?
A. pT4N1M0
B. pT3N0M0
C. pT2N1M0
D. pT1N2M0
A. Nasopharynx
B. Infratemporal fossa
C. Nasal cavity
D. Orbit
Correct answer is D. RATIONALE: Parameningeal sites include the middle ear, nasal cavity,
paranasal sinuses, nasopharynx, infratemporal fossa/pterygopalatine, and parapharyngeal
areas. Orbital disease is considered a favorable site and is treated with lower-dose radiation
therapy and chemotherapy.
90. According to the International Germ Cell Cancer Collaborative Group Consensus
Classification System, what is the expected 5-year overall survival rate for a patient with
a nonseminomatous germ cell tumor classified as having a poor prognosis?
A. 90%
B. 70%
C. 50%
D. 30%
Correct answer is C. RATIONALE: Five-year overall survival for patients included in the test
set was 48%. In the validation study, the 5-year overall survival for this patient population was
57%. The best answer above is 50%. REFERENCE: International Germ Cell Consensus
Classification: a prognostic factor-based staging system for metastatic germ cell cancers.
International Germ Cell Cancer Collaborative Group. Journal of Clinical Oncology. Feb 1997;
15(2):594-603.
91. The cytotoxicity and radiosensitization produced by gemcitabine are affected by the loss
of function of:
A. ATM.
B. MLH1.
C. BRCA1.
D. NBS1.
92. What is the effective source position for electrons from the isocenter for a 100-cm SAD
treatment machine?
A. 100 cm
B. 99.8 cm
C. 99.0 cm
D. 90.0 cm
Correct answer is D. RATIONALE: The source for most of the electrons is from the scattering
foils located near the photon target in the treatment head.
93. Which of the following factors is used in the Gail model to predict an individual’s risk for
the development of breast cancer?
95. What percent of neuroblastomas occur in the low thoracic or abdominal paraspinal
ganglia?
A. 5%
B. 30%
C. 45%
D. 60%
96. Which of the following factors is associated with the highest risk of treatment failure for
patients with squamous cell carcinoma of the head and neck of unknown primary?
A. Basaloid differentiation
B. Lymphoepithelial histology
C. Number of involved lymph nodes
D. Extranodal extension
Correct answer is D. RATIONALE: Extranodal extension is associated with the highest risk of
treatment failure for patients with squamous cell carcinoma of the head and neck of unknown
primary.
97. According to the EORTC 20884 (Aleman) trial, what involved-field radiation dose (in Gy)
was delivered to the lymph node sites in patients who had a complete response to
MOPP-ABV chemotherapy for stage III or IV Hodgkin lymphoma?
A. 20
B. 24
C. 30
D. 36
Correct answer is B and C. RATIONALE: For patients who had a complete response to
chemotherapy, a radiation dose of 24 Gy or 30 Gy was delivered to the lymph node sites.
REFERENCE: Aleman, et al. New England Journal of Medicine (NEJM). 2003.
98. According to the Rubin and Casarett tissue classification system, which of the following
classes includes intestinal crypt cells?
Correct answer is D. RATIONALE: The Rubin and Casarett tissue classification system was
developed in the 1960s and represented an extension and refinement of the Bergonié and
Tribondeau system first introduced some 60 years earlier. Using this system, tissues are
categorized as being one of four main "classes," based on the particular tissue's proliferation
kinetics and cellular differentiation status. As rapidly dividing, undifferentiated stem cells
supplying the gut epithelium, crypt cells would be classified as VIM or Class I, and represent the
most radiosensitive of the four types (VIM > DIM > RPM > FPM, ranked from most sensitive to
most resistant).
99. Based on the table shown below, what is the PDD for a 10-MV beam with a field size of
6 x 12 cm2 at a depth of 15 cm and an SSD of 110 cm? (Please note: The depth of
maximum dose for a 10-MV beam is 2.5 cm.)
PDD Table*
Field Size (cm2)
6x6 8x8 10 x 10 12 x 12
56.2% 57.1% 57.9% 58.5%
*10-MV beam at 15-cm depth and 100-cm SSD
A. 55.1%
B. 57.3%
C. 58.2%
D. 59.0%
PDD2 =
( SSD2 + d max ) 2 ( SSD1 + d ) 2 (110 + 2.5) 2 (100 + 15) 2
PDD1 × × = 57 . 1 × × = 58.2%
( SSD1 + d max ) 2 ( SSD2 + d ) 2 (100 + 2.5) 2 (110 + 15) 2
100. A clinical trial is conducted to investigate a drug’s effect on bone loss in elderly patients.
X-rays from middle-aged and elderly participants in the study will be distributed to one of
two radiologists to be interpreted. Which of the following factors is most important to
consider in ensuring the validity of the x-ray results?
Correct answer is A. RATIONALE: Each image will be read only once, so any systematic
differences between readings by the two radiologists will be difficult to separate from other
effects on bone loss. By itself, this is acceptable if the differences can be shown to be small
and/or controlled by use of a standard protocol for feature identification and data recording. Age
is known to be related to bone loss, however, so it is important that the age distributions of the
patients whose images are read by each radiologist are approximately the same. If not, any
bias due to the reader will become confounded with age, making the study results difficult to
interpret. If age is related to the time of day at which patients are available to participate in the
study (e.g., middle-aged working participants during evenings and on weekends, elderly or
retired participants during the day), the effect may be strong enough to rob the study of
usefulness. Confounding can be controlled to some extent by design; that is, by making sure
that the age profiles are similar for both radiologists. Randomizing the order in which images
are read also does not reduce reader bias. Having each radiologist read half of the images
ensures that the characteristics of reading by each radiologist will be equally represented, but it
does not reduce the bias due to the reader. Timely data collection tends to improve data
quality, and it is a good goal for the study, but it does not reduce bias or confounding.
101. Which of the following features is associated with Hodgkin lymphoma in children?
Correct answer is C. RATIONALE: Fifteen to twenty percent of children present with stage IV
Hodgkin lymphoma. Twenty-five to thirty percent of children have B symptoms. Nodular
sclerosing histology is the most common subtype in all age groups.
102. According to the updated Silverstein trial data, what is the 12-year local recurrence rate
in patients with DCIS and a surgical margin of ≥1 cm after breast-conserving surgery?
Correct answer is B. RATIONALE: While recurrence rates in this favorable subset of women
with margins ≥1 cm in the Silverstein ductal carcinoma in situ (DCIS) experience are generally
lower than reported in prospective randomized trials, there remained a large difference in local
recurrence with radiation therapy in their long-term update of results. REFERENCE:
MacDonald, et al. American Journal of Surgery (Am J Surg). 2006;192:420-2.
103. Based on a retrospective analysis of the ANITA trial, which of the following stages of
NSCLC is most likely to have the best response to postoperative radiation therapy
alone?
A. pT3N0M0
B. pT2N1M1
C. pT2N1M0
D. pT2N0M0
104. Which of the following statements about small bowel tumors is FALSE?
105. The uterine arteries run to the uterine fundus via what ligament?
A. Broad
B. Round
C. Cardinal
D. Uterosacral
Correct answer is A. RATIONALE: Basic anatomy question, useful for understanding the
different types of hysterectomies (in part defined by the degree of parametrial resection in
relation to the artery)
Correct answer is C. RATIONALE: The tumor suppressor protein p21WAF1/CIP1 binds to and
inhibits the activities of CDK2 and CDK4. It is involved in cell cycle checkpoint control,
especially in the progression from G1 into the S cell cycle phase. The expression of p21 is tightly
controlled by the tumor suppressor protein p53, which serves as a positive transcription factor
for the WAF1/CIP1 gene.
107. A man is diagnosed with urothelial cancer in the renal pelvis. What is the risk that a
synchronous or metachronous urothelial cancer will be found elsewhere in the renal
pelvis, ureter, or bladder?
A. <5%
B. 5% to 10%
C. 11% to 20%
D. >20%
Correct answer is D. RATIONALE: Urothelial cancers commonly arise in the setting of "field
cancerization," as a result of exposure of the entire urothelial tract to an associated
predisposing risk factor (e.g., environmental carcinogen). Therefore, any patient with a newly
diagnosed primary urothelial cancer is at significant risk for a synchronous or metachronous
urothelial cancer. For upper urothelial tract cancers, it is estimated that 2% to 4% of patients will
present with bilateral involvement. Meanwhile, approximately 25% of patients will have
multifocal disease in the renal pelvis and ureter, while 50% of patients will have synchronous or
metachronous disease involving the bladder. REFERENCE: Olgac, et al. American Journal of
Surgical Pathology (Am J Surg Path). 2004;28:1545-1552.
108. What is the RBE for protons used in radiation therapy beams?
A. 1.00
B. 1.05
C. 1.10
D. 1.20
Correct answer is C. RATIONALE: In vivo studies have shown protons to have an RBE of 1.10
compared with photon beams. This value has been accepted into clinical use. REFERENCES:
Delaney and Kooy, eds. Proton and Charged Particle Radiotherapy. Gerweck L, Paganetti H.
Radiobiology of Charged Particles. Philadelphia: Lippincott, Williams, and Wilkins Publishers.
2008.
109. Based on the German Rectal Cancer Study, which of the following outcomes in patients
with rectal cancer was significantly improved by preoperative chemoradiation versus
postoperative chemoradiation?
A. Pelvic control
B. Overall survival
C. Distant metastatic rate
D. Postoperative wound complications
111. Which of the following statements about squamous cell carcinoma of the hypopharynx is
true?
Correct answer is C. RATIONALE: Squamous cell carcinomas of the hypopharynx are rare,
although pyriform sinus cancers are much more common than posterior pharyngeal wall (PPW)
cancers and have a late presentation with one of the symptoms being hoarseness related to
vocal cord fixation. Outcomes are poor with lower neck involvement, which is important in the
era of systemic chemotherapy, possibly requiring induction chemotherapy. Swallowing function
can be poor when treating posterior pharyngeal wall (PPW) cancers, including treatment of all
the constrictor muscles and the larynx.
112. A 65-year-old man with stage IIB diffuse large B-cell lymphoma has a 10-cm mediastinal
mass, an LDH serum level of 300 U/L, and an erythrocyte sedimentation rate (ESR) of
50 mm/h. His ECOG performance status is 2. Which of the following factors is
associated with the worst prognosis?
A. Staging, B symptoms
B. High ESR, B symptoms
C. Bulky disease, high ESR
D. Performance status, high LDH level
A. Dicentrics
B. Reciprocal translocations
C. Terminal deletions
D. Micronuclei
114. A beam spoiler typically is used during total skin electron therapy to:
Correct answer is D. RATIONALE: A beam spoiler is used to improve the beam uniformity and
degrade the energy of the electron beam, thereby shifting the percent depth dose (PDD) to
produce a shallower depth dose. The remaining answers are incorrect for the following
reasons:
A. One technique to reduce x-ray contamination from striking a patient, which is typically
forward directed, is to treat the patient at an extended distance and angle the beam by +/-20o
above the central axis (Stanford technique). A plastic spoiler would be insufficient to attenuate
contaminate photons.
B. Since the skin is the area of interest and electrons are used for treatment, dose and/or dose
rate at the patient's midplane is not an issue for total skin electron therapy (TSET).
C. To reduce the dose to sensitive structures, lead shields are used. In particular, to protect
the lens of the eye, eye shields are used during treatment.
115. Which of the following statements about bladder preservation consisting of TURBT,
radiation therapy, and chemotherapy for muscle-invasive bladder cancer is FALSE?
A. Over two thirds of surviving patients at 5 years will have a functioning bladder.
B. Stage-by-stage cystectomy outcomes are superior to bladder-preserving therapy.
C. Good response rates of 59% to 87% in patients have been achieved, according to
different RTOG trials.
D. Reevaluation can be done 4 to 6 weeks after completion of therapy or after the initial
portion of therapy.
Correct answer is B. RATIONALE: Understanding the basic concepts and rationale for
bladder-sparing therapy in Europe and the United States are important for appropriate patient
selection and evaluation during therapy. REFERENCE: Rodel, et al. Journal of Clinical
Oncology (JCO). 2006;24:5536-5544. Sweeney, et al. ASCO Educational Book. 2009. pp 200-
208.
116. Approximately what percent of U.S. patients diagnosed with DCIS receive breast-
conserving surgery and radiation therapy?
A. 40%
B. 60%
C. 85%
D. 90%
Correct answer is A. RATIONALE: Approximately 40% of patients with DCIS are treated with
breast-conserving surgery and radiation therapy, 30% are treated with breast-conserving
surgery alone, and 30% are treated with mastectomy. REFERENCE: Smith, et al. International
Journal of Radiation Oncology, Biology, Physics (Int J Radiat Oncol Biol Phys). 2006;65:1397-
1403. Baxter, et al. Journal of National Cancer Institute (J Natl Cancer Inst). 2004;96:443-8.
117. Chemoradiation followed by surgery for esophageal cancer is LEAST likely to produce:
Correct answer is A. RATIONALE: Adding surgery to chemoradiation reduces the local relapse
rate but does not impact overall survival (admittedly, this was for squamous cell carcinomas).
REFERENCE: Stahl M, Stuschke M, Lehmann N, Meyer HJ, Walz MK, Seeber S, Klump B,
Budach W, Teichmann R, Schmitt M, Schmitt G, Franke C, Wilke H. Chemoradiation with and
without surgery in patients with locally advanced squamous cell carcinoma of the esophagus.
Journal of Clinical Oncology (J Clin Oncol). Apr 1, 2005;23(10):2310-7.
118. According to the GOG 123 (Keys) trial, the addition of chemotherapy to preoperative
radiation therapy improved the absolute 3-year overall survival rate for patients with
stage IB2 cervical cancer by what percent?
A. 2%
B. 5%
C. 10%
D. 20%
Correct answer is C. RATIONALE: Five of the six studies comparing postoperative radiation
therapy versus chemoradiation showed an overall survival benefit. In the Keys study, the
survival improved from 74% to 83%. REFERENCE: Keys. New England Journal of Medicine
(NEJM). 1999;340:1154-1161.
119. According to the AJCC TNM staging system for NSCLC, a tumor invading the
diaphragm is classified as stage:
A. T1.
B. T2.
C. T3.
D. T4.
Correct answer is C. RATIONALE: Invasion of the diaphragm by the primary tumor for patients
with non-small cell lung cancer (NSCLC) is classified as stage T3.
120. Which of the following treatments would be most appropriate for a 6-month-old child with
stage 1, low-risk neuroblastoma after complete tumor resection with no organ- or life-
threatening symptoms?
A. Chemoradiation therapy
B. Radiation therapy only
C. Chemotherapy only
D. Close follow-up
Correct answer is D. RATIONALE: Patients with low-risk neuroblastoma have a cure rate of
higher than 90%. After complete tumor resection for stage 1 disease, close observation or
follow-up is the most appropriate management. REFERENCES: NCI PDQ Neuroblastoma.
(http://www.cancer.gov/cancertopics/pdq/treatment/neuroblastoma/HealthProfessional). COG
9641 protocol. Matthay KK, Haas-Kogan D, Constine l. Neuroblastoma. Pediatric Radiation
Oncology. 4th edition. Chapter 6. Philadelphia: Lippincott Williams & Wilkins Publishers. pp 179-
222. Perez, et al. Biologic variables in the outcome of stages I and II neuroblastoma treated with
surgery as primary therapy: a children's cancer group study. Journal of Clinical Oncology. Jan
2000;18(1):18-26.
121. Which of the following proteins is required for homologous recombination repair?
A. Rad51
B. Artemis
C. DNA-PKcs
D. DNA ligase IV
122. The quality of a superficial x-ray beam is usually determined by measuring the:
Correct answer is B. RATIONALE: The quality of treatment beams used for superficial therapy
is determined by measuring the half-value layer (HVL) in a specified material (i.e., aluminum)
and is specified in millimeters. REFERENCE: Khan. Physics of Radiation Therapy. Chapter 4.
123. According to the St. Gallen International Expert Consensus, which of the following
pathologic tumor-staging characteristics in a 60-year-old patient is categorized as
intermediate-risk breast cancer?
Risk category
Intermediate risk Node negative AND at least one of the following features:
pT >2 cm, OR
Grade 2-3 OR
Presence of peritumoral vascular invasion, OR
HER2/neu gene overexpressed or amplified, OR
Age <35 years
Node positive (1–3 involved nodes) AND
HER2/neu gene neither overexpressed nor amplified
Nil Nil —
Intermediate ET alone, or CT → ET CT
risk
CT → ET (CT + ET) —
(CT + ET) — —
High risk CT → ET CT → ET CT
REFERENCES: Haffty BG, Buchholz TA, Perez CA. Early-stage breast cancer. Halperin EC, Perez
CA, Brady LW, eds. Perez and Brady’s: Principles and Practice of Radiation Oncology. 5th edition.
Chapter 53. Philadelphia: Lippincott Williams & Wilkins Publishers. 2008;1206-1207. Goldhirsh A, Glick
JH, Gelber RD, et al. Meeting highlights: international expert consensus on the primary therapy of early
breast cancer 2005. Annals of Oncology (Ann Oncol). 2005;16:1569-1583.
124. According to the MRC CR07 randomized trial, a short course of preoperative radiation
therapy (5 Gy x 5 fractions) versus selective postoperative chemoradiation significantly
reduced the local recurrence rate for patients with rectal cancer in which of the following
locations?
Correct answer is D. RATIONALE: Preliminary results indicate that a routine short course of
preoperative radiation therapy significantly reduced local recurrence and improved disease-free
survival at 3 years when compared with a highly selective postoperative approach.
REFERENCE: Lancet. 2009;373:811–20.
125. FIGO stage IIIB endometrial cancer involves direct extension to the:
A. serosa.
B. adnexa.
C. vagina.
D. cervix.
Correct answer is C. RATIONALE: FIGO stage IIIB endometrial cancer involves metastasis or
direct extension to the vagina. Stage IIIA involves the serosa and or adnexa by direct extension
or metastasis. A stage II cancer involves the cervix either by endocervical glandular involvement
only (IIA) or by cervical stromal invasion (IIB).
126. Which of the following statements about squamous cell carcinoma of the pyriform sinus
is true?
127. A 50-year-old woman presents with a mass in the lesser curvature of the stomach, and
biopsy results reveal that she has MALT lymphoma. Which of the following treatment
options would be most appropriate?
Correct answer is D. RATIONALE: Patients with gastric MALT lymphoma and Helicobacter
pylori infection should receive first-line therapy for Helicobacter pylori infection, and their
treatment response should be evaluated for at least 6 months before making a decision on
whether to include second-line therapy of involved-field radiation therapy. REFERENCES:
Bayerdorffer E, Neubauer A, Rudolph B, et al. Regression of primary gastric lymphoma of
mucosa-associated lymphoid tissue type after cure of Helicobacter pylori infection. MALT
Lymphoma Study Group. Lancet. 1995;345:1591–1594. Roggero E, Zucca E, Pinotti G, et al.
Eradication of Helicobacter pylori infection in primary low-grade gastric lymphoma of mucosa-
associated lymphoid tissue. Annals of Internal Medicine (Ann Intern Med). 1995;122:767–769.
128. Which of the following types of radiation will yield the highest surviving fraction of
Chinese hamster ovary cells when delivered as two 1.5-Gy fractions separated by
3 hours as opposed to a single 3-Gy fraction?
A. 250-kVp x-rays
B. 15-MeV neutrons
C. 25-MeV alpha particles
D. 100-MeV carbon ions
130. What is the positive predictive value of PET imaging for 100 patients who have the
following results?
True positives: 36
True negatives: 18
False positives: 34
False negatives: 12
A. 51%
B. 60%
C. 67%
D. 74%
A. <1 year
B. 3 years
C. 5 years
D. >7 years
Correct answer is D. RATIONALE: In patients with 1p19q codeleted tumors, the median
survival has not been reached with 7 to 8 years of follow-up. Patients who have tumors with
intact 1p19q chromosomes had a median survival of only 1.8 and 2.8 years, based on the
EORTC and RTOG trials. REFERENCES: van den Bent MJ, Carpentier AF, Brandes AA, et al.
Adjuvant procarbazine, lomustine, and vincristine improve progression-free survival but not
overall survival in newly diagnosed anaplastic oligodendrogliomas and oligo-astrocytomas: a
randomized European Organization for Research and Treatment of Cancer phase III trial.
Journal of Clinical Oncology. 2006;24:2715-2722. Cairncross G, Berkey B, Shaw E, et al. Phase
III trial of chemotherapy plus radiotherapy compared with radiotherapy alone for pure and mixed
anaplastic oligodendroglioma: Intergroup Radiation Therapy Oncology Group Trial 9402.
Journal of Clinical Oncology. 2006;24:2707-2714.
132. What is the estimated probability that a patient with clinical stage T1c prostate cancer
with a Gleason score of 3+3 and a PSA level of 6 ng/mL has extracapsular extension?
A. <10%
B. 20%
C. 30%
D. >50%
A. 80 to 100 cGy/hr
B. 45 to 55 cGy/hr
C. 15 to 25 cGy/hr
D. <10 cGy/hr
Correct answer is B. RATIONALE: This is a basic low dose rate (LDR) radiation implant
question, which is necessary for understanding the prescription dose for a cervical implant.
REFERENCE: Nag S, et al. The American Brachytherapy Society recommendations for low-
dose-rate brachytherapy for carcinoma of the cervix. International Journal of Radiation
Oncology, Biology, Physics (Int J Radiat Oncol Biol Phys). Jan 1, 2002;52(1):33-48.
Correct answer is D. RATIONALE: The percent labeled mitosis technique is used to determine
the individual cell cycle phase durations and overall cell cycle time of a proliferating cell
population, either in vitro or in vivo. REFERENCE: Hall and Giaccia. Radiobiology for the
Radiologist. 6th edition. Chapter 21.
136. The label "6 MV" used for linear accelerators during radiation therapy means that:
Correct answer is D. RATIONALE: Linear accelerators beam energy labels are specified by
the energy that electrons acquire in the waveguide. When the electrons strike the target, the
resulting x-rays that are produced will have a range of energies upwards of approximately 6
MeV. It is a convention to drop off the "e" and designate the spectrum of energies by the term "6
MV." This is discussed in Chapter 4 of Khan's Physics of Radiation Therapy and Karzmark's
Linear Accelerator Primer.
137. According to the Danish 82b (Overgaard) and British Columbia (Ragaz) trials, the
addition of postmastectomy radiation therapy to the chest wall and regional lymph nodes
improved overall survival in premenopausal women with one to three positive lymph
nodes by what percent?
A. 3%
B. 5%
C. 10%
D. 13%
Correct answer is C. RATIONALE: Both studies found that the overall survival was improved
by 10% for patients receiving postmastectomy radiation therapy. Note: There were study design
differences in the choice of systemic therapies, radiation doses/fractionation as well as
differences in systemic therapy and radiation sequencing schedules. None of these factors
appeared to affect the improved overall survival finding reported in both studies.
REFERENCES: Overgaard M, Hansen PS, Overgaard J, et al. Postoperative radiotherapy in
high risk premenopausal women with breast cancer who receive adjuvant chemotherapy. New
England Journal of Medicine (NEJM). 1997;337:949-955. Ragaz J, Jackson SM, Le N, et al.
Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast
cancer. New England Journal of Medicine (NEJM). 1997;337:956-962. Ragaz J, Olivotto IA,
Spinelli JJ, et al. Locoregional radiation therapy in patients with patients with high-risk breast
cancer receiving adjuvant chemotherapy: 20-year results of the British Columbia randomized
trial. Journal of the National Cancer Institute (J Natl. Cancer Inst). 1997;97:116-126.
138. Which of the following treatments (listed in order of administration) would be most
appropriate after incomplete resection of a high-risk neuroblastoma?
139. Based on the CALGB 8984 phase II study, what was the local recurrence rate at
10 years for patients with stage T2 rectal tumors after full-thickness wide local excision
with or without chemoradiation?
Correct answer is C. RATIONALE: In this study, all patients with stage T2 rectal cancer
disease received 54 Gy of irradiation with 5-FU postoperatively. In spite of this treatment
regimen, 10-year results showed a local recurrence rate of 18%. For this reason, fewer centers
offer wide local excision (WLE) for stage T2 rectal tumors. REFERENCE: Dis Colon Rectum.
Aug 2008;51(8):1185-91; discussion 1191-4.
140. What is the FIGO stage for an endometrial cancer with pelvic lymph node involvement?
A. IIB
B. IIIC
C. IVA
D. IVB
Correct answer is B. RATIONALE: FIGO stage IIIC represents metastases to the pelvic and or
para-aortic lymph nodes. FIGO stage IIB includes cervical stromal invasion. FIGO stage IVA
involves invasion of the bladder and or bowel mucosa. FIGO stage IVB involves distant
metastases. Pelvic lymph nodes in the TNM classification are represented by an N1
designation.
141. Which of the following histologies of stage T1N0 skin cancer of the scalp has the worst
prognosis?
A. Angiosarcoma
B. Squamous cell carcinoma
C. Merkel cell carcinoma
D. Melanoma
142. A 70-year-old woman has grade 1 follicular lymphoma involving the pelvic lymph nodes.
Which of the following management options would be most appropriate for this patient?
Correct answer is C. RATIONALE: Patients with low-grade follicular lymphoma have several
options for disease management: observation, radiation therapy, and chemotherapy provide an
equal chance of survival for this patient. REFERENCE: Horning ST. Natural history of and
therapy for the indolent non-Hodgkin lymphomas. Seminars in Oncology (Semin Oncol).
1993;20:75-80.
143. Most radiation-induced HPRT gene mutations in human cell lines involve:
A. transitions.
B. transversions.
C. frame shifts.
D. large deletions.
Correct answer is D. RATIONALE: For mammalian cells grown in culture, the HPRT
mutagenesis assay is used to detect mutations in the HPRT gene, which codes for the enzyme
hypoxanthine-guanine phosphoribosyl transferase. This enzyme is involved in the purine
nucleotide salvage pathway, and as such, its loss is not a lethal event. Transitions,
transversions, and frame shifts are all small, point mutations; however, most ionizing radiation-
induced mutations are large, often involving the deletion of most or all of the gene.
144. A radiation survey is taken 1 m from a patient who received a brachytherapy implant.
How many half-value layers (HVLs) of lead would be required to reduce the exposure
rate at 1 m from 6.7 mR/hr to 2 mR/hr?
A. 0.7 cm
B. 1.0 cm
C. 1.7 cm
D. 2.0 cm
I ⎛ − ln(2) × t ⎞
Correct answer is C. RATIONALE: = exp⎜ ⎟ , if t = x HVL, then
Io ⎝ HVL ⎠
2 ⎛ − ln(2) × xHVL ⎞
= exp⎜ ⎟ = exp(− ln(2) × x) , and solving for x,
6.7 ⎝ HVL ⎠
⎛ 2 ⎞ 1 − 1.209
x = ln⎜ ⎟× = = 1.74 cm
⎝ 6.7 ⎠ − ln(2) − 0.693
145. What is the negative predictive value of PET imaging for 100 patients who have the
following results?
True positives: 36
True negatives: 18
False positives: 34
False negatives: 12
A. 74%
B. 67%
C. 60%
D. 51%
Correct answer is C. RATIONALE: The negative predictive value is defined as the number of
true negatives/(number of true negatives + number of false negatives). In this case, 18/(18+12)
= 60%.
146. Which of the following tumor marker serum levels is most common in a patient with a
pure germinomatous intracranial germ cell tumor?
A. Bone scan
B. PET/CT scan
C. ProstaScint scan
D. MRI
Correct answer is A. RATIONALE: Patients with high-risk prostate cancer need to have a bone
scan to evaluate or rule out metastatic disease.
148. What is the risk that a patient with FIGO stage IIIB cervical cancer will have paraaortic
lymph node involvement?
A. 5%
B. 15%
C. 20%
D. 30%
Correct answer is D. RATIONALE: Patients with FIGO stage IB cervical cancer have a 5.6%
risk for paraaortic lymph node involvement; patients with FIGO stage II-IV have a 29.3% risk for
paraaortic lymph node involvement. REFERENCES: Perez. Principles and Practice of
Gynecologic Oncology. 1st edition. 1992. Lagasse LD, et al. Results and complications of
operative staging in cervical cancer: experience of the Gynecologic Oncology Group.
Gynecologic Oncology. Feb 1980;9(1):90-8.
149. Which of the following statements about the 2009 AJCC TNM staging criteria for lung
cancer is true?
A. Tumor size of >5 cm has been reclassified from stage T2 to stage T3.
B. Multiple tumor nodules in the same lobe have been reclassified from stage T4 to
stage T3.
C. The N stage classification has been changed to reflect the number of lymph nodes
involved.
D. The M stage classification has not changed.
Correct answer is B. RATIONALE: This item tests the summary changes of the 2009 AJCC
lung cancer staging classifications: The T-stage classifications have been redefined: Stage T1
has been subclassified into stage T1a (≤2 cm in size) and stage T1b (2 cm to 3 cm in size).
Stage T2 has been subclassified into stage T2a (3 cm to 5 cm in size) and stage T2b (5 cm to 7
cm in size). Stage T2 (>7 cm in size) has been reclassified as stage T3. Multiple tumor nodules
in the same lobe have been reclassified from stage T4 to stage T3. Multiple tumor nodules in
the same lung but a different lobe have been reclassified from stage M1 to stage T4. The N
stage classifications have remained unchanged. The M stage classifications have been
redefined. Stage M1 has been subdivided into stage M1a and stage M1b. Malignant pleural
and pericardial effusions have been reclassified from stage T4 to stage M1a. Separate tumor
nodules in the contralateral lung are considered stage M1a. Stage M1b designates distant
metastases.
150. Which of the following factors increases the risk for CNS dissemination in a patient with
retinoblastoma?
Correct answer is D. RATIONALE: Involvement of the optic nerve beyond the lamina cribrosa
is a known risk factor for CSF spread because of the access of retinoblastoma cells to the
subarachnoid space (the optic nerve is surrounded by meninges). REFERENCE: Halperin EC,
Kirkpatrick JP. Retinoblastoma. Pediatric Radiation Oncology. 4th edition. Chapter 5.
Philadelphia: Lippincott Williams & Wilkins Publishers. pp 135-176.
A. Only progenitor cells can migrate to the site of a normal tissue injury.
B. Tumors are thought to contain stem cells but not progenitor cells.
C. Like stem cells, progenitor cells can proliferate indefinitely.
D. Progenitor cells are totipotent, and stem cells are not.
152. When measuring the output of a linear accelerator, the temperature correction term
utilized must correct for temperature dependence of the:
A. density of water.
B. density of air in an ion chamber.
C. coefficient of expansion of the ion chamber.
D. electrometer sensitivity.
A. Rectum
B. Ascending colon
C. Descending colon
D. Transverse colon
A. Carcinosarcoma
B. Leiomyosarcoma
C. Low-grade endometrial stromal sarcoma
D. High-grade undifferentiated sarcoma
Correct answer is B. RATIONALE: A PET scan is very sensitive in detecting a high metabolic
state, such as in tumors, but provides poorer spatial resolution in cross-sectional anatomy as
compared to CT or MRI scans. A PET scan has been shown to be as sensitive as a bone scan
in detecting bone metastasis.
159. Approximately how many autosomal-recessive genetic disorders would be expected (per
Sievert per 106 births) for the first-generation progeny of irradiated parents?
A. 3000
B. 750
C. 50
D. 0
A. 15o
B. 30o
C. 45o
D. 60o
Correct answer is C. RATIONALE: Wedge angle = 90° – hinge angle/2 = 90° – 85°/2 = 90° –
42.5° = 47.5o, which is closest to a 45o wedge angle.
161. Which of the following management options is most appropriate for an intracranial non-
germinomatous germ cell tumor after surgical resection?
162. Which of the following statements about the use of radiation therapy for renal cell
carcinoma is true?
Correct answer is B. RATIONALE: HPV has been found to be associated with 70% of cervical
cases worldwide. There are currently two different vaccines available: Cevarix, Glaxo Smith
Kline, a bivalent vaccine against serotypes 16 and 18 and Gardasil, Merck and Co, a
quadrivalent vaccine against serotypes 6, 11, 16, and 18. Current data suggests that it is
effective in reducing cervical, vulvar, vaginal, and anogenital cancers with 93% efficacy. The
data has not yet proven its efficacy in reducing oropharyngeal cancer. Current
recommendations suggest vaccination of sexually inactive females only, though there is
evidence to vaccinate sexually active women who are seronegative for HPV. REFERENCE:
International Journal of Gynecological Cancer. October 2009;19(7):1166-76.
164. Which of the following treatments would be most appropriate for a patient with poor
pulmonary function and stage I NSCLC involving the right hilum?
A. Radiofrequency ablation
B. Conventional fractionated radiation therapy
C. Stereotactic body radiation therapy
D. Wedge resection, followed by brachytherapy
A. 15%
B. 30%
C. 50%
D. 65%
A. embryonic fibroblasts.
B. bone marrow stem cells.
C. lymphocytic leukemia cells.
D. lung adenocarcinoma cells.
Correct answer is C. RATIONALE: Hewitt and Wilson first developed the limiting dilution assay
in the late 1950s as a means of determining the radiation dose response curve for murine
lymphocytic leukemia in vivo. (The method has since been adapted for use with several other
experimental tumors.) Since the assay endpoint is transmission of the leukemia to recipient
mice and not the counting of colonies, it is necessarily a non-clonogenic assay. One notable
finding of the original study was that it took the injection of, on average, only two (previously
unirradiated) leukemia cells to transmit the disease to 50% of syngeneic mice. REFERENCES:
Joiner and van der Kogel. Basic Clinical Radiobiology. 4th edition. 2009. Chapter 4. Hall and
Giaccia. Radiobiology for the Radiologist. 6th edition. Chapter 20.
168. What is the recommended V20 value for patients who receive IMRT after extrapleural
pneumonectomy for mesothelioma?
A. <7%
B. 17%
C. 23%
D. 30%
Correct answer is A. RATIONALE: The standard recommendation of keeping V20 below 35%
for patients who have lung cancer (when both lungs are counted as the total lung volume) and
are receiving thoracic radiation therapy (RT) does not apply to patients with mesothelioma
following pneumonectomy. The remaining lung has to be protected as much as possible from
RT, and several institutions (Beth Israel/Harvard; Duke; MD Anderson) described severe
pulmonary toxicity if the V20 was not kept below 7%. In addition, V5 is emerging as an
important parameter to watch, since IMRT frequently “floods” the remaining lung with low-dose
RT.
169. Which of the following features is included in the Nottingham histological grading system
for breast cancer?
A. Cell size
B. Cell shape
C. Stromal pattern
D. Tubule formation
170. Which of the following characteristics is associated with the Intergroup 0130 randomized
trial that evaluated postoperative chemoradiation for patients with high-risk colon
cancer?
Correct answer is C. RATIONALE: The Intergroup 0130 was a randomized trial that evaluated
the addition of adjuvant radiation therapy to chemotherapy in patients with resected colon
cancer. Patients were eligible if they had stage T3N+ or T4 disease. The trial was closed due
to poor accrual, but there was no significant difference in either disease-free or overall survival.
171. What postoperative management option would be most appropriate for a pathologic
stage II low-grade endometrial stromal sarcoma?
A. Observation
B. Pelvic radiation therapy only
C. Vaginal brachytherapy only
D. Pelvic radiation therapy with vaginal brachytherapy
173. Which of the following outcomes is most likely to occur if a pregnant woman receives
2.5 Sv of radiation during the preimplantation stage of gestation?
A. Microcephaly
B. Spina bifida
C. Embryonic death
D. Mental retardation
Correct answer is C. RATIONALE: Animal studies indicate a lower frequency of births when
irradiation occurs very early in gestation, presumably due to death of the embryo. Based on
related studies of Japanese A-bomb survivors, excess cases of congenital malformations,
microcephaly, and mental retardation were more characteristic of irradiation later in pregnancy,
during the organogenesis and early fetal stages (approximately 4-25 weeks gestation).
REFERENCE: Hall and Giaccia. Radiobiology for the Radiologist. 6th edition. 2006. Chapter 12.
174. The electrons produced by a linear accelerator operated in electron mode will pass
through which of the following structures before exiting the linear accelerator?
A. Scattering foil
B. Flattening filter
C. Target
D. Klystron
Correct answer is A. RATIONALE: Of the items listed, the generated electrons that can be
used clinically will only pass through the scattering foil before exiting the linear accelerator
(linac). The target and flattening filter are only in place when the linac is operated in photon
mode. The target is used to convert electrons to bremsstrahlung x-rays, and the flattening filter
is used to flatten the forward-directed x-rays at a specified depth in phantom (typically 10 cm).
Lastly, a klystron is a microwave amplifier used to power and accelerate the electrons through
the accelerator waveguide.
TMZ + RT RT alone
A. 40% 10%
B. 27% 11%
C. 10% 2%
D. 2% 1%
Correct answer is C. RATIONALE: The addition of TMZ to RT increases overall survival for
patients with glioblastoma multiforme. The 2-year overall survival rate with RT plus
temozolomide is 27%, and the 5-year overall survival rate is 10%. REFERENCE: Stupp R,
Hegi ME, Mason WP, et al. Effects of radiotherapy with concomitant and adjuvant temozolomide
versus radiotherapy alone on survival in glioblastoma in a randomized phase III study: 5-year
analysis of the EORTC-NCIC trial. Lancet Oncology. 2009;10:459-466.
177. What is the most common site of lymph node metastasis in a patient with penile cancer?
A. Inguinal
B. Obturator
C. Paraaortic
D. Hypogastric
178. Oral cavity cancer most commonly occurs in which of the following sites in both
American men and women?
A. Lip
B. Oral tongue
C. Floor of mouth
D. Buccal mucosa
Correct answer is B. RATIONALE: According to SEER 2007 data: Option B, the oral tongue,
is the most common site for cancer of the oral cavity (38%). Option C, the floor of mouth, is the
second most common site (26%). These two sites are followed by all other sites of the mouth:
Option D, buccal mucosa (18%); and Option A, the lip (18%).
179. Which of the following treatment strategies is most appropriate for a patient who has
stage IIIB NSCLC with KPS of >70?
Correct answer is A. RATIONALE: The standard treatment for a patient with stage IIIB non-
small cell lung cancer (NSCLC) is concurrent chemoradiation with fractionated radiation
therapy. This is supported by at least three randomized phase III trials: The West Japanese
study, Czech Republic study, and RTOG 9410. The CALGB 39801 study did not show a
significant advantage of survival in patients treated with neoadjuvant carboplatin and Taxol
before concurrent chemoradiation. The HOG Phase III study failed to show a significant benefit
of adjuvant docetaxel (Taxotere) chemotherapy, while the Locally Advanced Multimodality
Project (LAMP) did report longer median survival in patients treated with fractionated radiation
therapy with concurrent and adjuvant carboplatin and Taxol. REFERENCES: Zatloukal, et al.
Concurrent versus sequential chemoradiotherapy with cisplatin and vinorelbine in locally
advanced non-small cell lung cancer: a randomized study. Lung Cancer. Oct 2004;46(1):87-98.
Furuse, et al. Phase III study of concurrent versus sequential thoracic radiotherapy in
combination with mitomycin, vindesine, and cisplatin in unresectable stage III non-small cell
lung cancer (NSCLC). Journal of Clinical Oncology (J Clin Oncol). Sep 1999;17(9):2692-9.
RTOG 9410 is to be published soon. Fournel, et al. Randomized phase III trial of sequential
chemoradiotherapy compared with concurrent chemoradiotherapy in locally advanced non-small
cell lung cancer: Groupe Lyon-Saint-Etienne d'Oncologie Thoracique-Groupe Français de
Pneumo-Cancérologie NPC 95-01 Study. Journal of Clinical Oncology (J Clin Oncol). Sep 2005
1;23(25):5910-7. Hanna, et al. Phase III study of cisplatin, etoposide, and concurrent chest
radiation with or without consolidation docetaxel in patients with inoperable stage III non-small
cell lung cancer: the Hoosier Oncology Group and U.S. Oncology. Journal of Clinical Oncology
(J Clin Oncol). Dec 10, 2008;26(35):5755-60. Belani, et al. Combined chemoradiotherapy
regimens of paclitaxel and carboplatin for locally advanced non-small cell lung cancer: a
randomized phase II locally advanced multi-modality protocol. Journal of Clinical Oncology (J
Clin Oncol). Sep 1, 2005;23(25):5883-91. Epub 2005 Aug 8. Erratum in: Journal of Clinical
Oncology (J Clin Oncol). Apr 20, 2006;24(12):1966.
180. Which of the following radiation treatments is most appropriate for acute lymphoblastic
leukemia involving the testes?
A. 18 Gy in 10 fractions
B. 24 Gy in 12 fractions
C. 30 Gy in 15 fractions
D. 36 Gy in 18 fractions
Correct answer is B. RATIONALE: Because the testicles are regarded as a sanctuary site,
testicular radiation therapy to a dose of 20-24 Gy in 2-Gy fractions is given as a consolidative
therapy after chemotherapy. REFERENCES: Hustu HO, et al. Extramedullary leukemia.
Clinical Haematology (Clin Haematol). 1978;7(2):313-337. Bowman WP, et al. Isolated
testicular relapse in acute lymphocytic leukemia of childhood: categories and influence on
survival. Journal of Clinical Oncology. Aug 1984;2(8):924-9. Kun L. Leukemias in children.
Pediatric Radiation Oncology. 4th edition. Chapter 2. Philadelphia: Lippincott Williams & Wilkins
Publishers. pp 15-39.
181. Which of the following statements about radiation carcinogenesis from diagnostic
imaging procedures is FALSE?
Correct answer is A. RATIONALE: The major sources of radiation exposure to the U.S.
population are natural background and medical exposure, with the contribution of the latter
having increased dramatically in the last 30 years due to the proliferation of relatively high-dose
medical imaging procedures, particularly CT scanning. Medical radiation exposure now
surpasses natural background radiation exposure as the leading contributor to the average
annual effective radiation dose in the United States (51% versus 48%, respectively), currently
estimated to be approximately 6.3 mSv. Concern about the possible carcinogenic risk of
imaging procedures has heightened in recent years due to epidemiological findings among the
Japanese A-bomb survivors of a statistically significant increased risk of cancer mortality after
exposure to radiation doses comparable to those delivered by CT scanners. This is especially
concerning given that CT scanning has increased disproportionately in the pediatric population,
who are both inherently more sensitive to radiation and have the longest potential lifespan to
manifest a cancer. REFERENCE: Mettler and Upton. Medical Effects of Ionizing Radiation, 3rd
edition. 2008. Chapter 2.
182. For 100-cm isocentric linear accelerators, the decrease in dose deposition due to the
inverse square factor for 1 cm depth in tissue is approximately:
A. 1.0%.
B. 1.5%.
C. 2.0%.
D. 2.5%.
Correct answer is C. RATIONALE: For 100-cm isocentric machines, the loss of photon fluence
per 1 cm of distance is approximately (100/101)2 = 0.98. This relationship holds for a relatively
large range of distances around 100 cm (i.e. (90/91)2 = 0.978 and (110/111)2 = 0.982.
183. An MRI is most likely indicated for breast cancer screening or staging when a patient:
Correct answer is D. RATIONALE: MRI is useful in evaluating the extent of DCIS involvement.
In the case of extensive intraductal component (EIC), MRI has a 95% accuracy rate vs. 36% for
mammography and ultrasound. MRI is not indicated for evaluating breast pain; clinical
evaluation and ultrasound are the primary studies to be completed. MRI is not indicated for
screening patients with silicone augmentation. Mammography with implant imaging protocols is
used for screening purposes. The safety of gadolinium-enhanced contrast agents during
pregnancy is not widely established at this time. REFERENCE: Berg WA, Birdwell, RL, et al,
eds. Imaging modalities – magnetic resonance imaging. Diagnostic Imaging. Salt Lake City:
Amirsys Publishers. 2006; part II-0: 36-37.
184. Which of the following features is associated with acute lymphoid leukemia?
A. Adult patients treated with an intense chemotherapy regimen can achieve cure rates
as high as those observed in children.
B. A patient’s ability to achieve a complete response after induction chemotherapy is
one of the strongest predictors of disease outcome.
C. High-risk patients who are positive for the Philadelphia chromosome should receive
allogeneic bone marrow transplantation.
D. It is more prevalent than acute myeloid leukemia in the U.S. population.
Correct answer is B. RATIONALE: Acute myeloid leukemia (AML) is more prevalent in the
U.S. population, with 9000 cases per year, when compared with acute lymphoid leukemia (ALL),
with 4000 cases per year. Achieving a complete response after induction chemotherapy is one
of the strongest prognosticators in predicting a patient’s outcome. High-risk patients may benefit
from myeloablative treatment with allogeneic bone marrow transplantation, and TBI is the
preferred conditioning regimen for a superior outcome. REFERENCE: De Vita, et al. Principles
and Practice of Oncology.
185. Which of the following stages is most appropriate for a patient who has colon cancer that
invades the subserosa with five positive lymph nodes?
A. T2N1 (IIIA)
B. T3N1 (IIIB)
C. T3N2 (IIIC)
D. T4N2 (IIIC)
Correct answer is C. RATIONALE: A tumor that has invaded the subserosa is a stage T3
lesion, and involvement of four or more lymph nodes is stage N2 disease.
186. According to the ASTEC surgical trial, women who had a pelvic lymphadenectomy to
treat stage I endometrial carcinoma experienced:
Correct answer is D. RATIONALE: The ASTEC surgical trial included more than 1400 women
with stage I endometrial cancer, randomized to receive a hysterectomy and bilateral salpingo-
oophorectomy (BSO) with or without pelvic lymphadenectomy. A median of 12 lymph nodes
were removed in patients who received lymphadenectomy. Results showed no evidence of
benefit in overall or recurrence-free survival for pelvic lymphadenectomy in women with early-
stage endometrial cancer. REFERENCE: The Lancet. January 10, 2009;373(9658):125-136.
Correct answer is C. RATIONALE: Practically all cases of mesothelioma will have multiple
pleural implants along the chest wall, all of which will be removed during pleurectomy and as
such would not constitute a contraindication to surgery. Pericardial pleura can be resected.
Extension through the diaphragm is a classic contraindication to complete resection. Epithelial
histologic subtype has a better prognosis than the sarcomatoid subtype and is more likely to
have prolonged survival after surgery.
A. Interleukin-8 (IL-8)
B. Thrombospondin-1 (TSP-1)
C. Vascular endothelial growth factor (VEGF)
D. Basic fibroblast growth factor (bFGF)
189. What is the primary photon interaction when a megavoltage beam strikes a patient?
A. Photoelectric effect
B. Compton scattering
C. Electron scattering
D. Bremsstrahlung
A. 53.3%
B. 80.0%
C. 90.4%
D. 97.1%
191. An MRI scan performed 1 month after completion of chemoradiation with temozolomide
for glioblastoma reveals enlargement of the contrast-enhanced lesion. Which of the
following management options would be most appropriate?
A. Second-line chemotherapy
B. Continuation of temozolomide
C. Resection of the lesion
D. SRS to the lesion
192. Which of the following histologic subtypes of urethral carcinoma occurs most commonly
in men?
A. Oral tongue
B. Floor of mouth
C. Alveolar ridge
D. Buccal gingiva
Correct answer is A. RATIONALE: According to SEER data, a lip primary has the best
prognosis with a 10-year survival rate of 87%, followed by the gums (70%) and the floor of
mouth (48%). The alveolar ridge and buccal gingiva are both portions of the gums. Oral tongue
cancer has the worst 10-year survival rate of 45%.
194. Which of the following adverse effects most commonly occurs in a patient with lung
cancer after administration of concurrent chemoradiation?
Correct answer is B. RATIONALE: Esophagitis is the most common side effect (about 40%-
50%) during treatment in patients treated with concurrent chemoradiation, according to all of the
phase III trials of patients treated with concurrent chemoradiation therapy. Esophagitis often
occurs at 3-4 weeks from the commencement of radiation therapy.
A. is used as consolidative therapy after initial remission in children with acute myeloid
leukemia.
B. is indicated for children who have acute lymphoblastic leukemia without the
Philadelphia chromosome.
C. does not include total body irradiation as part of the bone marrow transplant
conditioning regimen.
D. requires an allogeneic bone marrow transplant.
A. e- + H2O → e-aq
B. [H2O+] → HO• + H+
C. e-aq + H+ → H•
D. H• + H• → H2
Correct answer is D. RATIONALE: The free radicals set into motion by the radiolysis of water
are believed to be responsible for about 70% of the total DNA damage produced by ionizing
radiation. On occasion, two free radicals will interact with each other instead of the DNA (or
other important bio-molecules), effectively "detoxifying" themselves. This action removes
potentially damaging free radicals from the cell.
198. Which of the following statements about phyllodes tumors arising in the breast is true?
199. Which of the following treatments would be most appropriate for a patient who has anal
canal cancer, is HIV positive, and has a CD4 count of 800 cells/mm3?
200. What is the incidence of pelvic lymph node metastasis for a grade 1 adenocarcinoma of
the endometrium with inner one-third myometrial invasion?
A. ≤5%
B. 10%
C. 15%
D. 20%
Correct answer is A. RATIONALE: Based on a prospective evaluation (by the GOG and
others) of surgicopathologic patterns of spread in patients with endometrial cancer, it is
recognized that much of the adverse prognosis associated with intrauterine risk factors is
mediated through lymph node involvement. The incidence of pelvic lymph node metastases is
5% or less for grade 1 or grade 2 tumors with inner one-third myometrial invasion. For tumors
with outer one-third myometrial invasion, lymph node disease was found in 19% of grade 2
cancers and in 34% of grade 3 cancers. REFERENCES: Cancer. 1987;60:2035-2041.
International Journal of Gynecologic Cancer. 2008;18(2):269-273.
201. According to the TNM mesothelioma staging system, a stage T3 tumor involves the:
Correct answer is C. RATIONALE: Mesothelioma evolves from the parietal pleura; therefore,
involvement of either parietal or visceral pleura denotes an early-stage tumor. A focal (in
contrast to diffuse) invasion of the chest wall is still potentially resectable; therefore, it is a stage
T3 tumor. Spinal invasion is not resectable and is a stage T4 tumor.
202. A 3½-year-old patient who has average-risk medulloblastoma should receive which of
the following craniospinal radiation therapy doses as part of a total radiation dose of
54 Gy before chemotherapy?
A. 13.2 Gy
B. 23.4 Gy
C. 30.6 Gy
D. 36.0 Gy
203. Which of the following statements about hypoxia-inducible factor-1 (HIF-1) is true?
204. Which of the following American Association of Physicists in Medicine Task Group
(AAPM TG) clinical protocols is currently recommended for calibration dosimetry of
external photon and electron beams in the United States?
A. AAPM TG21
B. AAPM TG43
C. AAPM TG51
D. AAPM TG64
206. Which of the following characteristics are associated with the best overall survival in a
patient with glioblastoma?
Correct answer is B. RATIONALE: Epigenetic silencing of the MGMT DNA repair gene by
promoter methylation compromises DNA repair and has been associated with longer survival in
patients with glioblastoma who receive alkylating agents. Younger patients have a better
survival rate than older patients. REFERENCES: Hegi ME, Diserens AC, Gorlia T, et al.
MGMT gene silencing and benefit from temozolomide in glioblastoma. New England Journal of
Medicine (NEJM). 2005;352:997-1003. Stupp R, Hegi ME, Mason WP, et al. Effects of
radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on
survival in glioblastoma in a randomized phase III study: 5-year analysis of the EORTC-NCIC
trial. Lancet Oncology. 2009;10:459-466.
207. Penile carcinoma invading the urethra or prostate should be classified as stage:
A. T1.
B. T2.
C. T3.
D. T4.
A. 50%
B. 30%
C. 10%
D. 5%
Correct answer is B. RATIONALE: According to SEER data, regional lymph node metastasis
decreases the 5-year survival rate by 40%. Distant metastasis further reduces the survival rate
to about 30%, ranging from 27% for oral tongue to 37% for lip cancer.
209. Which of the following factors is typically required when stereotactic body radiation
therapy is used to treat lung tumors?
Correct answer is A. RATIONALE: While 20% of patients with clinical early-stage lung cancer
may have involved lymph nodes, patterns of failure from stereotactic body radiation therapy
(SBRT) series do not demonstrate a high lymph node failure rate. Currently, CTV expansions
are NOT allowed on the ongoing RTOG 0618 study. Also, a photon energy of >15 MV is
specifically discouraged due to the typically small field used and lack of electronic equilibrium
from highly energetic laterally scattered electrons. Generally, peripheral tumor locations
(defined as tumors that are >2 cm from the bronchotracheal tree) are favored for SBRT, due to
the higher toxicity associated with the treatment of central lung lesions.
210. Which of the following findings is associated with a poor prognosis in children who
present with acute lymphoblastic leukemia?
Correct answer is D. RATIONALE: Options A-C are favorable features for acute lymphoblastic
leukemia (ALL). The presence of translocation t(9;22) is a high-risk feature associated with a
worse treatment outcome. REFERENCE: Kun L. Leukemias in children. Pediatric Radiation
Oncology. 4th edition. Chapter 2. Philadelphia: Lippincott Williams & Wilkins Publishers. pp 15-
39.
211. Which of the following statements about anatomically undefined functional subunits
(FSUs) is true?
A. The kidney and liver are examples of tissues with anatomically undefined FSUs.
B. Tissues with anatomically undefined FSUs can be rescued by migration of surviving
clonogens from outside the radiation field.
C. Tissues with anatomically undefined FSUs have a parallel arrangement.
D. Tolerance doses for tissues with anatomically undefined FSUs are lower than for
tissues with anatomically defined FSUs.
Correct answer is B. RATIONALE: It is important to remember that FSUs have two different
characteristics: 1) whether they are contained within an obvious anatomical or histological
boundary or not (i.e., anatomically defined or anatomically undefined) and 2) how they are
arranged functionally within the tissue (i.e., "in parallel" or "in series"). Both are considerations
when attempting to model the volume dependence of tissue tolerance to radiation. For
example, the liver is a tissue with putative functional subunits that are anatomically defined (i.e.,
the lobule), but are organized in a parallel arrangement, whereas the spinal cord behaves as if
its FSUs were arranged in series. Yet, what constitutes an FSU in the anatomical sense
remains unclear (anatomically undefined). Tissues with anatomically undefined FSUs have an
advantage in that they can be rescued from potential failure by the migration of surviving
clonogens from outside the radiation field, so-called "tissue rescuing units." Anatomic or
histological boundaries presumably make this impossible for tissues with anatomically defined
FSUs.
212. Which of the following modes of intensity modulation is most reliable and capable of
delivering highly conformal dose distributions but is relatively labor intensive?
A. Compensating filter
B. Dynamic jaws
C. Dynamic MLC
D. Static MLC
Correct answer is A. RATIONALE: Compensating filters are very reliable as they do not
depend on electronic hardware and software interfaces on a linear accelerator, and they are
also capable of delivering highly conformal dose distributions. The major shortcoming of a
compensating filter is labor associated with production and daily treatments with multiple trips to
the treatment room required by therapists to exchange the filters.
213. What is the most appropriate dose range of radiation therapy for a patient with a
completely resected Masaoka stage III thymoma?
A. 36 to 40 Gy
B. 41 to 45 Gy
C. 50 to 55 Gy
D. 60 to 66 Gy
Correct answer is C. RATIONALE: While the optimal postoperative radiation therapy (RT)
dose for patients with a resected thymoma is not fully established, many authors recommend a
dose of at least 50 Gy. Since local control rates achieved with doses between 50 to 54 Gy are
high (80-97%), it seems unnecessary to administer radiation doses of ≥60 Gy.
214. What is the 95% confidence interval for a specificity of 0.6 if the standard error is 0.08?
A. 0.40 to 0.80
B. 0.44 to 0.76
C. 0.48 to 0.72
D. 0.52 to 0.68
Correct answer is B. RATIONALE: The correct answer is B since 95% confidence bounds are
computed as the value of interest +2 times the standard error.
215. Which of the following conclusions about the addition of chemotherapy to radiation
therapy for anal cancer is supported by randomized trial data?
Correct answer is C. RATIONALE: The RTOG 8704 study compared concurrent radiation
therapy (RT) with 5-FU with or without mitomycin C. There was no significant difference in
overall survival, but there was a significant decrease in colostomy rates in the mitomycin C arm
(use of mitomycin C and 5-FU). Cisplatin-based chemotherapy was evaluated in RTOG 98-11,
which randomized patients to induction cisplatin/5-FU, followed by concurrent RT with
cisplatin/5-FU versus the standard concurrent 5-FU/ mitomycin C with RT. The cisplatin arm
had a significantly worse colostomy rate. Both the EORTC of the UKCCR showed an
improvement in colostomy rates with chemoradiation (5-FU/mitomycin C) versus RT alone, but
no significant difference in overall survival.
216. Which of the following conditions would be most likely to reduce the chance for survival
in a patient with squamous cell carcinoma of the vagina?
Correct answer is B. RATIONALE: The prognosis for a patient with squamous cell carcinoma
of the vagina depends primarily on the stage of disease, but survival is reduced in patients who
are older than 60 years of age, are symptomatic at the time of diagnosis, have lesions in the
middle or distal third of the vagina, or have poorly differentiated tumors. REFERENCE:
Gynecologic Oncology. 1991;40(1):12.
217. Which of the following is a small molecule tyrosine kinase inhibitor that targets the
EGFR?
A. Erlotinib
B. Temsirolimus
C. Cetuximab
D. Imatinib
218. What is the advantage of tomotherapy over IMRT that uses less than five fields for
treatment plans?
Correct answer is B. RATIONALE: Multiple-field deliveries give better dose conformity. The
differences between tomotherapy and IMRT becomes negligible when more than nine field
angles are used.
A. mandible.
B. thoracic spine.
C. iliac wing of the pelvis.
D. diaphysis of the long bone.
Correct answer is A. RATIONALE: Complete surgical resection has been found to be the most
important treatment for patients with ependymoma. Following maximal surgery, local radiation
therapy is recommended. Routine chemotherapy and craniospinal radiation therapy are no
longer recommended because of the lack of efficacy.
221. What was the local recurrence rate of a single brain metastasis after resection and
observation, according to the randomized trial that evaluated WBRT versus observation
after resection of a single brain metastasis as reported by Patchel?
A. 16%
B. 26%
C. 36%
D. 46%
Correct answer is D. RATIONALE: A 46% rate of local recurrence at the original site was
reported after surgery alone, which was 10% in the group receiving WBRT. Distant brain
metastasis occurred in 37% versus 7% in the observation vs. WBRT groups, respectively.
REFERENCE: Patchel. JAMA. 1988;280:1485-1489.
222. Circumcision is performed before radiation therapy in patients with penile carcinoma to:
223. A patient who receives radiation therapy to the primary site only for clinical stage N0 oral
cavity cancer is most likely to have a neck failure rate of:
A. 70%.
B. 50%.
C. 30%.
D. 10%.
Correct answer is C. RATIONALE: Turner, et al, (1996) analyzed a series of 268 patients who
received radiation therapy to the primary site only for oral cavity cancer with clinically negative
lymph nodes (stage N0) and found an overall neck failure rate of 31%. The risk of subsequent
neck failure varied between the sites of oral cavity and was as high as 40% for oral tongue
cancers.
224. Which of the following factors is associated with a poor prognosis for patients with
chronic lymphocytic leukemia (CLL)?
Correct answer is B. RATIONALE: It is important to be aware of the risk factors for chronic
lymphocytic leukemia (CLL) to discuss the prognosis and outcomes of therapy with patients.
A. It has shown promise for patients with certain tumors when combined with radiation
and/or cisplatin, but it has not met overall clinical expectations.
B. In the presence of oxygen, it is rapidly ubiquitinated and targeted for proteasomal
degradation.
C. A high incidence of peripheral neuropathy in patients receiving it significantly limits
its maximum-tolerated dose.
D. The enzymes responsible for reducing it to its toxic metabolite under hypoxic
conditions are carbonic anhydrase and lysyl oxidase.
226. What is a significant concern with the use of proton radiation therapy for pediatric
patients?
A. N2A
B. N3A
C. N3B
D. N3C
Correct answer is C. RATIONALE: Stage N3B breast cancer = metastases in the ipsilateral
internal mammary node(s) and axillary lymph node(s). Stage N2A breast cancer = metastases
in the ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures. Stage
N3A breast cancer = metastases in the ipsilateral infraclavicular lymph node(s). Stage N3C
breast cancer = metastases in the ipsilateral supraclavicular lymph node(s). Clinically apparent
is defined as detected by imaging studies (excluding lymphoscintigraphy) or by clinical
examination or grossly visible pathology. REFERENCE: AJCC Cancer Staging Manual, 6th
edition. 2002;227.
228. Which of the following conditions most likely would require a treatment break for a
patient receiving chemoradiation for anal canal cancer?
A. Moist desquamation
B. Secondary infection of desquamated skin
C. Two to three episodes of diarrhea daily
D. Rectal irritation during defecation
Correct answer is B. RATIONALE: Treatment breaks, while often necessary, should be limited
as much as possible when patients are receiving chemoradiation for anal canal cancer. Moist
desquamation in itself is not an indication for a break, unless there are signs of an infection
present. Rectal irritation should be managed conservatively. Diarrhea should only result in a
break if it cannot be controlled with medications.
229. What is the recommended dose to the vaginal mucosa when low-dose-rate intracavitary
brachytherapy is used to treat carcinoma in situ of the vagina?
A. 30 to 40 Gy
B. 45 to 55 Gy
C. 60 to 70 Gy
D. 80 to 90 Gy
Correct answer is C. RATIONALE: Thymic carcinomas are highly malignant tumors with a high
risk of both local and distant failure despite aggressive therapy. Although no universally
accepted standard treatment exists, best results seem to be reported with a maximum safe
resection, followed by immediate postoperative radiation therapy (RT) given concurrently with
cisplatin-based combination chemotherapy. Due to the tumor’s infiltrative nature, most studies
use RT given to the entire tumor bed and mediastinum rather than to the area of suspected
residual disease only. Radiation doses in the range of 60 to 70 Gy may be associated with a
better outcome.
231. Which of the following hereditary syndromes is most likely to be found in a 1-year-old
patient who has an enlarged abnormally enhancing optic chiasm?
A. Neurofibromatosis
B. Tuberous sclerosis
C. von Hippel-Lindau
D. Li-Fraumeni
232. Which of the following organs has a TD5/5 of approximately 30 Gy for whole-organ
irradiation using conventional fractionation?
A. Liver
B. Lung
C. Brain
D. Kidney
Correct answer is A. RATIONALE: The TD5/5 (total dose associated with a 5% probability of a
complication within 5 years after radiation therapy) for whole-liver irradiation is approximately 30
Gy for conventional fractionation with x-rays. The TD5/5 is 17.5 Gy for the whole lung, 23 Gy for
the whole kidney, and 45 Gy for the whole brain. REFERENCE: Hall and Giaccia.
Radiobiology for the Radiologist. 6th edition. 2006. Chapter 19 (and Table 19.2).
233. CT-based image-guided radiation therapy (IGRT) refers to the use of CT imaging:
A. Sunburst pattern
B. Onion skin effect
C. Multifocal sclerotic lesions
D. Lytic lesion in the diaphysis
235. According to the RTOG 9508 (Andrews) trial, which of the following should be the
standard treatment for patients with one to three brain metastases?
A. EBRT
B. Brachytherapy
C. Chemoradiation
D. Surgery
Correct answer is D. RATIONALE: The primary mode of therapy for male urethral carcinoma is
surgical excision. However, because of the rarity of this disease, comparison of cure rates with
surgery or radiation therapy is difficult.
237. Intergroup Study 0099 for nasopharyngeal cancer (NPC) concluded that:
A. adjuvant 5-FU and cisplatin chemotherapy were well tolerated with high treatment
completion rates.
B. the results of the radiation therapy alone arm were worse than expected compared
to other published results.
C. chemotherapy improved 3-year event-free survival only.
D. chemotherapy improved 3-year overall survival only.
Correct answer is B. RATIONALE: When compared with radiation therapy (RT) alone,
chemotherapy resulted in a significant benefit for both event-free survival (EFS) and overall
survival (OS) at 3 years and 5 years. However, controversies remain, particularly regarding the
magnitude of benefit because the results of the RT alone arm were grossly inferior to those
achieved by most centers. Adjuvant chemotherapy was poorly tolerated.
238. Which of the following rearrangements is most often associated with follicular
lymphoma?
A. Bcl-2
B. Bcl-16
C. VEGF
D. MALT
239. Which of the following cellular features best differentiates necrosis from apoptosis?
240. Which of the following groups of paraneoplastic syndromes is associated with thymoma?
Correct answer is C. RATIONALE: IMRT requires several times more monitor units than
conventional radiation treatment delivery. An increased number of monitor units can result in
higher doses delivered to patients if something goes wrong during treatment delivery. This type
of damage is typically not possible with conventional radiation therapy.
242. Which of the following sites of metastases is most common in patients with ER-negative
breast cancer?
A. Liver
B. Lung
C. Bone
D. Soft tissue
Correct answer is ABCD. RATIONALE: The liver is 17%. The lung is 28%. The bone is 33%.
Soft tissue is 51%. REFERENCES: Clark GM, Sledge GW Jr., Osborne CK, et al. Survival
from first recurrence: relative importance of prognostic factors in 1,015 breast cancer patients.
Journal of Clinical Oncology. 1987;5(1):55-61.
Correct answer is B. RATIONALE: The perirectal lymph nodes are the first echelon lymph
nodes. The most common histology is squamous cell carcinoma. Inguinal lymph nodes are
always included in the radiation treatment. The distinction is that positive inguinal lymph nodes
are given a higher radiation dose.
244. A vulvar cancer arising on the labia minora with involvement of the upper urethra is
classified as stage:
A. T1.
B. T2.
C. T3.
D. T4.
Correct answer is D. RATIONALE: According to the 1997 AJCC staging manual, vulvar
tumors involving the lower urethra and/or vagina and anus are classified as T3. Upper urethral
involvement is classified as T4.
245. A 15-year-old girl with a large, unresectable, nonmetastatic iliac wing Ewing’s sarcoma
has an excellent response to 12 weeks of chemotherapy. Which of the following
chemoradiation therapy approaches should be recommended?
Correct answer is D. RATIONALE: Gross unresectable disease is treated with a radiation dose
of 55.8 Gy. A full dose of radiation therapy is administered to the infiltrative disease before
chemotherapy, and it is delivered to the non-infiltrative “pushing” tumor bulk after chemotherapy.
246. A person is most likely to die after exposure to 10 Sv of total-body irradiation within:
247. The statement that “less than 20% of lung should receive more than 30 Gy” represents
a:
Correct answer is D. RATIONALE: Since both the maximum dose (= more than 30 Gy) and
maximum volume (= less that 20% of lung) are prescribed, this statement represents a dose
volume histogram (DVH) constraint.
248. What is the most common anatomical location for a melanoma involving the vulva?
A. Clitoris
B. Mons pubis
C. Labia majora
D. Vaginal vestibule
Correct answer is C. RATIONALE: Most vulvar cancers (including melanomas) arise on the
labia majora or minora.
249. Which of the following radiation treatment schedules is recommended for management
of desmoid tumors?
Correct answer is D. RATIONALE: Radiation therapy is indicated for inoperable tumors, after
incomplete microscopic resection and resection for recurrent tumor with negative surgical
margins. A total dose of 50-55 Gy is recommended postoperatively. For inoperable or
recurrent desmoids, the recommended total dose is 60-65 Gy. After primary radiation therapy,
the control rates do not differ from those after adjuvant radiation therapy. In most studies, tumor
size had no prognostic influence on local control. According to a metaanalysis (698 cases in 13
studies) local control after complete resection with radiation therapy improved by 17%
compared with surgery alone. With macroscopic (R2) and microscopic (R1) tumor rests,
patients with adjuvant radiation therapy had better results than this. According to the patterns of
care study in Germany, the long-term local control rate was 81.4% after primary radiation
therapy and 79.6% after resection and postoperative radiation therapy. REFERENCES:
Seegenschmiedt MH. Radiotherapy of nonmalignant diseases. Halperin EC, Perez CA, Brady
LW, eds. Perez and Brady’s: Principles and Practice of Radiation Oncology. 5th edition. Chapter
89. Philadelphia: Williams & Wilkins Publishers. 2008;1949-1950.
250. Which of the following factors is associated with an increased risk for the development of
meningioma?
A. Cranial irradiation
B. Testosterone therapy
C. Neurofibromatosis type 1
D. Ovarian cancer
251. Before receiving treatment, a 69-year-old man with stage T2c adenocarcinoma of the
prostate has a PSA serum level of 18 ng/mL and Gleason score of 4+4. According to
RTOG 9202 randomized trial data, the optimal amount of time for administration of
androgen deprivation therapy in conjunction with radiation therapy is:
A. 4 months.
B. 6 months.
C. 2 years, 4 months.
D. indefinitely.
Correct answer is C. RATIONALE: RTOG 9202 was a randomized trial including 1554 men
with clinical T2c-T4 disease. Patients were treated with 65 to 70 Gy and randomized to receive
4 months or 2 years, 4 months of androgen deprivation therapy (ADT). ADT consisted of
flutamide and goserelin for 2 months before and 2 months during radiation therapy. Men
randomized to receive adjuvant ADT were treated with goserelin for an additional 2 years. For
the subset of men with a Gleason score of ≥8, long-term ADT was associated with an
improvement in all endpoints measured, including overall survival. REFERENCE: Horwitz, et al.
RTOG 9202. Journal of Clinical Oncology (JCO). 2008;26:2497-2504.
252. Which of the following statements about oropharyngeal squamous cell carcinoma is
true?
Correct answer is B. RATIONALE: The tonsil is the most common site of oropharyngeal
squamous cell carcinoma, followed by the base of tongue. The incidence of oropharyngeal
squamous cell carcinoma in the tonsil and base of tongue continued to increase by 3.9% and
2.1% per year through the late 1990s in the United States. HPV-positive tumors are more likely
to be undifferentiated, have basaloid features, and are more frequently associated with lymph
node metastasis.
253. Which of the following histologic subtypes of non-Hodgkin lymphoma is CD5 antigen
positive?
A. Mantle
B. Diffuse large cell
C. Marginal
D. Follicular
A. autophagy.
B. cytokine signaling.
C. the oxygen effect.
D. the bystander effect.
A. 0 and +1500
B. −250 and +1250
C. −500 and +1500
D. −1250 and +250
Correct answer is D. RATIONALE: If the window level is set at −500 HU and the window width
is set at 1500 HU, the range of displayed Hounsfield units (HUs) is −500 ± 1500/2 = −500 ± 750
= −1250 HU and +250 HU.
256. According to Truong, et al (British Columbia Cancer Agency), which of the following two
factors were the best predictors of the actuarial 10-year risk of locoregional recurrence
for patients undergoing mastectomy without radiation therapy for stage T1N0 or T2N0
breast cancer?
257. Which of the following tumor stages is most appropriate for a 2-cm pancreatic
adenocarcinoma that involves the duodenum but does not involve the celiac axis or
superior mesenteric artery?
A. T1
B. T2
C. T3
D. T4
Correct answer is C. RATIONALE: Tumor that extends beyond the pancreas but without celiac
axis or superior mesenteric artery (SMA) involvement is stage T3.
258. Which of the following statements about germ cell tumors is true?
259. Which of the following genetic aberrations is most commonly found in patients with
Ewing’s sarcoma?
A. t(2;13)
B. t(11;22)
C. 1p deletion
D. 11p13 deletion
261. In contrast to CT scans, MRIs are used in CNS treatment planning because they:
A. Surgery alone
B. Adjuvant chemotherapy
C. Neoadjuvant chemotherapy
D. Neoadjuvant irradiation
263. What is the minimum number of mitoses per 10 high-power fields required to diagnose
an anaplastic (malignant) meningioma, according to the WHO criteria?
A. 5
B. 10
C. 15
D. 20
264. According to a planned subset analysis of the Swedish randomized (Bill-Axelson) trial,
radical prostatectomy versus watchful waiting resulted in the greatest improvement of
overall survival in men with prostate cancer and:
Correct answer is A. RATIONALE: In this study, a planned subset analysis revealed that only
men who are younger than 65 years of age appeared to derive a disease-specific survival
benefit with prostatectomy. This randomized trial comparing radical prostatectomy to watchful
waiting in men with early-stage disease in the pre-PSA screening era (clinical stages T1b, T1c,
or T2) showed a statistically significant difference in overall survival (OS) at 10 years. After 10
years, the difference in OS was approximately 73% versus 68%; absolute difference 5.0%;
relative risk of death 0.74 (95% confidence interval, 0.56–0.99). This benefit was restricted to
men younger than 65 years at the time of surgery (P = .01 in a planned subset analysis of the
effect of age on treatment efficacy). This highlights the importance of life expectancy in
selecting men most likely to benefit from local therapy for localized prostate cancer. Older men
are more likely to die from a competing risk of mortality, thereby minimizing the potential benefit
of treating a prostate cancer that could otherwise take several years to progress. REFERENCE:
Bill-Axelson, et al. New England Journal of Medicine (NEJM) 2005;357:1977-1984.
265. What is the contralateral neck failure rate in patients with stage T1-T2N0 tonsillar
carcinoma treated with ipsilateral neck irradiation alone?
A. 15%
B. 10%
C. 5%
D. <1%
Correct answer is C and D. RATIONALE: O'Sullivan, et al, reported a 3-year local regional
control (LRC) of 77% and a contralateral neck failure rate of only 3.5% in 228 patients who have
tonsillar carcinoma treated with ipsilateral neck radiation therapy (RT) alone. Specifically, there
was no contralateral neck failure in 118 patients with stage T1-T2N0 tumor in that series
(O'Sullivan, et al, 2001).
266. A 43-year-old man presents with stage IA mantle cell lymphoma. Which of the following
radiation doses (in Gy) would be most appropriate?
A. 46
B. 42
C. 36
D. 28
Correct answer is C. RATIONALE: According to the 2009 Practice Guidelines by the National
Comprehensive Cancer Network (NCCN), a radiation dose of 30 to 36 Gy is most appropriate
for early-stage mantle cell lymphoma.
267. According to the NCRP, what is the annual permissible dose limit for occupational
exposure to the lens of the eye?
A. 10 mSv
B. 50 mSv
C. 100 mSv
D. 150 mSv
Correct answer is D. RATIONALE: NCRP Report 116, published in 1993, is the latest report on
general radiation protection criteria and includes annual radiation exposure limits for
occupational radiation workers and the general public. Cataract formation, a deterministic
radiation effect, is the basis for exposure limits to the lens of the eye and is currently set at 150
mSv per year.
268. Which of the following diagnostic imaging tests can acquire images in arbitrary planes or
orientations?
A. CT
B. MRI
C. PET
D. SPECT
Correct answer is B. RATIONALE: MRI does not depend on axial image acquisition and
images can be acquired in arbitrary planes in the patient.
269. What is the most significant predictor of locoregional recurrence of breast cancer in a
patient after a mastectomy?
Correct answer is D. REFERENCE: Harris J., et al, eds. Patient selection for postmastectomy
radiation therapy. Diseases of the Breast. 4th edition. Philadelphia: Williams & Wilkins
Publishers. 2009;602-604.
270. Prophylaxis for tumor lysis syndrome should be considered before initial treatment of:
Correct answer is A. RATIONALE: Prophylaxis for tumor lysis syndrome should be considered
before treatment of chronic lymphocytic leukemia (CLL). REFERENCE: 2009 Practice
Guidelines by the National Comprehensive Cancer Network (NCCN). p 9.
271. Which of the following regions of tumor involvement is classified as stage T3 ampulla of
Vater adenocarcinoma?
A. Melanoma
B. Adenocarcinoma
C. Clear cell carcinoma
D. Squamous cell carcinoma
Correct answer is D. RATIONALE: The most common tumor histology for vulvar cancers is
squamous cell carcinoma (85%). The second most common histology is melanoma, comprising
about 10% of all cases. Other histologies are significantly less common (<5%).
273. According to the Lung Cancer Study Group randomized trial, which of the following
results was demonstrated in patients who had a limited resection versus a lobectomy for
stage T1N0M0 NSCLC?
Correct answer is A. RATIONALE: There was a 75% increase in local recurrence rate (p=0.02)
in patients with stage T1N0M0 non-small cell lung cancer (NSCLC), 30% increase in overall
mortality (p=0.08), and 50% increase in cancer-specific mortality (p=0.09). REFERENCE: Lung
Cancer Study Group. Annals of Thoracic Surgery (Ann Thorac Surg). 1995;60:615-22.
274. A 16-year-old patient presents with a painful, enlarging mass in the distal thigh. Plain
film radiography reveals a permeative diaphyseal femoral lesion with periosteal new
bone formation lifting the bone cortex. What is the most likely diagnosis?
Correct answer is D. RATIONALE: Osteosarcoma is the most likely diagnosis for a patient who
is 16 years of age and presents with this disease location. The plain film with the cortical
abnormality (Codman’s triangle) is suggestive of a malignant process. Ewing’s sarcoma tends
to have metaphyseal rather than diaphyseal involvement.
275. Which of the following statements about the interaction between hyperthermia and low-
LET ionizing radiation is true?
276. Which of the following radionuclides has the LEAST penetrating radiation?
Correct answer is A. RATIONALE: The more penetrating or the higher the radiation energy,
the higher the half-value layer (HVL) in millimeters of lead that is required for radiation shielding.
Hence, Palladium-103, with the smallest HVL, has the lowest radiation energy.
277. Which of the following statements about radiation-induced soft tissue sarcomas is true?
A. Patients who have an Rb (retinoblastoma) gene mutation are at increased risk for
development of the condition.
B. Soft tissue sarcomas of the breast are most commonly associated with ipsilateral
irradiation from breast-conserving therapy.
C. Radiation-induced soft tissue sarcomas can develop outside the area in which high-
dose therapy was administered.
D. Angiosarcoma is the most common histological subtype.
278. What is the most likely diagnosis for a 45-year-old man with impotence, infertility, and
gynecomastia?
A. Observation
B. Reexcision
C. Radiation therapy
D. Immunotherapy
280. What is the expected 5-year local control rate for a patient with stage T1-T2N0 tonsillar
carcinoma treated with definitive radiation therapy?
A. 80%
B. 60%
C. 40%
D. 20%
281. Heat-shock proteins reduce both heat-induced cell killing and radiosensitization because
they:
Correct answer is C. RATIONALE: T1/2 = 0.693/λ; hence, the radionuclide with the shortest half
life, Cesium-131 (T1/2 = 9.7 days), exhibits the largest decay per day, or the largest daily
fractional decay.
283. Which of the following statements about the AJCC staging system for soft tissue
sarcomas is true?
Correct answer is C. RATIONALE: All clinical examination and radiological findings are used to
define the soft tissue sarcoma stage. The site of disease is an important prognostic factor that
is not incorporated into the current AJCC staging system. Kaposi’s sarcoma is not staged
according to the rules of soft tissue sarcomas. Regional lymph node involvement is assigned
stage IV status, regardless of grade, tumor size, and absence of diffuse metastatic disease.
REFERENCE: Kotilingam D, et al. Staging soft tissue sarcoma: evolution and change. CA: A
Cancer Journal for Clinicians. 2006;56:282-291.
A. Single-fraction SRS
B. Permanent interstitial brachytherapy with 125I seeds
C. Hypofractionated stereotactic radiation therapy
D. Conventionally fractionated EBRT
A. 2.5%
B. 3.5%
C. 5.5%
D. 8.5%
Correct answer is B. RATIONALE: The 7-year actuarial rate of ipsilateral breast cancer
recurrence for both DCIS and invasion was 7.7% for patients receiving tamoxifen and 11.1% for
patients who did not receive tamoxifen. The difference is 3.4%. Tamoxifen therapy resulted in a
44% reduction in the risk of subsequent invasive tumor recurrence but had no significant effect
on ipsilateral noninvasive breast recurrence. Positive tumor margins were significantly
associated with breast recurrence. Tamoxifen reduced ipsilateral breast failure by 22% with
negative margins and 44% in cases with positive or unknown margins. REFERENCES: Wazer
DE, Arthur DW. Breast: stage Tis. Halperin EC, Perez CA, Brady LW, eds. Perez and Brady’s:
Principles and Practice of Radiation Oncology. 5th edition. Chapter 52. Philadelphia: Lippincott
Williams & Wilkins Publishers. 2008;1171. Fisher B, Dignnam J, Wolmark N, et al. Prevention
of invasive breast cancer in women with ductal carcinoma in situ: An update of the National
Surgical Adjuvant Breast and Bowel Project Experience. Seminars in Oncology. 2001;28:400-
418.
286. Which of the following carcinomas of the parotid gland has the highest risk for regional
spread?
A. Ductal
B. High-grade mucoepidermoid
C. Adenoid cystic
D. Adenocarcinoma
Correct answer is ABCD. REFERENCE: Izandro Re´gis de Brito Santos, MD, Luiz P.
Kowalski, MD. Multivariate analysis of risk factors for neck metastases in surgically treated
parotid carcinomas. Archives of Otolaryngology-Head & Neck Surgery (Arch Otolaryngol Head
Neck Surg). 2001;127:56-60.
287. A worse prognosis is associated with patients who have chronic lymphocytic leukemia
and deletion of which of the following short-arm chromosomes?
A. 4
B. 8
C. 17
D. 22
Correct answer is D. RATIONALE: Ultrasound can confirm the presence of a solid testicular
mass, and of the listed options, it is the most appropriate next step in evaluation. If a solid
(rather than cystic) mass is confirmed on ultrasound, a testicular neoplasm must be considered.
289. Which of the following survival curve parameters is associated with the greatest capacity
for sublethal damage recovery?
Correct answer is B. RATIONALE: A cell or tissue characterized by a low α/β ratio will exhibit
more sublethal damage recovery than one with a high α/β ratio. A lower α/β ratio implies that a
larger fraction of the overall amount of cell killing is due to a two-hit process (i.e., a larger β
component), and it is the interaction between these two different lesions in space and time that
defines sublethal damage and its repair. In terms of the target theory model, the parameters
most associated with the capacity for sublethal damage recovery are n, the extrapolation
number, and Dq, the quasi-threshold dose. Large, not small, values for these parameters are
characteristic of a survival curve with a broad shoulder, which in turn implies a large capacity for
sublethal damage recovery.
A. 6 MeV.
B. 9 MeV.
C. 12 MeV.
D. 16 MeV.
292. Which of the following test findings should be used to determine the gross tumor volume
delineation during radiation therapy planning for a patient with a fibrillary astrocytoma?
Correct answer is D. RATIONALE: Fibrillary astrocytomas are WHO grade 2 and typically do
not have significant enhancement. However, for delineation of the gross tumor volume (GTV),
both the FLAIR and T1-weighted contrast-enhanced MRI images should be evaluated. These
tumors are not able to be seen very well on CT scans with or without contrast.
293. A 65-year-old Caucasian man with a 30-pack-year smoking history presents with gross
hematuria. Cystoscopy reveals no abnormalities in the bladder, but urine cytology
reveals cells consistent with urothelial carcinoma. What is the most appropriate next
step in management?
A. IV pyelogram
B. Total-body bone scan
C. Nephroureterectomy
D. Systematic biopsies of the bladder
Correct answer is A. RATIONALE: Gross hematuria with positive cytology and a normal
cystoscopy should raise the suspicion for upper tract disease (ureters or renal pelvis). The best
reasonable next step is an IV pyelogram, which will help visualize the ureters and renal pelvis
for filling defects. CT and/or ureteroscopy also can be done.
294. Which of the following maxillary sinus carcinomas is most likely to benefit from elective
lymph node irradiation?
295. Which of the following tests would be best to monitor late effects in a patient after
treatment for Hodgkin lymphoma?
Correct answer is B. RATIONALE: Patients treated for Hodgkin lymphoma may be at a higher
risk for cardiovascular events at an earlier onset than patients with non-Hodgkin lymphoma.
REFERENCE: 2009 Practice Guidelines by the National Comprehensive Cancer Network
(NCCN). p 11.
296. As chromatin compaction increases, the amount of radiation-induced DNA damage is:
A. unaffected.
B. increased.
C. decreased.
D. variable.
Correct answer is C. RATIONALE: The complexing of DNA with histone proteins and the
resulting condensation of the chromatin serve important roles in terms of regulating DNA's
"accessibility" for the purposes of transcription, replication, and repair. By the same token, the
DNA associated with highly compacted chromatin is less accessible to the radiation-induced
free radicals that might otherwise damage it. REFERENCES: Chiu S and Oleinick NL.
Radiation Research (Radiat. Res). 1996;148:188-192. Warters RL, et al. Radiation Research
(Radiat. Res). 1999;151:354-362.
297. Which of the following beam energies will produce the largest absorbed dose to the skull
bone for a patient with a brain lesion?
A. 120 kVp
B. 60Co
C. 6 MV
D. 20 MV
Correct answer is A. RATIONALE: The “f” factor for the absorbed dose to bone is much
greater for superficial treatments (120 kVp) than for the other megavoltage energies.
298. Which of the following tumor sites in patients with Ewing’s sarcoma is associated with
the worst prognosis?
A. Rib
B. Shoulder girdle
C. Femur
D. Pelvis
Correct answer is D. RATIONALE: The duration of time from initial onset of symptoms to
diagnosis for Ewing's sarcoma is one of the longest of all pediatric malignancies. Although
overt metastases are present in approximately 25% of patients at diagnosis, subclinical
metastases are suspected in 80-90% of patients. Patients with tumors in the extremity
generally have a better prognosis than those in the axial skeleton, such as the pelvis.
299. VEGF-based therapies are most likely to be beneficial for patients with which of the
following types of tumor?
A. Pilocytic astrocytoma
B. Fibrillary astrocytoma
C. Ganglioglioma
D. Glioblastoma
300. Which of the following radiation fractionation schedules used to treat squamous cell
carcinoma of the skin involving the nasolabial fold is associated with the worst
cosmesis?
A. 7.0 Gy x 5
B. 4.5 Gy x 10
C. 3.0 Gy x 17
D. 2.5 Gy x 20
Correct answer is A. RATIONALE: Fraction sizes of >5 Gy are associated with worse
cosmesis. REFERENCES: Silva JJ. International Journal of Radiation Oncology, Biology,
Physics (IJROBP). 2000;47(2):451-459 (PMH experience). Lim JT. Clinical Oncology (R Coll
Radiol) 1992;4(4):236-239. Petrovich Z. American Journal of Surgery (Am J Surg).
1987;1549(4):447-450.
A. 5%
B. 10%
C. 15%
D. 20%
Correct answer is C. RATIONALE: Apoptotic and dye exclusion assays only provide a
"snapshot" of the fraction of cells dead or dying at the time of the assay. The clonogenic assay,
however, is the gold standard for the determination of cellular radiosensitivity, even though it
takes longer to complete and is more expensive and labor intensive overall. Further, it takes
into account multiple modes of cell death (e.g., apoptosis, mitotic catastrophe, permanent
growth delay, etc.) that occur over the entire colony formation period, typically a week or more.
Not all cell types are amenable to the clonogenic survival assay however.
303. How many half-value layers (HVL) of shielding are required to reduce transmitted
radiation from 1.6% to 0.2%?
A. 2 HVL
B. 3 HVL
C. 4 HVL
D. 5 HVL
Correct answer is B. RATIONALE: Each half-value layer (HVL) will decrease transmission of
radiation by one half. Therefore, 3 HVL (1.6% x 0.5 x 0.5 x 0.5 = 0.2%) must be added to
reduce the amount of transmitted radiation to 0.2%.
304. Which of the following findings is associated with the best prognosis for patients with
Ewing's sarcoma?
Correct answer is D. RATIONALE: Systemic symptoms such as fever and elevated CPK are
considered poor prognostic factors. Patients with metastatic tumors in the axial skeleton tend to
have a poorer prognosis compared to those with metastatic disease in the extremities. At least
18 chromosomal translocations have been identified in the Ewing's sarcoma family (EWSF).
For example, the presence of the EWSF exon 7 fusion to FLI1 exon 6 occurs in approximately
60% of patients and is a favorable prognosticator.
305. Which of the following chemotherapy drugs is mostly likely to decrease the contrast-
enhanced tumor volume in patients with glioblastoma?
A. BCNU
B. Irinotecan
C. Bevacizumab
D. Temozolomide
A. Inguinal orchiectomy
B. Transscrotal orchiectomy
C. Transscrotal needle biopsy
D. Radiation therapy
Correct answer is A. RATIONALE: A solid testicular mass should be treated initially with an
inguinal orchiectomy. Subsequent treatments will be determined on the basis of the pathology.
Biopsy may be considered if ultrasound shows a hypoechoic mass with calcifications, but
inguinal orchiectomy is generally the preferred method of surgery for a solid testicular mass.
Transscrotal approaches are not favored due the perceived risk of scrotal recurrences;
however, studies have not confirmed this risk. AFP and β-hCG should also be obtained prior to
surgery.
307. Which of the following sites of basal cell carcinoma has the best prognosis?
A. Lower lip
B. Columella
C. Periauricular
D. Paranasal
Correct answer is A. RATIONALE: Basal cell carcinoma (BCC) alone in the H-zone has a
higher local recurrence rate. The lower lip is not in the H zone.
A. caspase 3.
B. caspase 9.
C. lysosomes.
D. SA β-galactosidase.
137
A. 55Cs
128
B. 52Te
125
C. 53 I
121
D. 54 Xe
Correct answer is D. RATIONALE: This question requires knowledge of the atomic symbol
( ZA ElementSymbol ), and a distinction between the atomic number, Z, and the atomic mass
number, A. Based on the equation provided, the atom with the smallest mass would have the
smallest nucleus; hence, D is the answer.
310. Which of the following treatments is most appropriate for patients with chondrosarcoma?
Correct answer is B. RATIONALE: Grade and histology are key in the decision-making
process for definitive management of chondrosarcomas. While intralesional curettage with
adjuvant therapy can be performed in low-grade tumors, wide local excision is recommended for
intermediate- to high-grade tumors. Low- and intermediate-grade tumors are thought to be
radioresistant due to a slower proliferation rate, but radiation can be used for high-grade tumors,
which are more radiosensitive. It is recommended that the radiation dose exceed 60 Gy, but
this can be hard to achieve due to dose constraints of adjacent organs. Chemotherapy is not
recommended after resection of low-grade chondrosarcomas.
311. Which of the following outcomes is most likely to be observed in patients who receive an
SRS boost in combination with fractionated radiation therapy and chemotherapy for
glioblastoma?
Correct answer is D. RATIONALE: RTOG 9305 showed no benefit for any endpoint to upfront
radiosurgery in the treatment of glioblastoma.
312. A 29-year-old man is found to have a 6.5-cm pure seminoma of the right testicle with
rete testis invasion after appropriate surgery is performed. His serum tumor markers are
within normal range, and his staging workup is otherwise negative. Which of the
following treatments is most appropriate for this patient?
Correct answer is A. RATIONALE: Adjuvant paraaortic lymph node irradiation is the best
choice among the options given. Bleomycin, etoposide, and cisplatin (BEP) chemotherapy is
typically not used for nonmetastatic seminoma. Mediastinal radiation therapy can result in
unacceptable late cardiac toxicity and does not provide a significant benefit. Single-agent
carboplatin may be considered, but not cisplatin. While surveillance could be considered, the
patient is not the best candidate based on his age, tumor size, and rete testis invasion, and
surveillance is not listed as an option. REFERENCE: Warde, et al. Journal of Clinical Oncology
(JCO). 2002;20:4448-52.
313. According to the RTOG 8305 trial, what is the expected complete response rate for a
4-cm melanoma treated with definitive radiation therapy?
A. 15%
B. 25%
C. 35%
D. 50%
314. Which of the following histologic subtypes is most common in patients with classic
Hodgkin lymphoma?
A. Marginal
B. Lymphocyte-predominant
C. Mixed cellularity
D. Mixed chromosomal
315. Which of the following proteins is involved in the activation of the G2/M cell cycle
checkpoint in response to DNA damage?
A. pRb
B. p16
C. p21
D. ATM
Correct answer is D. RATIONALE: ATM plays a major role in the activation of the G2/M cell
cycle checkpoint in response to DNA damage, including that caused by ionizing radiation
exposure. The proteins p21, p16 and pRB are involved with the G1/S cell cycle checkpoint.
REFERENCE: Choudhury A, Cuddihy A, and Bristow RG. Seminars in Radiation Oncology
(Semin. Radiat. Oncol). 2006;16:51-58.
316. Which of the following equations correctly describes the beta decay of 137Cs?
v
+ 0ν + 0.66 MeV
137 137
A. 55 Cs →
56 Ba + −10 β 0
v
+ 0ν + 0.66 MeV
137 137
B. 55 Cs →
54 Ba + +10 β 0
v
+ 0ν + 0.66 MeV
137 137
C. 55 Cs →
55 Ba + 00 β 0
v
+ 0ν + 0.66 MeV
137 137
D. 55 Cs →
54 Ba + −10 β 0
beta decay, a neutron in the nucleus is converted into a proton, along with the emission of a
beta particle and an anti-neutrino. As such, during beta decay, we would expect the atomic
number of the decaying nucleus to increase by one, and the atomic mass to remain constant,
which is shown in option A. Option (B) is an example of positron [ +1 β ] decay, the symbol
0
shown in (C) is incorrect, and (D) results in an unbalanced equation [55 ≠ 54 + (-1)].
317. Surgery is preferred in the treatment of patients with Ewing’s sarcoma that involves the:
A. rib.
B. femur.
C. sacrum.
D. humerus.
Correct answer is A. RATIONALE: There have been no trials directly comparing surgery to
radiation for local therapy, thereby causing the local treatment of choice to remain somewhat
controversial. Generally, though, surgery is preferred for expendable bones, such as the rib or
small bones of the hands and feet. Initially, concerns over dissemination of tumor throughout
the bone marrow lead to larger radiation fields; but, with the use of multi-agent chemotherapy,
this has fallen out of favor for "tailored fields" involving pre- and post-chemotherapy volumes.
318. Which of the following initial management steps would be most appropriate for a patient
with progressive or relapsed Hodgkin disease?
A. Additional chemotherapy
B. Consolidative radiation therapy
C. Stem cell transplant
D. Repeat biopsy
A. Subependymoma
B. Tanycytic ependymoma
C. Myxopapillary ependymoma
D. Anaplastic ependymoma
320. Which of the following findings in a 65-year-old patient with transitional cell carcinoma of
the bladder is the best indication for bladder conservation with chemotherapy and
radiation therapy?
321. What is the best treatment approach for patients with anaplastic thyroid carcinoma?
A. Mantle cell
B. Diffuse large B-cell
C. Extranodal marginal zone
D. Follicular
Correct answer is B. RATIONALE: Diffuse large B-cell lymphoma is most common and
represents about one third of all non-Hodgkin lymphomas.
323. Which of the following drugs combined with radiation therapy increases the risk of
radiation pneumonitis?
A. Tirapazamine
B. Bevacizumab
C. Docetaxel
D. Cisplatin
A. 5 to 20 MeV.
B. 30 to 50 MeV.
C. 75 to 100 MeV.
D. 110 to 300 MeV.
325. Which of the following factors is considered a risk factor for the development of
osteosarcoma?
326. Which of the following conditions is LEAST likely to benefit from gross total resection?
Correct answer is B. RATIONALE: Patients with CNS germinomas have a greater than 90%
overall survival rate with radiation- or chemoradiation-based therapies. Gross total resection is
not required.
327. Which of the following statements about interpreting study results reported with
confidence intervals is true?
A. An observed result has to be within the parameters of the interval to reject the null
hypothesis.
B. If the intervals of the studied parameters overlap, the results are more likely to be
significant.
C. The smaller the interval, the more reliable are the results.
D. The width of the interval is not impacted by sample size.
Correct answer is C. RATIONALE: Confidence intervals are used to assess the reliability of an
estimate. If an observed result falls outside of the interval, then the null hypothesis can be
rejected. The size of the interval bars is directly impacted by the number of subjects in the
sample size, i.e., the larger the number, the shorter the interval. The smaller the interval, the
more dependable are the results. Non-overlapping confidence intervals on a graph indicate a
true difference between study groups and, thus, more significant results. REFERENCE:
http://en.wikipedia.org/wiki/Confidence_interval
328. Which of the following foramina at the skull base should be included in the postoperative
radiation field for a patient with adenoid cystic carcinoma of the submandibular gland?
A. Ovale
B. Jugular
C. Rotundum
D. Lacerum
Correct answer is A. RATIONALE: Following the pathway of the V3 to the skull base leads to
the foramina ovale.
329. Which of the following factors is NOT included in the International Prognostic Index for
diffuse large B-cell lymphoma?
A. Hemoglobin level
B. Number of extranodal sites
C. Disease stage
D. Age
Correct answer is A. RATIONALE: The hemoglobin level is only considered in the follicular
lymphoma international prognostic index (FLIPI), not International Prognostic Index (IPI).
330. What is the FIGO stage of an ovarian carcinoma with extension to the fallopian tube
without involvement of other sites in the pelvis or abdomen?
A. IC
B. IIA
C. IIB
D. IIC
Correct answer is B. RATIONALE: According to the FIGO staging system, involvement of one
or more ovaries with extension and/or metastases to the uterus and/or fallopian tubes without
other sites of involvement is designated as stage IIA. If there is extension to the pelvis, it is
stage IIB. Stage IC patients have disease limited to the ovaries with capsule rupture or ascites.
Stage IIC patients have either stage IIA or IIB, but with tumor on the surface of one or both
ovaries, or with ascities present containing malignant cells or with positive peritoneal cytology.
REFERENCE: Halperin EC, Perez CA, Brady LW, eds. Ovary. Perez and Brady’s: Principles
and Practice of Radiation Oncology. 5th edition. Chapter 68. p 1635.