FC Rad Onc(SA) Part I THE COLLEGES OF MEDICINE OF SOUTH AFRICA Incorporated Association not for gain Reg No 1955/000003/08

Part I Examination for the Fellowship of the College of Radiation Oncologists of South Africa 8 April 2013 Physics, Apparatus Construction Paper 1 (3 hours) All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer) Examination number Section 1 To be answered in the space provided 1 Match the following description with the particles listed below a) The particle responsible for MR Imaging. b) Emitted by the cathode of any x-ray tube. c) Has the shortest path length in water (assuming the particles listed below all have the same energy). d) Has no charge. e) Is emitted in -plus decay. A) B) C) D) E) 2 Electron. Positron. Neutron. Alpha particle. Proton.

Indicate which statements are true or false With respect to photoelectric interactions a) K, L and M characteristic x-rays may be produced if the photon energy is greater than the binding energy of the K shell electrons. () b) Interactions can occur only with loosely bound electrons. () c) The probability of occurrence is greatest when the incident photon energy is a little less than the binding energy of the electrons. () d) The probability of interaction is proportional to Z3. () (4) Circle the correct answer The threshold for pair production is a) 1.02keV. b) 0.51keV. c) 981MeV.

d) e) 4

1.02MeV. 0.51Mev.

(2)

Circle the correct answer The difference between exposure and dose is the difference between a) The rad and the Gray. b) Absorption of ionising radiation and biological effect. c) Photons and charged particles. d) Ionisation in air and absorption in a medium. e) Ionising and non-ionising radiation. Circle the correct answer The SI units for dose (D) and radioactivity (A) are a) Joule and Becquerel. b) Rad and Becquerel. c) Gray and Becquerel. d) Roentgen and Curie. e) Joule and Curie. Match the following quantity with the formula listed below a) Tissue Maximum Ratio (TMR). b) Backscatter Factor (BSF). c) PDD/100. a) b) c) d) e) Dose rate at dmax / Dose rate at depth at SSD (Source-surface Distance) Dose rate at depth / Dose rate at dmax at SSD (Source-surface Distance) Dose rate at dmax / Dose rate at depthat SAD (Source-Axis Distance) Dose rate at depth / Dose rate at dmax at SAD (Source-Axis Distance) Dose rate at dmax / Dose rate in air at SAD (Source-Axis Distance)

(2)

(2)

(6)

Circle the correct answer Applying the rule of thumb, what is the energy (in MeV) of the electron beam required to treat to an 80% depth of 4cm a 4. b) 6. c) 8. d) 12. e) 18. (2) Circle the correct answer The use factor in radiation protection is a) The fraction of the total workload that the primary beam points at the barrier in question. b) The fraction of the work day that the area in question is occupied by members of the public. c) The fraction of the work day that the area in question is occupied by radiation workers. d) A factor used to compute the thickness of secondary barriers only. e) Depends on the energy of the primary beam. (2)

Section 2 To be answered in separate books 2 a) Define and write concise notes on the following terms. Give their units where applicable. (Diagrams may be used where necessary) i) Specific activity. (2) ii) Effective energy of an x-ray beam. (2)

b) c)

d)

e)

State the equation describing the exponential absorption of a monochromatic radiation beam in a filter material, indicating the meaning of each term in the equation. (5) Discuss all the radiation protection considerations and safety devices that are necessary before a typical modern remote after-loading system may be used for interstitial and/or intra-cavitary radiotherapy. (5) Explain in detail how the following may be determined on a linear accelerator i) Collimator axis of rotation. ii) Radiation isocentre. (5) Describe the functions of the following components that are found in a standard Linear Accelerator that is used for photon and electron therapy i) Scattering foil. (2) ii) Flattening filter. (2) iii) Dose monitoring ion chambers. (2) [25] The Radiotherapy Simulator, the Computed Tomography (CT) Simulator and Electronic Portal Imaging Device (EPID) play important roles in the radiation oncology patient planning and treatment process. For each of these devices, list the special features that make these devices useful in the planning and treatment process i) Radiotherapy Simulator. (4) ii) Computed Tomography (CT) Simulator. (3) iii) Electronic portal imaging device (EPID). (3) ICRU Report No. 50 recommends a target-dose uniformity within specific percentage limits of the dose delivered to the ICRU reference point. What are these percentage limits? (2) In vivo dosimetry using semiconductor diodes or thermoluminescent detectors (TLDs) serves as an ultimate check of dose delivered to the patient. Give an advantage and disadvantage of using diodes and TLDs respectively for in vivo dosimetry. (3) In modern 3D conformal radiotherapy treatment planning specific imaging tools are used. Briefly describe each of the following tools i) Digitally reconstructed radiograph (DRR). (3) ii) Beams eye view (BEV). (3) iii) Rooms eye view (REV). (2) iv) Image fusion (Image registration). (2) [25] A wedge filter is commonly used to modify the dose distribution of a photon beam in radiotherapy patient treatment planning. Please draw the isodose distribution for a wedged photon beam (eg. a 6 MV beam) and indicate the wedge angle on your isodose distribution. (5) The graph in this illustration is used as a tool to evaluate patient dose distributions. Please give the name of this graph and use the graph to determine the target volume and critical structure volume that would receive 30 Gy. (5)

a)

b)

c)

d)

a)

b)

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d)

Briefly explain each of the following techniques that are used in Brachytherapy i) Interstitial implant. (2) ii) Intracavitary implant . (2) iii) Hot loading treatment. (3) iv) Afterloading treatment. (3) Intensity Modulated Radiotherapy (IMRT) is commonly applied using either a segmented multileaf collimator (SMLC) mode or a dynamic multileaf collimator (DMLC) mode. Briefly distinguish between these two treatment modes. (5) [25]

FC Rad Onc(SA) Part I THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain Reg No 1955/000003/08

Part I Examination for the Fellowship of the College of Radiation Oncologists of South Africa

9 April 2013 Paper 2 Radiobiology and Cancer Biology (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer)

a)

b)

Explain the following i) Radiation bystander effect. (2) ii) Dose-rate effect. (4) iii) Mechanism of the radioprotector, amifostine. (2) iv) Non-homologous repair of radiation damage. (3) v) Why alpha particles have an OER of 1? (3) i) Define the concept of tolerance in radiotherapy. (2) ii) Explain how the tolerance guidelines given below for lung and spinal cord relate to tissue architecture/ arrangement of functional subunits and functional reserve. (lung 5 marks, cord 4 marks). (9) [25] Define the terms i) Kick Off Time (Tk). (2) ii) Accelerated repopulation. (2) iii) Draw a graph to illustrate the definitions above. (2) Define the terms i) Labelling Index (LI). (2) ii) Potential tumour doubling time (Tpot). (2) iii) Explain the relationship between LI and Tpot. (2) i) List the phases of the cell cycle, describe the approximate times of different phases, and draw a DNA histogram indicating the relative proportions of cells in each phase. (4) ii) Define the Cell Loss Factor of a tumour and list the possible ways by which this occurs. (4) iii) Explain how the following would be assessed experimentally i) Tumour Control Dose 50 (TCD50). ii) Tumour growth delay. (5) [25] Describe the mechanisms of the following cytotoxics including whether they have any synergy with radiation i) Cis-platinum. (3)

a)

b)

c)

a)

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ii) 5-fluorouracil. (3) Explain the cancer biology of the following specific changes in gene/protein expression i) HER2 amplification in approximately 30 % of breast cancers. (3) ii) Mutations of genes such as APC, KRAS and p53 in colorectal cancers. (6) iii) Overexpression of Bcl-2 in acute myelocytic leukaemia, which may make cells resistant to therapy and may be associated with poor outcomes. (3) Explain the radiobiological relevance of the following to a radiotherapy treatment where 2 fractions are given per day i) Time between fractions. (2) ii) Repair half time of tissue. (2) iii) Fraction size. (1) iv) Overall treatment time. (1) v) Overall treatment dose. (1) [25] Define the term alpha/beta ratio in the Linear quadratic model. (2) Define the term Biological Effective Dose (B.E.D). (2) For a total treatment time, T, that is much longer than the Kick off time, Tk, explain how a decrease in the tumour BED caused by repopulation of the cancer during a course of fractionated radiotherapy with a radiosensitivity of alpha cell kill per Gy, and potential doubling time (Tpot) can be calculated. (4) iv) Calculate the difference in the tumour BED for a cancer of the cervix with a Tpot= 5 days, radiosensitivity (alpha)= 0.3 Gy-1 and kick off time Tk = 19 days for the following fractionated radiotherapy protocols, taking tumour repopulation into account. (Ln2=0.693). i) 2.5 Gy per fraction to a total dose of 40 Gy (Overall time, T=22 days). ii) 1.8 Gy per fraction to a total dose of 45 Gy (T=33 days). (5) Write short notes on the following i) Cancer Stem Cells. (4) ii) Epithelial to Mesenchymal Transition (EMT) in cancer cells. (4) iii) Draw a graph of the probability of inducing a second malignancy with radiation versus age and explain why the probability of a second cancer changes with age. (4) [25] i) ii) iii)

a)

b)

FC Rad Onc(SA) Part I THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain Reg No 1955/000003/08

Part I Examination for the Fellowship of the College of Radiation Oncologists of South Africa

10 April 2013 Paper 3 Applied Anatomy (2 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer)

a) b) c) d) e) f) g) h)

Which lymph node groups drain the cervical, thoracic and abdominal oesophagus? (5) What local structures could a cervical oesophageal carcinoma invade? (4) Describe the three main branches of the coeliac trunk. (3) Which lymph node groups could potentially be involved with an early low rectal carcinoma? (3) Describe the relations of the posterior pancreas. (4) What is the cause of jaundice in a carcinoma of the head of the pancreas? (1) Describe the origins and branches of the brachial plexus. (3) What anatomical structures are removed in a modified radical mastectomy and axillary node clearance? (2) [25] Describe the bony landmarks for the left kidney. (1) What are the relations of the right kidney? (3) Describe the pelvic path of the ureter in a female. (4) What lymph node stations would potentially be involved in a testicular tumour? (2) What are the areas at risk for local invasion in advanced prostate carcinoma? (3) Describe the lymphatic nodal stations of the upper 1/3, middle 1/3 and the lower 1/3 of the vagina. (3) Describe the relations of the cervix. (4) What is removed at a Wertheims hysterectomy for cervical carcinoma? (2) Describe the relations of the spleen. (3) [25] Describe the lymph drainage of the tongue. (5) i) What different cartilages make up the skeleton of the Larynx? (3) ii) Name the nerves responsible for innervation of the muscles of the Larynx. (2) Several muscles are responsible for eye movement. Which muscles are responsible for the following? (3) i) Turning the eye inwards medially. ii) Turning the eye up and in. iii) Turning the eye up and out. Name two possible surgical approaches for drainage of the maxillary sinus. (2) What lymph nodes are responsible for lymph drainage from the Parotid gland? (2)

a) b) c) d) e) f) g) h) i)

a) b) c)

d) e)

f) g) 4 a) b) c) d) e) f)

In the middle cranial fossa on each side of the base of the body of the sphenoid bone is a crescent of four foramina. Name them as well as the nerves passing through them.(5) Name the borders of the tonsillar fossa. (3) [25] Describe the anatomy of the Trachea, specifically mentioning bony landmarks. Describe the lymph drainage of the lungs. What are the relations of the Superior Vena Cava? Discuss the blood supply of the Thyroid gland. Where is the Medulla Oblongata situated? What lobe of the brain is found i) In front of the central sulcus and above the lateral sulcus. ii) Below the lateral sulcus. iii) Below and behind the parieto occipital sulcus. (5) (4) (5) (4) (4) (3)

[25]