Physics

1. Electron incident on target made of high Z material. Which of the following is true?
a. A filter must be added to remove the low energy electrons
b. X-ray is produced when target is heated by thermionic emission
c. Even if monoenergetic electron beam is incident on target, x-ray produced will still be a
spectrum
d. X-ray is produced only when the incident electron beam energy is higher than the outermost
shell electron
e. Peak energy of x-ray depends on Z

2. Superficial X ray, what determines the quality of it most?

a. separation between anode and cathode
b. size of focal spot
c. Target material
d. Tube current
e. Tube voltage

3. K shell binding energy 80 kev, L shell 20 kev. Now with one 40 kev photon and interact with these
shells only. What are the possible energies of photoelectric interaction
a. 20kev
b. 20 and 40kev
c. 40kev
d. 60kev
e. No photoelectric interaction possible with this energy

4. PE interaction = Z^n, value of n

a. 3
b. 2
c. 1
d. -2
e. -3

5. What is the best description for Compton scattering?

a. dependent on 1/Z
b. probability depends on E2
c. probability depends on electron density/cm3
d. max energy gained by scattered photon is when the angle of deflection is 180 degrees
e. binding energy of electron = energy of incoming photon

6. How to define quality of MV photon?

a. TPR 20-10
b. Percentage dose at 10cm
c. TAR 20-10
d. HVL

7. Narrow beam monoenergetic beam passing through a medium, the transmission through medium
a. can be calculated with HVL
b. same as broad spectrum beam
c. same as polyenergetic beam with the same mean energy

8. kV Xray beam quality is defined by HVL. Which is correct about HVL?

a. should be calculated with broad energy beam
b. beam geometry need to reduce scatter from absorbed medium
c. HVL1 always equal to HVL2
d. HVL calculated by narrow energy beam is greater than wider energy beam
9. Only one type of device can directly measure absorbed dose of MV energy
a. Calorimeter
b. Free air ion chamber
c. Farmer type
d. TLD
e. Diode

10. Percentage of transmission per cm to 6 MV photon due to inverse square law effect: (100cmSSD)
a. 1%
b. 2%
c. 3%
d. 4%
e. 5%

11. Shielding for 6MeV electron thickness should be

a. 1mm
b. 2mm
c. 3mm
d. 4mm
e. 5mm

12. Correct about FFF

a. lower dose rate
b. increase effective energy
c. PDD slope fall off steeper
d. increase dose outside field
e. primary barrier need to be thickened

13. What is the definition of stopping power of electron?

a. depth of maximum transmitted
b. rate of energy lost per unit length
c. only related to collision
d. only related to radiation

14. Electron treatment to a superficial sternal skin lesion. There is increased radiation at soft tissue/ sternum
interface, what is the explanation?
a. Bremsstrahlung photon
b. ionization of bone
c. Photoelectric effect
d. Compoton effect
e. elastic collision with nuclei
f. electron scatter

15. Endoscopic treatment of rectum tumor with kV energy X-ray. What is the predominant process with
cancer tissue?
a. Auger and photoelectric
b. Compton and coherent scattering
c. Compton and photoelectric
d. Compton and pair production
e. Pair production and photoelectric

16. 3cm x 3cm cone is placed to a 6cm x 6cm electron beam. What is the difference compared to 6cm x
6cm field?
a. Increased effective energy
b. Dmax is reduced
 c. MU/Gy is greater at Dmax that that of 6cm x 6cm

17. About penumbra

a. Decrease with increasing CSD
b. Increase with increasing SCD
c. Difference between 10% and 90% at plane of isocenter
d. Larger in upper jaw than lower jaw

18. Patient centered QA which 2 of the followings can identify the error in isocenter placement.
a. independent plan review
b. independent MU review
c. phantom testing
d. in vivo dosimetry

19. Best describe helical tomotherapy

a. Couch move, gantry not move
b. Gantry move, couch static
c. Collimating MLC rotating around moving couch

20. Patient noted pregnancy after completion of RT to breast. Conception 4 days before completion of RT.
Which of the following statements are true?
a. scattered RT to pelvis is low, no significant effect
b. no need to report incident if already informed not to get pregnant before Tx
c. non -stochastic effect
d. no significant effect to organogenesis at this stage
e. CNS defect

21. Relative reporting of scattered to primary photons at depth of Dmax on central axis
a. strongly dependent on SSD
b. smaller for rectangular fields than for square ones of same area
c. larger for MV beams compared with keV beams
d. independent of field size
e. independent of thickness of underlying tissue

22. Air kerma rate at 0.5m of a Ir-192 source is 16 cGy/hr. Now standing 3m away, behind a concrete wall
(4 x TVL thickness), what is the air kerma rate at the operator?
a. 0.444uGy/hr
b. 4.444uGy/hr

23. A 6MV AP opposing field is setup isocentrically to treat a patient of 20cm thickness, giving 40Gy in
20Fr at mid plane. table is shown below.
Depth in cm PDD (measured at 90cm)
0 27.3%
3 100%
5 94%
10 77%
15 62%
20 50%
If the two field has equal weight, find the dose at the skin surface in each fraction
a. 1.0
b. 2.0
c. 3.0
d. 55
24. MV portal image
a. Lower radiation risk
b. Better contrast
c. can correlate patient’s position with MLC positioning

25. Diode least affected by

a. pressure
b. temperature
c. field size
d. energy
e. SSD

26. Which of the following will decrease employee’s radiation exposure the most in managing sealed source
a. Place three HVL-thick material between source and employee
b. Increase distance from source to employee by a factor of three
c. Place one TVL-thick material between source and employee and double the duration of
managing sealed source
d. Place two HVL-thick material between source and employee and half the duration of managing
sealed source

27. Which ones of the following contribute to the system error? (multiple answer)
a. gas in rectum in planning CT
b. bowel gas during treatment CT
c. tension at buttock in planning CT
d. ? set up error at each fraction
e. inaccurate laser alignment during QA

28. What is the time required for radioactivity of I-125 to reduce to <1%?
a. 180 D
b. 240 D
c. 300 D
d. 360 D
e. 420 D

29. Given 9-18MeV electron PDD table. To treat a skin tumor, initially plan to treat w/ 12MeV photons.
Skin dose required 95%
a. add 0.5cm bolus, keep 12MeV
b. add 0.5cm bolus, increase energy to 15MeV
c. add 1 cm bolus keep 12MeV
d. add 1cm bolus, increase energy to 15MeV

30. electron capture decay:

a. I131 undergoes electron capture decay
b. Proton → neutron + antineutrino
c. Excessive energy may be released as Auger electron

31. SABR lung with severe COPD, 54Gy /3 Fr, tumor moves 2.5cm with respiration, what is the most
appropriate statement?
a. abd compression
b. deep breath hold
c. gate with breathing
d. include tumor in ITV
e. active breath hold

32. About radioactivity

a. All involved a change in nucleus
 b. All involved emission of at least one gamma ray photon
c. Can be explained by compton scattering, photoelectric effect, pair production
d. Only occur in naturally occurring isotope
e. Principally involve the movement of electrons between orbits

33. About IMRT to prostate

a. Use of non-coplanar treatment
b. Use of photon beam more than 6MV
c. Prescription of dose at ICRU reference point
d. Prescription of dose at mean/ median dose of PTV
e. Prescription of dose at minimum dose of PTV

34. What is the most accurate description about inverse planning?

a. Beam quality independent to treatment planner
b. Beam quality independent to prescribed dose
c. Obtain mathematically optimal plan
d. Obtain clinically optimal plan

35. IMRT to lung

a. Increase energy will result in dose buildup at tumor/ lung interface

36. Gonads received 1Gy, quality factor 2 for proton, tissue weighting factor 0.08
a. 0.16mSv
b. 160mSv

37. 100cGy/hr dose rate at 0.5m. At 5m ? + 3 TVL

a. 10μGy
b. 1μGy
c. 100μGy
d. 1cGy

38. According to IRMER 2017, which of the following is correct?

a. Controlled area is defined as dose rate 20mSv/hr
b. Operator is to justify the exposure to radiation
c. Lens dose limit is 10mSv/year
d. Effective dose limit (whole body) is 20mSv per any calendar year
e. Radiation protection advisor is ultimately response for radiation protection in radiotherapy

39. Electron passes through 10cm water with lead shield. What is the dose from highest to lowest?
1: before shield 2: same level as 1 without shield around 3: below shield 4: adjacent to shield 5: same
level as 4 without shield around
40. Different parts of a LINAC was labeled A,B,C,D,E. (A is the target, B is the primary collimator, C is the
flattening filter, D is the monitor chamber, E is a motorized wedge underneath the ionization chamber)
Function of C?

a. Harden the beam

b. Enhance dose uniformity

41. Different parts of a LINAC was labeled A,B,C,D,E. (A is the target, B is the primary collimator, C is the
flattening filter, D is the monitor chamber, E is a motorized wedge underneath the ionization chamber)
Function of D?
a. Terminate beam when target dose delivered
b. flattens the photon beam at 10cm depth
c. for monitoring the output of the LINAC and for calibration of the machine

42. Beam profile with more details was given. Calculate the symmetry.

distance from central axis effective dose %

+10cm 50

-7cm 102

-3cm 100

+3cm 98

+7cm 99

-10.3cm 50

a. 1%
b. 2%
c. 3%
d. 4%
e. 5%
43. Refer to above diaphragm. Calculate the field size.
a. 9.6cm
b. 19.0cm
c. 20.3cm
d. 20.9cm

44. Proton therapy:

a. have the greatest LET at depth
b. inconsistent depth of treatment
c. same rate of eneryg loss along path

45. Superficial Xray treatment: originally used 2mm Al barrier -> now use 1mm only. Effects:
a. increase HVL layer required
b. decrease in PDD

46. What is the benefit of Tongue and groove MLC

47. Patient checking mechanism. Which can detect change in isocenter (multiple options of 2)
a. Planning CT calculation
b. MU calculation
c. Dose calculation on a ?phantom
d. In vivo dose
Stastics

1. Survival of CA lung in terms of weeks = 3, 4, 5, 6, 7, 10, 11, 11, 35, 182. Which best describes the data
a. median
b. mean
c. mode
d. range
e. hazard ratio

2. Best representation of numerical data (eg BP) in a group of cancer patients

a. bar chart
b. pie chart
c. scatter plot
d. histogram
e. survival curve

3. Outliners
a. must be excluded to avoid skewed data
b. can be adjusted by sensitivity analysis

4. How to increase specificity of test

a. Decrease prevalence
b. Increase prevalence
c. Increase test threshold
d. Decrease test threshold

5. scatter plot
a. Poor for non-linear relationships
b. Can be used for relationship between continuous variables

6. Study as shown.

What is the most likely explanation of the graph’s appearance? (exact wordings)
a. The confidence intervals suggest that CTC grade 4 was the least common grade of skin toxicity
b. The confidence intervals suggest that the most patients in the study had CTC grade 4 skin
toxicity
c. The estimates of mean skin volumes within each CTC grade are very precise
d. There is a statistically significant increasing trend in skin toxicity with decreasing volume of
skin irradiated >4000 Gy
e. There is no association between skin toxicity and volume of skin irradiated >4000Gy
7. Urine test to differentiate high & low grade bladder cancer. Calculate the negative predictive value of
the urine test
Pathology

High grade Low grade Total

Urine test High grade A B A+B

Low grade C D C+D

Total A+C B+D

a. D/(C+D)
b. D/(B+D)
8.

9. Scatter plot (y axis = plasma concentration, X axis= dose of nicotinazole) R^2 0.12xx P 0.04
Given Y = 1.62x - 0.5..

a. correlation is 0.12, P = 004

b. Y decline by ? when X increase by 1mg/kg
c. Y increase by 1.4 when X increase by 1mg/kg
d. Y increase by 2.5 when X increase by 2mg/kg
10.
11. source population definition
a. all list of people from population from which samples are drawn
b. population when inclusion and exclusion criteria applied
c. population from which samples are drawn

12. conduct an observational study about occupational exposure ( of detergents) and risk of different
cancers. the most appropriate source population
a. all 18-80 adult in the population
b. all 18 -80 adult who follow in cancer hospital
c. all 18-80 adult who have high occupation and follow cancer hospital
d. all 18-80 adult working in high risk occupation
e. Children attending cancer hospital

13. present the data in wilcoxon rank sum test instead of t test, what additional information will be
provided?
a. CI will not be available
b. p value will be provided
c. risk ratio with CI available
d. will change into t distribution
e. present with R2
14. Study about disease free survival in patient undergoing SBRT vs conventional RT
a. What is DFS?
b. interpretation of p value and CI
15. Meta analysis about immuno ve chemo for NSCLC
a. what is the benefit of meta analysis
b. I2 interpretation (I2 54%, p 0.00)
i. can only use random effect testing
ii. there is significant statistical heterogeneity ….. have to pay extra caution in interpreting
the data
iii. there is significant statistical heterogeneity between studies
c. Conclusion of IO vs chemo p value (p<0.05)
d. Interpret P value of 0.79 (OS between male and female)
16. CA stomach; 2 groups of patients -> either D1 gastrectomy or D2 gastrectomy to compare ?outcome
a. Chi square test
b. McNemar test

17. 50 patients with CA cervix. Each undergoes at PET and an MRI to assess the positivity of PA LNs.
According to MRI: 21/50 patients had + LN mets. According to PET-CT 30/50 patients had + LN mets.
To investigate this relationship, which test should be used?
a. chi square test
b. McNemar’ test
c. Wilcoxen sign rank test
d. paired t test
e. unpaired t test

18. What is the best statement to describe ANOVA?

a. It compares means of samples
b. It generalizes the t test & allows comparison of more than 2 groups
c. It is especially useful for large samples
d. It does not assume normal distribution of samples

19. Looking at NSCLC. Histologist is either SqCC/ adenoCA. There are also other risk factors (smoking,
BMI, X ). What regression should we use to look at the relationship between histology & risk factors
a. logistic regression
b. linear regression
c. poisson regression
d. Cox regression
e. non-parametric regression

20. Shows a scatter diagram (X axis: radiation dose; Y axis: %change reduction in tumour size) ?Shows no
correlation
a. Scatter diagram useful to show relationship of continuous variables
b. scatter diagram is bad for small sample groups
c. scatter diagram is bad for non-linear relationships

21. Investigate relationship between dose of hypoxic radiosensitizer Nimorazole(x-axis) and plasma
concentration of nimorazole (y-axis) Shows a scatter diagram, with value of R2 (1.x) available:
a. The correlation between dose of Nimorazole and plasma concentration of nimorazole is 1.x
b. increase in certain amount of X will increase a certain amount of Y

22. Why a certain test with high sensitivity and high specificity still have low PPV?
a. low disease prevalence

23. Long term survival of a disease is 80%. New treatment available with 20% relative reduction of risk
from death. What is the relative increase in survival?
a. 4%
b. 5%
Stem question on IMRT vs conventional RT in SqCC HND
Curative-Intent Radiotherapy for Squamous Cell Carcinoma of the Head and Neck in Sri Lanka: The Impact of
Radiotherapy Technique on Survival - PubMed (nih.gov)

Aims: We conducted a retrospective analysis of patients with squamous cell carcinoma of the head and neck
(SCCHN) treated with curative-intent radiotherapy at the National Cancer Institute of Sri Lanka to determine
the impact of the treatment technique on disease-free survival (DFS).

Results: In total, 408 patients were included in the study, with 138 (34%) being treated with IMRT in the linear
accelerator. More than 75% of patients were of stage III or IV at diagnosis. The 2-year DFS of the whole cohort
was 25% (95% confidence interval 21-30%). Patients treated with IMRT in the linear accelerator had a superior
DFS in comparison with those treated with conventional radiotherapy in the cobalt teletherapy units (P < 0.001,
hazard ratio 0.64, 95% confidence interval 0.5-0.82). Higher stage, cobalt treatment and use of neoadjuvant
chemotherapy were adversely associated with DFS on multivariate analysis.

24. What is DFS

a. Progression of disease when there is cancer cells in the body
b. Progression of disease (and death) when there is cancer cells in the body
c. Recurrence of disease after curative intent treatment
d. Recurrence of disease (and death) after curative intent treatment

25. What can you conclude about the staging of this population
a. metastatic disease
b. advanced disease

26. The 2-year DFS of the whole cohort was 25%. What can you conclude
a. Recurrence is 25% (range of 21-30% ) within 2 years
b. Recurrence is 75% (range of 70-79%) within 2 years

27. P < 0.001, hazard ratio 0.64, 95% confidence interval 0.5-0.82. What can you conclude
Pharm 2024 spring (focus on new questions but not all ~20 new questions)

Conversion of MST 60mg BD to fentanyl patch

-25mcg/hr
-50mcg/hr
-75mcg/hr
-100mcg/hr
-125mcg/hr

Decrease efficacy of sunitinib

-rifampicin
-simvastatin
-amoxicillin
-cyclizine
-bisoprolol

Erlotinib interaction
-carbamazepine
-lamotrigene
-atorvastatin
-nifedipine
-propanol

Inhibit paclitaxel metabolism

-carbamazepine
-phenytoin
-diclofenac
-erythromycin
-rifampicin

Regarding ibuprofen
-long half life of 22hours
-little protein bound less than 9%
-metabolised in liver and excrete in kidney
-metabolised in liver and excrete in bile
-target specific and not widely distributed

Which cause loss of rivaroxaban effect

-olaparib
-temodol
-eribulin
-enzalutamide
-cisplatin

24 years old, 60kg, Cr 70, use carboplatin AUC =7, no capping, use cockcroft-gault formula (did not provide)
A. 665mg
B. 735mg
C. 875mg
D. 1030mg
Contraindicated for Parkinson disease
-aprepitant
-olanzapine
-domperidone
-metoclopramide
-cyclizine

Important S/E of Eribulin

-oral ulcers
-impaired glucose tolerance
-dyspnea
-prolong QTc
-decrease LVEF

100mg IV methylprednisolone, corresponding to oral

-10mg dexa
-16mg dexa
-80mg pred
-100mg pred
-125mg pred

Least neurotoxic
-carboplatin
-paclitaxel
-docetaxel
-oxaliplatin
-vincristine

Cause HFS
-cetuximab
-irinotecan
-docetaxel
-liposomomal doxorubicin

Use ribociclib, fulvestrant, goserelin, denosumab for CA breast, which is correct

-denosumab stabilised RANK/RANKL for increase osteoclast function
-fulvestrant is an irreversible, steroidal aromatase inhibitor
-goserelin in a LHRH antagonist
-ribociclib is an androgen receptor antagonist
-ribocilcib is a selective CDK4/6 inhibitor

Which drug most toxicity with RT

Gemcitabine
Cyclophosphamide
Cisplatin
Etoposide
Use of trametinib + dabrafenib, CrCl 45ml/min
-Dose reduction by 1 level of trametinib, suspend dabrafenib
-Dose reduction by 1 level of dabrafenib, suspend trametinib
-Can use normal dose of both trametinib and dabrafenib
-Dose reduction by one level of both drug

————————
CBRB 2024 spring (focus on new questions but not all, ~20 new equations, more in RB)

SBRT to lung 50Gy/5Fr, spinal cord received 30Gy. What is the EQD2 of cord (a/b ratio is 2)?
- 30
- 40
- 50
- 60
- 70

Rodent re-RT study:

- tolerance of epidermis restore within 2 months
- same re-RT tolerance for early and late reaction
- late subcutaneous fibrosis is independent of initial treatment
- late subcutaneous fibrosis is more severe if more aggreesive initial treatment
- early skin reaction is independent to initial treatment after 6 months

HIF:
- HIF2 is most widely expressed
- HIF regulate several processes: erythropoiesis, angiogenesis, invasion, metastasis etc
- VHL proficient tumour has increased HIF and enhanced angiogenesis
- HIF become active when oxygen conc is 10-15%
- in hypoxic condition, HIF is degraded and allow binding

CDK4/6
-bind to cyclin D
-bind to cyclin E
-promote vasodilation
-enforce G2 cell cycle arrest

Function of BAD, BID, BIX in apoptosis

-anti-apoptotic BCL2 family
-pro-apoptosis BCL2 family
-neutralizing BH3 domain containing protein
-inhibitor of apoptosis

MMR
-CpG rich site
-Tandem repeat of 6-10 nucleotides, disperse in genome
-role in maintain chromosomal stability
-role in altering splicing site
-as TTAGGG sequence at the cap of chromosomes

CpG methylation
-CpG island is in promoter of many genes
-CpG dinucleotide is low frequency in genome
-Methylation of guanine lead to gene silencing
-Hypermethylation lead to gene expression
-Methylation decrease rate of mutation
Most accurate for growth factor receptor & drug acting on it
-bevacizumab inhibit VEGF receptor
-epidermal growth factor is a transmembrane cell surface receptor (exact wording)
-paracrine growth factor act on the cell who produce them
-trastuzumab act on produce of ERBB2 oncogene