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Clinical
Oncology
FRCR part 1 BOF
Physics/Cancer & Radiobiology

Contents

Physics
Pharmacology
Cancer/Radiobiology

Physics
1. Bohr atom:
A.
B.
C.
D.
E.

Electron tightly bound by nucleus have more energy than loosely bound electrons
L shell is the innermost shell
Electron fall from inner to outer electron shell to produce characteristic X ray
Energy level of electron affected by atomic number
Innermost shell at most contains 4 electrons

Answer: A
K is the innermost shell. When outer electron fall from outer to inner vacant shell, extra
energy will released as characteristic radiation. Innermost contains 2 electrons.
2. Regarding Compton scattering / Pair Production / Photoelectric effect which is
correct:
A. total amount of incoming photon energy is shared among positron and electron
pair
B. chance of pair production increase with energy
C. minimum amount of energy for pair production is 0.511MeV
D. electron and positron separated in 180 degree opposite direction
E. photoelectric effect predominant in radiation energy 30MeV.

Answer: B
Total amount energy shared after deducted from the required energy for production of
electron and positron paired (1.02MeV)
3. Which of the following is true about attenuation of therapeutic MV X-ray?
A.
B.
C.
D.
E.

related to inverse square law

associated with scattering
related to electron density of material
directly proportional to atomic number
not related to energy of the radiation beam

Answer: C
Compton effect predominantly in therapeutic megavoltage radiotherapy and 30kV25MeV.
It is proportionate to electron density and inversely proportionate to energy of the
photons.

4. Which is correct regarding TLD-100

A.
B.
C.
D.

threshold dose at 0.01Gy (10-5 Gy)

linear response to 10 Gy
sensitvity independent after 20Gy (>10gy become supralinear)
detect at the range of 10 -3-103 Gy

Answer: B
TLD-100 has the detection range at 10-5-103 Gy, thus threshold of 10 -5 Gy and has a
linear response till 10 Gy then after 10Gy showed supralinearity.
5. CPE equilibrium can occur at
A.
B.
C.
D.
E.

at the building up region

penumbra region
at dose maximum
50% isodose line
tissue interface

Answer: C
CPE equilibrium can occur at Dmax, after Dmax its defined as transient CPE.
6. Which of the following is true about penumbra
A.
B.
C.
D.
E.

increase with scatter radiation at different depth

increase with source size
increase source to skin separation
increase with decrease depth from surface
Cobalt 60 source has the smallest penumbra

Answer: C
Penumbra increased with in SSD, source diameter and depth from surface & source
diaphragm distance. Co 60 has the largest penumbra as Cobalts sources has largest
source of 2cm.
7. What is the thickness of lead shield needed for electron with energy X?
A.
B.
C.
D.
E.

2X
X/2
X/3
X/4
X/5

Answer: B
Energy/2 equal to thickness of shield in mm. Rule of thumb X/5 is the Dmax,X/4 is the
90% isodose & X/3 80% isodose, surface dose is X+70% stated in textbook. But, in daily
practice 90% coverage is calculated by E/3 and energy >18MeV rarely used.
8. Which is correct about electron energy of 10MeV
A.
B.
C.
D.
E.

beyond 50cm depth no radiation dose

use to cover 5 cm target
skin dose less than 15 %
can use 5mm lead shield
lost 4 MeV for every cm attenuation

Answer: D
In order to treat a lesion effectively, it must be covered by 90% isodose line. Rule of
thumb, E/3=90% thus to cover a 5cm target, min 15MeV needed. Electron lost 2Mev/cm.
9. Which is not correct about area equivalent?
A.
B.
C.
D.
E.

same amount of scatter dose

same amount of radiation dose
same PDD
same radiation to scatter ratio
same absolute area

Answer: E
Formula 2ab/(a+B) a= wide, b= length to get an area equivalent to a standard field for
an asymmetrical radiated field area.
10. Which is not account for extending CTV to PTV according ICRU?
A.
B.
C.
D.
E.

radiation field border daily variation placement

breathing movement
organ movement
setup error
microscopic disease

Answer: E
Microscopic disease is included in expanding from GTV to CTV.
11. Which of the following is correct about LINAC component
A. steering magnet use to direct the beam to the filter
B. focusing magnet to direct electron to target
C. magnetron to induce current 0.5mA through waveguide system (Ans 100mA)

D. pulse electron 50keV is directed to the magnetron by modulator(Ans 100eV)

Answer: B
Pulse electron of 100eV is directed to magnetron by modulator. Magnetron induced
current of 100mA through waveguide.
12. Which instrument used to measure the activity of brachytherapy source?
A.
B.
C.
D.
E.

diode
ion chamber
TLD
Well-type ion chamber
chromatic film

Answer: D
Well - type chambers is used for calibration and standardization of brachytherapy
sources.
13. An unstable element undergone decay with atomic mass no decrease by 4 and
atomic no decrease by 1. What decay process/processes has taken place?
A.
B.
C.
D.
E.

alpha alone
alpha with beta +ve
alpha with beta ve
beta ve alone
Electron capture

Answer: C
When the element emitted an alpha particle, atomic mass no decrease by 4 and atomic no
decrease by 2 but another beta-ve decay occurred where a neutron turn into a proton & an
electron (b particle), the atomic no only decreased by 1 as there is an addition of proton.
14. Why MRI cannot be used to acquire images for dose calculation alone?
A.
B.
C.
D.
E.

blurring of images at extreme ends when it has large field

H&N images with tooth prosthesis will leads to artefact
pelvic images with hip prosthesis will have artefact
MRI cannot used in DICOM setting
image pixel resolution has no correlation with electron interaction process

Answer: E
There is no electron density information available for heterogeneity corrections on the
dose calculations

15. For dose rate calculation of sealed radioactive source with known air kerma
reference, which of the following will affect the dose rate calculation?
A.
B.
C.
D.

source size
distance
filtration
half life

Answer: B
Brach therapy is governed by inverse square law where distance plays the major role.
16. Which of the following is wrong regarding biological half life
A. depends on the physical half-life
B. half of the radionuclide excreted from the body.
C. Effective half life is equal biological half life if physical half life of the
radionuclide is relative long compare to biological half life.
D. Depends on the functions of the organ

Answer: A
1/Effective half life=1/ biological half life + 1/ physical half-life
If physical half-life extreme long 1/ physical half-life approximately 0 thus effective half
life is equal biological half life. Excretion of the radionuclide is organ function i.e
GFR/cardiac output dependent.
17. To delineate the target volume, what is the role of clinical oncologist to delineate
CTV and PTV under law in UK?
A.
B.
C.
D.
E.

Practioner
medical physics expert
radiation protection adviser
operator
referrer

Answer: D
According, Regulation IR(ME)R, Operator-carry out the technical aspects of radiation
planning,do not have to be health-care registered i.e oncologist, physicist, radiographer or
dosimetrist. Practioner- Health-care registered professional entitled by employer to justify
and authorize patient to radiation exposure i.e oncologist

18. What is correct about IRR 1999?

A.
B.
C.
D.
E.

effective dose limit of non-classified worker = 6mSv/yr

effective dose limit of classified worker to hands= 150mSv/yr
must define role of medical physicist in local rules
controlled area with dose limit <6mSv
supervised area with effective dose 3 tenth specified limitation (1/10)

Answer: B
Effective dose limit of classified worker =6 mSv/yr or 3/10 th of a dose limit e.g.150
mSv/yr hand dose (annual limit 500mSv/) or 50 mSv/yr lens dose(annual limit 150mSv).
Controlled areas defined as any area where received > 6 mSv/yr or >3/10th dose limit or
> 7.5 uSv/h.
19. Online verification, which has the lowest radiation risk?
A.
B.
C.
D.

kV diagnostic x ray
on rail CT
cone beam CT
portal image with film

Answer: A
Typical effective dose for a Chest x ray and CT abdomen is 0.02 and 8 mSv respectively
or put in another way as 1 CT scan equal 400 cxr. Portal film is taken using megavoltage
x-ray.

20. What is the modality commonly use for target delineation in neurosurgery SRS?
A.
B.
C.
D.
E.

MRI
PET
CT
USG
SPECT

Answer: A
Commonly modality is MRI as its good in differentiate soft tissue esp in brain and pelvic.
CT provided better contrast/resolution of the structure i.e bone, muscle but not in soft
tissue.PET and SPECT are functional scan, PET is good in delineate GTV but doesnt
provided structure of the imaging.PET/CT fusion scan is better option but not common
available.

21. In Superficial X ray, what determine the quality of it?

A.
B.
C.
D.
E.

separation between anode and cathode

size of focal spot
material of the target used
voltage applier across the tube
cooling systems

Answer: D
Superficial x-ray beam quality production depends on voltage, mA and filter.
22. Which of the following is correct about proton?
A.
B.
C.
D.
E.

broad Bragg peak has same penetration

low LET
can be manipulated by wax filter
can be manipulated by lead shield
has more normal tissue damaged.

Answer: C
Proton is high LET radiation which has a narrow Bragg peak where all the energy
deposited at thus min dose distribution along the radiation pathway (normal tissue). In
order to be clinically effect to treat a larger area, the Bragg peak can be manipulated by
wax filter.
23. Bremsstralung radiation what is the source of it?
A.
B.
C.
D.
E.

Photon with orbital electron interaction

photon interaction with electromagnetic field of nucleus
photon interaction with nuclear force of nucleus
electron interaction with the electromagnetic field of nucleus
photo absorbed total by the nuclues

Answer: C
All the protons & neutrons hold together by the strong force or nuclear force.
Bremsstrahlung radiation occurred as there is sudden deceleration of the incoming
electron due to Coulomb interactions with nuclei.
24. Given 10MeV electron with field size change from 10x10cm to 3x3cm, which of
the following is correct?
A. higher Dmax
B. steeper slope
C. lower practical range

D. lower surface dose

E. increase depth dose

Answer: D
Surface dose of electron beam increased with field size, energy of the beam, SSD and
beam directed <60 degrees (beam obliquity). Minimal field size for electron is 4x4cm, if
smaller field size use, depth dose & dmax & closer to skin surfaceas not enough lateral
electron equilibrium.
25. You want to irradiate an area with two 20 cm long field and match at 5 cm depth.
SSD = 100cm. What should be the skin separation for no overlap?
A.
B.
C.
D.
E.

0.5 cm
1 cm
2cm
5cm
10cm

Answer: B
Assuming two 20cm field irritated from same distance of
100cm and both triangles are symmetrical.
Tan = S1/5= 10cm/100cm
S1= 5 x 10/100 = 0.5cm
Gap is S1+S2(symmetrical) = 2 x0.5cm = 1cm

26. For IMRT prostate, what of the following contributes to set up error most?
A.
B.
C.
D.
E.

expansion from CTV to PTV

shape of CTV
position of CTV
organ movement
patient movement

Answer: D
According ICRU, PTV is taking into consideration of internal and external margin. Organ
movement contributed most of the setup error where current method to overcome this by
IGRT i.e IMRT + CT or ultrasound or stereoscopic X-rays during radiotherapy.

27. V20 of lung define as

A.
B.
C.
D.
E.

volume of lung received more than 20% of total dose

volume of lung received 20% of total dose
volume of lung received less than 20% of total dose
volume of lung received 20Gy
volume of lung received > 20Gy

Answer: D
28. Treatment of superficial lesion

skin

tumour
4cm
5.5 cm

Point X

Lung

Choose a suitable energy

A.
B.
C.
D.
E.

8MeV
10 MeV
12 MeV
15 MeV
18 MeV

Answer: C
E/3=90% according to formula. The answer selection given by the FRCR above is
8,10,12,15,18MeV...there is no answer given that suit x 4 if using textbook formula of
E/4= 90% isodose.So, FRCR using E/3 =90% isodose line.Electron energy selection
calculated using the tumor depth not diameter of tumor as isodose is a join points of
equal dose- a planar representation of the dose distribution, meaning dose will be same at
the same line/surface as long as the line/surface cover by the beam.Explanation for this
answer given in question 7 previously.
29. Radiation dose accuracy: 2Gy at a one point, Day-to-day basis
A. 1.98 2.02
B. 1.96 2.04
C. 1.94 2.06
D. 1.99 2.01
E. 1.88 2.12

Answer: C
Daily QA programme for LINAC - X- ray /Electron output constancy allow 3%
3% x 2Gy= 2
30. Diode least affects by
A. pressure
B. temperature
C. field size
D. energy
E. SSD

Answer: A
31. What are the following components need to be adjust in Linac machines to
produce electron beam
A.
B.
C.
D.
E.

removed the target

added in flattening filter
removed the scattering foil
removed the bending magnet
removed ionization chamber

Answer: A
Production of electron beam by removing the target/flattening filter but added in
scattering foil to produce larger electron beam.
32. MLC leaf decreased width will
A.
B.
C.
D.
E.

increase conformity
decrease tongue and groove effect
deceased interleaf leakage
less MU needed
better than larger width MLC

Answer: A
Quality of the shape by MLC depends on the width of each leave,smaller leave width
can shape better and more conformity to the shielded area. Tongue and groove is
designed to reduce interleaf leakage.
33. Which of the following dosimeter good in detection of small field dose change

A.
B.
C.
D.
E.

farmer type ionization chamber

parallel type ionization chamber
diode
calorimeter
GeigerMller detectors

Answer: C
Farmer and parallel type have larger surface for detection small area dose changes
compared diode or TLD which are smaller and more sensitive in small area dosimetry
changes.
34. Paris System
A.
B.
C.
D.
E.

reference dose rate: 75% basal dose rate

source separation should be constant in any one implant
different sources with different linear activities
sources placement must be perpendicular
linear source strength can be varied with each implant.

Answer: B
Paris system-Reference dose rate is a fixed percentage (85%) of the basal dose rate.
- Sources must be linear and their placement must be parallel
- Centres of all sources must be located in the same (central) plane
- Linear source strength (activity) must be uniform & identical for all sources in the
implant
- Adjacent sources must be equidistant from one another
35. Iodine 131
A.
B.
C.
D.
E.

Half life 8 hours

Pure beta emitter
Commonly used in solid tumor bone mets
Dose for thyroid ca: 370MBq
Has beta energy 606 keV

Answer: E
I-131 decays with a half-life of 8.02 days with beta minus 606 keV and gamma emissions
364 keV (not pure beta emitter).I-131 commonly used in thyroid imaging (WBS) &
treatment of thyrotoxicosis, and thyroid cancer. Doses used in the ranging of 2.55.5
GBq.
36. Cs-137
A. Half life 30yrs

B.
C.
D.
E.

Used in HDR
Generate 0.36MeV radiation
Emitted no gamma ray
After decay, it released unstable daughter Barium.

Answer: A
Cs-137 underwent beta- decayed and released 0.66MeV gamma ray and stable daughter
Ba-137.Common used in intracavity or interstitial LDR temporary implants.
37. Which of the following is false regarding Quality factor (Q)of a radiation beam
A.
B.
C.
D.
E.

Dose x Quality factor = Equivalent dose

Q for fast neutrons and alpha particles are 5 times of that of x-ray
Q depends on different organ and tissue
SI Unit of Q = Sv
Q for photon and electron is different

Answer: C
Quality factor (Q) of a radiation beam is the radiation weighting factor (WR). WR for
photon and electron equal 1 for all energy and neutron is 5-20.
Equivalent dose = Absorbed dose X radiation weighting factor (WR).
Tissue weighting factor (WT) depends on different organ and tissue.
38. Immobilizer head frame
A.
B.
C.
D.
E.

facilitate set up, reproduce patient position

not used for electron beam
correct beam alignment
make off tissue-equivalent material
doesnt required adjustment after edema of the face subsided.

Answer: A
Immobilizer designed to be comfortable and position reproducible. It required adjustment
if any changes in patient outer contour i.e edema, tumor growth or regression in order to
minimize setup error.
39. Which is true about TLD
A.
B.
C.
D.
E.

In vivo dosimetry due to instant dose read out

Precision 2%
For measuring scatter outside treatment field
Useful only in the range of 20mGy to 20Gy
Suitable for dose calibration

Answer: C
TLD is suitable for in vivo dosimetry and detection small area dose due to its relative
small size device with precision of 3% and detection range of 10-3-103 Gy. It has no
instant dose read out and not suitable for dose calibration.

40. Expansion of CTV to PTV, which contribute least

A.
B.
C.
D.
E.

set up errors
uncertainty in CTV definition
beam penumbra
internal organ motion
systematic difference between stimulator and during treatment

Answer: C
41. Breast tangential field where high dose at lung but low dose towards skin
possibilities except:
A.
B.
C.
D.
E.

Isocentre 10 degree posteriorly

1cm bolus
Increase energy
Smaller wedge angle
Large area of breast tissue defect

Answer: B
Bolus is made of tissue-equivalent material to increase surface dose. Wedge is used as
tissue missing compensator.
42. Regarding production of superficial X-Ray is true:
A.
B.
C.
D.

Target is made of lead

Target heated by filament
Target is the cathode
Efficiency of X-ray production in superficial and orthovoltage energy range 2%
or less (others transformed into heat energy)
E. Spinning target
Answer: D
Target is made of tungsten and its a static target compared diagnostic xray target which
is spinning target. Electron produced by thermionic emission in the cathode are
accelerated towards the anode (target) by the difference voltage potential
43. Wax on lead behind ear when treated with electron beam

A.
B.
C.
D.
E.

to reduce back scatter

to reduce lead contamination
to reduce dose to scalp
to enhance radiation effect
to reduce ear movement

Answer: A
Electrons may be backscattered if they encounter a dense material ie bone interfaces/
metal prostheses which will lead to dose in the soft tissue surrounding the dense
material.
Internal shield a lead coated with low atomic number materials (wax) to the electron
back- scattering into surrounding healthy tissue.
44. CT simulator limitation except
A.
B.
C.
D.
E.

Bulging I.I.
Higher radiation dose
Concave couch
Limitation of patient position
differentiation of soft tissues

Answer: C
Couch still same as the diagnostic and therapeutic Ct scan couch which is flat.
45. IMRT property compare conventional radiotherapy techniques which is false
A. Non uniform fluence delivered to point from given many direction
B. High dose conformed to shape of target volume and minimal dose to normal
tissue
C. IMRT use dynamic wedge
D. IMRT use non-coplanar beam
E. IMRT has problem in isolated shield area(island block) with MLC
Answer: C
Conventional radiotherapy techniques use coplanar (2D) limited beam fields and less
conformal compare IMRT.
46. Primary barrier, which is the most cost effective material
A.
B.
C.
D.
E.

Lead
Concrete
Steel
Boron
Cerrobend

Answer: B
Typical concrete thickness for Linac- 1barrier 200cm & 2barrier 120cm. Neutron door
typically filled with borated paraffin to absorb neutron produced.

47. Which is true about absorbed dose:

A.
B.
C.
D.
E.

J/m2
Not related to air kerma
Only follow inverse square law
Can be measured by ion chamber directly
Absorbed dose is equal kerma during CPE

Answer: D
Absorbed dose is the amout of energy absorbed from a radiation beam via radiation
interactions (mainly excitations and ionizations and distance travel- inverse square law)
in the medium per unit mass of absorbent ~1J/Kg=1Gy. Exposure is ion created by
photons per unit mass of air ~ C/kg which can be measured by ion chamber.
48. Ionization chamber in linac machine detected increased value after repeated
measurement. What is the most appropriate reason?
A.
B.
C.
D.
E.

Atmosphere pressure increase

Temperature increase
Volume in chamber reduced
Increase energy
Pulse radiation

Answer: A
Principle ionization of gas chamber-ionising radiation interacts with known mass of air in
chamber which produces ions. Ion charges collected & connected to electrometer which
converts charge to signal impulse. If temperature (gas less expanded) or pressure (gas
compressed), more charge being collected hence resulted in false reading.

49. To specify beam energy for superficial X-ray

A.
B.
C.
D.
E.

HVL
TPR
kVp
beam current
Dose rate

Answer: A

50. Which of the following is true

A.
B.
C.
D.
E.

A dose rate of 1Gy/hr is considered as low dose rate

HDR is defined as dose rate larger than 6Gy/hr
Cs137 is used for HDR treatment
Co60 is used for LDR treatment
HDR treatment cannot use rigid fixed-geometry multi-channel applicators

Answer: A
HDR defined as > 12 Gy/hr commonly use source is 192Ir. LDR defined as 0.3 - 2 Gy/ hr.
Cs137 is used for LDR treatment.

Summary for common calculation questions

1. penumbra for a source
2. MU for SAD/SSD techniques
3. electron energy selection
4. shield thickness for electron
5. HVL
6. Radioactivity
7. effective half-life

Pharmacology
1. Xeloda is superior than oral 5FU because
A.
B.
C.
D.
E.

more potent agent against TS

act on different targets
is actively absorbed by tumor cell in gut
prodrugs that will preferably turned active in tumor cell
different side effect profile

Answer: D
Prodrug metabolized by 3 enzymes
1. Capecitabine5DFCR by Carboxyesterase in liver
2. 5DFCR 5DFUR by cyti dine deaminase in liver and tumor
3. 5DFUR5FU thymidine phosphorylase in tumor
2. Which is true regarding Vincristine
A.
B.
C.
D.
E.

inhibit formation of microtubules

lead to severe bone marrow suppression
lead to alopecia
can be given intrathecally
given same day with intrathecal methotrexate

Answer: A
Vincristine- neurotoxic is the dose limiting factor. Vinblastine causes more
myelosupression.
Vincristine given intrathecal is fatal should not be given on the same as intrathecal
methotrexate to avoid mistake.
3. Which of the following about Temozolomide is false:
A.
B.
C.
D.
E.

well absorbed orally

side effects increased with prolonged administration
no need to reduce dose if renal impairment
predispose patient to Pneumocystis jirovecii pneumonia
patient taking TMZ should avoid sun

Answer: C
Severe renal impairment (Clcr <36 mL/minute/m2) have to use with caution. Patient
should be given prophylaxis antibiotic Azithromycin/Erythromycina as predisposes
patient to Pneumocystis jirovecii pneumonia. It also leads to hyperphotosensitivity.

4. Which drug induced myelosuppression recover earliest:

A.
B.
C.
D.
E.

Cyclophosphmide
Melphalan
mitomycin C
busulfan
carmustine

Answer: A
Cyclophosphmide recovered 7-10 days after cessation whereas busulfan, nitrosoureas,
mitomycin-c and Melphalan can cause more delayed and prolonged myelosuppression i.e
myelosupression delayed till 4-6 weeks.
5. What is the starting dose for phase I studies?
A.
B.
C.
D.
E.

1/2 of TD50 in human

1/2 of TD 10 in mice studies
1/10 of TD10 in mice studies
1/5 of AUC in mice studies
Maximally tolerated dose in mice studies

Answer: C
Phase I involved small number patient trial to test safety dose & dose-toxicity
relationship. It start at 1/10 of TD10 in mice (killed 10% of mice) in fit pts.Step- wise
increment in dosage according to Fibonacci to determine dose limiting toxicity(DLT) and
stop at Maximum tolerated dose(MTD).
6. What is the method used in stepping up tolerated dose in phase I studies?
A.
B.
C.
D.
E.

Fibonacci
Beronecci
Kaplan Meier
Karnofosky
Devitta

Answer: A
7. In phase II studies, if Gehan design is used. How many patients are needed to
prematurely terminate the study if no tumour response is noted which indicate
20% of the study population?
A. 10
B. 14

C. 24
D. 30
E. 40

Answer: B
In this classic design, 14 or 19 patients (corresponding to response rates of 20% or 15%)
are initially treated, and if no responses are observed, the drug is considered inactive
8. What is the method to ensure balanced no patients in 2 treatment groups in RCT?
A.
B.
C.
D.
E.

Stratification
block randomization
randomized discontinuation
enrichment
simple randomization

Answer: B
Simple randomization does not guarantee of equal or approximately equal sample size in
each treatment group. Stratified & block randomization ensure sample size in each
treatment group.
9. What is the definition of PR in RECIST criteria?
A.
B.
C.
D.
E.

30% reduction in tumour size in monodimensional measurement of tumour size

50% reduction in tumour size in monodimensional measurement of tumour size
30% reduction in tumour size in measurement in 2 dimensions of tumour
50% reduction in tumour size in measurement in 2 dimensions of tumour
none of the above

Answer: A
RECISTS- For measurable lesion where target lesion (TL) defined as lesions in
conventional CT> 2cm or spiral CT>1cm. Unidimensional- longest dimension (LD) only
taken for each lesion. Sum of the 5 LD targets and compared with baseline scan to assess
response.
PR define as >30% in the sum of the LD of TL at 4 weeks. PD define as >20% sum
of observed or appearance of new lesions.Bidimensional (product of LD and greatest
perpendicular diameter of any lesion) for measurable lesion used in WHO criteria.
10. Which of the following drug cannot be administered by syringe driver?
A.
B.
C.
D.

Cyclizine
Midazolam
Diazepam
Haloperidol

E. buscopan
Answer: C
Syringe driver is a small, portable battery-driver infusion pump, used to give medication
subcutaneously via a syringe usually over 24 hours.Choice of infusion sites include:
anterior chest wall
lateral upper arms
anterior abdominal wall
area over scapula (in confused or disorientated patient)
The above,diamorphine and octreotide can be given subcutaneously.
Diazepam, chlorpromazine and prochlorperazine are too irritant to be administered SC.
http://www.patient.co.uk/doctor/syringe-drivers for more info.
11. What is the equivalent dosage of s/c diamorphine if oral morphine 360mg is
given?
A.
B.
C.
D.
E.

30mg
60mg
120mg
360mg
720mg

Answer: C
Analgesic

Equianalgesia
Relative strength to oral
oral morphine 10mg equal
morphine

< potent
tramadol
dihydrocodeine

1/10
1/5

100
50

=potent
Oral morphine
Hydrocodone

1
1

10
10

>potent
S/C morphine
Oxycodone
Diamorphine

2
2
3

5
5
3.33

12. If a patient with brain metastais is given phenytoin,

A.
B.
C.
D.
E.

decrease dosage of dexamethasone

increase dosage of dexamethasone
no change in dosage of dexamethasone
change to prednisolone
change to hydrocort

Answer: B
Phenytoin increases the metabolic clearance rate of cortisol and steroid i.e
dexamethasone/prednisolone and reduces the plasma half-life of dexamethasone by up to
50% by inducing liver enzymes such as CYP3A4, which metabolizes dexamethasone into
the hydroxyl metabolite. Patients with brain tumors on anticonvulsants may therefore
need higher doses of dexamethasone to control brain edema. However, particular care
should be taken in dose escalation of steroids
13. Active metabolite of cyclophosphamide/ ifosfamide , acrolein can
A. damage to urothelial mucosa
B. leads to ifo-nephropathy
C. leads no harm and get excreted
D. leads to ifos-encephalopathy
E. can be mainly managed by adequate hydration
Answer: A
Hemorrhagic cyctitis can be prevented by enough hydration and mesna which bind to
acrolein. The metabolite that leads to ifos- nephropathy/ encephalopathy is
chloroacetaldehyde.

14. Metabolism of diamorphine to active metabolite

A.
B.
C.
D.
E.

methylation
acetylation
demethylation
deacetylation
phosphorylation

Answer: D
Diamorphine is a prodrug that is metabolized rapidly by deacetylation(by enzyme
esterase) to an active metabolite, 6monoacetylmorphine then morphine.
15. Which of the following is not a targeted drug:
A.
B.
C.
D.
E.

Octreotide
Herceptin
Rituximab
Iressa
Streptozocin

Answer: E
Streptozocin is an alkylating agent.

Agents
Octreotide
Herceptin
Rituximab
Iressa/Cetuximab

Target receptor
somatostatin receptors
Her-2
CD20
egfr

16. When treating with Imatinib, which of the following can be co-administered
without compromising safety or efficacy:
A.
B.
C.
D.
E.

Rifampacin
Aspirin
Phenytoin
Carbamezepine
Fluconazole

Answer: B
P450 Inducers- Carbemazepines, Rifampicin, Alcohol(chronic), Phenytoin, PhenobarbCRAP2
P450 inhibitor- Isoniazid, Quinidine ,Cimetidine,Ketoconazole,Erythromycin
17. Prolonged treatment with Tamoxifen is associated with
A.
B.
C.
D.
E.

Increased risk of ovarian cancer

Increased risk of endometrial cancer
Reduced effect with prolonged treatment
Decreased sensitivity to AI
Not associated with thromboembolism

Answer: B
Tamoxifen increase risks of endometrial cancer and thromboembolism.
18. Which of the following has clinically significant interaction with ethanol and
cheese?
A.
B.
C.
D.
E.

Bleomycin
Procarbazine
Doxorubicin
Vincristine
Etoposide

Answer: B
Procarbazine is metabolized and activated in the liver. It inhibits MAO thus increasing
the effects of sympathomimetics, TCAs, and tyramine i.e cheese and grape. When
combined with ethanol, procarbazine may cause a disulfiram-like reaction.

19. Which statement best describe Goserelin:

A.
B.
C.
D.
E.

Initially cause increase of LH & FSH

Common to have drug interaction
Castration level reached within 2 weeks
gynecomastia is common
Need dose reduction in renal dysfunction

Answer: A
Initially stimulate FSH and LH production, negative feedback leads to downregulation of
LHRH receptors LH/FSH testosterone production. Acute flare up due to sudden,
temporary worsening of tumour- related symptoms following the start of treatment with
the
initial use of LHRH analogue. Castration level reached in three to four weeks after the
start of treatment. No dose adjustment for renal impairment.
20. Which statement best describe Flutamide:
A.
B.
C.
D.
E.

It is a steroidal anti-androgen
It is a pure androgen antagonist
It has severe hepatotoxicity profile
gynecomastia is uncommon
Diarrhoea is uncommon

Answer: B
Antiandrogens are classified as steroidal or nonsteroidal. Non-steroidal antiandrogens
examples are s nilutamide and flutamide. Antiandrogens inhibit circulating androgens by
blocking androgen receptors thus suppressing androgen synthesis. Flutamide common
side effects are mild AST increased transiently, gynecomastia, nausea, vomiting and
diarrhoea.
21. Which of the following is not the mechanism of herceptin :
A.
B.
C.
D.
E.

Breakage of heterodimer of Her-2 receptor

Activate the antibody mediated cytotoxicity
Activate cytokine release
Blockage of ligand
Blockage of signal transduction by Her-2 receptor.

Answer: A
Herceptin is a monoclonal antibody which binds to the extracellular domain of the human
epidermal growth factor receptor 2 protein thus blockage of signal transduction by Her-2
receptor and mediates antibody-dependent cellular cytotoxicity by inhibiting proliferation
of cells which overexpress HER-2 protein

22. Which of the following will block the kinase of EGFR:

A.
B.
C.
D.
E.

Cetuximab
Herceptin
Gefitinib
Sorafenib
Erlotinib

Answer:D
Sorafenib and Sunitinib are multikinase inhibitor wheares the rest are EGFR receptor
binder.
23. Which of the following about bioreductive agent is true :
A.
B.
C.
D.

Preferentially kill well oxygenated cells

Became activated after electron donated
Cisplatin is commonly used as bioreductive agents in radiotherapy
Thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS)
occurred rarely as adverse effect
E. It is a strong irritant.

Answer:D
Bioreductive agents i.e mitomycin,,nitroimidazoles and Tirapazamine. This agent
selectively kills hypoxic cells and are metabolically reduced (where electrone gained)
intracellularly in O2- deficient (hypoxic) tissues to form cytotoxic compounds.Activation
of bioreductive drugs need hypoxia and reductases.TTP/HUS and vesicant are the known
side effects of mitomycin.
24. Which has the least risk of neurotoxicity:
A.
B.
C.
D.
E.

Gemcitabine
Oxaliplatin
Paclitaxel
Docetaxel
Vincristine

Answer: A
Common chemo-induced neurotoxicity agents are platinum, taxane and vinca alkaloids.

25. Which of the following is true regarding Irinotecan

A.
B.
C.
D.
E.

Is a Topoisomerase II inhibitor
Is a prodrug that activated by hydrolase
diarrhoea mediated by acute cholinergic effect only
Chronic dirrhoea treated with IV atropine
Expression P170 by MDR gene leads to drug resistance

Answer: E
Irinotecan stabilize this (topoisomerase-1 & DNA complex) and prevent religation that
leads to collision of complex and advancing replicating fork DNA break.Its a prodrug
activated by carboxylesterase to SN- 38.Acute diarrhea mediated by acute cholinergic
effect and treated and prevented by IV atropine which occurred <24 hour of the
Irinotecan given. Delayed diarrhoea caused by SN-38 that irriated the intestinal mucosal
and treated with Tablet Loperamide around the clock and considers antibiotic
metronidazole for colitis dirrhea persistent.

Cancer & Radiobiology

1. Which of the following protein are responsible for causation of Burkitts lymphoma,
t (8:22) caused by EBV infection:
A.
B.
C.
D.
E.

EBNA
C-myc
Ras
PIK3
Heat shock protein

Answer: A
Epstein-Barr nuclear antigen 1 (EBNA-1), is required for survival of EBV-positive
Burkitt's lymphoma. Inhibition of EBNA-1 decreases survival of these tumor cells by
inducing apoptosis. EBNA-1 is critical for the continued survival of EBV-associated
Burkitt's lymphoma.
2. LOH means
A. Amplification
B. Loss of allele
C. Translocation
D. Tranfection
E. Overexpression of gene

Answer: B
2 hits Knudsons theory. 1st mutation i.e germline or somatic mutation to one allele.
2nd somatic mutation cause a cell to lose its 2nd normal gene - "loss of heterozygosity"
or "LOH" thus be predisposed to develop into a tumor classic example retinoblastoma.
3. Inheritance pattern of Li-Fraumeni syndrome
A.
B.
C.
D.
E.

Somatic mutation
Autosomal dominant
Autosomal recessive
Sex-linked
Autosomal dominant with low penetrance

Answer: B
Li-Fraumeni syndrome (LFS) is a highly penetrant, autosomal dominant human familial
cancer predisposition. Highly penetrant, the trait it produces will almost always be
apparent in an individual carrying the allele. Mutated tumor suppressor p53 responsible
for this syndrome which prone to develop sarcoma,CNS tumor(glioma) and breast cancer.

4. Which of the following is the correct pair:

A.
B.
C.
D.
E.

Bloom syndrome and TP53 mutation

HNPCC and APC gene mutation
Hereditary papillary renal cancer and BRCA 2
Thyroid papillary cancer and VHL
Gorlin syndrome and PTCH gene mutation.

Answer: E
Bloom syndrome mutations in the BLM gene located at 15q26.1. HNPCC associated
MSH2/MLH1 microsatellite instability. Renal cell cancer associated with VHL. Papillary
thyroid cancer with RET mutation.APC gene mutation FAP colon cancer.
5. Which of the following is correct pair of gene and its protein products location:
A.
B.
C.
D.
E.

Her 2 - protein at nuclear membrane.

Ras - cytoplasmic signaling protein
ABL intracellular tyroxine kinase
Myc- attached to cell membrane
Serine/threonine kinases-(Mtor)- at mitochondria membrane

Answer: B
EGFR receptor which is transmembrane protein structure that contained 1) extracellular
ligand binding 2) short intra-membrane component and 3) Intracellular domain with
tyrosine kinase activity.Her-2 receptor (EGFR 2)is one of the 4 EGFR 1-4 receptor.
RAS is membrane bound and activate cascade of signaling protein. Myc is an
intracellular transcription factor. mTOR is a member of the PI3K-related kinase (PIKK)
family involved in the signal transduction pathway at cytoplasm.
6. Upon DNA damage, p53 will activate which of the following for G1/S phase arrest:
A. p21
B. cyclin D1
C. p16
D. cyclin E
E. CHEK2

Answer: A
DNA damaged detected by p53, if the damage is minor and repairable will leads to p53
protein p21 level inhibits cyclinE-cdk2 complexes resulted in inhibition of
phosphorylation of Rb protein i.e Rb proteins remain bound to transcription factor
E2F G1/S arrest for DNA repair. If major damaged detected by p53 and it will induce
apoptosis to the damaged cells.

7. Smallest clinical detected size

A.
B.
C.
D.
E.

10-3
10-6
10-9
10-12
10-15

Answer: C
Clinical detectable mass is 1g or 10-9 no of cells and after tumor cell undergone 30
divisions.
8. Capase 9 will interact with which of the following during activation of apoptosis:
A.
B.
C.
D.
E.

Bax
Bid
IAPs
Apaf-1
Puma

Answer: D
Cytochrome C+ Caspases 9+Apaf1 formation of apoptosome. Apoptosome activate the
Caspases 3 in the intrinsic pathways. In a viable cell, the proapoptotic members are Bax,
Bak, and BH3-only proteins which are antagonized by antiapoptotic members such as
Bcl-2.
9. Adriamycin will form complex with which of the following DSB:
A.
B.
C.
D.
E.

Topoisomerase I
Topoisomerase II
Mitotic spindle
DNA polymerase
Carboxyesterase

Answer: B
Topoisomerase I inhibitor i.e Irinotecan, Topotecan, Topoisomerase II inhibitor are
antracycline and etoposide.DNA topoisomerase II catalyzes the double-stranded breaking
repaired and resealing of DNA which indirectly regulate transcription, replication and
recombination of DNA.If topo II is inhibited and it will lost the DSB repaired functions.

10. Which of the following is the effect of hypoxia:

A.
B.
C.
D.
E.

stimulate cell growth

increase cellular pH
increase angiogenesis
photons radiotherapy more effective
Perfusion limit hypoxic due to cancer growth away from vessels

Answer: C
In normoxic state, HIF- will be hydrolyzed after recognized by VHL. In hypoxic, HIF-
stabilized and dimerize with HIF-, acts as transcription factor for a) Metabolism - GLUT
1 & 3 b) Angiogenesis - VEGF c)Metastases -CA9. Acute hypoxia is due to transient
closure of capillaries Perfusion limit hypoxic.
Reason:
1. Plugging of vessels by circulating blood/tumour cells
2. Collapse of vessels d/t high interstitial oncotic pressure
3. Spontaneous vasoconstriction
11. Protein responsible for the effect of hypoxia as stated above:
A.
B.
C.
D.
E.

HIF
Ras
VHL
VEGF
Angiostatin

Answer: A
Max distance oxygen can diffuse from a capillary roughly 150 m. Delivery of oxygen
from blood vessels to distance tissue is limited by diffusing capacity- Diffusion limited
hypoxia aka Chronic hypoxia. Pro-angiogenic factors are VEFG,PDGF, Angiopoietin and
etc. Anti-angiogenic factors are Trombospondin, Angiostatin and endostatin.
12. Which of the following will degrade protein for MHC-I presentation:
A.
B.
C.
D.
E.

Lyzosome
Proteasome
Golgi
Endoplasmic reticulum
Macrophage

Answer: B
Class I MHC molecules bind peptides generated from degradation of cytosolic proteins
by the proteasome.

13. Which of the following test can test for SSB:

A.
B.
C.
D.
E.

Alkaline elution
Neutral comet assay
Neutral elution assay
-H2AX
pulsed-field gel electrophoresis

Answer: A
Except alkaline elution, the rest of the tests are used to detect DSB (double stranded
break)
14. Which of the following is responsible for repair of DNA cross linkage:
A.
B.
C.
D.
E.

BER only
NER only
BER and HR
NER and HR
MMR

Answer: B
Nucleotide/Bulky DNA lesions/adducts by repaired by nucleotide excision repair. Base
mismatch is repaired by mismatch repair (MMR).
15. Which of the following not account for the lethal effect after exposure to single
fraction of 10Gy:
A.
B.
C.
D.
E.

vomiting
diarrhea
loss of gut clonogenic cells
lost of sensorium
latent period of 1-2 weeks

Answer: B
Total body irradiation of >10Gy will leads to gastroenterology effects i.e vomiting,
diarrhea and lost of gut clonogenic cells with latent period of 1-2 weeks. Total body
irradiation of >2.5Gy will leads to myelosuppression in which lymphocytes are the first
to get depleted subsequently patients will get infection with latent period of 1-2
months.CNS syndrome only occurred if given >200Gy.

16. Which is true about Potentially lethal damage (PLD)

A.
B.
C.
D.
E.

Hits to critical sites/targets are not sufficient to cause death

repaired under all conditions
demonstrated with a delayed plating experiment
has repair half-life T1/2 = 11/2 hr
direct effect of radiation

Answer: C
Hits are sufficient to cause death but may be repairable if mitosis is delayed by
suboptimal growth conditions ie the presence of favorable environmental features or cell
cycle arrest
demonstrated with a delayed plating experiment, defined as an SF resulting from
incubation of cells under non-growth conditions in various hr bet 2 # following
irradiation. SLD repair half-life T1/2 = 11/2 hr and recovery completely by 2 hours.
17. A 67 yr old lady was planned to have 40Gy in 10fractions to metastatic skin lesion,
because of inconvenience, on the first day of RT, patient said that she will only come
for RT for one day, if / for early toxicity is 10, / for late toxicity is 2, which of
the following dose in single fraction will have same acute toxicity as the original RT
treatment:
A.
B.
C.
D.
E.

16
17
18
19
20

Answer: C
Isoeffective dose formula D2 = (d1 + /)
D1 (d2 + /)
D = total dose, d= dose/#
To calculate dose for 1 # in D2 = d2
D(D+10) = 40(4+10) = 560
After try and error, 19 is best estimate.

2 different protocols for isoeffect

18. In clonogenic assay, 500 cells plated and irridated, 78 colonies growth .Plating
efficacy of 55%, the surviving fraction is:
A.
B.
C.
D.
E.

15%
20%
28%
35%
80%

Answer: C
SF =

Colony no rad_____
Seeded cell no rad x PE

Solution:
SF= Colony growth after irritated (78)/ [seeded no (500) x 55/100%)
= 78/(500 x .55)
= 0.283
Ans given in % then 0.283/1 x 100% = 28%
19. A patient with ca prostate with bone metastasis, he had RT to lumbar spine by 8Gy/1
Fr for pain control, patient was confirmed to have cord compression subsequently,
assume / for late toxicity is 2, how many fractions should be given if plan for 50Gy
in total, 2Gy/Fr.
A.
B.
C.
D.
E.

5 Fr
15Fr
20Fr
25Fr
30Fr

Answer: B
EQD2= D(d+ /)
(2+ /)

/ spinal cord 2

For 8Gy/1Fr, EQD2= 20 Gy

Remaining dose to be given is 50-20=30Gy and subsequently 30gy given in 2Gy/Fr, so
there is another 15 Fr remaining.
20. In Linear-Quadratic equation, if value is 0.03, value is 0.3, what is the survival
percentage after treatment with RT of 2Gy.
A.
B.
C.
D.
E.

15%
20%
28%
35%
80%

Answer: C

LQ model SF= e-(D+D2)

= e-(2x0.03 + 0.3 x 2 square)
= 0.28
21. What is correct about concurrent chemoradiotherapy?
A.
B.
C.
D.
E.

Commonly used chemotherapy agent in H&N is oxaliplatin

Chemotherapy given to dampen the side effect
Radiosensitiser has the synergistic effect with radiotherapy
Amifostine is developed to enhance the radiotherapy effect
Ideal radiosensitiser should reaches tumour and normal tissue in same
concentration

Answer: C
Radiosensitizers is an agent that increases the sensitivity of cells to radiation
Ideal radiosensitizer
Acts selectively in tumour compared to normal tissue
Reaches tumour in adequate concentration
Different toxicity profile fr RT
Enhance RT effect
Commonly used CCRT agent in H&N is cisplatin, amifostione is a radioprotector.
22. Which of the following is flexible type tissue:
A.
B.
C.
D.
E.

Kidney
Bone marrow
Gut
Mucosa
Skin

Answer: A
Flexible type tissue consists of 2 type of population cells thats stem cells mature cells
i.e late-responding tissue.
23. In multi-target model of survival curve, which of the following represent the repair
capacity:
A.
B.
C.
D.
E.

D0
D1
Dq
D10
N

Answer: C
D0 is the dose that decreases the surviving fraction to 37%, while D10 is the dose that
decreases the surviving fraction to 10% - D10= 2.3 x Do (1 log kill).Shoulder
region(started to bend) Dq- where sublethal damage repair occurred.
24. For relationship between RT to breast and second malignancy
A.
B.
C.
D.

Increase risk of 2nd malignancy, inproportionate with dose

Increase risk of 2nd malignancy, proportionate with dose
Not increase risk of malignancy
Develop 2nd malignancy after certain threshold

Answer: A
Stochastic Effects is where no threshold dose for these effects and probability of severity
with dose. Deterministic Effect is where a specific threshold dose to be reached and
severity of effects proportional to dose. Stochastic effect example: late effects of
radiation i.e carcinogenesis & inherited mutation.
25. What is true about fractionation of radiotherapy:
A.
B.
C.
D.
E.

Reoxygenation-improved efficacy of radiotherapy in protons therapy.

accelerated repopulation can be solved by hypofractionation.
Hypofractionation improved late side effect
Hyperfractionation worsened early side effect
CHART is an accelerated hyperfractionated regime for lung cancer

Answer: E
Reoxygenation-improved efficacy of photons radiotherapy not in protons therapy as low
LET radiation depends on indirect effect to damage the DNA and oxygen required as
explained by Oxygen-fixation hypothesis. SCC of the head & neck and cervix,
hyperfractionation
to
counter
this
accelerated
repopulation.
Hypofractionation(>2gy/fraction) worsen late side effect, hyperfractionation(<1.8-2Gy/#)
improved early side effect.