Post-Test Questions

Article One (pp. 3–11)

1. When should transarterial chemoembolization (TACE) no longer be pursued in the hepatocellular carcinoma (HCC) patient population?

   • Failure to achieve an objective response after at least two treatments

   • Clinical progression of disease to ECOG performance >2

   • Emergence of new hepatic foci remote from the treated territory

   • Development of a contraindication to TACE once therapy has been initiated

   • All of the above are indications to discontinue TACE therapy

2. Which of the following was a finding not supported by the PRECISION V trial?

   • Demonstrated a trend toward improved outcomes in the drug-eluting beads (DEB) population but did not reach statistical significance

   • Showed significantly less increase in the elevation of liver enzymes following DEB therapy compared with oily TACE

   • DEB therapy demonstrated a significantly higher rate of chemotherapy-induced side effects than oily TACE

   • Demonstrated a significant improvement in the objective response rate and disease control rate in the DEB arm compared with the oily TACE arm in patients with advanced disease

   • None of the above

3. Which of the following is true regarding the SPACE study?

   • Is an ongoing open-label study comparing DEB and sorafenib in the treatment of advanced HCC

   • The objective of the study is to evaluate combination DEB and sorafenib in the treatment of patients with advanced HCC

   • All patients receive sorafenib, and half are randomized to receive DEB

   • The study is being conducted at 40 centers in Asia and North America

   • All of the above are false

   Article Two (pp. 12–20)

4. All of the following are true regarding colorectal cancer except:

   • Half of all patients with hepatic metastases from colorectal cancer can undergo surgical resection

   • Hepatic metastases are present in 20 to 30% of all colorectal cancer patients at the time of diagnosis

   • Up to 60% of all colorectal cancer patients develop liver metastases at some point during their disease process

   • The 5-year survival rates in patients with metastatic disease is 10 to 15%

   • All of the above are true

5. Median survival for patients undergoing yttrium therapy for metastatic colorectal cancer to the liver is:

   • 3 to 6 months

   • 6 to 9 months

   • 9 to 12 months

   • 12 to 15 months

   • 15 to 18 months

6. Types of transarterial therapies that have been used in the treatment of colorectal cancer metastatic to the liver include all of the following except:

   • Hepatic arterial infusion therapy

   • Chemoembolization

   • Radioembolization

   • Percutaneous hepatic perfusion

   • All of the above have been used

   Article Three (pp. 21–27)

7. In the United States, the incidence of both intrahepatic and extrahepatic cholangiocarcinoma is rising.

   True or false?

8. Recent literature suggests that the following drug combinations except which one may improve survival times of patients with cholangiocarcinoma by an extra 3 months?

   • Doxorubicin and gemcitabine

   • Gemcitabine and cisplatin

   • Oxaliplatin and gemcitabine

   • All combinations have shown increased effectiveness

   • None of the above combinations have shown increased effectiveness

9. Median survival rates for patients with intrahepatic cholangiocarcinoma undergoing DEB-TACE range from:

   • 4 to 12 months

   • 6 to 18 months

   • 12 to 24 months

   • 12 to 30 months

   • 24 to 48 months

   Article Four (pp. 28–38)

10. Liver-directed therapies are used in patients with metastatic neuroendocrine tumors who:

    • Have symptoms related to hormonal access

    • Have symptoms related to tumor bulk

    • Have rapidly progressive disease

    • Have liver-dominant disease, even in the presence of extrahepatic metastases

    • All of the above

11. The following is false regarding liver-directed therapies for metastatic neuroendocrine tumors:

    • Embolization therapies can elicit a carcinoid crisis

    • Carcinoid crisis is treated by intravenous administration of 200 µg of octreotide

    • Postembolization syndrome occurs only rarely in patients with metastatic neuroendocrine tumors undergoing chemoembolization.

    • Octreotide can be given prophylactically prior to liver-directed therapies in this patient population

    • All are true

12. Radioembolization has not been proven to be effective in the treatment of metastatic neuroendocrine disease.

    True or false?

    Article Five (pp. 39–48)

13. Which of the following therapies has not been evaluated in the locoregional treatment of metastatic uveal melanoma?

    • Chemoembolization

    • Immunoembolization

    • Radioembolization

    • Isolated hepatic perfusion therapy

    • All have been evaluated

14. Which of the following is correct regarding survival rates following chemoembolization for metastatic uveal melanoma?

    • Overall survival times for patients who do demonstrate an imaging response to therapy is 12 to 22 months

    • Overall survival times for patients who do not demonstrate an imaging response to therapy is 12 to 22 months

    • Overall survival times for all patients is 12 to 22 months

    • None of the above

15. Which of the following is correct regarding uveal melanoma?

    • Overall 5-year survival from the time of diagnosis is 30%

    • Up to 75% of all patients develop systemic metastases

    • In patients with metastases, nearly half demonstrate involvement of the liver

    • Metastatic disease to the liver occurs after diagnosis of the primary tumor in 90% of patients

    • None of the above are correct

    Article Six (pp. 49–55)

16. In which of these clinical scenarios has radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) proven to be effective?

    • Resectable HCC

    • Unresectable HCC

    • As a bridge to transplant

    • Recurrent HCC

    • All of the above

17. RFA has been shown to be effective in the treatment of liver metastases from all of the following primary sources except:

    • Breast cancer

    • Renal cell carcinoma

    • Pancreatic cancer

    • Neuroendocrine tumors

    • Gastric cancer

18. In the large study by Koda et al (>13,000 patients), the overall complication and mortality rates from liver RFA were:

    • 1.2% and 0.1%, respectively

    • 3.5% and 0.04%, respectively

    • 4.5% and 0.4%, respectively

    • 5.5% and 0.07%, respectively

    • None of the above

    Article Seven (pp. 56–66)

19. Theoretical advantages of microwave include all of the following except:

    • Produces highly predictable ablation zones

    • Capable of generating high temperatures

    • Little to no heat-sink effect

    • Does not require ancillary components such as grounding pads

    • Is highly conducive to the use of multiple probes

20. Ablation with microwave has better survival rates and lower complication rates than ablation with RFA.

    True or false?

21. The following are current limitations of microwave ablation therapy except:

    • Unpredictability to the size of the ablation zone

    • Large-diameter probes (13 to 14F)

    • Shaft heating

    • Inability to burn the track on removal of the probes

    • All of the above are limitations

    Article Eight (pp. 67–73)

22. Which of the following regarding electroporation is true?

    • Causes cell death through heat caused by friction

    • Always causes irreversible damage

    • Increases temperature in exposed tissue to ≥60°C

    • Has always been used to kill cancer cells

    • All of the above are false

23. Which of the following is true regarding the use of irreversible electroporation (IRE) adjacent to hepatic vessels?

    • The heat-sink effect is as pronounced with IRE as it is with radiofrequency ablation

    • Damage to the adjacent vessels is more pronounced that with other ablative techniques

    • Ablation zones with IRE are typically seen up to the margin of blood vessels

    • All of the above are true

    • None of the above are true

24. Current limitations to IRE include:

    • Limited clinical experience in humans

    • Need for multiple needle placements regardless of the size and number of treatment zones

    • Inability to ablate the track on removal of the needles

    • Parallel placement of the probes is mandatory

    • All of the above

    Article Nine (pp. 74–81)

25. All of the following are considered relative contraindications to combination therapy except:

    • ECOG Performance Status >1

    • Renal or cardiac insufficiency

    • Uncorrectable coagulopathy

    • Serum bilirubin >2 mg/dL

    • None of the above

26. The optimal time period between thermal ablation and chemoembolization is 1 month.

    True or false?

27. Which of the following is a theoretical benefit of combining thermal ablation with chemoembolization?

    • There is an increased effect of chemotherapy drugs due to sublethal hyperthermia at the margins of ablation zones

    • There is a decrease in the heat-sink effect following preablation embolization therapy

    • Both of the above

    • Neither of the above