Post-Test Questions

Article One (111–117)

1. When performing irreversible electroporation, what level of sedation is sufficient?

   • No sedation required

   • Local anesthesia

   • Monitored anesthesia care (MAC)

   • General anesthesia

2. Which of the following conditions would make IRE an unfavorable choice?

   • Tumor location adjacent to the common bile duct

   • Tumor location adjacent to the portal vein

   • Patient with severe bradycardia (< 30 bpm)

   • Patient with metastatic disease

3. What is the proposed mechanism of action of irreversible electroporation?

   • Thermal

   • Creation of nano sized holes in the cell membrane

   • DNA nucleating

   • Protein destruction

4. What is the major advantage of IRE over traditional thermal ablation modalities (RFA, microwave, cryo)?

   • Typically does not require sedation

   • Offers much more protection to adjacent structures such as bile ducts and vessels

   • Offers wider zone of ablation

   • Is the best ablation modality for immediate postprocedure monitoring using imaging

   Article Two (118–124)

5. Which of the following is an indication of treatment failure following thermal ablation of primary lung tumors?

   • An initial perilesional ground glass halo with or without an increase in lesion size on CT during the first 2 months

   • A residual nodule that is stable or decreasing in size; an elongated linear nodule due to fi brosis; or atelectasis

   • Cavitation of the treated lesion

   • Incomplete disappearance of the initial nodule

   • None of the above are indicative of treatment failure

6. Regarding complications arising from thermal ablation in the lungs, which of the following is NOT true?

   • The reported major complication rate after lung RFA is ~10%

   • Pneumothorax requiring chest tube insertion has an incidence of 20 to 25% in a large cohort of patients

   • Nerve injury can aff ect the phrenic, brachial, left recurrent laryngeal, intercostal nerves, and the stellate ganglion

   • Hemorrhage from cryotherapy of lung tumors has a theoretically higher risk of hemorrhage due to the lack of a cautery eff ect observed with heat-based ablation

   • The reported mortality rate after lung tumor RFA is 2%

7. Which of the following is NOT an indication for ablative treatment of pulmonary nodules?

   • Patients who are not candidates for curative surgical resection as a result of cardiorespiratory comorbidity or poor vital lung function

   • Patients being considered for ablation should have an Eastern Cooperative Oncology Group performance status of > 2

   • Life expectancy of > 1 year

   • Lesions smaller than 3 cm

   • All are indications

   Article Three (125–128)

8. The following statements about laparoscopic-assisted microwave ablation are correct EXCEPT:

   • Laparoscopic microwave ablation is used in the treatment of hepatocellular carcinoma

   • The recurrence rates after microwave ablation of colorectal metastases are dependent on the size of the intrahepatic masses.

   • Five-year patient survival rates after microwave ablation of colorectal metastases are better in those patients undergoing hepatic resection.

   • Laparoscopic microwave ablation of hepatocellular carcinoma demonstrates 1-year recurrence rates of approximately 20%.

9. Laparoscopic microwave ablation of liver tumors is associated with

   • Comparable disease-free survival rates as patients undergoing resection

   • Published morbidity rates in > 30% of patients

   • A higher incidence of tract seeding than radiofrequency ablation

   • Radiation damage to the surrounding tissues

10. Advantages of laparoscopic assistance during thermal ablation of liver tumors include

    • Ability to survey the abdomen for extrahepatic intraperitoneal spread of disease

    • Ability to treat lesions located in areas that are difficult to reach percutaneously

    • Ability to visually confi rm placement of the antenna and move the liver to minimize contact with surrounding organs

    • Provides complementary real-time guidance for placement of the antenna including ultrasound and visual intraperitoneal imaging

    • All of the above

    Article Four (129–137)

11. All of the following statements regarding chemical ablation technique are true EXCEPT:

    • Direct injection of a high-concentration ethanol using a multi-side-hole needle in a tumor at multiple sites not only increases the interstitial pressure but also enables a greater local concentration gradient, which results in the high convective and diff usive flux of the agent into the cytoplasm.

    • When acetic acid and sodium hydroxide are mixed together, it creates an exothermic neutralization reaction. Exothermic neutralization is a chemical reaction that occurs between an acid and a base, in which heat, salt, and water are produced.

    • In several randomized controlled trials, in the treatment of small HCC, RF ablation demonstrates an approximately 20% higher survival rate at 3 to 4 years with fewer treatment sessions than PEI.

    • Due to multiple session numbers, high local progression rate, and variable ablation zones in RF ablation compared with PEI, the use of RF ablation is now signifi cantly limited to when PEI ablation cannot be performed safely (e.g., in cases with the tumor located close to the large vessels or critical organs).

12. All of the following statements are true regarding thermal ablation techniques EXCEPT:

    • HIFU is a thermal ablation technique using focused acoustic energy that is precisely delivered from an extracorporeal source to the focal zone.

    • Laser ablation is a thermal ablation technique using laser light transmitted to the lesion via bare-tip quartz fi bers with diameter of 300 to 600 μm inserted through multiple, small-caliber needles.

    • IRE is a thermal ablation technique using short pulses of high voltage electrical energy that is applied to a targeted tissue through electrodes.

    • MW ablation is a thermal ablation technique using high-frequency (900–2,500 MHz) electromagnetic fields to create rapid frictional movement of water molecules.

13. All of the following statements are true regarding thermal ablation techniques EXCEPT:

    • MW ablation has several advantages including a large ablation zone, less heat sink eff ect, and faster ablation times.

    • Postablation syndrome includes fl u-like illness, low-grade fever, nausea, and/or vomiting. The incidence and severity are similar between MW ablation and RF ablation.

    • RF ablation should be considered a very effective treatment modality for large HCC ( 5 cm) compared with other thermal ablation techniques.

    • Cryoablation is associated with the cytokinemediated systemic syndrome, known as “cryoshock,” which includes fever, tachycardia, and tachypnea.

    Article Five (138–48)

14. Cryoablation is less commonly used in the treatment of liver tumors than other ablation modalities for all of these reasons EXCEPT:

    • Cryoablation requires placement of multiple cryoprobes given its small size of ablation zone.

    • There is more risk of diaphragmatic injury and postprocedural pain when treating hepatic dome tumors.

    • There is more risk of hemorrhage because it does not cauterize the needle tract.

    • There is more risk of parenchymal crack after cryoablation.

15. All of the following are factors that may increase the risk of tumor seeding along the needle tract in the liver tumor ablation EXCEPT:

    • Well-diff erentiated tumor

    • Subcapsular location of the tumor

    • Prior percutaneous biopsy

    • Biopsy results can help guide follow-up after ablation

    • Multiple placement of ablation needls

16. Which of the following is FALSE regarding ablation treatment of renal tumors?

    • A minimum of 5 mm of fat between the target tumor and the adjacent bowel is suggested to be sufficient insulation to protect from thermal damage.

    • Genitofemoral nerve injury may occur if ablation zone is close proximity to the psoas muscle.

    • Tumor seeding along the needle tract is as common as liver ablation.

    • Hematuria occurs infrequently after ablation and is typically self-limited and resolves within 12 to 24 hours.

    Article Six (149–156)

17. The following maneuvers can be used to displace the adrenal gland from adjacent structures EXCEPT:

    • Repositioning the patient

    • Angling the CT gantry

    • Hydrodissection

    • Different phases of inspiration

    • All of the above can be used

18. Regarding chemical ablation of the adrenal gland:

    • Agents typically used are betadine and ethanol.

    • Placement of a sheath needle is typically performed to improve distribution of the agent.

    • Chemical ablation works by protein denaturation that causes coagulative necrosis and thrombosis of small vessels.

    • With chemical ablation, there is higher risk for collateral damage to adjacent organs compared to thermal ablative methods.

    • All of the above are true.

19. True or False? Complete response by imaging criteria is necessary to achieve symptomatic control following ablation of functioning adenomas?

    • True

    • False

    Article Seven (157–166)

20. The mechanism of action by which microwave ablation causes cell death is:

    • Cellular crystal formation

    • Agitation of water molecules causing frictional heat

    • Nanopore formation from electrical current placed across cell membrane

    • Intracellular microbubble formation

21. A theoretical advantage that irreversible electroporation may have over current ablative technologies is in the:

    • Treatment of exophytic < 4 cm lesions

    • Treatment of the anteriorly located right kidney lesion

    • ITreatment of the central lesion in close proximity to the collecting system

    • None of the above

22. Based on scientifi c data presented, what outcome differences exist comparing cryoablation with radiofrequency ablation?

    • Cryoablation has a reduced complication profile

    • Radiofrequency ablation has a reduced complication profile

    • Cryoablation shows better oncologic outcome

    • Radiofrequency ablation shows improved oncologic outcome

    • There is no signifi cant diff erence between oncologic and complication outcomes

23. True or False? Cryoablation may be a less painful ablation modality than radiofrequency ablation.

    • True

    • False

    Article Eight (167–179)

24. What bone lesion is best suited for primary cure utilizing RFA?

    • Chondroblastoma

    • Osteoid osteoma

    • Plasmacytoma

    • Eosinophilic granuloma

25. What techniques have been described to reduce cryoablation thermal injury complications?

    • Fluid displacement

    • Warmed solution placed on overlying skin

    • Intermittent image surveillance of ice formation

    • All the above

26. What are important pre-procedure clinical considerations for palliative management of bone tumors?

    • Quantitative assessment of pain

    • Patient treatment expectations

    • Evaluation of potential complications

    • All the above

    Article Nine (180–186)

27. Hepatic malignancies in which of the following locations is an absolute contraindication to ablation?

    • Caudate lobe

    • Adjacent to the gallbladder

    • Hepatic hilum

    • Hepatic dome

28. Which of the following factors have been shown to affect prognosis after ablation?

    • Size of the lesion

    • Child-Pugh class

    • Number of lesions

    • All of the above

29. Combination therapy with RFA plus TACE has been shown to improve survival outcome in which setting?

    • Small HCC

    • Medium size HCC

    • Multifocal HCC

    • All of the above

    Article Ten (187–192)

30. The greatest clinical impact of PET/CT prior to percutaneous ablation of hepatic tumors is to:

    • Further evaluate the size of the target lesion(s).

    • Identify unexpected extra-hepatic metastases.

    • Predict which lesions are most likely to recur following ablation.

    • Identify adjacent structures at risk during ablation.

31. FDG administered prior to percutaneous ablation may be used for all of the following EXCEPT:

    • To target a lesion not seen with other imaging modalities.

    • To confi rm optimal placement of the ablation probe for ablation.

    • To evaluate the completeness of ablation.

    • To visualize the introducer needle tip with PET.

32. All of the following statements regarding PET/CT following percutaneous ablation of hepatic tumors are true EXCEPT:

    • Increased rim enhancement of an ablated lesion seen with MRI 48 hours after treatment is an indicator of residual disease.

    • A focal area of increased FDG uptake peripheral to a central photopenic area seen with PET 48 hours after treatment is an indicator of residual disease.

    • PET/CT has been shown to be more sensitive and specific in detecting residual or recurrent disease after ablation compared to both contrast enhanced MRI and CT.

    • PET/CT can detect residual tumor that can be masked on contrast enhanced MRI, CT or ultrasound 48 hours after treatment.

    Article Eleven (193–202)

33. Treatments for Fibroadenoma include all of the following EXCEPT:

    • Watchful waiting.

    • Repeated core biopsy until entire lesion is excised

    • Surgical resection

    • Ablation

    • Radiation therapy

34. Options for image guidance for breast tumor ablation include all of the following EXCEPT:

    • Stereotactic X-ray machine

    • MRI

    • Ultrasound

    • Near-Infared imaging

35. Cryoablation is being studied regarding immunomodulation, in order to stimulate a patient's immune system to destroy their own cancer cells.

    • True

    • False