Flashcards in Melanoma Deck (28):
Melanoma originates from these embyonic cells?
neural crest cells which migrate to skin, aerodigestive tract and uvea
Recognized risk factors?
-personal or family history
-multiple benign or atypical nevi (>50)
-intermittent severe sunburns
-sensitivity to sun exposure
Subtypes of melanoma (order of frequency) ?
-Superficial spreading (70%): sun-exposured, classic irregular nodule
-Nodular (20%): rapid growing, homogenous darkly pigmented
-Lentigo maligna: chornically solar-damaged skin, older pts on head and neck
-Acral lentiginous: Asian and african descent: subungually on the palms and soles
-Desmoplastic: rare and aggressive; usually amelanotic
-Uveal melanoma: can dx w/o biopsy, usually met to liver
Most common molecular features and historical correlate?
-Activating BRAF (50%) mutations; usually seen in intermittently solar damaged skin rather than chronic
-KIT: usually acral lentignous
-NRAS (15%): can be seen in both
-GNAQ or GNA11: 50% of uveal
What is molecular feature of inherited melanoma
-alteration of tumor suppressor CDKN2A encoding p16INK4A and p19ARF
What is summary of TNM staging in melanoma?
0: confined to epidermins
I: Ib: 4cm with ulceration
III: positive nodes: IIIa: Ib disease with 1-3micronodes, IIIb: any size with 1-3 macro nodes no ulceration, IIIc: IIIb with ulceration or in-transit mets/satellites
Prognostic variables in primary cutaneous melanoma?
Lymph node positivity
Breslow depth (tumor thickness)
mitotic rate (thin primary
Melanoma with no nodes is treated how?
Surgery with adequate margins
Margin recommendations for melanoma?
Tumor size: Margin
melanoma in situ: 0.5 cm
0.5-1mm: 1.0 cm
1-2mm: 1.0-2.0 cm
When do you perform sentinal lymph node mapping/ biopsy? Data? Survival Benefit?
lesions >=1cm in breslow depth; if high risk features than
What is standard of care for positive nodes on SLN mapping in melanoma?
complete lymphadenectomy (this is being formally answered in MSLT-II)
What is satellitosis?
at least 1 seperate focus adjacent to primary
What is in-transit?
not immediately adjacent but within draining nodal basin
Standard of care for in-transit?
surgical resection if possible
What is survival for Stage IIIA, IIIB & IIIC in melanoma respectively?
80, 60, & 40%
What defines Stage III disease in melanoma and how is it managed?
Lymph node involvment,
surgical resection followed by adjuvant therapy or observation
What are adjuvant options?
clinical trial, radiotherapy (for regional control) or high dose interferon alpha-2b
How is interferon usually given?
20 million units/m2 IV M-Fx4 weeks followed by 10 million units/m2 subq 3xweek for 48 weeks
What's the data show for interferon in stage IIB-III melanoma?
OS and DFS at 5 years that disappears in meta-anaysis with median follow-up of 12.6 years
In addition to standard toxicities, what else are you concerned for with interfereon therapy?
liver dysfunction myeosupression and depression
What is standard surviellance for early stage melanoma followed by resection?
Exam 3-4 months, for first 2 years, then q6 months for next 3 years
NO imaging, only at clinican's discretion
LDH is only lab value to follow
What is management of recurrent disease?
- if local can resect; if unresectable considered hyperthermic or isolated limb infusion
What is Stage IV melanoma further classified by? (2 factors beginning with L)
location and LDH
What is M1a, M1b or M1c disease imply? And respective survival?
M1a: distant skin, subcutaneous or nodal metastatic disease with normal LDH (30%)
M1b: lung metastasis with normal LDH (20%)
M1c: visceral mets or any mets with LDH elevation (10%)
What if available, is the most important therapeutic option, melanoma?
What are your options for unresectable melanoma?
-nivolumab +/- ipi
-dabrafenib + trametinib (mek inhibitor)
Name an unusual side effect of vemurafenib therapy?
incidence of squamous cell carcinoma and keratoacanthoma