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FRCR2 > melanoma > Flashcards

melanoma Flashcards

1
Q

What are the referrals based on genetics for melanoma

A

Families with ≥3 cases of melanoma
x2 cases of melanoma in first degree relatives
First degree relative with melanoma and pancreatic cancer (P10 or P16)

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2
Q

What sites of melanoma are there

A

Skin
CNS & uveal
Aerodigestive - nasopharynx and oral cavity
GU tract

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3
Q

What subtypes of melanoma are there

A

Superficial spreading (commonest)
Nodular
Lentigo maligna, typically on the face
desmoplastic - acral lentiginous are typically on palms, soles, nail beds and mucosal surfaces

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4
Q

What stage of melanoma is signified by satellite and in transit mets
And how is each defined

A

Stage 3 - dermal lymphatic involvement

Satellite lesions < 2cm from primary tumour
In-transit lesions >2cm from primary tumour, but not beyond draining LN

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5
Q

How to examine a lesion suspicious for melanoma

A

A - asymmetry
B - border
C - colour
D - Dynamics - changing
E - elevation

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6
Q

How is a lesion biopsied

A

Excision biopsy with 2mm margin, reported for ulceration, depth of invasion and clearance of margins

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7
Q

What investigations are done for a potential metastatic melanoma

A

History and examination
Excision biopsy
Genetic testing if stage IIC or above
SNLB if stage 1b or higher (≥T2a)
Imaging
Bloods - raised LDH is prognostic

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8
Q

When is a sentinel LN biopsy done for melanoma

A

Stage 1b or above (≥T2a)

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9
Q

When is genetic testing indicated for metastatic melanoma

A

Stage IIC or above

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10
Q

What imaging is done for a pT1a metastatic melanoma

A

pT1a (low risk) - no additional ix necessary

pT1b-T4b -> US for locoregional LN metastasis, CT, PET, MRI brain
pT3b or above - brain MRI and PET
Whole body MRI If <24 years old with stage III/IV

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11
Q

What imaging is done for a pT1b-4b metastatic melanoma

A

pT1b-T4b -> US for locoregional LN metastasis, CT, PET, MRI brain

pT3b or above - brain MRI and PET
Whole body MRI If <24 years old with stage III/IV

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12
Q

What imaging is done for a metastatic melanoma pT3b or above

A

pT3b or above - brain MRI and PET
Whole body MRI If <24 years old with stage III/IV

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13
Q

When is whole body MRI indicated for metastatic melanoma

A

<24yrs with stage III-IV

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14
Q

How is T1 stage of melanoma split

A

T1a is size <0.8mm and not ulcerated
T1b is ≤0.8mm and ulcerated, or 0.8-1mm and either ulcerated or not

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15
Q

How are the M+ stages of melanoma defined

A

M1a = skin/subcutaneous mets or distant nodes
M1b = lung mets
M1c = visceral, but not CNS mets
M1d = CNS mets

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16
Q

What is the nodal status of stage 1-3 metastatic melanoma

A

Stages 1 & 2 are node negative
Stage 3 = node positive

17
Q

How is stage 1 melanoma defined

A

T1-T2a N0

18
Q

How is stage 2 melanoma defined

A

T2b-T4b N0

19
Q

How is stage 2 melanoma defined

A

N+ (1-3)

20
Q

How is stage melanoma defined

A

M+ (a-d)

21
Q

How does the breslow thickness of a melanoma affect the excision margin

A

Breslow thickness: <1mm
Excision margin: 1cm

Breslow thickness: 1-2mm
Excision margin: 1-2cm

Breslow thickness: 2-4mm
Excision margin: 2-3cm

Breslow thickness: >4mm
Excision margin: 3cm

22
Q

For what stage of melanoma should adjuvant treatment be considered

A

Stage 3 - ie node positive

23
Q

What is the management of a stage 1a melanoma

A

stage 1A = T1a-b (<1mm)

WLE only, according to Breslow thickness

24
Q

What is the management of a stage 1b-2c melanoma

A

Stage 1b (T2a) - stage 2c (T4) - >1-4mm, N0
WLE + SLNB

25
Q

How is stage 2 melanoma subdivided

A

stage 2A, 2B, 2C

2A = T2b-T3a (1-2mm and ulcerated, or 2-4mm and not ulcerated)

2B = T3b-T4a (2-4mm and ulcerated, or >4mm and not ulcerated)

2C = T4b (>4mm and ulcerated)

26
Q

When is adjuvant pembrolizumab indicated

A

Completely resected stage ≥2b melanoma

27
Q

What is the management of a stage 3 melanoma

A

Stage 3 = node positive
If resectable -> WLE +SLNB & adjuvant treatment (B-raf dependent)

B-Raf V600E+ -> adjuvant dab/tram
B-Raf V600E- -> adjuvant nivolumab or pembro

28
Q

How is the management of stage 4 melanoma divided

A

Stage 4 = M+

Resectable disease (primary and mets)
Unresectable disease

29
Q

When is adjuvant RT indicated for melanoma
What is the recommended dose

A

Cannot have adjuvant systemic treatment
Positive margins not amenable to further surgery / not adequate
Sites where local control is critical, such as head and neck

48Gy/20#

30
Q

What is the management of resectable stage 4 melanoma

A

If metastasis is resectable -> metastatectomy & adjuvant nivolumab (1yr), regardless of B-Raf status

31
Q

How is the management of unresectable stage 4 melanoma divided

A

By B-Raf V600E status

32
Q

What is the management of B-Raf WT non-resectable stage III/IV metastatic melanoma

A

Ipi/nivo first line, followed by maintenance nivolumab, independent of PDL1 status, if PS0-1

PS2 - single agent nivolumab or pembrolizumab

2nd line - single agent ipilimumab, if not received previously

3rd line - chemo or BSC

33
Q

What is the management of B-Raf mut non-resectable stage III/IV metastatic melanoma

A

If quick disease response needed, encorafenib/binetinib, with ipi/nivo or single agent pembrolizumab or nivolumb on progression

OR

Ipi/nivo or single agent pembrolizumab or nivolumb, with encorafenib/binetinib on progression

34
Q

When is nivolumab indicated for metastatic melanoma

A

Adjuvant treatment for completely resected stage 3 or 4 metastatic melanoma
or single agent 2nd line for Braf WT or mutant melanoma

35
Q

When is dabrafenib/trametinib indicated in melanoma

A

adjuvant treatment of respected stage 3, b-raf v600e positive (assuming Ras WT)

36
Q

What toxicities to dabrafenib and trametinib cause

A

Dabrafenib - anterior uveitis

Trametinib - retinitis, retinal vein occlusion, retinal detachment
If retinal vein occlusion, trametinib should be stopped permanently

37
Q
A

FRCR2 (28 decks)

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