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Melanoma Flashcards

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1
Q

Review updated tumor staging guidelines for melanoma.

A
  • Tx: cannot be assessed
  • T0: no primary tumor
    -Tis: in situ
  • T1: ≤ 1.0 mm
    — a: ≤ 0.8 mm w/o ulceration
    —b: 0.8- 1.0 mm without ulceration, ≤ 1.0 mm w/ ulceration
  • T2: 1.1-2.0 mm
    —a: w/o ulceration
    —b: w/ ulceration
  • T3: 2.1 - 4.0 mm
    — a: w/o ulceration
    — b: with ulceration
    -T4: > 4 mm
    —a: w/o ulceration
    — b: w/ ulceration
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2
Q

Review general overview of lymph node staging in melanoma

A

-Nx: regional nodes can’t be assessed
-N0: no regional Mets
-N1: 1 node
-N2: 2 or 3 nodes
-N3: ≥ 4 nodes

Subcategories for each
-A: clinically occult node(s) w/o satellites, local recurrence, or transit Mets
-B: clinically detected node(s) “ ^”
-C: no satellites (N1), 1 clinically occult node w/ “^” (N2), 2 or more nodes clinically occult or with satellites, local recurrence, or in transit Mets in > 1 node

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3
Q

Review the metastasis staging for melanoma

A

-M0: no Mets
-M1a: Mets to skin, subQ or distant LN
—(0) normal LDH
—(1) elevated LDH
-M1b: Mets to lung
—(0) normal LDH
—(1) elevated LDH
-M1c: Mets to all other visceral sites
—(0) normal LDH
—(1) elevated LDH
-M1d: Mets to brain
—(0): normal LDH
—(1): elevated LDH

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4
Q

What is recommended regarding genetic expression profile outside of clinical study?

A

Don’t recommend genetic expression profile outside of clinic study

Still get SNLB

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5
Q

What are liquid biopsies being explored for in melanoma?

A

Prognosis, monitor treatment response, genetic tumor evolution, and acquired drug resistance

Based on circulating tumor cells, cell-free tumor DNA, microRNA

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6
Q

What is the significance of the presence of BRAF in melanoma prognosis?

A

Independent prognostic factor for progression and recurrence free survival

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7
Q

What predicts response and prolonged survival in patients treated with pembrolizumab or nivolumab?

A

Undetectable cell-free tumor DNA level at baseline or within 8 weeks of therapy

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8
Q

What is the effect of surgery timing after biopsy on mortality risk?

A

Surgery within 30 days of biopsy lowers mortality risk

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9
Q

What margin is recommended for Breslow thickness < 1 mm?

A

1 cm margins

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10
Q

What margins are recommended for Breslow thickness > 1 but ≤ 2 mm?

A

1-2 cm margins

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11
Q

What margins are recommended for Breslow thickness > 2 mm?

A

2 cm margins

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12
Q

What technology is used for identifying sentinel lymph nodes in melanoma surgery?

A

Indocyanine green based technology

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13
Q

What are the advantages of indocyanine green over methylene blue?

A

Highest tissue penetration, visualization up to 1 cm deep, lack of radiation, lower side effect protein, less false negatives

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14
Q

Does complete lymph node dissection after positive SLNB increase survival benefit?

A

No increased survival benefit compared to observation of nodal basin

Complete dissection if evident disease; may depend on subgroups of melanoma

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15
Q

What are melanomas derived from?

A

Melanocytes in the stratum basale

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16
Q

What are the four layers of the epidermis from deep to superficial?

A
  • Stratum basale
  • Stratum spinosum
  • Stratum granulosum
  • Stratum corneum
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17
Q

What additional layer is found in glabrous skin?

A

Stratum lucidum

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18
Q

What type of cells are found in the stratum basale?

A

Basal cells

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19
Q

What do basal cells differentiate into?

A

Keratinocytes

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20
Q

What is formed in the stratum spinosum?

A

Intercellular connections via desmosomes

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21
Q

What do keratinocytes have in the stratum granulosum?

A

Keratohyalin granules

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22
Q

In the stratum corneum, how are the cells arranged?

Study These Flashcards
A

Compact and surrounded by a lipid layer

23
Q

Where are Merkel cells located?

Study These Flashcards
A

Stratum basale

24
Q

Where are Langerhans cells found?

Study These Flashcards
A
  • Stratum spinosum
  • Stratum granulosum
  • Dermis
25
What is a congenital melanocytic nevus associated with?
Abnormalities of the vertebral column, including spina bifida
26
What is the recommended treatment for giant congenital melanocytic nevus?
Surgical treatment does not reduce risk. Risk of melanoma in this population is 0.7 - 2.9% vs. 0.6% in the general population. Melanoma is a generic biological risk rather than related to the nevus itself. Melanoma highest risk on trunk lesions, but can still occur in satellite lesion instead of the gain nevus itself.
27
What defines a giant nevus?
* 20 cm in greatest dimension in an adult or will be once child grown * Nevus > 100 cm² in area * Nevus that cannot be excised in one stage
28
What is the melanoma risk in patients with multiple congenital nevi?
> 3 nevi indicates malignant potential
29
What is the second most common subtype of melanoma?
Nodular melanoma
30
When should non-urgent surgery for melanoma in pregnancy be performed? What if the risk of waiting is unacceptable?
In the second trimester to avoid preterm contractions and spontaneous abortion. If risk to high >> perform a wide local excision with local anesthetic after a preioerative lymphoscintigraphy with delayed sentinel node biopsy during general anesthesia in the second trimester or after delivery
31
Where are nodular melanomas commonly seen?
* Trunk * Head * Neck
32
What is a characteristic appearance of nodular melanoma?
Dark, dome-shaped with a blood blister appearance Show a rapid vertical growth phase
33
What is the most common subtype of melanoma?
Superficial spreading melanoma
34
What characterizes superficial spreading melanoma?
Lateral spreading of malignant melanocytes in the epidermis in sun exposed skin or from pre-existing nevi
35
What is the typical location for lentigo maligna?
Chronically sun-exposed areas like face and neck
36
What is the treatment of choice for lentigo maligna? What if they are not surgical candidate?
Wide local excision (5-10 mm margins) Can’t do Mohs b/c can’t interpret melanocyte proliferation on frozen section; must send for permanent for final margins Second line therapy is radiation and 5% imiquimod (clearance rate of 50-93% and 24.5% recurrence); can also be used on positive or close margins after excision if re-excision not possible or would cause unacceptable morbidity.
37
Where is acral lentiginous melanoma seen and in what population?
Found on palms, nail bed, soles of feet Dark-skinned patients
38
What is the typical prognosis for acral lentiginous melanoma?
Worse than other melanoma subtypes (5 year survival 80% vs 91% in other types)
39
What is a characteristic feature of subungual melanoma?
Longitudinal band > 3 mm or irregular border, extension onto periungal skin (Hutchison’s sign - extends from top of nail to nail bed and into eponychium), single finger involvement
40
What is the current recommendation for biopsy in subungual melanoma?
Perform a biopsy of any subungual lesion after 4 weeks without significant change
41
What type of melanoma is desmoplastic melanoma?
Rare subtype with aggressive local growth
42
What is the best method of biopsy for suspected melanoma?
Excisional biopsy
43
What is the standard surgical treatment for melanoma?
Wide local excision + sentinel node biopsy if < 0.75 mm + high risk factors (ulceration, male sex, head/neck location), consider for 0.8-1.0 mm, all > 1 mm need SLNB. SLN biopsy does not increase survival - it is diagnostic Must be sent for permanent sections for final margins. Frozen sections (aka MOHs) not an option in melanoma
44
What is the purpose of immunoscoring and immunoprofiling?
To evaluate preexisting antitumor immunity, identify therapeutic targets, and predict response to immunotherapy or small molecule inhibitors. ## Footnote Involves microscopy and molecular testing of the primary tumor or metastatic disease.
45
What role does CTLA-4 play in immune response?
Downregulates immune response by transmitting inhibitory signals to T cells. ## Footnote Ipilimumab is an anti-CTLA-4.
46
How does PD-1 affect T cell proliferation?
Inhibits T cell proliferation and survival by binding PDL-1. ## Footnote Nivolumab and Pembrolizumab are anti-PD-1.
47
What correlation exists between PDL-1 expression in pretreatment biopsies and clinical outcomes?
Correlates with response and survival. ## Footnote Important for predicting the effectiveness of immunotherapy.
48
List some immune-mediated adverse responses associated with immunotherapy.
* Rash * Diarrhea * Colitis * Vitiligo * Hypopituitarism * Hypophysitis * Adrenal insufficiency ## Footnote PD-1 inhibitors are associated with fewer adverse responses.
49
What is the function of BRAF in cell growth?
Regulates cell growth by mitogen-activated protein kinase. ## Footnote Mutation common is BRAF-V600E.
50
What are the side effects of BRAF inhibitors?
* Arthralgia * Fatigue * Diarrhea * Cutaneous toxicity * Keratoacanthoma * Well-differentiated SCC ## Footnote Effects can be mitigated by adding a MEK inhibitor.
51
What is the benefit of combining BRAF and MEK inhibitors?
Increased tumor response, decreased drug resistance, and decreased SCC due to unmasking of oncogene cancer RAS mutations in sun-damaged skin. ## Footnote This combination therapy helps manage side effects and improve efficacy.
52
When is immunotherapy considered in melanoma
Stage III melanoma (positive nodes)
53
Review pathological staging of melanoma

Skin Cancer/ Skin Lesions/ Soft Tissue (3 decks)

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