Melanoma (Cut Off for Exam 2)

Question 1

ABCDE of Melanoma Detection

Answer 1

• Asymmetry
• Borders (even or uneven)
• Color (multiple or one)
• Diameter (>6 mm)
• Evolving (changing)

Question 2

Sunscreen

Answer 2

• SPF extends time to skin burn
• Apply 15-30 minutes before sun exposure
• Protect lips with SPF15+ lip balm
• Reapply every 2 hours during exposure and after swimming or sweating
• Water resistant shown to be effective for up to 40 min of swimming

Question 3

Non-Melanoma BCC

Answer 3

• Most common
• Usually develop on sun-exposed areas like face, head, or neck
• If not removed completely, BCC can recur in same place on skin
• Those with previous BCC are more likely to develop new ones in different places

Question 4

Non-melanoma cSCC

Answer 4

• Cutaneous squamous cell carcinoma
• Found on surface of lungs, thyroid, and esophagus
• 2nd most common
• Commonly appear on sun exposed areas like face, ears, neck, lips, back of hands
• Can develop in scars or chronic sores elsewhere

Question 5

Melanoma Types

Answer 5

• Cutaneous

- Uveal

Question 6

Non-Melanoma Risk Factors

Answer 6

• UV light exposure
• Fair-colored skin
• Age
• Male
• Chemical exposure
• Previous skin cancer
• Smoking
• Viruses
• Immunocompromised
• Solid organ transplant recipients

Question 7

NM Treatment Options

Answer 7

• Goal: Cure and maximally preserve function

- Surgery, radiation (non-resectable), and chemotherapy are all options

Question 8

Non-melanoma + Surgery

Answer 8

• Moh’s micrographic surgery
• Curettage and electrodessication
• Surgical excision

Question 9

Non-melanoma + Chemo

Answer 9

• Not routinely used for BCC or SCC
• Topical imiquimod or 5-FU if surgery or radiation isn’t appropriate
• Metastatic disease is preferentially treatment
• Hedgehog inhibitors are very active against BCC

Question 10

NM-BCC Treatment

Answer 10

• Surgery: complete removal
• High risk patients may need radiation, cryotherapy, topical 5-FU or imiquimod
• Rarely reaches advanced stages so systemic therapy usually not used
• Advanced BCC more likely to use targeted therapy

Question 11

NM-SCC Treatment

Answer 11

• Surgery: complete surgical removal
• High risk patients may need radiation, cryotherapy, topical 5-FU or imiquimod
• Chemo may by an option through immunotherapy might be used first (cisplatin, 5-FU)
• Cemiplimab

Question 12

Hedgehog Pathway Inhibitors

Answer 12

• Vismodegib (Erivedge)
• Sonidegib (Odomzo)
• Used to treat advanced/recurrent BCC
• Capsules taken daily
• AE: muscle spasms, joint pain, hair loss, fatigue, changes in taste, poor appetite, weight loss, NVD/C, itchy skin

Question 13

EGFR Inhibitors

Answer 13

• Cetuximab (Erbitux)

- AE: rash, diarrhea, mouth sores, loss of appetite

Question 14

NM-BCC Follow-up

Answer 14

• Every 6 months for 5 years

- 36% of patients with develop another primary BCC w/in 5 years

Question 15

NM-SCC Follow-up

Answer 15

-Every 3 months for 5 years
THEN
-Every 6 months indefinitely

Question 16

Melanoma Treatment

Answer 16

• Goal/strategy based on stage

- Surgery, radiation, and chemo can all play a role

Question 17

Melanoma Surgery

Answer 17

• Complete surgical excision is best chance for cure
• May be used as single modality in localized and regional disease
• Sentinel lymph node mapping and evaluation

Question 18

Melanoma Radiation

Answer 18

• Limited role in melanoma
• Adjuvant therapy for prevention of nodal relapse in high-risk patients
• Stereotactic radio surgery can be useful for isolated brain metastasis

Question 19

PD1 Inhibitors

Answer 19

• MoA: blocks checkpoints that stops T-cells from attacking other cells in the body, boosts immune response
• Indication: advanced SCC that cannot be cured with surgery or RT

Question 20

Immune-Related Adverse Events

Answer 20

• Inflammation of organs: skin, liver/lungs, endocrine, GI
• Prevent with close monitoring and patient education
• Treat with 1-2 mg/kg/day of prednisone or methylprednisolone for up to 3 days, taper steroid over 4+ weeks
• If no response in 3 days, “steroid refractory,” consider additional forms of immune suppression

Question 21

BRAF Inhibitors

Answer 21

• BRAF mutation occurs in 40-60% of melanomas
• CYP3A4 substrates, so be aware of DDIs
• Toxicities: nausea, diarrhea, pyrexia, dermatologic, arthralgia, fatigue, alopecia

Question 22

MEK Inhibitors

Answer 22

• Used for BRAF 600E mutation

- Toxicities: Dermatologic, diarrhea, edema, cardiomyopathy, retinopathy, fatigue, peripheral edema

Question 23

BRAF/MEK Combo

Answer 23

• Better outcomes when combined
• Decreased incidence of dermatologic toxicities
• More pyrexia occurs

Question 24

KIT Mutation

Answer 24

• Imatinib
• Toxicities: Fatigue, edema, myelosuppression, cardiomyopathy, hepatotoxicities, GI discomfort, GI perforation, bullous dermatologic reactions

Question 25

NRTK (+)

Answer 25

- Larotrectinib or Entrectinib | - Toxicities: Neurotoxicity, increased LFTs, cough, N/V

Question 26

T-VEC

Answer 26

- Talimogene Laherparepvec - Live oncolytic virus, generally modified HSV1 - Indication: unresctable cutaneous, SQ, and/or nodal tumors with recurrent melanoma after initial surgery - Viral shedding may occur, avoid direct contact with treat site, dressings, body fluids - Inject volume based on lesion size - Toxicities: herpes, injection-site rxn, immune-mediated events, fatigue, chills, pyrexia

Question 27

Aldesleukin (IL-2)

Answer 27

- MoA: promotes proliferation, differentiation, and recruitment of T/B/NK cells/thymocytes - Reserve for younger, healthier patients due to toxicities - AVOID in patients with inadequate organ reserve, poor PS, CNS involvement - Premeds - Toxicities: capillary leak syndrome, visceral edema, constitutional symptoms, pruritis, eosinophilia, hepatic/renal dysfxn, N/V

Question 28

BCG

Answer 28

- Bacillus of Calmette and Guerin Vaccine - Active immunity against mycobacterium tuberculosis - Off label use for melanoma - Toxicities: skin rxn, infections, anaphylaxis

Question 29

Melanoma + Chemo

Answer 29

- Limited role - First line therapies are immune or targeted therapies - Toxicities: nausea, myelosuppression, renal tox, hypersensitivities