Melanoma FRCR CO2A Flashcards
(106 cards)
1
Q
origin of melanocytes and its migration
A
neural crest and migrates to basal layer of the epidermis and the uveal tract
2
Q
Types of cutaneous melanoma
A
- superficial spreading
- nodular
- acral lentiginous
- lentigo maligna melanoma
3
Q
Reason for rise in MM
A
- increased detection
- excessive recreational exposure to sunlight
4
Q
peak incidence and commonly affected race
A
4th and 5th decade
white>non white (10 x)
5
Q
RFs for Melanoma
A
- UV rad exp’
- skin type: fair skin with blond or red hair
- no of common naevi
- family hx
- CDKN2A : inherited germline mutation
6 . PUVA treatment
6
Q
Protective Role
A
Vitamin D
7
Q
Prevention strategies
A
- spend time in the shade between 11 am to 3 pm
- avoid getting sunburnt
- cover up with a hat, t shirt and sunglasses
- take extra care with sun protection for children
- SPF 15 sunscreen
8
Q
Pathology of mlenoma
A
atypical melanocytes that infiltrates into the dermis
no of mitoses, LVSI and regression
9
Q
feature of superficial spreading melanoma
A
- 70%
- pigmented lesions often flat or with slight elevation, irregular border and irregular pigmentation
- micro: dominant horizontal growth
10
Q
Nodular melanoma features:
A
- 15% of cases
- raised, nodular lesion, blue - grey to completely amelanocytic
- a/w ulceration / bleeding
- micro : no or minimal horizontal growth but ext dermal invasion
11
Q
Acral lentiginous melanoma features?
A
- 10 % of cases
- palms, soles, subungual regions (great toe, thumb)
- less related to UV exp
- micro: acanthosis of epidermis, atypical melanocytes
12
Q
lenti maligna melanoma (LMM)
A
5%
older pts usually on face
chronic sun exposure
precursor lesion: Hutchinson’s freckle, 5 % progress to LMM
13
Q
Breslow thickness
A
measures the depth of a melanoma tumor from the surface of the skin to the deepest point of the tumor cells, and is measured in millimeters
14
Q
Breslow thickness staging
A
Tis: Melanoma cells are only in the very top layer of the skin (epidermis).
T1: Melanoma is 1mm thick or less.
T2: Melanoma is between 1mm and 2mm thick.
T3: Melanoma is between 2mm and 4mm thick.
T4: Melanoma is more than 4mm thick.
15
Q
spread of Melanoma
A
skin, subcut tissues and LNs
16
Q
local spread of melanoma
A
initially, horizontal growth f/b vertical growth through dermis
17
Q
Satellite nodules and in transit nodules
A
satellites nodules: cut or subcut nodules less than 2 cm from primary tumor
in transit nodules: beyond 2 cm but not beyond the draining LNs
18
Q
metastatic spread of melanoma
A
Lung
Liver Bone
Brain
small bowel
meninges
GB
adrenals
19
Q
main c/f of cut melanoma
A
pigmented lesion with an irregular edge and irregular pigmentation
20
Q
ABCDE rule for melanoma
A
examination rule
A: Asymmetry
B: Boder irregular
C: Color irregular
D: Diameter > 5 mm
E: Elevation
21
Q
Revised 7 point check list
A
Major Features:
1. change in size of lesion
2. irregular pigmentation
3. irregular border
Minor features
1. inflammation
2. largest diameter 7 mm or greater
3. OOzing crusting or bleeding
22
Q
D/D of melanoma
A
- basal cell papilloma
- pigmented BCC
- thrombosed angioma
- pyogenic granuloma
- Dermatofibroma
23
Q
Investigations and Staging of melanoma
A
- Dermatoscopy:
- excision of the lesion s/times incisional
- C/E of LNs
24
Q
margin requirement as per lesion size
A
< 1 mm: 1 cm
1 - 2 mm: 1-2 cm
2 - 4 cm : 2 - 3 cm
> 4 cm : 3 cm
25
Surgery for localized cut melanoma
Wide excision of primary lesion, margin depends on breslow thickness
26
Elective Lymph Nodal Dissection (ELND)
in presence of SLNB positive
27
when is therapeutic complete node dissection advised in melanoma
clinically palpable nodal disease
28
current UK practise for SLNB
Melanoma > 1 mm
29
Stage IA adjuvant Rx
observation
30
Stage IB Adjuvant Rx
depends on SLN report, if negative observation
if +, further work up
31
stage Ib or II
adjuvant Pembrolizumab
(category 1)
* Nivolumab (category 1)
32
stage IIIA/IIIB/IIIC adjuvant treatment
Nivolumab
Pembrolizumab
Dabrafenib/
trametinib if BRAF V600 mutation
positive
33
stage wise 5 yr OS
I: 91 %
II: 64 %
III: 40 %
34
Prognostic factors at time of presentation:
1. Tumor Thickness
2. Ulceration
3. LNs
4. gender (female better than males)
5. Anatomical location (extremities better than face)
6. Age
35
Role of RT in melanoma
SRT/SRS for brain mets
36
metastatic melanoma Rx
Nivolumab/ipilimumab (category 1)
Nivolumab and relatlimab
(category 1)
* Anti-PD-1 monotherapyd,f,g
Pembrolizumab (category 1)
Nivolumab (category 1)
Other recommended regimens
* Combination targeted therapy if BRAF
V600 mutation positive
Dabrafenib/trametinib (category 1)
Vemurafenib/cobimetinib (category 1)
Encorafenib/binimetinib (category 1)
* Pembrolizumab/low-dose ipilimumabo
(category 2B)
37
What is the most aggressive form of skin cancer?
Melanoma
## Footnote
Melanoma is increasing in incidence, particularly in Europe.
38
By what percentage has the incidence of melanoma risen in Europe since the 1960s?
3–8% per year
## Footnote
This statistic indicates a significant increase in melanoma cases over time.
39
What is the lifetime risk of melanoma for men in the UK?
1 in 147
## Footnote
The risk for women in the UK is 1 in 117.
40
What is the lifetime risk of melanoma for men in Australia?
1 in 25
## Footnote
The risk for women in Australia is 1 in 35.
41
What has improved the overall survival rates of melanoma?
Early detection
## Footnote
Survival rates for higher stage disease have improved very little in the past 10 years.
42
At what age does the peak incidence of melanoma occur?
Middle age (40s)
## Footnote
Less than 10% of cases occur in childhood.
43
What is the main risk factor for cutaneous melanoma?
Ultraviolet sun radiation (especially UVB)
## Footnote
History of blistering sunburns increases risk by 2.5 times.
44
What is the relative risk (RR) of melanoma for people with freckling?
RR 2.5
## Footnote
Other surrogate markers of sun sensitivity also include burn without tanning (RR 1.7), red hair (RR 2.4), and blue eyes (RR 1.6).
45
What genetic factors increase the risk of melanoma?
Strong family history and inherited mutations in CDKN2A and CDK4
## Footnote
These mutations can lead to a 60–90% lifetime risk of melanoma.
46
How does having multiple benign naevi affect melanoma risk?
Increases the risk (RR 11)
## Footnote
Multiple atypical naevi also contribute to increased risk.
47
What is the relative risk of melanoma for transplant recipients?
RR 3
## Footnote
Patients with AIDS have a risk of RR 1.5.
48
What is the risk of developing a further melanoma for those with a previous melanoma?
2–10%
## Footnote
This risk increases further with two previous melanomas.
49
What is the most common histological variant of cutaneous melanoma?
Superficial spreading melanoma
## Footnote
Often arises within a pre-existing naevus.
50
What are the characteristics of nodular melanoma?
Symmetrical, uniform dark blue-black lesions
## Footnote
Amelanotic nodular melanomas are often misdiagnosed.
51
Where does lentigo maligna melanoma typically occur?
Sun-exposed areas of head, neck, and hands
## Footnote
These lesions are often large (often >3 cm) and arise from Hutchinson’s freckle.
52
What type of melanoma occurs on the palms, soles, and subungual regions?
Acral-lentiginous melanoma
## Footnote
Occurs with the same frequency in whites and non-whites.
53
What percentage of melanoma cases in whites are acral-lentiginous melanomas?
2–8%
## Footnote
In non-whites, this type accounts for 40–60% of melanoma cases.
54
What are the other forms of melanoma?
Ocular, mucosal, and vulval
## Footnote
These subtypes represent different locations where melanoma can occur.
55
What are the key histological features assessed in melanoma?
Type of melanoma, greatest thickness, radial or vertical growth phase, excision margins, immunohistochemical stains
## Footnote
Histological assessment is crucial for determining prognosis.
56
What is the most frequently used immunohistochemical stain in melanoma?
S100
## Footnote
S100 also stains benign melanocytes, which can complicate diagnosis.
57
What should be included in the detailed history when assessing melanoma?
* Duration of lesion presence
* Changes in lesion
* Origin from pre-existing lesion
* History of sun exposure and burns
* Family history of melanoma
## Footnote
A thorough history helps in evaluating risk factors.
58
What does the initial assessment of suspected melanoma include?
Detailed examination, clinical photograph of the lesion, full skin examination, examination for lymphadenopathy and hepatomegaly
## Footnote
This comprehensive assessment is essential for accurate diagnosis.
59
What are the clinical signs of melanoma?
* Itching
* Bleeding
* Ulceration
* Changes in a pre-existing mole
## Footnote
Recognizing these signs is critical for early detection.
60
List the ABCDE features used to distinguish early melanoma from a benign mole.
* A – Asymmetry
* B – Border irregularity
* C – Colour variation
* D – Diameter of >6 mm
* E – Evolution (change in lesion)
## Footnote
These features help identify potentially malignant lesions.
61
What are some prognostic factors in cutaneous melanoma?
* Breslow thickness
* Ulceration
* Presence of satellite lesions
* LDH
* Vascular invasion
* Surgical margin
* Clark’s level
* Nodal disease
* Extranodal metastases
* Mitotic count
## Footnote
These factors significantly influence the outcome and management of melanoma.
62
What is indicated in the absence of clinical evidence of metastatic disease in regional lymph nodes?
No staging investigations are indicated.
63
What may be useful for patients with thick primary tumors (>4 mm)?
CT scan.
64
What has been debated regarding node negative patients?
The role of elective lymph node excision.
65
What did initial retrospective studies show about elective node dissection?
A survival benefit.
66
What did four randomized studies find about elective node dissection?
No survival advantage.
67
What is the sentinel node (SN)?
The node to which lymph initially drains from a tumor.
68
What is the risk of sentinel node metastasis for a tumor thickness of less than 0.8 mm?
1% SN positivity.
69
What is the risk of sentinel node metastasis for tumors greater than 4 mm thick?
36% risk.
70
What is the correlation between sentinel node positivity and survival?
Strong correlation; 90% 5-year survival for SN negative vs. 56% for SN positive.
71
Is there a proven overall survival benefit from the routine application of SN in cutaneous melanoma?
No.
72
What is the predicted incidence of SN positivity for lesions >4 mm thick?
30–40%.
73
What does the ongoing MSLT-II trial aim to examine?
The benefit of complete dissection on survival.
74
What has no trial shown in relation to adjuvant chemotherapy for localized malignant melanoma?
A survival benefit.
75
What did a pooled analysis of three ECOG studies show about high dose interferon?
Improves relapse-free survival but not overall survival.
76
What is the standard procedure for tissue diagnosis in melanoma?
Excision biopsy with a 2–5 mm clinical margin.
77
What are the recommended surgical margins for melanoma based on thickness?
* 1 cm for lesions <1 mm * 1–2 cm for lesions 1–2 mm * 2 cm for lesions >2 mm.
78
What is the TNM AJCC system used for?
Staging melanoma and related prognosis.
79
What is the 5-year survival rate for Stage IA melanoma?
95%.
80
What is the prognosis for patients with non-visceral metastases?
Up to 18 months survival.
81
What is the median survival for patients with visceral involvement or elevated serum LDH?
4–6 months.
82
What is the treatment approach for isolated metastasis in melanoma?
Surgery may be the best option.
83
What is the common site for surgical resection of melanoma metastases?
Skin, brain, and lung.
84
What is typically not performed for liver metastases?
Surgical resection.
85
What is the role of radiotherapy after surgical resection of solitary metastasis?
Useful, especially after brain metastasis resection.
86
What are the treatment options for palliative radiotherapy?
* Bone metastasis * Spinal cord compression * Rapidly enlarging skin metastases.
87
What is the standard intravenous chemotherapy drug for metastatic melanoma?
Dacarbazine
## Footnote
Dacarbazine has a response rate of 10–20% and a median duration of response of 3–6 months.
88
What are the typical dosing regimens for Dacarbazine?
850–1000 mg/m2 every 3–4 weeks
## Footnote
Nausea is the main side effect of Dacarbazine.
89
What is Temozolamide?
An oral analogue of Dacarbazine that crosses the blood-brain barrier
## Footnote
It is more expensive and has no improvement in response rates compared to Dacarbazine.
90
True or False: Combination chemotherapy is superior to single agent drugs in metastatic melanoma.
False
## Footnote
There is no evidence that combination chemotherapy is superior in terms of response rates or survival.
91
What are the response rates for immunotherapy with high dose interleukin-2 (IL-2) or interferon alpha?
10–21%
## Footnote
Toxicities include hypotension, capillary leak syndrome, sepsis, and renal failure.
92
What is ipilimumab?
A monoclonal antibody against cytotoxic T-lymphocyte antigen 4 (CTLA-4)
## Footnote
It showed improved overall survival in previously treated patients with unresectable stage III/IV melanoma who were positive for HLA-A*0201.
93
What side effects are associated with ipilimumab treatment?
Rash, colitis, diarrhoea, and hepatitis
## Footnote
These side effects can occur during the treatment.
94
What did a meta-analysis of combining chemotherapy with an immune modulator show?
Improved response rates but no survival benefit
## Footnote
This suggests that while combination treatments may work better in some cases, they do not necessarily extend life.
95
What is isolated limb perfusion used for?
To establish good local control in disseminated skin metastases of a limb
## Footnote
TNF-alpha and melphalan are used in this procedure.
96
What is radiofrequency ablation (RFA) used for?
Treatment of liver and lung metastases when surgery is not possible
## Footnote
RFA is generally used for metastases less than 5 cm in size.
97
What are some newer agents being developed for melanoma treatment?
VEGF, BRAF, bcl-2
## Footnote
Studies are ongoing to assess the potential benefit of agents like bevacizumab and sorafenib.
98
What is the significance of prognostic factors in melanoma?
They help determine survival rates and treatment approaches
## Footnote
Prognostic factors include age, tumor size, and involvement of the ciliary body.
99
What is the follow-up protocol after surgery for melanoma patients?
Full skin and nodal examination, abdominal examination, and blood tests for high-risk patients
## Footnote
CT reassessment is suggested prior to surgery for nodal recurrence.
100
What is ocular melanoma?
A rare subtype of melanoma occurring in the eye, most commonly in the choroid
## Footnote
It has a high risk of metastasis, especially to the liver.
101
What are the common sites for mucosal melanoma?
Head and neck, female genital tract, anorectal
## Footnote
Mucosal melanomas constitute less than 2% of all melanomas.
102
What is the treatment of choice for mucosal melanoma?
Surgical resection with clear margins
## Footnote
Treatment can be challenging due to the location of the tumors.
103
True or False: Radiotherapy has shown an improvement in survival for mucosal melanoma.
False
## Footnote
Radiotherapy has not shown an improvement in survival and is not standard practice.
104
What is the prognosis for ocular melanoma after successful treatment of the primary?
Long-term survival is less than 35%
## Footnote
This is despite successful treatment of the primary tumor.
105
What complications may arise from the treatment of ocular melanoma?
Cataracts, glaucoma, retinopathy, and vitreous hemorrhage
## Footnote
These complications can occur with radiotherapy.
106
ABCD of melanoma
A – Asymmetry.
* B – Border irregularity.
* C – Colour variation.
* D – Diameter of >6 mm.
* E – Evolution (change in lesion).
