Melanoma & Skin Cancer

Question 1

What is a melanoma?

Answer 1

• Melanoma is a malignant tumor of
  melanocyte origin
• often occurs on the skin
• primarily due to the highest concentration
  of melanocytes in all other parts of the
  body, and is most often described in skin
  tumors

Question 2

What are the localisation of Melanoma and Clinical types of melanoma?

Answer 2

Localisation:
- skin
- ocular
- submucosa = oral, GIT, vagina, urethra
- Melanoma of unknown primary (MUP syndrome)

Clinical types:
- superficial
- nodular
- lentigo melanoma and lentigo maligna
- Acral lentiginous melanoma
- Amelanotic and desmoplastic melanoma

Question 3

What are the risk factors?

Answer 3

hereditary:
- familial nevus dysplastic syndrome
- increased no.of moles (>120)
- > 6mm mole size
- FHx of + melanoma

Acquired:
- excess exposure to sun
- skin freckles

Question 4

What is the ABCDE detection of melanoma?

Answer 4

Asymmetry
Border
Colour
Diametre
Evolving

Question 5

PTH immunoprofile for melanoma?

Answer 5

Typical imunoprofile: S100+, HMB45+, MelanA+

Question 6

What are the stages of Breslow scale?

Answer 6

STAGE 1: < 1mm

STAGE 2: 1-2mm

STAGE 3: 2.01-4mm

STAGE 4: > 4mm

Question 7

Where does ocular melanoma metastasise?

Answer 7

Ocular melanoma metastasizes exclusively in liver (80%), rarely in CNS, while other sites are extremely rare (almost never)

Question 8

-What is the treatment for unresectable/metastatic?

Answer 8

• anti-PD 1 monotherapy
  pembrolizumab
• BRAF mutation
  Dabrafenib

Question 9

What are some prognostic parameters in Melanoma?

Answer 9

Histological:
- Breslow scale (or Clark Scale)
- ulceration
- pigmentation
- melanoma regression
- TILS (Non-BRISK & BRISK)
- Cell type (epitheloid, spindle)

Clinical:
- LDH levels
- early vs advanced clinical stage
- number of metastatic sites

Question 10

Local disease treatment for melanoma?

Answer 10

Excision margin based on depth in Breslow (mm)

Wide Local Excision Margins

Melanoma iS = 0.5cm margin

< 2mm (T1-T2) = 1 cm margin

> 2mm (T3-T4) = 2 cm margin

*done alongside sentinel lymph node biopsy

Question 11

What is the ESMO treatment guideline for stage I-III melanoma?

Answer 11

• assess in SLN is positive or negative

Negative:
- FU, if relapse, then complete LN dissection (CLND)
- adjuvant tx

Positive:
- Adj Tx
or US based FU, assess for relapse, then CLND

Question 12

When is RT recommended in melanoma?

Answer 12

• Post op RT incase of at least 1 of the following:
• 3 pathological LN
• Extracapsular spreading
• LN metastasis > 3 cm

Question 13

Significance of adjuvant treatment in melanoma?

Answer 13

• beneficial to administer adj tx of high risk primary cutaneous melanoma (stage III and resectable IV)

Immune Checkpoint Inhibitor (ICI) e.g. pembrolizumb

Target Therapy e.g. dabrafenib for BRAF mutation

Question 14

ESMO treatment of inoperable stage III-IV BRAF mutated melanoma?

Answer 14

1st line is immunotherapy
pembrolizumab

2nd line is targeted therapy
Dafrafenib

*if LDH elevated this can be 1st line due to high tumour burden

Question 15

What are the types of basocellular carcinoma (BCC)?

Answer 15

• nodular
• superficial
• Morfeaform
• pigmentous
• fibroepithelial

Question 16

Basic treatment for skin BCC?

Answer 16

• small dimension: surgery
• larger dimension: surgery, RT
• locally advanced: Neoadj hedgehog inhibitors, salvage surgery and RT
• metastatic: hedgehog inhibitor e.g. vismodegib

Question 17

What is skin SCC and its basic treatment?

Answer 17

• ulcerative or exophytic lesion of skin
• metastatic potential > BCC, frequently in regional LN

First line treatment is surgery

Question 18

What is Merkell Cell Carcinoma (MCC)

Answer 18

• high aggressive neuroendocrine skin carcinoma with high metastatic potential
• pink papula appearance with 20% from polyoma virus
• Pink papula (≈ 65% local, 26% in lymph nodes, 8% distant metastases)
• local disease treated by surgery
• advanced stage ICI e.g. pembrolizumab
• chemotherapy (Etopozid+Cisplatin)

Question 19

What is Kaposi Sarcoma? (KS)

Answer 19

• indolent vascular tumour of endothelian origin
• caused by human herpes virus 8 (HH8)
• AIDS related
• mostly indolent but may be aggressive
• described as skin cancer, but histologically not

Question 20

Types of KS?

Answer 20

• Classic: purple slow-growing macula (lower extremity, nose, ears)
  Indolent disease course
• Endemic: benign lymphadenopathy and children with fulminant lymphadenopathy (no HIV)
• Iatrogenic: immunosuppressive patients in SOLID organ tx or autoimmune disease
• Epidemic: HIV infection, in homosexuals, most aggressive form with M in LN and viscera

Question 21

Diagnosis of KS?

Answer 21

• Pathohistological verification
• HIV status
• Lung, abdomen, pelvis CT
• Endoscopy
• PET-CT

Question 22

Localised KS treatment?

Answer 22

• surgical excision
• cryotherapy
• laser ablation
• vincristine as a cytotoxic agent for intralesional application

Question 23

Systemic KS treatment?

Answer 23

• cART for HIV/AIDS
• Doxorubicin, Paclitaxel

Question 24

Is secondary skin cancer rare?

Answer 24

Yes

Although rare, it is still possible e.g. via haematological cancer

Biopsy and PH verification for diagnosis

Question 25

Hematological cutaneous infiltration (leukomid)?

Answer 25

• Leukomid = skin myeloid sarcoma
• AML which infiltrates skin in a form of leukemid
• Presents as M4 and M5, FAB subtype of AML
• cutaneous infiltration as first sign of AML or AML relapse
• Tx same as for AML
• poor prognosis