258. Melanoma

Question 1

Epidemiology of melanoma (age, sex, race, deadliness)

Answer 1

Most serious form of skin cancer
5th leading cancer in men, 7th in women
20x more common in whites than AA
Risk increases as people age (avg 65 yrs)
More common in men overall, higher rates in women under 50

Question 2

Risk factors for melanoma

Answer 2

Genetics: family Hx, light skin, tendency to burn, red/blonde hair, light eyes, DNA repair defects

Environment: UV light, Sunburn, Equatorial Latitudes, Tanning

Gene-Environment Interaction: High number of atypical/dysplastic moles, freckles, personal hx of melanoma

Question 3

Development/Evolution of Melanoma

Answer 3

UV skin damage = DNA damage (amount of melanin = photoprotection)

(with increasing UV damage/point mutations)
Melanocyte = Nevus = Intermediate Neoplasm = Melanoma in situ = Invasive Melanoma = Metastases

Question 4

Key mutations in Melanoma

Answer 4

BRAF mutation: driver gene - treatable with BRAF-i’s

CDK2NA/P16: germline mutation for giving you many moles that can become malignant, also assoc with pancreatic cancer

Question 5

Public Guidelines for Melanoma Dx on self-exam

Answer 5

A - asymmetry
B - border irregular
C - color
D - diameter (large)
E - evolution

Question 6

Dermoscopic features of melanoma

Answer 6

pink structureless region with polymorphic vessels/dot vessels
Peripheral black dots
Pseudopods/segments
Blue-gray structures
White Lines/Streaks
General Haziness

Question 7

Most important indicator for melanoma dx

Answer 7

Breslow thickness (deeper = worse prognosis)
If >0.8mm deep - recommend lymph node biopsy

then: tumor thickness, ulceration, mitotic rate, regression, clark level (least helpful)

Question 8

Gold standard for Melanoma tx

Answer 8

Surgical Excision

Question 9

Adjuvant tx for Stage III melanoma (LN mets)

Answer 9

Excision + adjuvant:
immunotherapy/targeted tx
Nivolumab/Pembrolizumab (Anti-PD-1) - blocks T Cell death
Ipilimumab: Anti-CTLA4-mAB - blocks T Cell inactivation

Question 10

Tx for Stage IV melanoma

Answer 10

Intralesional Injection: Talimogene Laherparepvec (TVEC): oncolytic pseudo-HSV1 virus that replicates and lyses tumor cells while started immune response

Adjuvant tx as well

Question 11

Preventative measures for melanoma

Answer 11

“Broad Spectrum” sunscreen - covers UVA/UVB

SPF 30 sunscreen (97% UV light - SPF 50 is 98%)