exam 2 lecture 5 (melanoma)

Question 1

What are melanocytes? use? What is melanoma?

Answer 1

Melanocytes are dendritic pigmented cells located in skin and eye. They synthesize melanin to protect tissues from UV raditaion

melanoma results from malignant transformation of skin melanocytes

Question 2

risk factors for melanoma

Answer 2

old white men.

tanning bed

Question 3

WHAT ARE THE DIFFERENT GROWTH PATTERNS OF MELANOMA AND HOW PREVALENT THEY ARE, who are they common in

Answer 3

1. Superficial spreading melanoma - 70% of cases, more in women
   nodular melanoma- 15% of cases, men
   Lentigo malina melanoma- elderly
   acral lentiginous melanoma- on palms and soles. In africans, asians, latinos

Question 4

Clinical presentation of meanoma

Answer 4

ABCDE
- Asymmetric
- irregular Borders
- wide variety of Colors
- DIameter of >6mm
- Evolution of mole

Question 5

how to diagnose melanoma

Answer 5

Biopsy of suspected lesion is gold standard
History and PE
CT scan if metastatic

Question 6

treatment overview of melanoma based on stages

Answer 6

Stage IB or IIA (lymph node negative
-clinical trial or observation

stage IIB or IIC (lymph node negative)
- clinical trial, observation, pembrolizumab

Stage III
- Nivolumab, pembrolizumab (both immunotherapies)

or dabrafenib/trametinib (if bRAF mutant), with or without radiation FOR A YEAR

unresectable stage III
-T-VEC, topical imiquimod, radiation, limb perfusion

Question 7

what is preferred adjuvant treatment in melanoma? What other drug is similar interms of efficacy and toxicity

Answer 7

nivolumab

pembrolizumab is similar interms of efficacy and toxicity

Question 8

What adjuvant is used for completely resected stage III disease with BRAF V600E or V600K mutations

Answer 8

Dabrafenib + trametinib

Question 9

Why are trametinib and dabrafenib given together

Answer 9

Trametinib is MEK inhibitor and BRAF like dabrafenib increases efficacy

BRAF inhibitor alone leads to resistance, that is why we add MEK inhibitor

Question 10

first line treatment options for metastatic melanoma

Answer 10

1. anti-PD-1 monotherapy
   -nivolumab
   -pembrolizumab
   -nivolumab and relatimab
2. combination targeted therapy if BRAF V600 mutation
   -Dabrafenib/trametinib
   Vemurafenib/cobimetinib
   -encorafenib/binimetinib (preferred)
3. certain circumstances
   - nivolumab/ipilimumab (lots of toxicities. Has to be a young and strong patient)

notice there are no chemo therapies.

Question 11

toxicity of dabrafenib/trametinib

Answer 11

Pyrexia (fever), fatigue, nausea

Question 12

2nd line tx options of metastatic tx of melanoma

Answer 12

same as 1st line except the addition of pembrolizumab/low dose ipilimumab if pt failed on anti PD-1 tx

and another difference is we MAY use chemo if we tried the anti PD-1 therapy (including pembro/ipili) and there are no BRAF mutations

Question 13

If we have a BRAF mutation with melanoma do we always go with BRAF therapy

Answer 13

Yes, works quicker.

Immunotherapy takes weeks to work

Question 14

What type of drug is vemurafenib? Unique toxicities?

Answer 14

BRAF inhibitor

toxicity- development of squamous cell carcinoma

Question 15

What is used as MEK inhibitor with vemurafenib

Answer 15

cobimetinib

Question 16

why is encorafenib/binimetinib used over vemurafenib/cobimetinib and dabrafenib and trametinib

Answer 16

Less fever, better tolerated

Question 17

what is something to know about immunotherapy compared to chemo

Answer 17

Make sure you do not stop immonotherapy treatment early, they make tumor worse before it gets better. Chemo is usually 2-3 cycles by immunotherapy needs about 4

Question 18

pembrolizumab toxicity

Answer 18

may cause colitis, diabetes, hypophysitis

give steroids if severe

Question 19

prognosis of melanoma

Answer 19

patients with melanoma>4mm thick have 50% risk of relapse

patients with lymph node involvement have a 50-85% risk

5 year overall survival 94%

Question 20

screening of melanoma? prevention?

Answer 20

full body exam

sunscreen
avoid tanning bed