Malignant Melanoma

Question 1

Malignant melanoma is the least common of the top 3 skin cancers. What is the annual incidence of this in the UK?

1 - 160
2 - 1600
3 - 16,000
4 - 160,000

Answer 1

3 - 16,000

Question 2

Is malignant melanoma more common in darker or fairer skin types?

Answer 2

• fair skin types

Question 3

When does malignant melanoma more commonly present?

1 - face
2 - head
3 - back
4 - legs

Answer 3

3 - back
- occurs on skin infrequently exposed to sun
- sudden bursts are worse when compared to cumulative exposure

Question 4

Which of the following is the main risk factor for skin cancer?

1 - socioeconomic background
2 - age
3 - family history
4 - gender

Answer 4

2 - age

Reflects long term accumulation of DNA damage

Question 5

Which of the following is the key risk factors for malignant melanoma?

1 - gender
2 - burning episodes
3 - sun bed exposure
4 - age

Answer 5

3 - sun bed exposure
- 86% of melanoma’s are caused by exposure to UV rays

Malignant melanoma are typically caused by overexposure to ultraviolet radiation

Question 6

Which of the following is a malignant melanoma?

Answer 6

• bottom left

Question 7

Melanoma Detection

A - Asymmetry
B - Border (irregular)
C - Colour (more than 2 colours)
D - Diameter (>7mm)
E - Evolution

LOOK FOR UGLY DUCKLING

Answer 7

• important to identify these things to the patient
• do not need all of these
• evolution is key!! History is therefore very important

Question 8

What is the best cure for melanoma?

1 - immunotherapy
2 - excision
3 - efudix cream
4 - early detection

Answer 8

4 - early detection
- prevent

• immunotherapy has improved those where early detection is not always done

Question 9

If a melanoma metastasises on the skin, should we be looking for further brown nodules?

Answer 9

• no
• typically red nodules close to the scar for melanoma excision

Question 10

What is the ONLY modifiable risk factor for skin cancer?

1 - sun exposure
2 - weight
3 - immunotherapy
4 - smoking
5 - age

Answer 10

1 - sun exposure

Question 11

Avoiding peak UV times can help mitigate the risks associated with skin cancer. What are peak UV times?

1 - 9am - 1pm
2 - 11am - 12pm
3 - 11am - 3pm
4 - 1-3pm

Answer 11

3 - 11am - 3pm

Question 12

Which of the following are ways to minimise UV exposure and reduce the risk of skin cancer?

1 - Wear hats, sun glasses, clothes
2 - Sunscreen on face and as needed elsewhere
3 - Broad spectrum of >SPF30
4 - Suncream containing UVA: 4-5 stars
5 - all of the above

Answer 12

5 - all of the above

Question 13

If a malignant melanoma is identified they are typically treated with a wide local incision. Which of the following would trigger the need to perform a sentinel lymph node biopsy?

1 - >65
2 - tumour depth >0.8mm
3 - >3 colours in melanoma
4 - bleeding from melanoma

Answer 13

2 - tumour depth >0.8mm

In high risk tumours, this threshold is lowered to >75mm

Breslow thickness is used to assess this

Question 14

Which of the following methods is most typically used to stage a melanoma if metastasis is suspected?

1 - whole-body and brain contrast-enhanced computed tomography (CT) scan
2 - whole-body and brain contrast MRI
3 - PET-CT
4 - X-ray

Answer 14

1 - whole-body and brain contrast-enhanced computed tomography (CT) scan

MRI may be used in special circumstances

Question 15

What is the main stay of treatment in patients with suspected malignant melanoma?

1 - cryotherapy
2 - beclometasone
3 - incision of melanoma, histology, depth measurement and return for wide excision
4 - wide local incision followed by chemotherapy and radiotherapy

Answer 15

3 - incision of melanoma, histology, depth measurement and return for wide excision

Question 16

If a sentinel lymph node biopsy is performed and lymph nodes are found to be positive, how are try typically treated?

1 - radiotherapy
2 - chemotherapy
3 - lymphadenopathy
4 - hormonal therapy

Answer 16

3 - lymphadenopathy

If it is a singular lymph node, lymph node dissection can be performed

Question 17

If a patient has metastatic disease associated with malignant melanoma they may be give adjuvant therapy alongside surgery/radiotherapy. This is commonly pembrolizumab, but what is the mechanism of action of this drug?

1 - binds to receptors on tumours and inhibits their growth
2 - inhibits PD-L1 on tumours cells
3 - inhibits cytotoxic T cells
4 - stimulates new antibodies against tumours

Answer 17

2 - inhibits PD-L1 on tumours cells

PD-L1 = Programmed death-ligand 1

PD-L1 on tumours is able to inhibit cytotoxic T cells so they do not kill the tumour

Without PD-L1, PD-1 on T cells can induce lysis of tumours

Question 18

Diarrhoea is a common adverse effect of chemotherapy medications. Which of the following side effects are the cause of Diarrhoea following chemotherapy?

1 - intestinal obstruction
2 - intussusception
3 - colitis
4 - all of the above

Answer 18

3 - colitis

Question 19

If a patient is experiencing diarrhoea as a side effect of chemotherapy medication, which of the following medications would be most effective at alleviating the diarrhoea?

1 - Loperamide
2 - Macrogol
3 - Senna
4 - Lactulose

Answer 19

1 - Loperamide
This is an Antipropulsives / Antidiarrhoeals

All the others are stimulants or laxatives and would make diarrhoea worse

Question 20

If a patient presents with suspected immunotherapy toxicity following melanoma malignancy therapy, all of the following should be performed, EXCEPT which one?

1 - admit and rehydrate
2 - give loperamide
3 - Bloods- FBC, U&Es, LFTs, CRP, TFTs
4 - blood transfusion
5 - Rule out infection (MC&S, C diff toxin)
6 - antibiotics for signs of colitis
7 - Steroids
8 - Sigmoidoscopy/ colonoscopy +/- biopsy

Answer 20

4 - blood transfusion

Question 21

A 73-year-old woman is seen by the dermatologist with a mole on her back. It measures 8mm in diameter, has irregular borders and is noted to have variation in colour. A biopsy taken confirms malignant melanoma with an invasive depth of 4mm, there is also ulceration present. The tumour is shown to carry a BRAF mutation and has a high mitotic rate. She has asked if she is likely to die from the illness.

Which is the worst prognostic factor in this case?

1 - BRAF mutation
2 - Depth of the lesion
3 - Diameter of the lesion
4 - Mitotic rate
5 - Ulceration

Answer 21

2 - Depth of the lesion

Accounts for around 70% of prognostic factor