Malignant Melanomas

Question 1

What are the RFs for malignant melanoma?

Answer 1

PH and FH of cutaneous melanomas
High density of common and atypical nevi
Immunodeficiency/immunosuppression
Sun sensitivity or exposure

Question 2

What are the clinical presentations of malignant melanoma?

Answer 2

Questionable lesions

Possible signs of metastasis

Question 3

What are the ABCDEs of nevi?

Answer 3

Asymmetry
Border irregularity
Color 
Diameter
Enlargment/evolution

Question 4

How are malignant melanomas diagnosed?

Answer 4

Review of patient history to identify RFs
Biopsy
Total dermatologic examination
Lymph node evaluation
May do additional imaging studies if metastasis suspected

Question 5

How are malignant melanomas staged?

Answer 5

TNM

Question 6

What factors affect the T in TNM system?

Answer 6

Tumor thickness
Mitotic rate: higher rate indicates cancer more likely to grow and spread
Ulceration: breakdown of skin over the melanoma. Worse prognosis with more ulceration

Question 7

What is stage 0 melanoma?

Answer 7

Melanoma in situ

Question 8

What is stage I melanoma?

Answer 8

Tumor < 1-2 mm in thickness

Question 9

What is stage II melanoma?

Answer 9

Tumor > 2 mm in thickness

Question 10

What is stage III melanoma?

Answer 10

Clinically positive nodes and/or separate distinct lesions

Question 11

What is stage III in-transit ?

Answer 11

Spread through lymph and begins to grow > 2cm away from the primary but before reaching the nearest lymph node

Question 12

What is stage IV melanoma?

Answer 12

Distant metastatic disease

Question 13

What are the prognostic factors for melanoma?

Answer 13

Tumor thickness
Mitotic rate
Tumor ulceration

Question 14

What are the treatment goals of localized melanoma?

Answer 14

Cure

Question 15

What are the treatment goals of regional disease?

Answer 15

Possible a cure if able to do surgery +/- adjuvant chemo

Question 16

What are the treatment goals of metastatic disease?

Answer 16

Slow progression
Prolong life
Improve QOL
Relieve acute sx

Question 17

What is the primary treatment for stages 0-I?

Answer 17

Wide excision +/- sentinel lymph node biopsy (SNLB) with thicker disease

Question 18

Is adjuvant therapy needed in stages 0-I?

Answer 18

No

Question 19

What is the primary treatment for stage II?

Answer 19

Wide excision +/- SLNB

Question 20

What is the adjuvant treatment for stage II melanoma?

Answer 20

Interferon alfa in select cases but not routinely used

Question 21

What is the primary treatment for stage III melanomas?

Answer 21

Wise excision + lymph node dissection

Question 22

What are the adjuvant treatment options for stage III melanoma?

Answer 22

None/observation
Radiation
Nivolumab/HD ipilimumab
Dabrafenib/trametinib (if BRAF V600 mutations)
Interferon alfa

Question 23

What is the primary treatment of stage IV melanomas?

Answer 23

Surgery if resectable
Systemic chemotherapy
+/- palliative radiation therapy

Question 24

What systemic therapies are first line options if the patient has wt BRAF V600?

Answer 24

Nivolumab
Pembrolizumab
Nivolumab + ipilimumab

Question 25

What are the systemic therapies that are first line if the patient has a BRAF V600 mutation?

Answer 25

``` Nivolumumab Pembrolizumab Nivolumab + ipilumab Dabrafenib + trametinib Vamurafenib + cobimetinib ```

Question 26

What are the PD-1 inhibitors?

Answer 26

Nivolumab | Pembrolizumab

Question 27

How do PD-1 inhibitors work?

Answer 27

Block interaction between PD-1 and PD-L1 which normally deactivates T cells

Question 28

What are AEs of PD-1 inhibitors?

Answer 28

``` Rash Pneumonitis Colitis Hepatitis Nephritis Renal dysfunction Hypothyroidism Hyperthyroidism ```

Question 29

What is the CTLA-4 monoclonal antibody?

Answer 29

Ipilimumab

Question 30

What was the first anti-cancer drug for advanced melanoma to demonstrate overall survival?

Answer 30

Ipilimumab

Question 31

What are the GI AEs of ipilimumab?

Answer 31

Diarrhea Colitis Blood in stool

Question 32

What is the treatment for the GI AEs of ipilumumab?

Answer 32

If moderate-severe = corticosteroids

Question 33

What are the AEs for skin AEs d/t ipilumumab?

Answer 33

SJS | Maculopapular rash

Question 34

How do we treat skin AEs d/t ipilumumab?

Answer 34

Topical or oral steroids

Question 35

What are the liver AEs d/t ipilumumab?

Answer 35

LFT elevation

Question 36

How do we treat AEs of liver d/t ipilumumab?

Answer 36

If severe = steroids

Question 37

Which anti-cancer drugs are MEK inhibitors?

Answer 37

Tramatinib | Cobimetinib

Question 38

What are the AEs for Debrafenib/trametinib and Vemurafenib/cobimetinib combinations?

Answer 38

Pyrexia Cutaneous malignancies Bleeding Thromboembolic events

Question 39

What is pyrexia associated with?

Answer 39

Chills Night sweats Dehydration Electrolyte abnormalities

Question 40

What is talimogene laherparepbvec indicated for?

Answer 40

unresectable recurrent melanoma in the skin or lymph glands

Question 41

How is talimogene administered?

Answer 41

Intralesional Injection

Question 42

How does talimogene work?

Answer 42

Virus relicates within cancer cell and secretes GM-CSF, which attracts dendritic cells and T cells

Question 43

What are the AEs of talimogene?

Answer 43

Injection site reactions Fatigue Chills Flu-like sx