Melanoma Flashcards
Melanoma risk factors
UV exposure
Precursor lesions- atypical or common nevi
Stage 1-2 definition
Tany N0 M0
Stage 1-2 treatment
Wide local excision (1-2 cm margin)
Offer sentinel lymph node biopsy to patients with cT2a or greater (> 1 mm depth)
If sentinel node negative or SLN bx not performed, no adjuvant therapy recommended
Clinically positive node treatment
Confirm with core bx or FNA
Wide local excision + therapeutic lymph node dissection
Consider adjuvant RT for multiple involved nodes, matted nodes, or extracapsular extension
Sentinel node positive treatment
Only applies to patients that were clinically node negative but had positive SLN bx
Preferred option is surveillance with nodal basin US, can consider completion lymph node dissection
Stage 3 definition
Lymph node positive, no distant mets
Stage 3 treatment
Complete resection followed by adjuvant pembro or nivo x 1 year or adjuvant dabrafenib+trametinib for BRAF V600 mutant
In very low risk patients with non-ulcerated primary <2mm and SLN metastasis <1mm, adjuvant toxicity may outweigh benefit
Stage 4 1L systemic treatment
Pembro Nivo Ipi/nivo- better intracranial activity than PD-1 monotherapy or dabrafenib+trametinib BRAF+MEK inhibitors Vemburafenib + cobimetinib + atezo
*Ipi monotherapy no longer recommended as first line
Dabrafenib/trametinib AEs
Fevers, chills
Back pain
Rash
Alopecia
Vemurafenib/cobimetinib AEs
Diarrhea Transaminitis Photosensitivity Rash HTN
Encorafenib/binimetinib AEs
Vomiting Palmar-plantar erythrodysesthesia Myalgias Alopecia Retinal detachment
2L+ systemic therapy
Same PD-1 and BRAF options as in 1st line
Pembro + low-dose ipi for tumors that progressed after prior PD-1
Imatinib for activating KIT mutation
Binimetinib for NRAS mutated that progressed after IO
Intralesional TVEC +/- ipi
Cytotoxic agents (dacarbazine, TMZ, paclitaxel)
Non-metastatic uveal melanoma treatment
Eye-preserving iodine plaque radiotherapy or enucleation (no difference in melanoma specific OS)
