Melanoma Flashcards
what study to do to detect lymph node mets
ultrasound
what study to look for distant mets
PET-CT scan
What study to look for brain mets
MRI
In stage 4 melanoma what lab is elevated that predicts poor prognosis?
LDH
how much lower risk for recurrence if the the sentinel node is not positive?
5% lower risk for recurrance.
Positive sentinel node no longer need a complete node dissection. What should you do?
Monitor the nodal basin with ultrasound
What percent of people with a positive sentinel node biopsy do not have other nodes involved.
80%
What are the current guidelines for lymph nodes if there is a positive sentinel node biopsy?
Ultrasound monitoring q 4mos for 2 years and
q6 mos for 3 through 5 years
At what melanoma stage would imaging be considered to evaluate specific signs or symptoms.
IIB-IV
When can imaging screens stop for asymptomatic recurrence of melanoma?
5 years
What are the two treatment arms of metastatic melanoma?
Immunotherapy
Targeted therapy
What do immuno therapy monoclonal antibodies do?
Block inhibitory signals of the immune system increasing the immune response.
What type of antibody is ipilimumab?
CTLA-4 CTLA-4 blocks antigen presentation to the T cell.
What type of antibodies are nivolumab and pembrolizumab.
PD-1 antibodies between Tcells and tumor cells
What type of antibody is atezolizumab
PD-L1 (program cell death ligand)
What pathway does melanoma targeted therapy affect?
MAP kinase signaling pathway - regulates cell proliferation
What is the common mutation in melanoma
BRAF (V600E/K)
When is a melanoma not a candidate for BRAF inhibition targeted therapy.
When a patient test BRAF negative for a mutation.
What is a BRAF inhibitor always combined with in treatment?
MEK inhibitor - MEK is a down stream product of BRAF production.
What is Talimogene laherparepvec (T-VEC)
oncolytic viral TX
What type of virus is Talimogene laherparepvec (T-VEC)
Herpes Simplex
On dermatoscopic exam list four features of Lentigo Maligna.
Hyperpigmented follicular openings.
Annular granular patterns
Pigmented Rhomboid structures
Dark Blotches and obliterated hair follicles.
In doing T staging for melanoma for AJCC guidelines what criteria was dropped from the 7th to 8th edition
Mitotic rate.
What is the new depth for T1a for melanoma
What would a melanoma of breslow thickness .87 be reported as.
.9 They now round to to the .1mm either up or down.
What are the two features in T staging a melanoma.
Breslow thickness and ulceration.
How many of the T stages in melanoma have a and b components.
all of them.
what does the b component represent in the T stages of melanoma
ulceration
what is the one exception to the b stage and ulceration.
A T1b can also be .8 to 1.0 without ulceration
The T stages of the melanoma are what type of staging
Clinical
What is the best way to biopsy a nail plate pigmented streak.
Proximal nail plate curl with a shave biopsy of the matrix.
what are features of a melanoma of the nail bed.
A pigmented band of varying color and thickness.
What percent of melanomas are familial?
10%
When should a sentinel node bx be considered?
any thing T1a
What is the risk percent of a T1a melanoma having a + sentinel node biospy?
<5%
Acral and mucosal melanomas are more likely to have what kind of mutations?
Kit
Lentigo Maligna melanomas are more likely to have what type of mutations.
UV induced NRAS mutations
superficial spreading melanomas are more likely to have what type of mutations
BRAF
uveal melanoma mutations are more likely what?
GNAQ
On histologic exam what is the one feature that might make one consider a sentinel node bx if the breslow thickness was <8mm
ulceration
Does pregnancy affect prognosis in a pregnant female with melanoma?
no
What drug is associated with development of multiple halo nevi
Infliximab (Remicade) tx for autoimmune disease.
What are some of the histopathological criteria for melanoma 5 with MART1 stain
When using MART 1 stain
- nests of three or more atypical melanocytes
- pagetosis (melanocytes above DE junction)
- Confluence of 9 or more adjacent melanocytes with variability along the margin.
- vertical stacking of melanocytes
- atypical nests in the dermis
What three stains should be used in desmoplastic Melanoma (spindle cell melanoma)
Sox10, S100, p16 other common melanoma stains may be negative.
In the year following a diagnosis of a halo nevus what is the risk for developing a melanoma for that year.
1%
What are the #1 and #2 sites for mets with a melanoma.
Skin and Lungs
where is the most common location for melanoma in men
back
Where is the most common location site for melanoma in women?
leg
Which type of melanoma on the head/neck is there no difference in survival btw wide local excision and Mohs.
nodular melanoma shows same survival rate for both types of surgery. Better survival for others with Mohs.
How might high citrus consumption lead to an increased risk for melanoma?
The psoralens in the citrus and Psoralen is a photo carcinogen (this is a theory)
High testosterone not only contributes to > risk for melanoma but what other cancer.
Prostate.
Is a nevoid melanoma a melanoma arising out of a nevus?
No, it is a melanoma that is easily mistaken both clinically and histologically as a nevus.
What is the key feature that distinguishes a lentigo maligna from melanoma in situ
Lentigo maligna is on chronic solar damaged skin.
What percent of Lentigo Maligna develop Lentigo Maligna melanoma
5%
What is happens to prognosis with regression?
Unsure, the point is being argued. Some say worse some studies say better. I would go with worse if they are talking about risk for mets.
On dermatoscopic exam melanin in the furrows vs the ridges is more likely to be benign or malignant on acral skin?
benign
on acral skin malignant melanoma melanocytes tend to aggregate around what structures.
acrosyringeal openings. sometimes you can see the acrosyringeal openings on the broad ridge
Parallel furrow patterns are what in acral pigmentation
benign (broad ridge narrow furrows)
Parallel ridge patterns are what in acral pigmentation
malignant (broad ridge narrow furrows)
After a lymphadenectomy in a node + patient what are the risk factors for recurrance
Extracapsular extension more than 4 nodes involved A node >3cm Cervical node involvement Recurrent disease
If someone is being treated for advanced melanoma with an immune check point inhibitor (umabs ) are they still at increased risk for a second melanoma
yes
What umab can cause pigment loss
Pembrolizumab (Think P for pigment loss)
What is a T1b stage for melanoma
What does the a and b mean in the staging of melanoma.
a without ulceration
b with ulceration
What is a T4b melanoma
> 4mm breslow thickness with ulceration
What breslow thickness would a .96 mm measurement be reported as?
1.0 mm the breslow thickness is rounded
What is a T3a melanoma stage
2.0-4.0 mm no ulceration
What is a T2 melanoma
1.0-2.0mm with unknown ulceration
