melanoma Flashcards
What are the referrals based on genetics for melanoma
Families with ≥3 cases of melanoma
x2 cases of melanoma in first degree relatives
First degree relative with melanoma and pancreatic cancer (P10 or P16)
What sites of melanoma are there
Skin
CNS & uveal
Aerodigestive - nasopharynx and oral cavity
GU tract
What subtypes of melanoma are there
Superficial spreading (commonest)
Nodular
Lentigo maligna, typically on the face
desmoplastic - acral lentiginous are typically on palms, soles, nail beds and mucosal surfaces
What stage of melanoma is signified by satellite and in transit mets
And how is each defined
Stage 3 - dermal lymphatic involvement
Satellite lesions < 2cm from primary tumour
In-transit lesions >2cm from primary tumour, but not beyond draining LN
N1c - satellite or in transit mets without regional nodes (n1a-b = one positive node otherwise)
N2c - satellite or in transit mets with 1 regional node
N3 - satellite or in transit mets with ≥2 regional node
How to examine a lesion suspicious for melanoma
A - asymmetry
B - border
C - colour
D - Dynamics - changing
E - elevation
How is a lesion biopsied
Excision biopsy with 2mm margin, reported for ulceration, depth of invasion and clearance of margins
What investigations are done for a potential metastatic melanoma
History and examination
Excision biopsy
Genetic testing if stage IIC or above
SNLB if stage 1b or higher (≥T2a)
Imaging
Bloods - raised LDH is prognostic
When is a sentinel LN biopsy done for melanoma
Stage 1b or above (≥T2a)
When is genetic testing indicated for metastatic melanoma
Stage IIC or above
(T4b)
What imaging is done for a pT1a metastatic melanoma
pT1a (low risk) - no additional ix necessary
pT1b-T4b -> US for locoregional LN metastasis, CT
pT3b or above - brain MRI and PET
Whole body MRI If <24 years old with stage III/IV
What imaging is done for a pT1b-4b metastatic melanoma
> pT1b -> US for locoregional LN metastasis, CT
pT3b or above - brain MRI and PET
Whole body MRI If <24 years old with stage III/IV
What imaging is done for a metastatic melanoma pT3b or above
pT3b or above - brain MRI and PET
Whole body MRI If <24 years old with stage III/IV
When is whole body MRI indicated for metastatic melanoma
<24yrs with stage III-IV
How is T1 stage of melanoma split
T1a is size <0.8mm and not ulcerated
T1b is ≤0.8mm and ulcerated, or 0.8-1mm and either ulcerated or not
How are the M+ stages of melanoma defined
M1a = skin/subcutaneous mets or distant nodes
M1b = lung mets
M1c = visceral, but not CNS mets
M1d = CNS mets
What is the nodal status of stage 1-3 metastatic melanoma
Stages 1 & 2 are node negative
Stage 3 = node positive
How is stage 1 melanoma defined
T1-T2a N0
How is stage 2 melanoma defined
T2b-T4b N0
How is stage 3 melanoma defined
N+ (1-3)
How is stage 4 melanoma defined
M+ (a-d)
How does the breslow thickness of a melanoma affect the excision margin
Breslow thickness: <1mm
Excision margin: 1cm
Breslow thickness: 1-2mm
Excision margin: 1-2cm
Breslow thickness: 2-4mm
Excision margin: 2-3cm
Breslow thickness: >4mm
Excision margin: 3cm
For what stage of melanoma should adjuvant treatment be considered
Stage 2b (T3b-4a) - adj pembro
otherwise stage 3+
What is the management of a stage 1a melanoma
stage 1A = T1a-b (<1mm)
WLE only, according to Breslow thickness
What is the management of a stage 1b-2c melanoma
Stage 1b (T2a) - stage 2c (T4) - >1-4mm, N0
WLE + SLNB
Completely resected stage 2B (T3b-4a) - adj pembro
When is adjuvant pembrolizumab indicated
Completely resected stage ≥2b melanoma
(T3b/T4a ie 2-4mm and ulcerated)
What is the management of a stage 3 melanoma
Stage 3 = node positive
If resectable -> WLE +SLNB +/- nodal clearance (if more than n1a & n2a)
Adjuvant treatment (B-raf dependent)
B-Raf V600E+ -> adjuvant dab/tram, or nivo or pembro
B-Raf V600E- -> adjuvant nivolumab or pembro
How is the management of stage 4 melanoma divided
Stage 4 = M+
Resectable disease (primary and mets)
Unresectable disease
When is adjuvant RT indicated for melanoma
What is the recommended dose
Cannot have adjuvant systemic treatment
Positive margins not amenable to further surgery / not adequate
Sites where local control is critical, such as head and neck
48Gy/20#
What is the management of resectable stage 4 melanoma
If metastasis is resectable -> metastatectomy & adjuvant nivolumab (1yr), regardless of B-Raf status, if complete resection
How is the management of unresectable stage 4 melanoma divided
By B-Raf V600E status
What is the management of B-Raf WT non-resectable stage III/IV metastatic melanoma
Ipi/nivo first line, followed by maintenance nivolumab, independent of PDL1 status, if PS0-1
PS2 - single agent nivolumab or pembrolizumab
2nd line - single agent ipilimumab, if not received previously
3rd line - chemo or BSC
What is the management of B-Raf mut non-resectable stage III/IV metastatic melanoma
1st line & PS0-1
Ipi/nivo -> main nivo if possible
If quick disease response needed, encorafenib/binetinib or dabrafenib/trametinib,
PS2 - pembro or nivolumab single agent
2nd line:
Ipilimumab if not received already
Single agent pembrolizumab if has received ipi
Nivolumb & relatlimab if immunotherapy naive
Dab/tram or enco/bini if not used first line
When is nivolumab indicated for metastatic melanoma
Adjuvant treatment for completely resected stage 3 or 4 metastatic melanoma
Stage 4 unresectable:
PS2 1st line
When is dabrafenib/trametinib indicated in melanoma
adjuvant treatment of resected stage 3, b-raf v600e positive (assuming Ras WT)
or as an option in B-Raf mut non-resectable stage 4 disease
What toxicities to dabrafenib and trametinib cause
Dabrafenib - anterior uveitis
Trametinib - retinitis, retinal vein occlusion, retinal detachment
If retinal vein occlusion, trametinib should be stopped permanently
what is given following resection of an isolated melanoma metastasis
adjuvant nivolumab 1yr (stage 4)
when can dab/tram be used adjuvantly in melanoma
stage IIIA (node positive disease) following resection if B-raf mutant
Stage 2B - use adjuvant pembro regardless of b-raf status
