Melanoma

Question 1

First line management of acral melanoma

Answer 1

Checkpoint inhibitors

Question 2

Drug approved for uveal melanoma and 2) HLA

Answer 2

HLA-A*02:01-positive
Tebentafusp

Question 3

Size threshold for SNLB in melanoma

Answer 3

Greater than 0.8 mm

Question 4

Dabrafenib tremetinib SE to know

Answer 4

Pyrexia

Question 5

encobimetinib SE to know

Answer 5

ocular toxicity

Question 6

Gene mutation associated with hereditary melanoma (familial atypical mole syndrome)

Answer 6

CDKN2A
p16

Question 7

FAM syndrome presentation

Answer 7

A lot of atypical appearing moles

Question 8

Other genetic syndromes associated with melanoma

Answer 8

BRCA2
pTEN (Cowden)
BAP1

Question 9

Stage III melanoma definition

Answer 9

nodal mets OR *in transit metastases

Question 10

Other indications for sentinel lymph node biopsy

Answer 10

• regression of tumor below breslow depth
• if base of tumor broadly transected on specimen (indicating tumor much thicker than actual read on path)
• presence of atypical features (melanocytic tumor of unknown potential)

Question 11

TVEC mechanism + role

Answer 11

• oncolytic virus
• very limited role, possibly local control in elderly patient ineligible for immunotherapy

Question 12

margins required in melanoma for wide local excision

Answer 12

IF <2mm, 1 cm margin
IF >2mm, 2 cm margin
*high yield

Question 13

When adjuvant immunotherapy is indicated in stage II melanoma

Answer 13

high risk, so stage IIB and IIC

Question 14

What are the BRAF/MEK combinations

Answer 14

dabrafenib/tremetinib
vemurafenib/cobimetinib
encorafenib/benimetinib

Question 15

BRAF targeted therapy class effects

Answer 15

• QT prolongation
• increased risk of cutaneous squamous
• Keratoacanthomas
• LFT elevation
• photosensitivity

Question 16

MEK targeted therapy class effects

Answer 16

• cardiotoxicity
• acne
• ocular toxicity

Question 17

BRAF/MEK combination SE to know

Answer 17

pyrexia

Question 18

uveal melanoma mutations

Answer 18

GNAC
GNA1

Question 19

uveal melanoma associated hereditary syndrome

Answer 19

BAP1

Question 20

mucosal and acral melanoma mutations

Answer 20

KIT

Question 21

mucosal and acral melanoma drug

Answer 21

IF KIT mutant, imatinib

Question 22

First line for metastatic merkel cell

Answer 22

immunotherapy

Question 23

Role of T-VEC in melanoma

Answer 23

• unresectable cutaneous, subcuteanous, or nodal disease (reduces pain, improves QOL)

Question 24

uveal melanoma surveillance

Answer 24

MRI abdomen (proclivity to met to liver)

Question 25

preferred first line for cutaneous SCC in transplant patient

Answer 25

carbo/taxol

Question 26

Stage III melanoma surveillance

Answer 26

CT chest/abdomen/pelvis and neck if head/neck primary q 3 months for first 3 years, then q months for up to 5 years
**Given positive sentinel lymph node biopsy, regional nodal US q 3 months (US surveillance of lymph node basin) (this was shown to be comparable to

Question 27

Important caveat to Stage III melanoma management

Answer 27

• IF less than 1 mm tumor burden in sentinel lymph node, then no adjuvant (proceed to US of nodal basin). They have very good outcomes and weren’t included in trials

Question 28

Most reported and least tolerated adverse effect of hedgehog inhibitors

Answer 28

muscle cramps or spasms

Question 29

What is the clinical significance of melanoma excised from subcutaneous tissue

Answer 29

• this is in transit disease that needs adjuvant immunotherapy

Question 30

Management of retinal detachment from MEK inhibitors

Answer 30

• rechallenge (doesn’t cause irreversible vision loss serious eye damage)

Question 31

Gene mutation more commonly found in mucosal melanoma

Answer 31

KIT

Question 32

Gene mutation more commonly found in acra melanoma

Answer 32

KIT

Question 33

avelumab premedications

Answer 33

acetaminophen + antihistamine
(high rate of severe infusion reactions, only checkpoint inhibitor that requires premedication)