Melanoma Flashcards
When microsatellitosis is present on a pathologic specimen or the wide excision, what stage is the patient upgraded to?
At the minimum Stage IIIB
When a patient has both microsatellitosis and a SNLB that is positive what stage does this denote?
This classifies them as having Stage IIIC
Having a positive SNLB denotes what stage?
Stage III
What is the treatment for Stage IA and IB melanoma?
Stage IA-wide excision only. No SNLB is needed. Stage IB-Wide excision but here you should consider doing a SNLB, but it is not required.
What is tx for Stage IB and II melanoma?
Wide excision and here you need to offer SNLB. If the SNLB was neg then you can do observation, clinical trial, or consider Pembro or Nivolumab for stage IIB or IIC and/or radiation to the tumor site. If the SNLB is positive you treat with Pembro, Nivolumab, or Dabrafenib/Trametinib for BRAFV600E mutation (you tx as Stage III).
When is wide local excision recommended to be done as definitive treatment?
For disease that is 2mm or higher in depth (T3 lesion and higher).
What is the treatment for Stage IIIB with negative SNLB or in those it wasn’t performed?
You can observe, send to a clinical trial, or consider giving Pembro, Nivolumab, or Dabrafenib/Trametinib if BRAF mutation is present.
What is the tx of Stage IIIA (w/positive SNLB)? How do you treat the positive lymph nodes? For those with low in transit disease less than 0.3 mm what can you do for these patients after surgery?
Pembro, Nivolumab, or Dabrafenib/Trametinib for BRAF mutation. They prefer you to do nodal imaging for surveillance as opposed to a CLNC which is not assoc with a a OS benefit. Remember for this stage you can consider doing imaging for staging but it is not needed. Low transit dx-observation
What is the tx for Stage IIIB/C/D melanoma?
For this stage you must obtain imaging for staging. The treatment options are: Pembro, Nivolumab, or Dabrafenib/Trametinib for BRAF mutation. Again CLND is not preferred, they prefer you to do nodal basin ultrasound as there is no survival benefit with dissection.
What is the tx for Stage III that has clinically positive nodes for nodal disease that is resectable?
Here you can offer neoadjuvant therapy using Pembro, Nivolumab/Ipi, or Nivo alone, or Nivo/Relatlimab, or Dabrafenib/Trametinib for BRAF. Or you can proceed with wide excision and therapeutic lymph node dissection. Remember that you still give adjuvant therapy using the typical options.
What adjuvant therapy options are available for Stage III clinically positive nodes?
You can give adjuvant therapy with Nivolumab, Pembro, and Dabrafenib/Trametinib for BRAF mutation. And/or nodal basin RT for high risk lesions, OR you can just observe with no adjuvant tx.
Encorafenib w/Binimetinib can be associated with what side effect? Dabrafenib w/Trametinib can cause what specific side effect? Vemurafenib/Cobimetinib?
Myositis-must check CPK levels. Dabrafenib/Trametinib-pyrexia. Vemurafenib/Cobimetinib-Photosensitivity.
What is TVEC therapy and what stages of Melanoma is it approved for?
TVEC is a genetically modified HSV-1 virus that has the gene for GCSF inserted to stimulate T cell activity against tumor cells. It is approved for limited resectable and unresectable IIIB-IV melanoma (in Stage III with clinically in-transit/satellite nodes)
What are some notable side effects of TVEC therapy?
Disseminated HSV infection, tissue necrosis, pneumonitis, vasculitis, glomerulonephritis, flu syndrome, DVT, impaired injection site wound healing
For a patient that has widespread disseminated metastatic disease that is BRAF positive what is the preferred treatment?
Due to the OS benefit it is preferred to give Ipi/Nivo over any of the BRAF therapy. However, if a patient has a large disease burden with many symptoms then you give BRAF directed therapy given that it responds faster than immunotherapy.
