Melanoma

Question 1

Risk factors associated with melanoma

Answer 1

Age greater than 15 
  Median age 61
History of cutaneous melanoma
Dysplastic nevi
High density of common nevi and atypical nevi Cutaneous melanoma in 1st degree relative Immunodeficiency or immunosuppression
High degree of freckling
Sunburns easily or tans rarely
Blonde or red hair
Blue, green, or gray eyes
Socioeconomic status (higher > lower)
Race (Caucasians > Hispanics > African Americans

Question 2

Pathogenesis of melanoma

Answer 2

Most often arise from epidermal melanocytes of the skin
-Can also arise from noncutaneous melanocytes

In adults, most melanocytes are located at the epidermal-dermal junction of the skin and the choroid of the eye
-May also be found in tissue such as meninges, the alimentary (GI) tract, and respiratory tracts

Question 3

Common clinical features of melanoma

Answer 3

Any lesion that changes appearance over time

A-asymmetry
B-border (irregular borders)
C-color (often variegated ranging from tan, blue-black, red, purple, or white)
D- diameter (frequently larger than 6mm)
E- enlargement/evolution (sudden change)

Other: a lesion that swells, bleeds, or oozes

Question 4

External risk factors for melanoma

Answer 4

Intense intermittent sun exposures
History of sunburn
More than four painful sunburns before age 15 years
Recreational sun exposure

Question 5

Other risk factors for melanoma

Answer 5

Maternal-fetal transfer
-Most likely cancer to metastasize to the placenta and fetus during pregnancy

Genetics

• Dysplastic nevus syndrome (DNS)
  
  • 8-10% of cases of melanoma are associated with DNS
  • 400-1000X increased risk than general population
• BRAF (V600E) somatic mutations
  
  • Occurs in 25%-75% of melanoma patients
  • Link between UV radiation and melanoma
  • Common in melanomas arising from skin with intermittent sun exposure

Question 6

____ makes up 90% of all melanomas

Answer 6

Cutaneous melanoma

Question 7

Development of melanoma (progression)

Answer 7

-Melanocytic Atypia

• Atypical melanocytic Hyperplasia
• Radial Growth Phase (early stage of melanoma when the tumor is thin and primarily intraepidermal in location)
• Primary Melanoma
• Lymph-Node Metastatic Melanoma
• Distant Metastatic Melanoma

Question 8

___ are involved in the progression more often than in most other solid tumors

Answer 8

Immune factors

Question 9

Melanoma cells can proliferate without ___

Answer 9

Growth factors

Question 10

___, although rare, are a well documented phenomenon seen in melanoma.

Associated with…

Answer 10

Spontaneous cancer regressions

Host immunity

Question 11

Stage:

Melanoma in situ

Answer 11

Stage 0

Question 12

Stage:

Melanoma with clinically positive nodes, microscopic satellitosis, and/or in-transit disease

Answer 12

Stage III

Question 13

Stage:

Melanoma with distant metastatic disease

Answer 13

Stage IV

Question 14

Tx for Stage 0-II melanoma

Answer 14

SLNB (-) or NA for Stage 0:

1. Clinical Trial
2. Observation
3. Interferon alpha

Question 15

Drugs that are only indicated if pt has a BRAF (V600) mutation

Answer 15

“nib”
dabrafenib
vemurafenib
trametinib

Question 16

Preferred meds for advanced/meta melanoma

Answer 16

Ipilimumab
Dabrafenib+trametinib*
Dabrafenib*
Vemurafenib*
* indicates BRAF (v600) mutation

Question 17

Examples of Immunotherapy in melanoma

Answer 17

Interferon

Interleukin-2

Question 18

High dose interferon (HDI)

Answer 18

Used in pts with high risk dz

-not stage 4

Question 19

IFN-alpha ADEs

Answer 19

fever
chills
psych/behavioral

Question 20

CTLA-4 targeted tx drug

Answer 20

Ipilumumab
increased upregulation of T-cells
1st drug to show survival benefit***

Question 21

Ipilumumab ADEs

Answer 21

Skin Rash

Colitis