Melanoma

Question 1

3 layers of the skin: Epidermis

Answer 1

Epidermis - outermost layer, protection, made of keratinocytes, melanocytes, langerhan cells, merkel cells

Question 2

Dermis

Answer 2

underlying layer, support and nutrients to the epidermis, made of collagen and elastin

Question 3

Subcutaneous fat

Answer 3

inner layer, support and cushioning for the dermis and epidermis, made of fat cells called adipocytes, nerves, blood vessels

Question 4

Function of the Skin

Answer 4

protect: barrier from impacts and pressure, wind, cold, temperature, UVR, Regulate: body temp, retention/absorption body fluids like sweat, vit D synthesis. Sensation: heat, cold, pressure, pain

Question 5

Two types of ultraviolet radiation

Answer 5

UVA: penetrated depper, damage is indirect, mediated by free radicals, damages cell membranes.
UVB: erythema or sunburn, direct damage to DNA

Question 6

UV Exposure

Answer 6

indoor tanning beds, locations close to the equator

Question 7

Medications/Medical Tx Risk

Answer 7

psoralen, UVA light tx, neonatal blue lights

Question 8

Environmental risks

Answer 8

Exposure to polyvinyl chloride in clothing, plastics, heavy metal, pesticide, radiation — leads to mutagenic change in DNA in melanocytes

Question 9

Superficial spreading melanoma

Answer 9

75% of all melanomas. preference for back in men and legs in women. radial lateral growth before invasive growth. begins as asymptomatic brown black macule with color variations, notching and scalloping

Question 10

Nodular Melanoma

Answer 10

15-30% of all melanomas. Common on sun exposed areas of head, neck, trunk. No radial growth, just vertical. dark shiny nodule. dark brown, black and most commonly blue, or pink or red

Question 11

Lentigo Maligna

Answer 11

5% of all melanomas. Head and neck sun damaged areas. Age > 60, starts as a freckle tan macule gradually darker and asymmetric, 5% progress to invasive melanoma

Question 12

Acral Lentiginous Mucosal Melanoma

Answer 12

<5%. palms, soles, under nails, mucosal membranes, in blacks and asians, dark brown black uneven patch, longitudinal band with or without nail dystrophy

Question 13

Staging

Answer 13

use Tumor, Node, Mets staging

Question 14

Tumor Category

Answer 14

depth: thickness in mm
subcategories: ulceration status, mitotis rate

Question 15

If suspicion for melanoma is high, this bx needs to be done

Answer 15

excisional with 1-2mm margins or a deep shave with epidermal and dermal layers to get depth

Question 16

Node category

Answer 16

presence and extent of regional lymph node mets. Subcategories: number of lymph nodes involved, micro or macro mets, satellite mets

Question 17

Sentinel lymph node biopsy

Answer 17

staging to eval for microscopic regional node involvement, recc for MM > 1mm thick or < 1mm but ulcer or have a higher mitotic rate > 1

Question 18

Clinical staging

Answer 18

microstaging of the primary tumor plus clinical or radiological date used in the evaluation of meds

Question 19

Pathological Staging

Answer 19

microstaging of the tumor plus patho info about regional lymph nodes

Question 20

surgery for primary melanoma

Answer 20

wide local excision, margins determined by depth of the tumor

Question 21

surgery for advanced melanoma

Answer 21

lymph node dissection for palpable or rad detected lymph nodes. limb perfusion of chemotherapy intravascularly for recurrent or unresectable in transit mets

Question 22

metastatectomy

Answer 22

those where met focus can be completely resected, those with a solitary site of meds like skin, lung, lymph note, etc. Those with long distance free interval between disease recurrence

Question 23

radiation

Answer 23

only used for adjuvent therapy for tumors w high risk recurrence or palliation for bone, brain, or spinal cord mets

Question 24

stereotactic radiosurgery

Answer 24

for brain mets, fewer high dose treatments, spares healthy brain tissue, can treat limited mets in the body

Question 25

Systemic Therapy

Answer 25

for high risk with survival < 50%. Interferon alfa2b, ipilimumab

Question 26

Checkpoint inhibitors

Answer 26

agents that take the brakes off T cells and enhance anti cancer immune response, work through the immune system and do not have a tumor response.

Question 27

Target Therapy

Answer 27

agents that inhibit cancer promoting genes (BRAF & NRAS)

Question 28

Interleukin-2

Answer 28

activates cell immunity and tumor growth, IV infusion needs to be hospitalized

Question 29

T-VEC Talimogene laherparapvec

Answer 29

modified oncolytic herpes virus to destroy melanoma cells and promote anti tumor response, intra tumor injections

Question 30

Chemotherapy

Answer 30

salvage therapy, limited efficacy. DTIC Dacarbazine

Question 31

Mucosal MM

Answer 31

Resp, alimentary, GU tracts which contain melanocytes. Worse prognosis.

Question 32

tx mucosal MM

Answer 32

resection if possible, target therapy if possible

Question 33

Ocular MM

Answer 33

iris, choroid, ciliary body. risks: light eye color, fair skin, burn easily, atypical nevi. visual symptoms or an incidental finding. dx on fundoscopic exam, bx not indicated radiotherapy tx