Melanoma

Question 1

Risk of nodal metastasis based on tumor thickness for melanoma:
<1mm without ulceration
1-4mm
>4mm

Answer 1

<1mm: <5%
1-2mm: 20%
2-4mm: 35%
>4mm: >50%

Question 2

Give a brief synopsis of melanoma trials

Answer 2

WHO melanoma program, US intergroup melanoma

Used to be 4cm margin for every melanoma. But these trials have been defining adequate data for various depths

Question 3

Explain the melanoma thickness and the margin

In situ
<1mm
1-4mm
>4mm

Answer 3

In situ: 0.5cm
<2mm: 1cm
>2mm: 2cm

Question 4

What to do for digit melanoma?

Answer 4

Amputate one joint proximal. Do sentinel node biopsy even for in situ disease

Question 5

Who should get a sentinel node biopsy for melanoma?

Answer 5

anything greater than or equal to stage Ib

> 0.8mm, any ulcerated

Question 6

What is the Clark level?

Answer 6

I: epidermis
II: into papillary dermis
III: abuts reticular dermis
IV: into reticular dermis
V: into subQ

Question 7

MSLT-1 trial. What did they want to answer?

What’s the bottom line?

Answer 7

Multicenter Selective Lymphadenectomy Trial

They wanted to answer: Among patients undergoing a wide excision for melanoma, does sentinel node biopsy with reflex completion lymphadenectomy improve melanoma specific survival compared with nodal observation?

For intermediate thickness melanoma 1-4mm, melanoma survival was improved w/ SLN

SLN-status was the most powerful prognostic factor for survival in clinically node negative pts

Question 8

Completion Lymphadenectomy has ONLY proven to be beneficial in what circumstance?

Answer 8

Ulcerated lesion with (+) SLN

Still do CLND for ALL (+) SLN

Question 9

What are the four approved adjuvant therapy for melanoma and their mechanisms of action?

Answer 9

High dose interferon (1mo high dose, 11mo low dose)
Low

Yervoy (Ipilimumab, CTLA-4)

Nivolomab (PD-1): more effective and less toxic than interferon & ipilumumab

dabrafenib BRAF inhibitor

Question 10

60% of melanoma are (+) for what mutation

Answer 10

BRAF V600E

Question 11

Borders of the femoral triangle

Answer 11

Adductor longus medially
Sartorius laterally
Inguinal ligament superiorly

Question 12

Borders of the axillary dissection

Answer 12

Axillary vein superiorly
Chest wall/serratus medially
Axillary skin/latissimus dorsi laterally
Tail of the breast inferiorly
Lat dorsi posteriorly
Pec major and minor anteriorly

Question 13

Explain the melanoma T staging based on Breslow depth

What is their chance of node metastasis?

Answer 13

5 yr survival
T1: <1 mm: 95-100% -> up to 5% chance of nodal
T2: 1 - 2 mm: 80-96% -> 5 - 20% chance of nodal
T3: 2.1 - 4 mm: 60-75% -> 25 - 40% chance of nodal
T4: >4mm: 50% -> up to 50% chance of nodal

Question 14

MSLT-2 trial. What was the question they wanted to answer?

What’s the bottom line?

Answer 14

What is the value of completion lymph node dissection for patients with melanoma with sentinel-node metastases?

The MSLT-2 trial demonstrated that CLND offers local disease control, but does not increase disease-specific survival rates in patients with melanoma with sentinel lymph node metastases.

So it improves chance of no local disease while you survive
But ultimately length of survival is same

Question 15

What classifies as T1b? Why is this important

Answer 15

Any ulcerated
>0.8mm depth/thickness

Need to do SLNB

Question 16

For melanoma, when do you do a metastatic workup with pet and etc before you do anything/excise

Answer 16

For depth > 4mm bc the chance of met is so high