Skin Flashcards
A patient comes to your office with a worrisome skin lesion for melanoma. What do you do?
Do a punch biospy. The most important thing that will direct your surgical care is the depth of a lesion. Doing a punch biospy is the best way to get this information.
- If worried enough about melanoma, don’t forget to do a thorough H&P (lymph node exam)
A patient comes to your office after having a shave/tangential biopsy of a lesion that returned as melanoma. Is punch biopsy needed?
No. Do not re-biopsy. When they come to see you after a shave/tangential biopsy there will just be a great big ugly scab over the area. There is no way to know where to do a repeat biopsy and there is no need to. It adds nothing. You just have to go with the depth on the intial biopsy.
What are worrisome features on melanoma pathology results?
- Ulcerations
- Mitotic rate >2/mm2
- Lymphovascular invasion
In melanoma, which lymph node basins would you examine for melanoma on upper extremity? Lower extremity? Trunk?
Melanoma can be tricky for lymph node basins, but the following are generally safe.
- Upper extremity - axillary lymph node basin
- Lower extremity - inguinal lymph node basin
- Trunk - inguinal, axillary, and cervical lymph node basins
In melanoma, what is the T staging?
T Staging (a = without ulcerations; b = with ulcerations)
- T1 - <1 mm
- T2 - >1.0-2.0 mm
- T3 - >2.0-4.0 mm
- T4 - >4.0 mm
In melanoma, what is the N staging?
N Staging (a = clinically occult; b = clinically detected; c = In-transit, Satellite, and/or Microsatellite mets)
- N1 - 1 node
- N2 - 2-3 nodes
- N3 - >3 nodes
What are the recommended margins for wide local excision of melanoma?
In melanoma, who should get a SLNB?
Safe answer:
- <0.8 mm WITH worrisome features (ulcerations, >2 mitoses/mm2, lymphovascular invasion.
- >/= 0.8 mm
Some exceptions to above: medically unfit, information won’t change treatment decision.
In melanoma, how do you find sentinel lymph nodes?
- Lymphoscintigraphy is done either the day of surgery or on the afternoon the day prior (higher dose). The images let you know which basin(s) to focus on. Gamma probe can be use in OR to help identify nodes.
- Isosulfan blue or methylene blue is injected intradermally at the site of the lesion.
SLNB is continued until all nodes that have gamma counts >10% of the highest SLN count and/or are blue in color are obtained.
In melanoma, should SLNB be sent for frozen pathology?
No. Send lymph nodes for permanent.
- Further staging imaging is required to plan for further treatment recommendations regardless of findings.
In melanoma, what do you do with a positive SLN?
- Full body PET scan for Staging.
- If PET shows additional node(s) of concern, MUST GO BACK and get those nodes
- Refer to Med Onc to discuss PD-1 directed therapy.
- Consider BRAF testing. Med Onc may be able to consider BRAF directed therapy.
- DISCUSS options of regional nodes:
- Observation (regional US); if PET doesn’t show +LNs
- q4months x2 years, followed by
- q6months x3 years
- Completion lymph node dissection
- Observation (regional US); if PET doesn’t show +LNs
In melanoma, what are the common systemic treatments?
-
anti-PD-1
- Nivolumab
-
BRAF/MEK inhibitor
- Dabrafenib
In melanoma surveillance/follow-up, what do you do if a LN becomes clinically noticeable and/or PET avid?
- +/- biopsy. Will likely excise the node either way.
- Perform a therapeutic lymph node dissection.
- If CLND already performed, excise the nodal recurrence. Then:
- Consider systemic therapy and/or locoregional RT.
During the work-up of melanoma, a patient has palpable nodes. What is the next step?
- Perform US guided biopsy
- Core needle preferred
- FNA okay
- Excisional if nothing else possible
If biopsy is negative, perform SLNB at time of WLE and be sure to excise biopsied node.
During the work-up of melanoma, a LN biopsy comes back positive. What are next steps and treatment plan?
- Imaging (PET scan)
- BRAF testing
- WLE + TLND (Therapeutic lymph node dissection)
- If no metastatic disease
- Adjuvant tx (Systemic and/or locoregional RT)