Skin Cancer

Question 1

What is melanoma?

Answer 1

Malignant tumor of the epidermal melanocytes

Question 2

Risk factors for melanoma

Answer 2

• Sun exposure
• Radiation
• Fair skin
• Family history
• Xeroderma pigmentosum
• Lentigo maligna

Question 3

What is the ABCDE criteria for melanoma?

Answer 3

Clinical suspicious features

• Asymmetry
• Border irregularity
• Color variegation
• Diameter >6mm
• Evolution

Question 4

Five types of skin cancer

Answer 4

• Superficial spreading (60%)
• Nodular (30%)
• Lentigo maligna melanoma (7%)
• Acral lentiginous (35-60% in Asians)
• Amelanotic (1%)

Question 5

Ugly duckling sign

Answer 5

In an individual with multiple nevi, a pigmented lesion obvious different from others is suspicious

Question 6

How to diagnose melanoma

Answer 6

Full thickness excision biopsy with 2mm margin

Question 7

Treatment of melanoma

Answer 7

Wide local excision depending on Breslow depth

• in-situ: 5mm
• ≤ 1mm: 1cm
• 2mm:1-2cm
• 2.01-4mm: 2cm
• >4mm: at least 2cm

Question 8

What is Breslow’s thickness?

Answer 8

Measure of the depth of the melanoma from skin surface to deepest point of the tumor (from granular layer to deepest melanoma cell)

Question 9

TNM/AJCC staging for melanoma

1. Stage I
2. Stage II
3. Stage III
4. Stage IV

Answer 9

• I: T2a or less, no nodes
• II: T2b, no nodes
• III: regional nodes (N1)
• IV: distant metastasis

Question 10

Tumor staging for melanoma

1. T1
2. T2
3. T3
4. T4
5. a
6. b

Answer 10

• T1: ≤1mm
• T2: 1.01 - 2mm
• T3: 2.01 - 4mm
• T4>4mm
• a: no ulceration
• b: ulceration

Question 11

Nodal staging for melanoma

Answer 11

N1: 1 LN

N2: 2-3 LN

N3: ≥4 LN

a/b/c: method of detection of regional LN

a: biopsy proven
b: clinical
c: presence of microsatelite/satelite met

Question 12

M staging for melanoma

Answer 12

• M0: no distant met
• M1a: met to skin / soft tissue/ muscle
• M1b: lung met
• M1c: non-CNS visceral sites
• M1d: CNS met

Question 13

Role of SLNB biopsy in melanoma

Answer 13

• Recommended in NICE guidelines for
• >0.76mm thick skin lesions with ulceration
• Stage Ib–IIc (ie. T1b-T4bN0)

Question 14

Advantages and disadvantages of SLNB

Answer 14

• Pros:
  
  • can upstage stage II to stage III
  • improvement in disease free survival and melanoma specific survival
• Cons:
  
  • Not curative
  • 3% local recurrence
  • 5% complications
  • GA

Question 15

Workup for stage III/ IV melanoma

Answer 15

• CBC
• LFT (elevated ALP → bone or liver met)
• LDH (prognostic factor for melanoma
• CXR
• SLNB
• CT T+A +/- P

Question 16

Treatment of melanoma by staging

Answer 16

• Stage 0: excision
• Stage 1 or 2: excision +/- lymph node management
• Resectable Stage 3: excision +/- LN management + adjuvant therapy + immunotherapy
• Unresectable Stage 3 / Stage 4/ recurrent: intralesional therapy, immunotherapy, signal transduction inhibitor, chemo, palliative local therapy

Question 17

Name a immunotherapy drug for Stage III/IV melanoma

Answer 17

PEMBROLIZUMAB

NIVOLUMAB + RELATLIMAB

IPILIMUMAB