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Solid Tumor Oncology > Skin Cancer > Flashcards

Skin Cancer Flashcards

1
Q

What is the T staging for cutaneous melanoma?

A

T1 <1 mm Breslow thickness
T2 1-2 mm
T3 2-4 mm
T4 >4mm

Any b designation means ulceration

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2
Q

What is N staging for cutaneous melanoma?

A

N1: 1 LN or any number of in-transit, satellite or microsatellite mets seen with no tumor involved nodes
N2: 2-3 LNs
N3: 4+ LNs

a=clinically occult (detected by SLNBx)
b=clinically detected

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3
Q

What is the local treatment for primary malignant melanoma in situ? if surgery, then what is the acceptable margin?

A

WLE, margin 0.5 cm

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4
Q

What is the local treatment for primary malignant melanoma in <2 mm? if surgery, then what is the acceptable margin?

A

WLE, margin 1 cm

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5
Q

What is the local treatment for primary malignant melanoma >2 mm depth? if surgery, then what is the acceptable margin?

A

WLE, margin 2 cm

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6
Q

When to perform SLNB in local cutaneous melanoma?

A

> 1 mm depth of invasion
Consider if <1 mm but high risk features like ulceration, signs of regression, BT >0.75 mm, elevated mitotic rate

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7
Q

Who should get a completion lymph node dissection after WLE?

A

Those with clinically apparent LNs (N2+). Those with clinically occult disease (N1), do not benefit

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8
Q

Who should be considered for adjuvant radiation of nodal basin? (4)

A

Extranodal extension
>4 LNs
H&N region
Desmoplastic disease

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9
Q

Who should not be considered for adjuvant nodal basin irradiation?

A

Groin melanoma - wound healing is a major problem

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10
Q

Adjuvant therapy for high-risk Stage IIB/IIC Melanoma?

A

Pembrolizumab

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11
Q

Adjuvant therapy options for BRAFwt Stage III Melanoma?

A

Ipilimumab 10 mg/kg (super toxic)
Nivolumab
Pembro

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12
Q

Adjuvant therapy for BRAFmut Stage III melanoma?

A

Dabrafenib + Trametinib
Could also do Nivo, Pembro, or Ipi (technically)

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13
Q

What is the difference in likelihood of having BRAF and NRAS mutations in cutaneous vs acral vs uveal melanoma?

A

45% BRAF and 20% NRAS in cutaneous
None in uveal
20% BRAF in acral, 10% NRAS in acral

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14
Q

What mutation is more commonly seen in mucosal melanoma?

A

c-KIT

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15
Q

What mutation is more commonly seen in acral melanoma?

A

c-KIT

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16
Q

What mutation is commonly seen in uveal melanoma?

A

GNAQ

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17
Q

What side effect of Dabrafenib is MORE commonly seen when combined with Trametinib compared to monotherapy?

A

Pyrexia

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18
Q

What side effect of dabrafenib is LESS commonly seen when combined with Trametinib?

A

Cutaneous SCC

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19
Q

What are three BRAK+MEKi combinations approved for metastatic melanoma?

A

Dabrafenib + Trametinib
Vemurafenib + Cobimetinib
Encorafenib + Binimetinib

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20
Q

Which BRAF+MEKi is least frequently used because of toxicity?

A

Vemurafenib + Cobimetinib

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21
Q

You have a patient with metastatic cutaneous melanoma on vemurafenib monotherapy and is responding well. But they develop new cutaneous SCCs. How do you manage it?

A

Excise the SCC and keep going on the Vem

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22
Q

6 Toxicities of Dabrafenib + Trametinib

A

Fever
Secondary cancer
Bleeding
Cardiomyopathy
Uveitis
Hyperglycemia
Rash
Fetal problems

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23
Q

Toxicity of Vemurafenib + Cobimetinib

A

Bad photosensitivity
Secondary cancers
Bleeding
Cardiomyopathy
Retinopathy
Fetal abnormalities

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24
Q

Toxicity of Encorafenib + Binimetinib

A

Cardiomyopathy
VTE
Ocular
ILD
Hepatotoxic
Rhabdo
Bleeding
Fetal tox

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25
Q

What happens if you give a BRAFi+MEKi to a patient with metastatic melanoma who has a non-V600 BRAF mutation?

A

Paradoxically cause progression

26
Q

Treatment of choice for KIT mutated metastatic melanoma?

A

Imatinib

27
Q

In someone with a BRAFmutated metastatic cutaneous melanoma, do you do immunotherapy or BRAF+MEKi first?

A

Immunotherapy first

28
Q

What are the two preferred first line therapies for metastatic cutaneous melanoma?

A

Ipi+Nivo
Relatlamab + Nivo

29
Q

What is TVEC and what is the use?

A

Intra-tumoral injection of oncolytic herpesvirus. Best used in patients with limited stage III disease. Not for metastatic disease

30
Q

Second line treatment for Metastatic cutaneous melanoma

A

Ipilimumab
High dose IL-2

31
Q

Third line therapy for metastatic cutaneous melanoma?

A

Lifleucel (autologous TIL therapy)
If progressed on ICI and BRAFi (if BRAF mut)

32
Q

Systemic treatment options for CNS metastatic melanoma for BRAFwt?

A

Ipi+Nivo is beneficial for those with ASYMPTOMATIC untreated brain mets. No difference in symptomatic patients

33
Q

Systemic treatment option for CNS metastatic melanoma with BRAF mutation?

A

Dabrafenib + Trametinib

34
Q

Management of oligometastatic cutaneous melanoma?

A

Surgical resection then adjuvant immunotherapy (nivo or pembro or BRAFi/MEKi for BRAF mutations)

35
Q

In mucosal melanoma, patients with what mutation are likely to have minimal to no sensitivity to TKIs?

A

KIT exon 17 mutations
Also KIT amplifications

36
Q

Preferred systemic therapy of metastatic uveal melanoma?

A

Tebentafusp for HLA 201*02
If not, then pembro, nivo, or Ipi+nivo.

37
Q

Most common metastatic site of uveal melanoma

A

Liver

38
Q

Treatment of Uveal melanoma metastatic only to the liver, progressed on Tebentafusp and immunotherapy.

A

Intra-hepatic melphalan

39
Q

Treatment of choice for asymptomatic CNS mets from melanoma?

A

RadiationTreat

40
Q

Treatment of choice for symptomatic CNS mets

A

Surgery if resectable

41
Q

4 systemic treatment options for metastatic mucosal melanoma with KIT mutation

A

Imatinib
Dasatinib
Nilotinib
Ripretinib

42
Q

8 high risk features of cutaneous basal cell carcinoma?

A

Poorly defined borders
>2 cm on trunk or extremities
Any lesion on H&N, hands, feet, pretibil, anogenital
Recurrent disease
Immunosuppressed patient
Site of prior RT
Aggressive growth pattern
+PNI

43
Q

Treatment for high risk local BCC?

A

Mohs or other resection

44
Q

When to given adjuvant radiation therapy for cutaneous BCC?

A

Positive margins

45
Q

Only approved option for metastatic BCC in first line?

A

Vismodegib

46
Q

2nd line metastatic treatment for BCC?

A

Cemiplimab

47
Q

Indications for sonidegib in BCC?

A

Locally advanced BCC that recurred after surgery or RT
Or for those who are not surgery or RT candidates
**Not approved for metastatic disease

48
Q

Main treatment for local Merkel Cell carcinoma

A

Surgery with SLNB

49
Q

Indications for adjuvant RT in Merkel cell carcinoma

A

> 1 cm tumor
Chronic T cell suppression
HIV
CLL
SOT
H&N primary
+LVI

50
Q

What pathology marker is a sensitive finding for Merkel cell carcinoma?

A

CK20

51
Q

4 treatment options for metastatic Merkel Cell Carcinoma

A

Avelumab
Pembrolizumab
Nivolumab
Retifanlimab

52
Q

Systemic therapy for recurrent or metastatic cutaneous SCC not curable by surgery or RT (2)

A

Pembrolizumab
Cemiplimab

53
Q

When to consider neoadjuvant treatment for cutaneous SCC?

A

Very rapid growth
Intransit mets
+LVI
Borderline resectable

54
Q

What systemic therapy can be given in neoadjuvant setting for cutaneous SCC?

A

Cemiplimab

55
Q

What comprises Stage IIB melanoma?

A

T3b or T4a, N0
(2-4 mm thick with ulceration or >4 mm thick without ulceration)

56
Q

What comprises Stage IIC melanoma?

A

T4b N0
>4mm thick with ulceration

57
Q

desmoplastic melanoma is different from typical cutaneous melanoma in what way?

A

High risk for local recurrence
Super responsive to immunotherapy
Low likelihood of driver mutation

58
Q

You have a patient with metastatic cutaneous melanoma in visceral crisis. NGS is pending. What to do to figure out if he is a candidate for BRAF/MEKi?

A

BRAF VE1 IHC testing

59
Q

In cutaneous melanoma, who can be considered for neoadjuvant treatment?

A

Stage III (clinically N+) who have resectable disease, but surgery would be morbid or difficult

60
Q

In cutaneous melanoma, what are two neoadjuvant treatment options for eligible patients?

A

Pembro
Ipi Nivo

Solid Tumor Oncology (20 decks)

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