Skin Cancer Flashcards
What is the T staging for cutaneous melanoma?
T1 <1 mm Breslow thickness
T2 1-2 mm
T3 2-4 mm
T4 >4mm
Any b designation means ulceration
What is N staging for cutaneous melanoma?
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
What is the local treatment for primary malignant melanoma in situ? if surgery, then what is the acceptable margin?
WLE, margin 0.5 cm
What is the local treatment for primary malignant melanoma in <2 mm? if surgery, then what is the acceptable margin?
WLE, margin 1 cm
What is the local treatment for primary malignant melanoma >2 mm depth? if surgery, then what is the acceptable margin?
WLE, margin 2 cm
When to perform SLNB in local cutaneous melanoma?
> 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
Who should get a completion lymph node dissection after WLE?
Those with clinically apparent LNs (N2+). Those with clinically occult disease (N1), do not benefit
Who should be considered for adjuvant radiation of nodal basin? (4)
Extranodal extension
>4 LNs
H&N region
Desmoplastic disease
Who should not be considered for adjuvant nodal basin irradiation?
Groin melanoma - wound healing is a major problem
Adjuvant therapy for high-risk Stage IIB/IIC Melanoma?
Pembrolizumab
Adjuvant therapy options for BRAFwt Stage III Melanoma?
Ipilimumab 10 mg/kg (super toxic)
Nivolumab
Pembro
Adjuvant therapy for BRAFmut Stage III melanoma?
Dabrafenib + Trametinib
Could also do Nivo, Pembro, or Ipi (technically)
What is the difference in likelihood of having BRAF and NRAS mutations in cutaneous vs acral vs uveal melanoma?
45% BRAF and 20% NRAS in cutaneous
None in uveal
20% BRAF in acral, 10% NRAS in acral
What mutation is more commonly seen in mucosal melanoma?
c-KIT
What mutation is more commonly seen in acral melanoma?
c-KIT
What mutation is commonly seen in uveal melanoma?
GNAQ
What side effect of Dabrafenib is MORE commonly seen when combined with Trametinib compared to monotherapy?
Pyrexia
What side effect of dabrafenib is LESS commonly seen when combined with Trametinib?
Cutaneous SCC
What are three BRAK+MEKi combinations approved for metastatic melanoma?
Dabrafenib + Trametinib
Vemurafenib + Cobimetinib
Encorafenib + Binimetinib
Which BRAF+MEKi is least frequently used because of toxicity?
Vemurafenib + Cobimetinib
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?
Excise the SCC and keep going on the Vem
6 Toxicities of Dabrafenib + Trametinib
Fever
Secondary cancer
Bleeding
Cardiomyopathy
Uveitis
Hyperglycemia
Rash
Fetal problems
Toxicity of Vemurafenib + Cobimetinib
Bad photosensitivity
Secondary cancers
Bleeding
Cardiomyopathy
Retinopathy
Fetal abnormalities
Toxicity of Encorafenib + Binimetinib
Cardiomyopathy
VTE
Ocular
ILD
Hepatotoxic
Rhabdo
Bleeding
Fetal tox
What happens if you give a BRAFi+MEKi to a patient with metastatic melanoma who has a non-V600 BRAF mutation?
Paradoxically cause progression
Treatment of choice for KIT mutated metastatic melanoma?
Imatinib
In someone with a BRAFmutated metastatic cutaneous melanoma, do you do immunotherapy or BRAF+MEKi first?
Immunotherapy first
What are the two preferred first line therapies for metastatic cutaneous melanoma?
Ipi+Nivo
Relatlamab + Nivo
What is TVEC and what is the use?
Intra-tumoral injection of oncolytic herpesvirus. Best used in patients with limited stage III disease. Not for metastatic disease
Second line treatment for Metastatic cutaneous melanoma
Ipilimumab
High dose IL-2
Third line therapy for metastatic cutaneous melanoma?
Lifleucel (autologous TIL therapy)
If progressed on ICI and BRAFi (if BRAF mut)
Systemic treatment options for CNS metastatic melanoma for BRAFwt?
Ipi+Nivo is beneficial for those with ASYMPTOMATIC untreated brain mets. No difference in symptomatic patients
Systemic treatment option for CNS metastatic melanoma with BRAF mutation?
Dabrafenib + Trametinib
Management of oligometastatic cutaneous melanoma?
Surgical resection then adjuvant immunotherapy (nivo or pembro or BRAFi/MEKi for BRAF mutations)
In mucosal melanoma, patients with what mutation are likely to have minimal to no sensitivity to TKIs?
KIT exon 17 mutations
Also KIT amplifications
Preferred systemic therapy of metastatic uveal melanoma?
Tebentafusp for HLA 201*02
If not, then pembro, nivo, or Ipi+nivo.
Most common metastatic site of uveal melanoma
Liver
Treatment of Uveal melanoma metastatic only to the liver, progressed on Tebentafusp and immunotherapy.
Intra-hepatic melphalan
Treatment of choice for asymptomatic CNS mets from melanoma?
RadiationTreat
Treatment of choice for symptomatic CNS mets
Surgery if resectable
4 systemic treatment options for metastatic mucosal melanoma with KIT mutation
Imatinib
Dasatinib
Nilotinib
Ripretinib
8 high risk features of cutaneous basal cell carcinoma?
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
Treatment for high risk local BCC?
Mohs or other resection
When to given adjuvant radiation therapy for cutaneous BCC?
Positive margins
Only approved option for metastatic BCC in first line?
Vismodegib
2nd line metastatic treatment for BCC?
Cemiplimab
Indications for sonidegib in BCC?
Locally advanced BCC that recurred after surgery or RT
Or for those who are not surgery or RT candidates
**Not approved for metastatic disease
Main treatment for local Merkel Cell carcinoma
Surgery with SLNB
Indications for adjuvant RT in Merkel cell carcinoma
> 1 cm tumor
Chronic T cell suppression
HIV
CLL
SOT
H&N primary
+LVI
What pathology marker is a sensitive finding for Merkel cell carcinoma?
CK20
4 treatment options for metastatic Merkel Cell Carcinoma
Avelumab
Pembrolizumab
Nivolumab
Retifanlimab
Systemic therapy for recurrent or metastatic cutaneous SCC not curable by surgery or RT (2)
Pembrolizumab
Cemiplimab
When to consider neoadjuvant treatment for cutaneous SCC?
Very rapid growth
Intransit mets
+LVI
Borderline resectable
What systemic therapy can be given in neoadjuvant setting for cutaneous SCC?
Cemiplimab
What comprises Stage IIB melanoma?
T3b or T4a, N0
(2-4 mm thick with ulceration or >4 mm thick without ulceration)
What comprises Stage IIC melanoma?
T4b N0
>4mm thick with ulceration
desmoplastic melanoma is different from typical cutaneous melanoma in what way?
High risk for local recurrence
Super responsive to immunotherapy
Low likelihood of driver mutation
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?
BRAF VE1 IHC testing
In cutaneous melanoma, who can be considered for neoadjuvant treatment?
Stage III (clinically N+) who have resectable disease, but surgery would be morbid or difficult
In cutaneous melanoma, what are two neoadjuvant treatment options for eligible patients?
Pembro
Ipi Nivo
