SM_258a: Melanoma

Question 1

Describe risk factors for melanoma

Answer 1

Melanoma risk factors

• Genetic: family history of dysplastic nevus, lightly pigmented skin, tendency to burn / inability to tan, red / blonde hair color, blue / green eyes, DNA repair defects
• Environmental: exposure to UV light, intense intermittent sun exposure, sunburn, residency in equatorial lattitudes, tanning
• Gene / environment interactions: melanocytic nevi (increased number., multiple dysplastic, congenital), freckles, personal history of melanoma

Question 2

___ sun exposure increases risk for melanoma more than ___ sun exposure

Answer 2

Intermittent sun exposure increases risk for melanoma more than constant sun exposure

Question 3

Melanocytes produce ____

Answer 3

Melanocytes produce melanin, which is the pigment found in skin, eyes, and hair

(melanoma is cancer arising from melanocytes)

Question 4

Describe the role of UV skin damage in causing DNA damage

Answer 4

Role of UV skin damage in causing DNA damage

• Cyclobutane pyrimidine dimers
• DNA damage occurs immediately upon exposure and cell repair begins afterward
• Amount of melanin in skin plays an important role in UV absorption and photoprotection
• 30% of melanomas develop within existing dysplastic devus
• 70% of melanomas develop de novo: no precursor lesion

Question 5

Guideline of ____ is used for referral to a genetics specialist in melanoma

Answer 5

Guideline of 3s is used for referral to a genetics specialist in melanoma

• Individual with 3 or more primary melanomas: 10-15% risk of P16 mutation
• Patients with ≥ melanomas among first or second degree relatives (45% risk of P16 mutation)
• Families w/ith presence of melanoma and/or pancreatic cancer in three family members (45% risk of P16 mutation)

Question 6

____ is most common type of melanoma, associated with ____, and involves ____ mutation

Answer 6

Superficial spreading melanoma is most common type of melanoma, associated with intermittent sun exposure, and involves BRAF mutation

(lentigo maligna melanoma is associated with chronically sun exposed skin and involves c-Kit and NRAS mutations)

Question 7

____ mnemonic is used to diagnose melanoma and stands for ____, ____, ____, ____, and ____

Answer 7

ABCDE mnemonic is used to diagnose melanoma and stands for asymmetry, border, color, diameter, and evolving

(general clinical exam, total body photography, dermoscopic exam)

Question 8

Dysplastic nevi are ____ and have ____ pigment deposition, ____ contour, and ____ margins

Answer 8

Dysplastic nevi are multicolored na dhave asymmetric pigment deposition, asymmetric contour (macular and papular), and distinct margins

(dysplastic nevus syndrome has risk of developing into melanoma)

Question 9

Management of the dysplastic nevi patient involves ____, ____, ____, and ____

Answer 9

Management of the dysplastic nevi patient involves close monitoring (full body exams every 6-12 months), dermoscopy of all atypical appearing nevi, whole body photos, and excision of any changing or markedly atypical nevi

Question 10

Describe the types of melanoma

Answer 10

Types of melanoma

• Superificial spreading melanoma
• Nodular melanoma
• Lentigo malignant melanoma
• Acral lentiginous melanoma

Question 11

Acral lentiginous melanoma has a higher incidence in ____ patients compared to other forms of melanoma and is associated with ____ prognosis because ____

Answer 11

Acral lentiginous melanoma has a higher incidence in dark skinned patients compared to other forms of melanoma and is associated with poorer prognosis because it is often not diagnosed

Question 12

Pink or red dot is ____ melanoma

Answer 12

Pink or red dot is amelanotic melanoma

Question 13

Describe workup / staging for melanoma

Answer 13

Melanoma workup / staging

• Dermatopathology
• Breslow thickness, Clark level
• Sentinel lymph node biopsy
• Following guidelines
• BRAF mutation testing
• Imaging: CXR, CT, MRI, PET/CT

Question 14

Do a sentinel lymph node biopsy for melanoma if Breslow thickness is ____

Answer 14

Do a sentinel lymph node biopsy for melanoma if Breslow thickness is greater than 0.8 mm

(stage IB and above)

Question 15

____ is the most important predictor of melanoma prognosis

Answer 15

Breslow level is the most important predictor of melanoma prognosis

(larger thickness associated with worse survival)

(radial growth phase is better than vertical growth phase, lymphatic / vascular invasion is poor prognosis, Clark level is not predictive of behavior of the melanoma, ulceration, mitotic rate, regression)

Question 16

___ presence is associated with poor survival

Answer 16

Tumor ulceration presence is associated with poor survival

(presence of ulceration upstages the tumor grade from an A to B stage)

Question 17

____ is most important pathologic assessment in addition to ulceration in predicting tumor aggression and involvement of lymph node

Answer 17

Mitotic rate is most important pathologic assessment in addition to ulceration in predicting tumor aggression and involvement of lymph node

(most predictive of lymph node involvement in tumors with 0.5 - 1 mm Breslow thickness)

Question 18

Describe treatments for melanoma

Answer 18

Melanoma treatments

• Surgery: Breslow depth tells you what excision margins should be used
• Targeted therapy
• Immunotherapy
• Biochemotherapy
• Radiation therapy
• Intralesional therapy

Question 19

Describe stage III melanoma workup and therapy

Answer 19

Stage III melanoma workup and therapy

• Workup: baseline imaging for staging - CT, PET/CT, brain MRI
• Treatment: primary (wide excision of primary tumor, no longer routinely recommended), adjuvant
• Adjuvant therapy if BRAF wild-type or unknown: nivolumab / pembrolizumab
• Adjuvant therapy if + BRAF V600 mutation: nivolumab / pembrolizumab

Question 20

Describe stage IV melanoma treatment

Answer 20

Stage IV melanoma treatment

• Talimogene laherparepvec: oncolytic virus based on modified HSV1 that was designed to selectively replicate in and lyse tumor cells while promoting regional and systemic antitumor immunity, insertion gene for GM-CSF
• Anti PD-1 monotherapy: pembrolizumab, nivolumab
• Targeted therapy if BRAF mutated

Question 21

Broad spectrum sunscreen covers ____ sun rays

Answer 21

Broad spectrum sunscreen covers UVA and UVB sun rays

Question 22

___ is responsible for most skin cancer deaths

Answer 22

Melanoma is responsible for most skin cancer deaths

(despite only comprising 5% of skin cancers)