27 Cancer of the Skin and Melanoma

Gerald P. Linette

QUESTIONS

Each of the numbered items below is followed by lettered answers. Select the ONE lettered answer that is BEST in each case unless instructed otherwise.

Question 27.1 What is the most prevalent significantly mutated gene in cutaneous melanoma?

A. BRAF V600K

B. BRAF V600R

C. BRAF V600E

D. NRAS Q61R

E. NRAS Q61K

Question 27.2 Which of the following is included in referral criteria for hereditary melanoma genetic counseling?

A. Parent with multiple skin cancers.

B. Pancreatic cancer and melanoma on the same side of the family.

C. Three or more siblings with actinic keratosis.

D. Two relatives on the same side of the family with melanoma and prostate cancer.

Question 27.3 Which of the following genes act as founding mutations implicated in the early transformation of cutaneous melanoma (Select two correct responses)?

A. NRAS

B. BRAF

C. TP53

D. MEK1

Question 27.4 Which of the following statements best explains the increased incidence of melanoma over the past 25 years?

A. Decreasing use of sunscreen among middle age persons.

B. High penetrance rate of CDKN2A mutations.

C. Increasing exposure to ultraviolet light.

D. Increasing use of birth control pills.

Question 27.5 What is the most common site for primary skin melanoma in females?

A. Back

B. Face

C. Lower extremities

D. Scalp

Question 27.6 Which one of the following features of primary melanoma is the most important prognostic factor?

A. Clark level

B. Breslow thickness

C. Mitotic rate

D. Anatomical location

Question 27.7 Basal cell nevus syndrome has been associated with mutations in which one of the following genes?

A. Patched gene 1

B. Sonic hedgehog

C. MEK1

D. NF1

Question 27.8 A 48-year-old woman was recently diagnosed with a nonulcerated 1.6-mm depth primary superficial-spreading melanoma excised from her back. The melanoma is nonmitogenic and the margins are negative. She is referred to you for further evaluation and no adenopathy is noted on examination. Which of the following is the most appropriate next step in clinical management?

A. PET-CT to complete the staging evaluation.

B. Referral back to the Dermatologist for annual skin checks.

C. Wide excision and sentinel lymph node mapping.

D. Wide excision followed by interferon for 1 year.

Question 27.9 A 55-year-old woman in excellent health presents to the Emergency Department with a 7-day history of headache and ataxia. She denies any recent illness and states that acetaminophen is no longer relieving her symptoms. You evaluate the patient and order a head CT examination, which reveals a 3-cm solitary lesion with surrounding vasogenic edema, present in the posterior fossa. The patient denies any past history of malignancy; however, your physical examination detects a cutaneous nonpigmented lesion on her ankle. You order dexamethasone 10 mg intravenously and the patient’s symptoms improve after 90 minutes. She wants to go home. You suspect a solitary brain metastasis. What is the next step in management?

A. Discharge the patient to home and make a referral to the patient’s primary care physician.

B. Discharge the patient to home and make a referral to the radiation and dermatology clinics.

C. Admit the patient and request a brain MRI followed by a neurosurgical consultation.

D. Admit the patient and request a palliative care consultation.

Question 27.10 A 29-year-old man is recently diagnosed with primary cutaneous melanoma. The pathology report confirms a T3b N2b M0 primary nodular melanoma excised from the left shoulder. The primary lesion was ulcerated and mitogenic (4/mm²). The patient is in excellent health and has no significant past medical history. The patient is referred to you for adjuvant treatment. What is the final stage of this patient’s melanoma?

A. Stage IIIA

B. Stage IIIB

C. Stage IIIC

D. Stage IV, M1A

Question 27.11 A 40-year-old woman with a history of ulcerative colitis, mitral valve prolapse, eczema, and stage 1 cutaneous melanoma presents with right inguinal adenopathy. Physical examination confirms a 4-cm node and core biopsy confirms malignant melanoma. BRAF mutational analysis is requested and BRAF V600E mutation is detected. Brain MRI is unremarkable; however, CT examination reveals numerous (>10) bilateral pulmonary metastases with the largest lesion measuring 1.2 cm in the left upper lobe. No other sites of distant metastases are evident and you conclude that this patient has stage IV, M1b disease. The patient does not want to participate in a clinical trial and wants to begin treatment as soon as possible. What is the best initial treatment for this individual?

A. Ipilimumab

B. BRAF inhibitor

C. MEK inhibitor

D. BRAF and MEK inhibitor combination

Question 27.12 A 73-year-old man with a past history of stage IIC nodular melanoma excised from his back 3 years ago presents to your office with lower back pain and fatigue for the past 2 weeks. Your physical examination is unrevealing. However, several laboratories are elevated, including serum alkaline phosphatase, and serum LDH (two times upper limit of normal). PET-CT examination the following day documents metastatic disease involving lungs, liver, peritoneum, and multiple osseous areas, including the lumbar spine. What is the most appropriate next step in management?

A. Request a brain MRI and a biopsy of a lung lesion.

B. Request a palliative care consultation.

C. Request a second opinion review of the primary cutaneous lesion excised 3 years ago.

D. Begin systemic therapy as soon as possible.

Question 27.13 A 36-year-old woman with a past history of cutaneous melanoma (stage IIB) has been followed by her dermatologist. She has active rheumatoid arthritis and is receiving methotrexate under the care of a local rheumatologist. She recently presented to the emergency department with complaints of headaches and was found to have a 3.5-cm solitary right parietal metastasis. The metastasis was surgically resected and confirmed as metastatic melanoma, BRAF V600E mutated. A postoperative body PET-CT examination was negative for additional disease and the hospital physicians told her that she has no additional evidence of disease. She is referred to you for treatment recommendations. What is the next best step in the management of her care?

A. Request radiation oncology consultation for stereotactic radiosurgery.

B. Request radiation oncology consultation for whole brain radiation.

C. Administer adjuvant chemotherapy.

D. Administer adjuvant interferon.

Question 27.14 A 27-year-old woman has metastatic melanoma, BRAF wild type (no mutation), stage IV, M1B. You recommended initial systemic treatment with ipilimumab and she completed four doses with no side effect or toxicity. Two weeks after the four dose a restaging CT examination is performed which reveals the appearance of a new 6-mm left upper lobe lesion as well as an increase of a baseline right lower lung lesion from 17 mm to 23 mm. The other lung metastases remain unchanged. You see the patient in your office the following day. She feels fine and has no complaints. Her laboratories are all within normal limits. However, the patient is anxious after you discuss the CT imaging results with her. She and her husband have many questions regarding other treatment options. What is your recommendation to this patient?

A. Despite the fact that her tumor is BRAF wild type, there is some evidence that treatment with a MEK inhibitor would be beneficial.

B. You recommend a repeat CT scan in 4 weeks based upon reports that 10% to 15% of patients treated with ipilimumab can have evidence of progression prior to documented response.

C. You recommend retreatment with four additional doses of ipilimumab.

D. You recommend immediate surgical consultation.

Question 27.15 A 66-year-old man with metastatic melanoma is receiving treatment with combination ipilimumab and nivolumab on a clinical trial. Fourteen days after the second dose, he calls your office to tell you that he has been having watery loose stools up to ten times a day for the past week. However, you are out of town and your nurse practitioner called in sick for the day. What is your recommendation to this patient?

A. Call your primary physician immediately.

B. Keep your scheduled appointment next week for the third dose but call sooner if the diarrhea gets worse.

C. Take loperamide as directed and keep hydrated.

D. Go to the local emergency department immediately for evaluation.

Question 27.16 A 70-year-old man from out of town presents to the emergency department with complaints of profound fatigue and headaches for the past 3 days. His vital signs are normal except for a blood pressure of 90/50. He denies fevers and diarrhea. His medical history is significant for gout, type 2 diabetes, and metastatic melanoma. He is receiving treatment with ipilimumab along with an experimental immunotherapy drug but he can’t remember the name of the investigational drug. He has received four cycles of treatment and is due for a restaging evaluation when he returns home in a week. Unfortunately, it’s a holiday weekend and no medical records are available. You request a CBC, CMP, and EKG along with a head CT and CT examination of the chest, abdomen, and pelvis. The chest CT confirms the presence of innumerable (>20) pulmonary metastases but none greater than 2 cm. The head CT is unremarkable. You are perplexed and unsure of the cause of his symptoms. You decide to order additional blood work. What is the most appropriate test to order?

A. Blood cultures

B. Serum LDH

C. Thyroid function tests

D. C-reactive protein

E. Discharge to home with instructions to call his oncologist

Question 27.17 A 75-year-old woman with a past history of recurrent basal cell carcinoma of the skin was recently found to have bilateral lung lesions. CT examination confirms 10 pulmonary lesions as well as several liver lesions. The 2.5-cm right upper lobe lesion is biopsied and confirmed as basal cell carcinoma. Her primary care physician tells her that she will need chemotherapy. She arrives in your office along with several additional family members, including her daughter who is a physician. They are distraught over the recent diagnosis and have solicited the opinions of various physicians. They understand her condition is incurable but desire the best treatment. What is your treatment recommendation?

A. Platinum-based chemotherapy for six cycles

B. Vismodegib

C. Trametinib

D. Immediate radiation oncology consultation

E. Immediate surgical consultation

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