Management of Cutaneous Melanoma

In this lecture to the Harvard Dermatology residents, we provide pearls for the management of cutaneous melanoma

Event Details

Event: Harvard Dermatology Resident Lecture

TABLE OF CONTENTS

Overview & Learning Objectives

• Understand the current therapeutic landscape for high-risk localized cutaneous melanoma
• Review treatment strategies for high-risk regionally metastatic melanoma
• Discuss management options for patients with metastatic melanoma

Clinical Cases

CASE 1

Synopsis

A 71-year-old Male with a history of NMSC presents for follow up to discuss the pathology results of a recent biopsy of a pigmented lesion on his back

Pathology reveals

• HISTOLOGIC TYPE: Superficial spreading melanoma
• PRECURSOR LESION: Not identified
• MAXIMUM TUMOR THICKNESS: 3.0 mm
• ANATOMIC LEVEL: At least level IV
• ULCERATION: Present
• MITOTIC RATE: 9 per mm2
  
• LYMPHOVASCULAR INVASION: Present, Foci suspicious for lymphovascular invasion
• METHOD OF DETECTION: Hematoxylin and eosin
  
• RADIAL GROWTH PHASE: Present
  
• VERTICAL GROWTH PHASE: Present
  
• TYPE OF VERTICAL GROWTH: Epithelioid
  
• MICROSATELLITES: Cannot be assessed
  
• PERINEURAL INVASION: Cannot be assessed
  
• TUMOR-INFILTRATING LYMPHOCYTES: Present, nonbrisk
  
• TUMOR REGRESSION: Absent
  
• MARGINS: Extending to inked lateral and deep resection margins

Case 1 Clinical Questions:

• What is this patient’s T stage?
  
• What would be your next steps in work up?
  • What would be your surgical plan?
    
  • What additional studies (if any) would you order?

CASE 2

Synopsis

A 68-year-old Male with a history of HTN, HLD, T3bN1aM0 melanoma presents for follow up to discuss next steps in management.

Relevant Work Up To Date: 

• Tumor:
  • 3.2 mm thick, ulcerated SSM with 5 mitoses, Right mid back
    
• Nodal:
  • 1/14 nodes positive for melanoma on sentinel lymph node biopsy
    
• Imaging:
  • No evidence of distant disease
    
• Molecular Testing:
  • BRAF p.V600E (c.1799T>A): absent
    
  • BRAF p.V600K (c.1798_1799delGTinsAA): present
    • INTERPRETATION: POSITIVE for variant in BRAF.

Case 2 Clinical Questions:

• What is this patient’s pathological stage?
  
• What are the therapeutic options for this patient?

CASE 3

Synopsis

A 58-year-old Female with a history of HTN, HLD, presents with a 3 cm ulcerated pigmented lesion on the right thigh. Physical exam reveals a 6 cm right inguinal mass.

Case 3 Clinical Questions:

• What are your next steps in management?
  
• If regionally metastatic melanoma is confirmed, what management options are available?

CASE 4

Synopsis

A 49-year-old Male with a history of pulmonary sarcoidosis presents with BRAF V600 mutated melanoma metastatic to the liver and lungs.

Case 4 Clinical Questions:

• What therapeutic strategies are available for this patient?
  
• Given the patient’s comorbidities, what would be your first-line treatment strategy?

Timeline of FDA-Approved Medications for Melanoma

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