Mr. B, a 40-year-old avid long-distance runner previously in good health, presented to his primary provider for a yearly physical examination, during which a suspicious-looking mole was noticed on the back of his left arm, just proximal to the elbow. He reported that he has had that mole for several years, but thinks that it may have gotten larger over the past two years. Mr. B reported that he has noticed itchiness in the area of this mole over the past few weeks. He had multiple other moles on his back, arms, and legs, none of which looked suspicious. Upon further questioning, Mr. B reported that his aunt died in her late forties of skin cancer, but he knew no other details about her illness. The patient is a computer programmer who spends most of the work week indoors. On weekends, however, he typically goes for a 5-mile run and spends much of his afternoons gardening. He has a light complexion, blonde hair, and reports that he sunburns easily but uses protective sunscreen only sporadically.
Physical exam revealed: Head, neck, thorax, and abdominal exams were normal, with the exception of a hard, enlarged, non-tender mass felt in the left axillary region. In addition, a 1.6 x 2.8 cm mole was noted on the dorsal upper left arm. The lesion had an appearance suggestive of a melanoma. It was surgically excised with 3 mm margins using a local anesthetic and sent to the pathology laboratory for histologic analysis. The biopsy came back Stage II melanoma.
- How is Stage II melanoma treated and according to the research how effective is this treatment?
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- Module 3: Stage II MelanomaMelanoma accounts for 90% of deaths associated with cutaneous tumors due to their increased risk of metastasis and the speed in which they can evolve (Garbe et al., 2016). 10-year tumor specific survival rates range from 75-85% for a primary tumor without metastasis (Garbe et al., 2016). Increase in age, male sex, and tumor locations on the head or neck all decrease prognosis (Garbe et al., 2016). The 10-year survival rate for those who have lymph node metastasis decreases to 20-40% (Garbe, et al., 2016). If the patient shows BRAF or MEK genetic mutations, inhibitors of these genes may be a viable treatment option to lower risk of recurrence. These genes are responsible for cell growth, proliferation, and survival (Garbe et al., 2016). In instances of inoperable melanomas or melanomas with distant metastases, immunotherapeutic drugs may be used to prolong survival or reduce tumor size (Garbe et al., 2016). It is estimated that roughly 45% of people with melanoma have a BRAF mutation (Garbe, et al., 2016). Vemurafenib and dabrafenib are examples of oral drugs approved in the US and UK that act on BRAF and MEK mutations and use of these is considered the gold standard of care (Garbe, et al., 2016). These drugs inhibit these mutations and can improve quality of life and increase longevity.ReferencesHuether, S. E., McCance, K. L., & Brashers, V. L. (2020). Understanding pathophysiology (7th ed.). Elsevier.Stage II melanoma. (2020). Melanoma Research Alliance. Retrieved February 3, 2021, from https://curemelanoma.org/about-melanoma/melanoma-staging/stage-2less1 UnreadUnread6 ViewsViews
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- Koster, B. D., van den Hout, M. F., Sluijter, B. J., Molenkamp, B. G., Vuylsteke, R. J., Baars, A., van Leeuwen, P. A., Scheper, R. J., Petrousjka van den Tol, M., van den Eertwegh, A. J., & de Gruijl, T. D. (2017). Local adjuvant treatment with low-dose cpg-b offers durable protection against disease recurrence in clinical stage i–ii melanoma: Data from two randomized phase ii trials. Clinical Cancer Research, 23(19), 5679–5686. https://doi.org/10.1158/1078-0432.ccr-17-0944
- Garbe, C., Peris, K., Hauschild, A., Saiag, P., Middleton, M., Bastholt, L., Grob, J.-J., Malvehy, J., Newton-Bishop, J., Stratigos, A. J., Pehamberger, H., & Eggermont, A. M. (2016). Diagnosis and treatment of melanoma. european consensus-based interdisciplinary guideline – update 2016. European Journal of Cancer, 63, 201–217. https://doi.org/10.1016/j.ejca.2016.05.005
- The first line of treatment for melanoma is removal using surgical means (Huether et al., 2020, pp. 1033-1034). The surgical excision will have a large border and a biopsy of the peripheral lymph node will be taken if the lesion is greater than 1mm (Huether et al., 2020, pp. 1033-1034). Prognosis is increased if the excision a biopsy occurs within 4-6 weeks of diagnosis (Garbe, et al., 2016). If the melanoma meets certain criteria that increases the risk of metastasis, adjuvant therapy can be used. Typically, adjuvant therapy is only used if the lesion is deeper or thicker than 4mm or if there is lymph node involvement (Koster et al., 2017). Patients that meet these criteria have an increased risk of recurrence due to the likelihood of melanoma cells remaining unseen in the body (Koster, et al., 2017). Adjuvant therapies include chemotherapy, the use of interferon-α, BRAF/MEK inhibitors, or immunotherapy with antibodies (Garbe, et al., 2016). Of these therapies, the use of interferon- α has shown the most promise in clinical trials (Garbe et al., 2016). Koster (2017) found that the use of low dose immunotherapy agents may reduce the instance of tumor recurrence by 26%. Research is being done on vaccines as well (Koster, et al 2017).
- Stage II melanoma is a grade of skin cancer that extends beyond the epidermis into the dermis of the skin (Stage II Melanoma, 2020). Typically, at this stage it is still considered a localized melanoma but is more likely to metastasize compared to its stage 0 or stage I counterparts (Stage II Melanoma, 2020) Melanoma itself is a malignant tumor that involves the melanocytic cells that are responsible for producing melanin (Huether et al., 2020, pp. 1033-1034). These cells begin to malignantly degenerate in the basal layer of the epidermis or the melanocytic nevus (Huether et al., 2020, pp. 1033-1034). While melanoma typically appears on the skin, it can also appear in the eyes, meninges, or mucosal surfaces (Garbe et al., 2016). Risks for melanoma include familial history, UV exposure, fair hair/skin, geographical location, and others (Huether et al., 2020, pp. 1033-1034). Mutations in the BRAF, RAS, NFI, or triple wild gene can also contribute to risk (Huether et al, 2020, pp. 1033-1034).
- Module 3, Eleany YaseinSubscribe
- Eleany Yasein posted Feb 2, 2021 10:22 PM
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- First acknowledged as a disease during the 1800s, melanoma is a skin cancer that is highly deadly (Davis, Shalin, & Tackett, 2019). However, treatment can be successful during the early stage of this cancer (Davis et al., 2019). The initial treatment for stage II melanoma is by surgical removal of the tissue (American Cancer Society, 2019). After the surgery, it is recommended that patients get a sentinel lymph node biopsy (SLNB) done, in order to detect whether or not the melanoma has spread to the nearby lymph nodes. If cancer is not detected around the lymph nodes, further treatment will not be necessary. However, close follow up will be crucial to the process. If the SLNB detects cancerous cells around the lymph nodes, all the lymph nodes in the area will be surgically eliminated. Moreover, targeted therapy drugs, as well as immune checkpoint inhibitor are recommended in order to reduce the chances of the cancer returning (American Cancer Society, 2019). American Cancer Society. (2019, August 14). Treatment of Melanoma Skin Cancer, by Stage. Retrieved February 02, 2021, from https://www.cancer.org/cancer/melanoma-skin-cancer/treating/by-stage.html less2 UnreadUnread10 ViewsViews
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- Koster, D. B., Van den Hout, F.C.M. M., Sluijter, J.R. B., Molenkamp, G. B., Vuylsteke, J.C.L.M. R., Baars, A., Van Leeuwen, A.M. P., Scheper, J. R., Van den Tol, P. M., Van den Eertwegh, J.M. A., & De Gruijl, D. T. (2017, October). Local Adjuvant Treatment with Low-Dose CpG-B Offers Durable Protection against Disease Recurrence in Clinical Stage I–II Melanoma: Data from Two Randomized Phase II Trials. Clinical Cancer Research, 23(19). doi: 10.1158/1078-0432.CCR-17-0944
- Davis, E. L., Shalin, C. S., & Tackett, J. A. (2019). Current state of melanoma diagnosis and treatment. Cancer biology & therapy, 20(11), 1366-1379. doi: 10.1080/15384047.2019.1640032