LWBK1006-27 LWW-Govindan-Review December 12, 2011 19:32
Chapter 27•Cancer of the Skin and Melanoma 381in ipilimumab-treated patients and typically manifests as diarrhea and
abdominal pain/cramping. Bowel perforation is uncommon but was seen
in less than 1% of patients treated in the phase III trial (NEJM, 2010). In
addition, immune-mediated hepatotoxicity, dermatitis, neuropathy, and
endocrinopathy (including hypopituitarism) are also seen in patients. Pre-
medication is not necessary; in fact, corticosteroids are contraindicated
in patients receiving ipilimumab unless used to treat autoimmune-related
toxicities. Myelosuppression is not seen in patients receiving ipilimumab
so weekly CBC is unnecessary. Routine laboratories drawn prior to each
dose of ipilimumab include CBC, CMP, and TSH. Interestingly, patients
over 65 years had similar outcomes in terms of safety and overall survival
compared to younger patients.Answer 27.13. The answer is C.
BRAF, downstream target of Kras in the mitogen-activated protein kinase
MAPK pathway, is commonly mutated in melanomas. The V600E muta-
tion appears to occur more commonly in sites of intermittent exposure
to UV, whereas melanomas from chronically sun-damaged skin are usu-
ally BRAF wild type. The partial response rates according to RECIST
criteria to PLX4032 in a phase I trial were 80%. The confirmed response
rate to PLX4032 (the oral BRAF inhibitor, vemurafenib) in patients with
metastatic melanoma is 48% by RECIST criteria in the phase III trial.Answer 27.14. The answer is B.
Although response rates are relatively high (>50%) with platinum-based
chemotherapy, it is unclear if chemotherapy prolongs survival. In addition
to platinum and etoposide, topotecan and doxorubicin are considered
active agents in Merkel cell carcinoma. Interleukin-2 and imatinib have
not been extensively studied for this disease. Surgical resection would
appear to be an option for selected patients with a single distant site in
instances that could be rendered disease free; however, most patients with
bilateral pulmonary metastases are not generally considered for surgery.Answer 27.15. The answer is D.
AKs are common lesions in sun-exposed areas and caused by UVB. Treat-
ment is usually indicated since there are no reliable predictors for progres-
sion into invasive squamous cell carcinomas. Cure rates from cryosurgery
are 98%.Answer 27.16. The answer is C.
Basal cell carcinoma, the most common human malignancy, has a slow
growth and, although more common in sun-exposed areas, may occur
in any part of the body. The most common type is the nodular, which
accounts for approximately 50% of the cases.Answer 27.17. The answer is B.
The patient has grade 3 immune-mediated enterocolitis until proven oth-
erwise. A clinical evaluation is necessary prior to the start of treatment