Page 34 - GP Fall Final 2017

display a specific mutation to a gene known It has been demonstrated that Xgeva has Among the risk factors for melanoma are
as BRAF. BRAF V600E and V600K muta- presented serious bone issues longer than ultraviolet (UV) light exposure, presence
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tions can be treated with BRAF and MEK zoledronic acid (Zometa ). Studies of pa- of a mole or moles (nevus/nevi) or atypical
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inhibitors such as dabrafenib and trametinib, tients with bone metastases have shown that moles (dysplastic nevi), dysplastic nevus
which are targeted to these mutations. The the rate of severe jaw bone complications syndrome or congenital melanocytic nevi,
inhibitors block the action of BRAF associ- was higher with longer treatment with Xge- patients with fair skin, freckling, light hair,
ated proteins which lead to errant signaling va . Xgeva is administered subcutaneously patients with a personal or family history
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that permits the growth and spread of can- with a dose of 120 mg every four weeks. of melanoma or other skin cancers, patients
cer cells. Unfortunately, healthy cells are who are immunocompromised, patients
also affected. The two drugs together have Melanoma with advanced age, and patients who have
been shown to be more effective yet no more The three main types of cells that comprise been diagnosed with xeroderma pigmento-
toxic than single agent treatment. The rec- the upper layer of the skin, or epidermis, are sum (XP) in which the skin cell’s ability to
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ommended daily dose is 150 mg of Tafinlar squamous cells, basal cells, and melano- repair DNA damage is affected. 10
every 12 hours and 2 mg of Mekinist. 4,5 cytes. Melanoma is derived from the abnor-
mal proliferation of the melanocytes, and is Melanoma: Detection and Diagnosis
Tafinlar and Mekinist may cause serious also known as malignant melanoma and cu- Melanoma is an uncommon but serious type
side effects including cranial, gastric, and taneous melanoma. Melanomas are usually of cancer. The incidence has been increas-
intestinal hemorrhaging, which could re- brown or black; however, some melanomas ing since the 1970’s. As with any cancer,
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sult in death. They may place patients at do not produce melanin and, therefore, can early detection of melanoma would allow
risk of new cancers, specifically cutaneous appear pink, tan, or white. While melano- for more treatment options and most likely a
squamous cell carcinoma, as well as new mas can develop anywhere on the skin, it better prognosis. Detection can be achieved
melanoma lesions. The skin should be ex- is more probable on the trunk in men and either by self-examination or by a health
amined every two months while on therapy on the legs in women. Other common sites care professional. Signs and symptoms to
and for at least six months subsequent to the are the neck and face. The risk of melano- consider can be guided by the “ABCDE
discontinuation of therapy. Additional side ma is lower at these sites in individuals with rule”: Asymmetry, Border, Color, Diame-
effects include colitis, blood clots, heart darkly pigmented skin. However, melano- ter, and Evolving. Tests to complete and to
complications (including heart failure), vi- ma may develop on the palms of the hands, consider include medical history, physical
sual complications, lung and respiratory the soles of the feet, and under the nails in exam, and skin biopsies. Biopsies include
issues, increased blood sugar/hyperglyce- African Americans. Although they are much shave/tangential, punch, incisional/exci-
mia, hemolytic anemia in patients with glu- less common sites, melanoma can also de- sional, and optical.
cose-6-phosphate dehydrogenase (G6PD) velop in the eyes, mouth, genitals, and anal
deficiency, skin reactions, fever, fertility area. While melanoma is less common than Melanoma: Staging
issues, and altered sperm counts. basal or squamous cell carcinoma, it is more As with any other malignancy, treatment
dangerous since it is more likely to metasta- of melanoma will depend on the stage and
Xgeva (Denosumab) size if not detected early. Skin cancer is the location of the tumor(s) and the overall
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Denosumab is a monoclonal antibody drug most common of all cancers. While mela- health of the individual. Stage 0 is usually
classified as a RANKL inhibitor, which noma only accounts for about 1% of skin treated by wide excision of the melanoma
works by controlling osteoclast function, cancers, it contributes to a large majority of along with a small margin of normal tissue
slowing bone resorption and increasing skin cancer related mortalities. adjacent to it. Stage I is similar to Stage 0
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bone density. The brand names are Xgeva with the margin of normal tissue removed
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and Prolia . It is used to treat osteoporo- In 2017, the American Cancer Society es- dependent on the thickness and location of
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sis, hypercalcemia, bone complications also timates approximately 87,110 newly di- the melanoma. Sentinel lymph node biop-
known as SREs (skeletal related events) and agnosed cases of melanoma and approxi- sies may be performed and the result may
cancer metastasis to bone. It is prescribed to mately 9,730 deaths from melanoma in the necessitate a lymph node dissection. Treat-
prevent fracture, spinal cord compression, United States. For the last 30 years, the rates ment for Stage II is similar to Stage I treat-
or need for radiation or surgery to bone with of melanoma have risen. It is 20 times more ment, but adjuvant immune therapy with in-
metastases from solid tumors. Prolia was common in Caucasians than African Amer- terferon may be advisable. Stage III would
approved for the treatment of osteoporosis icans. The lifetime risk is 2.5% in Cauca- indicate resection of the tumor with appro-
and Xgeva for the prevention of skeletal sians, 0.1% in African Americans, and 0.5% priate margin considerations, lymph node
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related events (SREs) in patients with bone in Hispanics. As people age, the risk of mel- dissection along with adjuvant immune
metastases from solid tumors. Denosum- anoma increases. The average age at diag- therapy with interferon, and radiation thera-
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ab has been associated with osteonecrosis of nosis is 63 years; however, it is not uncom- py to the lymph node areas, especially with
the jaw, however the underlying pathogene- mon to be diagnosed under 30 years of age. significant nodal involvement. Isolated limb
sis is still under investigation. perfusion (infusion of a limb with a heated
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Figure 7: Intraoral view: exposed area of bone Figure 8: Panoramic film. Figure 9: Periapical film of upper right quadrant.
in upper right quadrant.
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