NSG-530-IKC – Advanced Pathophysiology

 

 

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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.

  1. How is Stage II melanoma treated and according to the research how effective is this treatment?

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    • Melanoma
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    • Lois Chappell posted Feb 8, 2021 7:45 PM
    •                 Melanoma is a disease in which cancer cells form in the cells that bring color to  our skin, melanocytes.  Our skin consists of two layers, the dermis, and the epidermis.  Skin cancer begins in the epidermis, which in itself is composed of three distinct layers, squamous cells, basal cells, and melanocytes.  Over the past thirty years, cases of melanoma have increased dramatically (Melanoma Treatment, 2020).  While usually seen in adults, this cancer can also be seen in children.                  Like all cancers, treatment should begin with prevention.  Educating patients and families to prevent and detect skin cancer is essential.  Clinicians can use the history and physical exam, along with the ABCDE ( asymmetry, border, color, diameter, evolving size) screening method to improve outcomes through early detection (Skin Cancer Foundation, 2020).  Treatment of melanoma begins with testing, which may include biopsy, lymph node mapping, CT studies, blood work and additional tests as warranted.   Standard treatment for melanoma includes surgery, chemotherapy, radiation, and immunotherapy.  Newer treatments include vaccine therapy.  Like all cancers, prevention and a healthy lifestyle are essential to best outcomes.           PDQ Adult Treatment Editorial Board.  May 2020.  Melanoma Treatment:  Patient Version.  PDQ Cancer Institute.  Retrieved from           Skin Cancer Foundation.  2020.  Melanoma warning signs, what you need to know about early detection.  Retrieved from  less0 UnreadUnread
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    •                 https://www.skincancer.org/skin-cancer-information/melanoma/melanoma-warning -signs-and-images.
    •                 https://www.ncbi.nlm.gov/books/NBK6950.
    • References
    •                 While most often found in the trunk, head and neck on men, women tend to develop melanoma on the arms and legs.  Risk factors are numerous and include fair complexion, light hair (red or blonde) and eye color (blue, green), exposure to sun or artificial light, genetics, moles, personal history of melanoma, family history of melanoma, history of sunburns with blistering, and being white (Melanoma Treatment, 2020).
    • Stage II Melanoma discussion Week 3Subscribe
    • Aina Oluwo posted Feb 3, 2021 7:21 PM
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    • Stage 11 MelanomaAccording to Melanoma Research Alliance (2021), the staging of melanomas can be divided into three that is; Stage IIA Melanoma: this is when the tumor is more than 1.0 millimeter and less than 2.0 millimeters thick with ulceration (broken skin) or more than 2.0 and less than 4.0 millimeters without broken skin. Mr. B’s tumor measurements, which are 1.6 x 2.8cm, falls under stage IIA. In Stage IIB Melanoma, the tumor is more than 2.0 millimeters and less than 4.0 millimeters thick with broken skin (ulceration) or more than 4.0 millimeters without ulceration. Stage IIC Melanoma, the tumor is more than 4.0 millimeters thick with broken skin (ulceration). In cases whereby the SLNB found cancer, doctors do recommend additional treatment (Adjunct Therapy) with an immune checkpoint inhibitor or targeted therapy drugs, which helps to lower the chances of the melanoma coming back (The American Cancer Society, 2019). Huether, S. E., McCance, K. L., & Brashers, V. L. (2020). Understanding pathophysiology (7th ed.). Elsevier.The American Cancer Society. (2019, August 14). Treatment of melanoma by stage. American Cancer Society. Retrieved February 1, 2021, from https://www.cancer.org/cancer/melanoma-skin-cancer/treating/by-stage.htmlless2 UnreadUnread6 ViewsViews
  • References
    • 2 RepliesReplies
    • View profile card for Melissa Morgan
    • Last post February 7 at 8:52 PM by Melissa Morgan
    • PDQ Adult Treatment Editorial Board. Melanoma Treatment (PDQ®): Health Professional Version. (2021). In: PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-,. 
    • References
    • Module 3Subscribe
    • Steven Bartos posted Feb 3, 2021 5:34 PM
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    • In stage II melanoma, it is considered a locally invasive cancer as it has not spread to other parts of the body. Research by Garbe et al. (2016) concluded that surgical excision is the primary interventional treatment for melanoma. However, risk still remains that melanoma may reoccur even after surgery, so it’s not completely effective. Stage II melanoma is broken down into three subdivisions: stages IIA, IIB, and IIC, going from IIA – IIC respectively as the thickness of the melanoma increases. As far as overall survival rates are concerned, stage IIA has a five-year survival rate of 80%, but for stage IIC this decreases to 53% (Lee et al., 2017). ReferencesKoster, B.D., van den Hout, M., Sluijter, B., Molenkamp, B., Vuylsteke, R., Baars, A., van Leeuwen, P., Scheper, R., van del Tol, M., van den Eertwegh, A., de Gruijil, T. (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 Research23(19), 5679 – 5685. https://doi.org/10.1158/1078-0432.CCR-17-0944more1 UnreadUnread5 ViewsViews
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    • View profile card for Dennies Jones
    • Last post February 7 at 9:21 AM by Dennies Jones
    • Lee, A.Y., Droppelmann, N., Panageas, K.S., Zhou, Q., Ariyan, C.E., Brady, M.S., Chapman, P.B., & Coit, D.G. (2017). Patterns and timing of initial relapse in pathologic stage II melanoma patients. Annals of Surgical Oncology24(4), 939 – 946. http://dx.doi.org.wilkes.idm.oclc.org/10.1245/s10434-016-5642-0
    • Garbe, C., Peris, K., Hauschild, A., Saiag, P., Middleton, M., Basthold, 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 Cancer63(1), 201 – 217. https://doi.org/10.1016/j.ejca.2016.05.005
    • Research on adjuvant immunotherapy has shown that this can have some benefit specifically to stage 2 melanoma. It is used after primary treatments such as surgery to lessen the chance of the cancer returning. Interferon (IFN)-α is an immunotherapy agent that was shown to be effective in some randomized trials at improving survival rates (Garbe et al., 2016). In another study, Koster et al. (2017) looked at stage I – II melanoma patients and performed randomized trials to determine whether or not a localized adjuvant low dose CpG-B treatment offers benefit after the tumor is removed. These were phase II trials, but the study found that this specific treatment presented as safe, boosted immunity, was associated with lower rates of melanoma re-occurrence, and improved survival rates.
    • Module 3 DiscussionSubscribe
    • Alfonsina Perez posted Feb 3, 2021 1:34 AM
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    •             Melanomas are defined as malignant tumors that come from melanocytic cells (Garbe et al., 2016). Melanoma tumors are mostly found in the skin but can also be found in the eyes and meninges (Garbe et al., 2016). The primary treatment for stage II melanoma is an excisional biopsy (Garbe et al., 2016). In an excisional biopsy, the entire tumor is removed with a wide local incision, as opposed to an incisional biopsy when only a portion of the tumor is removed (Garbe et al., 2016). Whenever possible, an excisional biopsy is the preferred method of tumor removal in the case of melanomas. In cases when the tumors have metastasis or the risk of metastasis or recurrent of cancer may be a risk, adjuvant therapies may be recommended and these include chemotherapy and radiation (Garbe et al., 2016). Another part of the treatment for stage II melanoma is to do a sentinel lymph node biopsy to see if any cancer cells have spread to the lymph nodes (Hieken et al., 2019). ReferencesBrożyna, A. A., Guo, H., Yang, S., Cornelius, L., Linette, G., Murphy, M., . . . Carlson, J. A.(2017). TRPM1 (melastatin) expression is an independent predictor of overall survival inclinical AJCC stage I and II melanoma patients. Journal of Cutaneous Pathology, 44(4),328-337. doi:10.1111/cup.12872Garbe, C., Peris, K., Hauschild, A., Saiag, P., Middleton, M., Bastholt, L., . . . EuropeanAssociation of Dermato-Oncology (EADO). (2016). Diagnosis and treatment ofmelanoma. european consensus-based interdisciplinary guideline – update 2016.European Journal of Cancer (1990), 63, 201-217. doi:10.1016/j.ejca.2016.05.005Hieken, T. J., Kane,John M., I.,II, & Wong, S. L. (2019). The role of completion lymph nodedissection for sentinel lymph node-positive melanoma. Annals of SurgicalOncology, 26(4), 1028-1034. doi:http://dx.doi.org.wilkes.idm.oclc.org/10.1245/s10434-018-6812-zless1 UnreadUnread4 ViewsViews
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    • View profile card for Jennifer Bryant
    • Last post February 6 at 6:10 PM by Jennifer Bryant
    •  
    •                Patients survival rate after treatment with the various modalities is highly dependent on the stage of the melanoma when diagnosed and the promptness of treatment. Brozyna et al., (2017), found that with surgical intervention patients have a survival rate of 88%. It is important to remember that the like hood of survival is highly dependent on the size of tumor, depth and whether there is metastasis present (Brozyna etal., 2017).
    • Melanoma Discussion PostSubscribe
    • Jennifer Bryant posted Feb 1, 2021 6:22 PM
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    • In this case study, Mr. B had a suspicious mole excised and pathohistology reported the tumor as Stage II Melanoma. This means the cancer cells are in both the epidermis and the dermis. Wide local excision of the tumor is the current standard of care. Alternative surgical techniques include Mohs micrographic surgery, a targeted, tissue preserving option. Recurrences due to inadequate excision, resulting in true local recurrence rates of 9% to 15% of the head and neck and 3% on the trunk and proximal extremities (Tolkachjov et al, 2017).        Stang, A.,  Roesch, A., Selma Ugurel, S., (2018) Melanoma, The Lancet, 392(10151), 971-      Hruza, G. J., M.D., Roenigk, R. K., M.D., Harmon, C. B., M.D. (2017). Understanding     Clinic Proceedings, 92(8), 1261-1271.less1 UnreadUnread3 ViewsViews
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    • View profile card for Aina Oluwo
    • Last post February 6 at 12:15 PM by Aina Oluwo
    •      mohs micrographic surgery: A review and practical guide for the nondermatologist. Mayo
    • Tolkachjov, S. N., M.D., Brodland, D. G., M.D., Coldiron, B. M., M.D., Fazio, M. J., M.D.,
    •      984.
    • Schadendorf, D., van Akkooi, A., Berking, C., Griewank, K. G., Gutzmer, R., Hauschild, A.,
    • American Cancer Society, 2021 Cancer Facts and Figures, 2021.
    • References
    • The hard, enlarged, non-tender mass the left axillary region should be biopsied. Lymph node biopsy is recommended for primary melanomas with a tumor thickness of at least 1.0 mm (Schadendorf et al., 2018). The 5 year survival rate for all stages of skin cancer is 93%. When detected early, such as the case of Mr B, a localized tumor that has not spread beyond the skin where it started, the 5 year survival rate is 99% (American Cancer Society, 2021). Ongoing screening and surveillance should occur due to increased risk factors: family history, personal history, light skin and ongoing UV exposure. Mr. B must be educated in prevention with sunscreen, protective clothing and limited sun exposure.
    • Stage II MelanomaSubscribe
    • Jazmin Jerez-Rivera posted Feb 2, 2021 2:41 PM
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    • Melanoma is cancer found in the melanocytes of the skin. Huether et. al. states, “Melanoma the most lethal form of skin cancer, can occur at many sites (2020, p. 280). Evidence suggests that occasional sun exposure leading to sunburn can increase the risk of melanoma. According to the American cancer society surgery to remove the cancerous area is the standard for treating stage II melanoma. Research by Domingues et. al. indicates that tumor excision “includes safety margins of 0.5 cm for in situ melanomas, 1 cm for tumors with a thickness of up to 2 mm, and 2 cm for tumors thicker than 2 mm” (2018, p. 35). There are also recommendations for a sentinel lymph node biopsy to check if the melanoma has spread to lymph nodes in the surrounding area. If cancer cells are found, then the lymph nodes in the area will be surgically removed. Other considerations are chemotherapy, targeted therapy and immunotherapy (Dominges et. al., 2018).ReferencesImmunoTargets and therapy7, 35–49. https://doi.org/10.2147/ITT.S134842https://www.cancer.org/cancer/melanoma-skin-cancer/treating/by-stage.html#written_byElsevier.less1 UnreadUnread3 ViewsViews
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    • View profile card for Candice Russell
    • Last post February 5 at 8:18 PM by Candice Russell
    • Huether, S. E., McCance, K. L., Brashers, V. L. (2020). Understanding Pathophysiology (7 Ed.).
    • American Cancer Society. (2019). Treatment of Melanoma Skin Cancer, by Stage.
    • Domingues, B., Lopes, J. M., Soares, P., & Pópulo, H. (2018). Melanoma treatment in review.
    • Mr. B’s melanomaSubscribe
    • Tallona Boddy posted Feb 2, 2021 7:13 PM
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    • Mr. B was diagnosed with a Stage II melanoma. Mr. B’s cancer was first suspected at his annual physical exam with his primary care physician.  Mr. B’s physician initially excised the suspicious mole and sent it to pathology.  Along with a suspicious mole, the physician also noted a non-tender mass in Mr. B’s left axillary region. The American Cancer Society (n.d.) states an additional step for the treatment of Stage II melanoma is to have a sentinel lymph node biopsy (SLNB) performed. Due to Mr. B’s noted non-tender mass in his axillary a SLNB should be discussed with Mr. B to determine if there are cancerous cells in his lymph nodes.  Melanoma Research Alliance (n.d.) states that the prognosis for stage II melanoma does have a high rate of recurrence or metastasis.  In 2018 the 5 year survival rate of localized melanoma (which includes stage II) is 98.4%.  ReferencesMelanoma Research Alliance. (n.d.). Stage 2 melanoma. https://www.curemelanoma.org/about-melanoma/melanoma-staging/stage-2/.less1 UnreadUnread1 ViewsViews
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    • View profile card for Jazmin Jerez-Rivera
    • Last post February 5 at 7:56 PM by Jazmin Jerez-Rivera
    • Utjés, D., Malmstedt, J., Teras, J., Drzewiecki, K., Gullestad, H. P., Ingvar, C., Eriksson, H., & Gillgren, P. (2019). 2-cm versus 4-cm surgical excision margins for primary cutaneous melanoma thicker than 2 mm: long-term follow-up of a multicentre, randomised trial. Lancet (London, England), 394(10197), 471–477. https://doi.org/10.1016/S0140-6736(19)31132-8
    • American Cancer Society. (n.d.). Treatment of melanoma by stage. https://www.cancer.org/cancer/melanoma-skin-cancer/treating/by-stage.html.
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    • View profile card for Tallona Boddy
    • Last post February 5 at 3:28 PM by Tallona Boddy
    • Treatment of melanoma by stage. (n.d.). American Cancer Society | Information and Resources about for Cancer: Breast, Colon, Lung, Prostate, Skin. Retrieved February 2, 2021,  https://www.cancer.org/cancer/melanoma-skin-cancer/treating/by-stage.html
    • Stark M. S. (2017). Melanoma treatment guided by a panel of microRNA biomarkers. Melanoma management4(2), 75–77. https://doi.org/10.2217/mmt-2017-0006
    • Stage 1 & stage 2 melanomas | Mount Sinai – New York. (n.d.). Mount Sinai Health System. Retrieved February 2, 2021, https://www.mountsinai.org/locations/waldman-melanoma-center/what-is/stage-1-and-2-melanoma
    •            doi: 10.15586/codon.cutaneousmelanoma.2017.ch7
    • The Surveillance, Epidemiology, and End Results (SEER) database provides survival statistics for different forms of cancer. SEER tracks 5-year survival rates for melanoma skin cancer, based on how far the cancer has spread. SEER groups cancer into localized, regional, and distant stages. In stage II melanoma, not spread beyond the skin, is considered localized. The five-year relative survival rate in localized SEER staging is 99% (Treatment of melanoma by stagen.d.) In the regional stage, cancer that has spread to nearby structures or lymph nodes, the 5-year survival rate is 66% (Treatment of melanoma by stagen.d.). The more advanced the cancer, the survival rates continue to decrease. Continued surveillance is important, even after completed treatment, due to high risk of reoccurrence and development of another melanoma. Self-skin assessment is recommended.
    • Surgery is the main treatment option in melanoma, if done during early stages, surgery can cure melanoma. Joyce (2017) stated, “surgery remains the mainstay of treatment of primary melanoma, and in the majority of cases it is curative” (p. 92). Wide excision, surgery that removes the melanoma, as well as some of the normal skin around it, is the standard form of treatment for stage II. The width of the excision depends on the thickness and location of the melanoma. If there is lymph node involvement a sentinel lymph node biopsy (SLNB) may be recommended. Treatment of melanoma by stage(n.d.) states “If an SLNB is done and does not find cancer cells in the lymph nodes then no further treatment is needed, although follow-up is still important” (p. 24). If cancer is found in SLNB, additional treatment with an immune checkpoint inhibitor or targeted therapy drugs may be recommended.
    •             The type of treatment will depend on the stage and location of the melanoma. Three factors used to determine staging of melanoma, consist of the TNM system. T category determines the tumor thickness and the presence or absence of ulceration. N category determines if regional lymph nodes are involved. M determines if distant metastasis has taken place. The American Joint Committee on Cancer (AJCC) made significant revisions to the melanoma TNM staging system. Balch et al. (2003) stated “the new staging system better reflects independent prognostic factors that are used in clinical trials and in reporting the outcomes of various melanoma treatment modalities” (p. 43).
    • Week 3 Discussion PostSubscribed
    • Gisselle Mustiga posted Feb 4, 2021 7:44 AM
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    • Melanoma is a skin disease that occurs when cancerous or malignant cells are formed in the melanocytes.  The number of individuals with this disease has continued to increase in the United States over the last three decades (Huether et al., 2020). Melanoma is quite common in adults compared to children and adolescents. Some of the notable signs of melanoma include a mole, which tends to changes in size, changes in skin pigmentation, and the presence of other satellite moles. The disease can be examined through skin exams, biopsy, and physical exams. It occurs in five stages;  Stage 0, also known as melanoma in situ, to stage IV. Each stage has preferred and most effective treatment methods. However, it should be noted that melanoma can recur after treatment.ReferencesPDQ Adult Treatment Editorial Board, (2020). Melanoma Treatment (PDQ®), Patient Version. PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute. https://www.ncbi.nlm.nih.gov/books/NBK65950/less1 UnreadUnread2 ViewsViews
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    • View profile card for Hilary Szpara
    • Last post February 5 at 2:44 PM by Hilary Szpara
    • Ward, W. H., & Farma, J. M. (2017). Cutaneous Melanoma: Etiology and Therapy [Internet]: Chapter 7; Surgical Management of Melanoma. Brisbane (AU): Codon Publications. https://www.ncbi.nlm.nih.gov/books/NBK481850/#:~:text=Surgery%20remains%20the%20best%20option,care%20for%20localized%20cutaneous%20melanoma.
    • Huether, S. E., McCance, K. L. & Brashers, V. L. (2020). Understanding Pathophysiology 7 th ed. Elsevier Mosby. https://www.sendspace.com/file/19s130
    • Stage II melanoma tends to extend beyond the skin’s outer layer (epidermis), thus reaching the dermis.  The most effective and best method for treating stage II melanoma is surgery. This involves performing minor surgeries of wider local excisions to get rid of the melanoma and the surrounding normal skin tissues (PDQ Adult Treatment Editorial Board, 2020). This is then followed by skin grafting, which involves taking skins from other parts of the body to replace the removed one. The procedure is essential in covering the wound caused by the surgery. Moreover, sentinel lymph node biopsy is recommended in checking the spread of melanoma to the nearby lymph nodes. Close follow-up is also essential in monitoring the patient’s outcomes. This treatment method has a 5-year survival rate of 92%, making it the best option for localized melanoma (Ward & Farma, 2017).
    • Module 3- MelanomaSubscribe
    • Joanne Hogan posted Feb 3, 2021 3:38 PM
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    • References
    •      Although stage II melanoma can be treated surgically, there is recurrence of this cancer even if patients have negative SLNB post-surgery (Koster et al., 2017). The mortality rate for recurrences of this cancer is 48.5%. The 10-year survival rate in early diagnosed (stage I and stage II) localized melanoma is 95%-40%. The survival rate drops to 68% to 40% if the lymph nodes are affected. According to randomized trial study, an immunotherapy, CpG-B has shown to reduce the recurrence of stage I-II melanoma. Moreover, this treatment has shown more survival rate for patients. CpG-B is an immunotherapy injection that is given through intradermal route. The study concluded that CpG-B has the potential to become a safe treatment for stage I and II melanoma. However, long-term randomized trial research is needed in order to make it a standard treatment (Koster et al., 2017).
    • Stage II melanomaSubscribe
    • Melissa Morgan posted Feb 3, 2021 9:35 PM
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    • Melanoma is the most serious form of skin cancer that if not caught early has a low survival rate (Huether, McCance & Brashers, 2020). This is because it can spread quickly and metastasizes to other areas of the body. “The morbidity and mortality of this disease vary according to the time of detection and accessibility to treatment” (Gao, et al., 2020, p. 1). Mr. B has light skin, has a family history of skin cancer, spends his weekends running and gardening, and only uses sunscreen sporadically; these are known risk factors for skin cancer. Gao, Y., Li, Y., Niu, X., Wu, Y., Guan, X., Hong, Y., Chen, H., & Song, B. (2020). Identification and Validation of Prognostically Relevant Gene Signature in Melanoma. BioMed Research International, 1–29. https://doi-org.wilkes.idm.oclc.org/10.1155/2020/5323614Motofei, I. G. (2019). Malignant Melanoma: Autoimmunity and Supracellular Messaging as New Therapeutic Approaches. Current Treatment Options in Oncology20(6), 1–15. https://doi-org.wilkes.idm.oclc.org/10.1007/s11864-019-0643-4 less1 UnreadUnread7 ViewsViews
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    • View profile card for Caroline Otto
    • Last post February 5 at 11:33 AM by Caroline Otto
    • Sun, R., Guo, M., Fan, X., Meng, Q., Yuan, D., Yang, X., Yan, K., & Deng, H. (2020). MicroRNA-148b Inhibits the Malignant Biological Behavior of Melanoma by Reducing Sirtuin 7 Expression Levels. BioMed Research International, 1–13. https://doi-org.wilkes.idm.oclc.org/10.1155/2020/9568976
    • Huether, S., McCance, K., and Brashers, V.  (2020).  Understanding Pathophysiology (7th ed.).  Elsevier.
    • References
    • Mr. B’s cancer is stage II and is localized. Therefore, treatment of melanoma involves a wide surgical excision of the primary lesion site if there is no evidence of metastatic disease (Huether, McCance & Brashers, 2020). A biopsy of the peripherally draining lymph node may be necessary if Mr. B’s lesion is greater than 1 mm deep (Huether, McCance & Brashers, 2020). “Lesions on the extremities have the best surgical prognosis” (Huether, McCance & Brashers, 2020, p. 1034). “Except for melanoma in situ, the surgical procedure is generally not enough when it is performed as monotherapy, local recurrence, and/or metastases develop in most patients after a variable period of time” (Motofei, 2019, p. 2). Mr. B has stage II melanoma, so after surgical removal of the lesion, treatment will likely involve either radiation therapy, chemotherapy, immunotherapy, oncolytic viruses, or targeted molecular therapy (Huether, McCance & Brashers, 2020). Mr. B is 40 years old, his lesion is located in his left arm (which has a better surgical prognosis than other areas of the body), is stage II, and the cancer has not metastasized. Whether this treatment will be effective depends on if all the cancerous cells were removed during surgery, and the recurrence or metastasizes of the cancer in the future. “However, despite promising progress in surgical resection, radiotherapy, and chemotherapy of melanoma, long-term survival remains extremely low due to recurrence and metastasis” (Sun, et al., 2020, p. 1).
    • Weekk 3 discussion, Stage II Melanoma
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    • Beth Certain posted Feb 3, 2021 10:54 PM
    • According to the Skin Cancer Foundation (2020), melanoma is diagnosed when suspicious looking tissue is biopsied to determine if cancer cells are present. This is done by sending the biopsy to the lab for analysis. Once the disease is diagnosed, and the type of melanoma has been identified, the next step is identifying the stage of the disease. Mr. B has been diagnosed with stage II melanoma. There are actually three subgroups of melanoma. The melanoma Research Alliance explains the following:Stage IIB Melanoma: A tumor in this stage is more than 2.0 millimeters and less than 4.0 millimeters thick with broken skin or more than 4.0 millimeters without ulceration.Because we only know Mr. B’s melanoma is stage II and there isn’t any information on the subgroups, the treatment for stage 2 melanoma is removing the tumor surgically. This procedure is a minor surgery using a wide, local incision, which usually cures local melanoma. Your doctor may suggest a sentinel lymph node biopsy to determine if the melanoma has spread to the nearest lymph node. If melanoma is detected in the biopsy, your doctor may recommend a complete “lymph node dissection (this removes all lymph nodes in a specific area of the body, surgically); however, this is not recommended in all instances” (Melanoma Resource Alliance, N.D.).Clinical trials allow patients access to treatments that have the potential to be more beneficial but have yet to be approved by the U.S. FDA. Clinical trials expand the understanding of the disease and improve future treatments for all patients. According to the Melanoma Research Alliance, Stage II Melanoma has an intermediate to high risk for recurrence or metastasis with appropriate treatment. As of 2018, there is a 98.4% of a 5-year survival rate for local melanoma to include Stage II. Once there is no evidence of disease following treatment, monthly self-exams should be performed of the skin and lymph nodes. The patient should have full-body skin exams by a trained dermatologist yearly for the rest of the patient’s life. Exams by your doctor should also be in the treatment plan, usually every 6-12 months for the first 5 years. Imaging tests can also be used to monitor for the recurrence of cancer.Melanoma Research Alliance (N.D.). Stage II Melanoma. Retrieved fromThe Skin Cancer Foundation. (June, 2020). Melanoma Stages. Retrieved from less0 UnreadUnread
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    • View profile card for Gisselle Mustiga
    • Last post February 5 at 11:04 AM by Gisselle Mustiga
    • https://skincancer.org/skin-cancer-information/melanoma/the-stages-of-melanoma/
    • https://www.curemelanoma.org/about-melanoma/melanoma-staging/stage. February 2, 2021
    • References
    • Some melanomas have certain features that increase the chance of metastasis and or recurrence. The doctor will determine what type of additional treatment may be needed to help delay or prevent cancer from returning. Adjuvant therapy is used to reduce the risk of melanoma returning.
    • Stage IIC Melanoma: The melanoma tumor is more than 4.0 millimeters thick with broken skin.
    • Stage IIA Melanoma: A melanoma tumor more than 1.0 millimeter and less than 2.0 millimeters thick (approximately the size of a new crayon point), with broken skin, or 2.0 to less than 4.0 millimeters without broken skin.
    • Stage II Melanoma’s and Adjuvent therapySubscribe
    • Caroline Otto posted Feb 5, 2021 10:35 AM
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    • The treatment for Stage 2 Melanoma is primarily treated once it has been staged, because if there are other skin melanomas found; the overall treatment will depend on the stage each of them are in.If the melanoma has spread into the lymph node, a complete lymph node dissection would be performed; but this may not be a treatment option in all cases.If a melanoma is suspected of returning, the physician may recommend “adjuvant therapy” which aids in preventing the melanoma from returning. This is usually done after surgery.Interferon (Intron and Sylatron) – This used to be the golden child of treatment, however over the past couple of years, the use of this medication has been discouraged due to the many toxic effects it has on the body and impact on survival.Ipilimumab (Yervoy) – Was the first immune checkpoint inhibitor ever studied in the adjuvant setting.Dabrafenib + Trametinib (Tafinlar + Mekinist)Adjuvent therapy is rapidly changing the way Melanoma is treated and is now considered the standard of care for many patients. Since this therapy is still in its infancy with limited research participants, its overall role in high-risk 2 and stage IIIA is still being defined (Davis, et.al. 2019).Neo-adjuvant Therapy is recommended when the goal is to shrink the melanoma prior to surgery. If the Melanoma is deeper or thicker than 4.0 millimeters thick it more than likely will involve nearby lymph nodes, and this disease has a high risk of recurrence because after surgery there is the risk that some of the melanoma cells may remain in the body.Participation however remains low and this seems to be because of not being aware of programs out there, as well as fear. There are benefits and risks associated to this form of therapy, however paramount is the early access to a potentially better treatment than one that already exists, and it may be free or be offered at no or low cost to the client.Davis, L. E., Shalin, S. C., & Tackett, A. J. (2019). Current state of melanoma diagnosis and treatment. Cancer biology & therapy, 20(11), 1366–1379. https://doi.org/10.1080/15384047.2019.1640032Trotter, S. C., Sroa, N., Winkelmann, R. R., Olencki, T., & Bechtel, M. (2013). A Global Review of Melanoma Follow-up Guidelines. The Journal of clinical and aesthetic dermatology, 6(9), 18–26.less0 UnreadUnread
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    • Moreno Nogueira, J. A., Valero Arbizu, M., & Pérez Temprano, R. (2013). Adjuvant treatment of melanoma. ISRN dermatology, 2013, 545631. https://doi.org/10.1155/2013/545631
    • References
    • Clinical Trials serves as an additional form of therapy.
    • There are many side effects associated with Adjuvent therapy and these adverse effects increase according to patient comorbidities such as; cardiac disease. The research is limited because of the amount of participants that have been studied.
    • Pembrolizumab (Keytruda)
    • Nivolumab (Opdivo)
    • Better outcomes have been demonstrated by the following medications, with less effects, however they are all in their infancy.
    • Examples of this are;
    • Staging melanomas gives physicians the information to ascertain which ones would most likely metastasize, and which ones would recur. The American Joint Committee on Cancer (AJCC) has identified that the staging of melanomas is not consistent, and many physicians over treat which has resulted in inaccurate numbers of incidence (Trotter, et. Al. 2013).
    • Stage 2 Melanoma however is treated by removing the tumor surgically, and adopting a wide local excision. In addition to that, the physician may recommend a “sentinel lymph node biopsy”, to determine if the melanoma has spread to the nearest lymph node (Moreno Nogueira, et. al, 2013).
    • Dennies JonesSubscribe
    • Dennies Jones posted Feb 2, 2021 1:58 PM
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    •    Mr. B was diagnosed with stage II melanoma based on the biopsy. He had the mole for several years and did not think anything of it until his physician noticed it. The mole has gotten larger over the past two years, shown symptoms of itchiness and a family history of skin cancer. Mr. B  will recognize early signs of skin cancer once educated on warning signs, which are any unusual skin condition change, especially a difference in size, borders, or color of a mole or other dark pigmented growth or spot (Huether et al., 2020). He said to have an enlarged, non-tender mass felt in the left axillary region. Even though he was diagnosed with stage II cancer, this could be a potential risk of cancer spreading more profoundly into the skin and entering the lymph nodes, allowing it to metastasize. At an early stage (stages I and II), cutaneous melanomas are defined within the American Joint Cancer (AJCC) classification by modern surgical staging by lacking lymph node involvement. High-risk cancer is considered ulcerated, involving the lymph nodes (Polkepovic & Luke, 2020). Polkepovic and Luke (2020) further stated, “thin melanomas (<2mm) accounted for over twice as many deaths from melanoma than thick melanomas (>4mm)” (p. 1167). It shows a higher need for an increased skin assessment and early diagnosis for early stages of Melanomas.           Mr. B’s diagnosis is commonly treated with adjuvant therapy. Surgically removing the cancerous skin with additional treatment of chemotherapy or radiation therapy is most effective.  Surgical treatment alone with high-risk shows an increase in the chance of recurrence in cancer. Melanoma is one highly immunogenic cancer- the immune system can be manipulated against the disease. Because of this, treatment of melanoma is moving to strategies that target the immune system (Khushalani, 2017).  The second way to target melanoma with the immune system is to block suppressive elements. The activity of the T cell is controlled by a series of molecular regulatory interactions, including those between cytotoxic T cell lymphocyte-associated antigen 4 (CTLA-4) and antigen-presenting cells (APC) and between programs death -1 (PD-1) and its primary ligand, PD-L1 on the melanoma cells (Khushalani, 2017). Mr. B will need continuous follow-up and skin assessment for any other skin cancer.References:Huether, Sue E., McCance, Kathryn L… Understanding Pathophysiology – E-Book (p. 169). Elsevier Health Sciences. Kindle Edition.                      less1 UnreadUnread13 ViewsViews
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    • View profile card for Alfonsina Perez
    • Last post February 4 at 12:20 AM by Alfonsina Perez
    • Poklepovic, A. S., & Luke, J. J. (2020). Considering adjuvant therapy for stage II melanoma. Cancer (0008543X)126(6), 1166–1174. https://doi-org.wilkes.idm.oclc.org/10.1002/cncr.32585
    • Khushalan, N. I. (2017). Evolving Strategies in the Treatment of Metastatic Melanoma. Journal of Managed Care Medicine20(1), 31–34.
    • Module 3 DiscussionSubscribe
    • Hilary Szpara posted Feb 3, 2021 1:53 AM
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    • For melanoma in stages I-IIIB, surgical removal is the primary treatment. However, depending on the size, thickness, and location of the tumor, safety margins may vary to help prevent regrowth of the tumor (Domingues, Lopez, Soares, & Pópulo, 2018). A systematic review of literature on stage-specific survival of melanoma in Europe revealed that overall survival rates for people with stage I/II was 91.6% for people coming from lower socioeconomic statuses (SES) and went up to 97.3%-98.3% for patients with a middle or high SES. Researchers believed that patients’ SES may lead to differences in early detection, treatment, and follow up (Svedman, Pillas, Taylor, Kaur, Linder, & Hansson, 2016). A systematic review of literature from 2020 suggested that the five-year disease-specific survival rates for patients with stage II melanoma ranged from 63-81%, with most studies reporting a survival rate of over 70% (Miller, Walker, Shui, Brandtmüller, Cadwell, & Scherrer 2020). The same literature review also showed that five-year disease-specific survival rates decreased to 36-63% when the patients had stage III melanoma, with most studies reporting rates of over 50% (Miller et al., 2020). It seems that for the most part, chance of survival with stage II melanoma is high as long as a patient has the appropriate treatment and is able to maintain proper follow up with medical providers.    less1 UnreadUnread7 ViewsViews
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  • View profile card for Amandeep Kaur
  • Last post February 3 at 8:51 PM by Amandeep Kaur
  • Svedman, F. C., Pillas, D., Taylor, A., Kaur, M., Linder, R., & Hansson, J. (2016). Stage-specific survival and recurrence in patients with cutaneous malignant melanoma in Europe – a systematic review of the literature. Clinical Epidemiology8, 109–122. https://doi.org/10.2147/CLEP.S99021
  • Miller, R., Walker, S., Shui, I., Brandtmüller, A., Cadwell, K., & Scherrer, E. (2020). Epidemiology and survival outcomes in stages II and III cutaneous melanoma: a systematic review. Melanoma Management7(1). https://doi.org/10.2217/mmt-2019-0022
  • Domingues, B., Lopes, J. M., Soares, P., & Pópulo, H. (2018). Melanoma treatment in review. ImmunoTargets and Therapy7, 35–49. https://doi.org/10.2147/ITT.S134842
  • Fritzinger NSG530 discussion Wk3Subscribe
  • Cassie Fritzinger posted Feb 3, 2021 4:21 PM
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  • According to the American Cancer Society (2021), melanoma is the most serious type of skin cancer and develops in the melanocytes. Melanoma is staged in a system from I-IV with some stages being broken down further into letters based on amount it has spread in the body (American Cancer Society, 2021). Melanoma Stage II is as reported by the American Cancer Society (2021), to be a tumor which is between 1mm and 4mm thick, which may or may not be ulcerated, and the cancer has not spread to the nearby lymph nodes or other body parts. Treatment for melanoma stage 2 includes immunotherapy, targeted drug therapy, wide excision of the melanoma with margins of healthy tissue and it will generally also include a sentinel lymph node biopsy to determine lymph node involvement.The usual treatment for stage 2 Melanoma would include the surgical removal along with a sentinel lymph node biopsy. Provided this determines there is no lymph node involvement treatment provides a favorable survival rate. However, if there is lymph node involvement survival rates decline. The 5-year survival rate for a patient with Stage 2 Melanoma is 99% unless there is lymph node involvement at which point it then decreases to 65% (Godman, 2020). American Cancer Society. (2021). Melanoma Skin Cancer. Retrieved February 1, 2021, From https://www.cancer.org/cancer/melanoma-skin-cancer.html  Mayo Clinic. (2021). Melanoma. Retrieved February 1, 2021, From https://www.mayoclinic.org/diseases-conditions/melanoma/diagnosis-treatment/drc-20374888less0 UnreadUnread
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  • Godman, H. (2020). What are the Prognosis and Survival Rates for Melanoma by Stage? Healthline. https://www.healthline.com/health/melanoma-prognosis-and-survival-rates
  • References
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  • Immunotherapy is a drug therapy which helps the body’s natural immune system fight the cancerous cells by interfering with the cancer cell’s protein which camouflages them from the immune system, which would normally attack the cell. This is typically done after a surgery has been performed to excise the melanoma (Mayo Clinic, 2021). Another form of treatment may include Targeted drug therapy which focuses on a specific weakness of the cancerous cell to cause the cell to die. This is often recommended if the cancer has spread to lymph nodes. For more advanced melanomas Radiation and Chemotherapy may be required due to their advanced and malignant nature (Mayo Clinic, 2021).
  • MelanomaSubscribe
  • Sheryl Dixon posted Feb 2, 2021 6:34 PM
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  • Melanoma is a cancer that is the most lethal form that can occur at many sites. The most common is on the skin of the lower legs, between the shoulders and the hips. Although for people with dark skin, its most found under the fingernails, toenails or the palm of their skin. Treatment of Melanoma with no evidence of metastatic disease involves a wide surgical excision of the primary lesion site (Huether, McCance & Brashers, 2020).Five types of standard treatment are used: Surgery, Chemotherapy, Radiation therapy, Immunotherapy, Targeted therapy. Wide excision (surgery to remove the melanoma and a margin of normal skin around it) is the standard treatment for stage II melanoma. The width of the margin depends on the thickness and location of the melanoma. Because the melanoma may have spread to nearby lymph nodes, many doctors recommend a sentinel lymph node biopsy (SLNB) as well.Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).Immunotherapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This cancer treatment is a type of biologic therapy.Signal-transduction inhibitors include:

    Combinations of BRAF inhibitors and MEK inhibitors used to treat melanoma include:

    Oncolytic virus therapy: A type of targeted therapy that is used in the treatment of melanoma. Oncolytic virus therapy uses a virus that infects and breaks down cancer cells but not normal cells. Radiation therapy or chemotherapy may be given after oncolytic virus therapy to kill more cancer cells. Talimogene laherparepvec is a type of oncolytic virus therapy made with a form of the herpesvirus that has been changed in the laboratory. It is injected directly into tumors in the skin and lymph nodes (National Center for Biotechnology Information, 2020). American cancer society, 2021 Treatment of Melanoma Skin Cancer, by Stage. Retrieved from https://www.cancer.org/cancer/melanoma-skin-cancer/treating/by-stage.htmlNational Center for Biotechnology Information, 2020. Melanoma Treatment. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK65950/

  • Huether, S. E., & McCance, K. L. & Brashers, V.L. (2020). Understanding Pathophysiology 7th ed. Elsevier Mosby
  •                                                                                                        References
  • Angiogenesis inhibitors: A type of targeted therapy that is being studied in the treatment of melanoma. Angiogenesis inhibitors block the growth of new blood vessels. In cancer treatment, they may be given to prevent the growth of new blood vessels that tumors need to grow. Early detection is critical to reducing mortality from metastatic disease (Huether, McCance & Brashers, 2020).
  • Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells. Targeted therapies usually cause less harm to normal cells than chemotherapy or radiation therapy do. The following types of targeted therapy are used or being studied in the treatment of melanoma: Signal-transduction inhibitor therapy: Signal-transduction inhibitors block signals that are passed from one molecule to another inside a cell. Blocking these signals may kill cancer cells. They are used to treat some patients with advanced melanoma or tumors that cannot be removed by surgery.
  • Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. External radiation therapy uses a machine outside the body to send radiation toward the area of the body with cancer. External radiation therapy is used to treat melanoma and may also be used as palliative therapy to relieve symptoms and improve quality of life (National Center for Biotechnology Information, 2020).
  • A lymph node biopsy of peripherally draining lymph node (sentinel node) is warranted for lesions greater than 1 mm deep. Lesions extremities have the best surgical prognosis. Radiation therapy, chemotherapy, immunotherapy (checkpoint inhibiters that block proteins to stop the immune system from attacking cancer cells and signal transduction), oncolytic viruses and targeted molecular therapy that inhibits gene mutations, in addition to vaccines, are used to treat metastatic disease and have demonstrated long-term improvement in disease outcome.
  • The type of treatment(s) your doctor recommends will depend on the stage and location of the melanoma. But other factors can be important as well, such as the risk of the cancer returning after treatment, if the cancer cells have certain gene changes, and your overall health (American cancer society, 2021).

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