Oncology Self-Assessment: Melanoma and Genitourinary Cancer

Oct 07, 2022

ASCO seeks to advance the education of all oncology professionals and ultimately facilitate and support enhanced patient care. The ASCO Oncology Self-Assessment Series on ASCO Connection consists of free case-based multiple-choice practice questions, educational links, and answer rationales from ASCO-SEP.  
Learn more about ASCO’s Educational products, such as the 2022 ASCO-SEP Digital Subscription, which includes the digital book, access to education courses and virtual meeting-related content, plus over 900 practice questions in the Question Bank. Oncology trainees and Training Program Directors can visit Education Essentials for Oncology Fellows (EEOF) to learn more and register for the new 2022-23 cycle. 
Correct answers are listed at the bottom of the page. 

Question 1: Melanoma 

A 56-year-old woman presents after a wide local excision and sentinel lymph node biopsy of a dark ulcerated lesion on her back. The final pathology report showed malignant melanoma measuring 4.5 mm in depth with negative margins. The sentinel lymph node biopsy from her left axillary area was negative. BRAF mutation was positive. Her disease stage grouping was stage IIC. Clinically, she has recovered well and is ready to resume work. She would like to know if there is anything else that she can do to prevent disease recurrence. 
Which of the following should you recommend now? 
  1. High-dose interferon 
  2. Pembrolizumab 
  3. Dabrafenib and trametinib 
  4. Observation 

Question 2: Genitourinary Cancer 

A 61-year-old woman presents with painless gross hematuria lasting six months. Last month, she was passing intermittent clots, and she now presents with urinary obstruction. A Foley catheter is placed. Her medical history consists of poorly controlled hypertension, poorly controlled type 2 diabetes mellitus, and chronic obstructive pulmonary disease resulting from a 90 pack-year smoking history. Baseline laboratory studies revealed significant acute kidney injury and creatinine clearance of 28 mL/min. She is referred to a urologist who performs a cystoscopy and identifies bulky, visible, invasive disease obscuring the bilateral ureteral orifices. The histopathologic report from transurethral resection of the bladder tumor reveals muscle-invasive disease penetrating to the perivesical tissue. Bilateral percutaneous nephrostomy tubes are placed, and her creatinine clearance recovers to 38 mL/min three weeks later. Her imaging reveals no metastatic disease. 
Which of the following is the most appropriate next step? 
  1. Radical cystectomy and pelvic lymph node dissection 
  2. Dose-dense or accelerated methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) chemotherapy 
  3. Gemcitabine and cisplatin chemotherapy 
  4. Gemcitabine and carboplatin chemotherapy 

Question 1 Rationale and References 

Correct answer: B. Pembrolizumab 
Rationale: Up until the KEYNOTE-716 trial, the only approved adjuvant treatment for melanoma of this stage was high-dose interferon. This randomized controlled trial demonstrated a statistically significant improvement in recurrence-free survival (RFS) at the time of the first interim analysis for patients randomly selected to the pembrolizumab arm compared with the placebo, with a hazard ratio of 0.65 (95% CI 0.46-0.92; P = .0132). The median RFS was not reached in either arm. This study led to the approval of pembrolizumab in this indication. High-dose interferon was the previous standard of care but has rarely been used owing to its toxicity. Dabrafenib and trametinib have not been studied in this indication. Observation remains an option for patients who decline to receive pembrolizumab; however, this patient would like to decrease her risk of disease recurrence rendering this option inappropriate. 
  • Luke JJ, Rutkowski P, Queirolo P, et al. LBA3 Pembrolizumab versus placebo after complete resection of high-risk stage II melanoma: efficacy and safety results from the KEYNOTE-716 double-blind phase III trial. Ann Oncol. 2021;32 (suppl_5): S1314-5. DOI: https://doi.org/10.1016/j.annonc.2021.08.2116  
  • Poklepovic AS, Luke JJ. Considering adjuvant therapy for stage II melanoma. Cancer. 2020;126(6):1166-74. DOI: https://doi.org/10.1002/cncr.32585  

Question 2 Rationale and References 

Correct answer: A. Radical cystectomy and pelvic lymph node dissection   
Rationale: This patient has compromised kidney function even after a bilateral percutaneous nephrostomy tube placement. By Galsky criteria, this patient is not a candidate for cisplatin combination chemotherapy. Carboplatin is inferior to cisplatin, and unlike cisplatin, an overall survival benefit has never been shown in the neoadjuvant disease state using carboplatin. Given that delays in cystectomy can lead to worse survival outcomes, multiple guideline committees recommend up-front radical cystectomy without systemic therapy. 
  • Galsky MD, Hahn NM, Rosenberg J, et al. Treatment of patients with metastatic urothelial cancer "unfit" for cisplatin-based chemotherapy. J Clin Oncol. 2011;29(17):2432-8. DOI: https://doi.org/10.1200/JCO.2011.34.8433  
  • Galsky MD, Chen GJ, Oh WK, et al. Comparative effectiveness of cisplatin-based and carboplatin-based chemotherapy for treatment of advanced urothelial carcinoma. Ann Oncol. 2012;23(2):406-10. DOI: https://doi.org/10.1093/annonc/mdr156  
  • Chu AT, Holt SK, Wright JL, et al. Delays in radical cystectomy for muscle-invasive bladder cancer. Cancer. 2019;125(12):2011-7. DOI: https://doi.org/10.1002/cncr.32048
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