WBR0250

Author	[[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Yazan Daaboul, M.D.)]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Genetics
Sub Category	SubCategory::Dermatology, SubCategory::Oncology
Prompt	[[Prompt::A 42-year-old Caucasian man presents to the dermatology clinic for a rapidly growing nevus on his back. The patient reports that the lesion has recently been increasing in size and has been getting progressively darker over the past few months. Evaluation of the lesion reveals a 9 cm x 4 cm asymmetrical nevus with irregular border and heterogeneous dark color. Excisional biopsy of the lesion reveals extensive proliferation of melanocytes, intraepidermal growth, and cellular atypia. Mutation of which gene is associated with the development of this patient's condition?]]
Answer A	AnswerA::''APC''
Answer A Explanation	[[AnswerAExp::Loss-of-function of the APC gene is associated with development familial forms of colorectal cancer.]]
Answer B	AnswerB::''WT1''
Answer B Explanation	[[AnswerBExp::Loss-of-function of the gene WT1 is associated with development of Wilms tumor.]]
Answer C	AnswerC::''DPC''
Answer C Explanation	[[AnswerCExp::Loss-of-function of DPC gene (Deleted in Pancreatic Cancer gene) is associated with development of pancreatic cancer.]]
Answer D	AnswerD::''BRAF''
Answer D Explanation	AnswerDExp::Activating mutation of the ''BRAF'' gene is present in the majority of patients with melanoma.
Answer E	AnswerE::''RB''
Answer E Explanation	[[AnswerEExp::Loss-of-function of the RB gene is associated with development of retinoblastoma and osteosarcoma.]]
Right Answer	RightAnswer::D
Explanation	[[Explanation::Melanoma is the most common fatal skin cancer that arises from the epidermal melanocytes, which are neural crest cells that migrate to the skin during embryogenesis. Normally, melanocytes play a role in the synthesis of melanin, a brown pigment with photoprotective properties. Important risk factors that contribute to the development of melanoma include chronic ultraviolet exposure, high frequency of sunburns, fair skin color, and freckles. Germline mutations that predispose to melanoma are also present, such as mutations in the CDKN2A tumor suppressor gene that encodes p16 and p19 in cases of familial melanoma. Most importantly, activating BRAF mutations in chromosome 7 are present in the majority of patients with melanoma, especially among those with no chronic sun exposure. Braf is a serine/threonine protein kinase that activates MAP kinase/ERK signaling pathway. Melanoma typically manifests as a growing, asymmetric nevus with irregular borders, heterogeneous discoloration, as that described in the vignette. The ABCDE of melanoma are important clues on history and physical examination: Asymmetry, Border irregularity, Color changes, Diameter > 6 - 8 mm, and Evolution over time. The diagnosis of melanoma requires excisional biopsy, which may show proliferation of melanocytes, dysplastic cells and atypia. If left untreated, melanocytes first proliferate randomly with an aberrant growth within an existing nevus. More advanced stages are characterized by a radial-growth phase with intraepidermal growth and penetration into the papillary dermis. Final stages demonstrate a vertical-growth phase with dermal invasion and widening of the papillary dermis before cancerous cells metastasize to other parts of the skin and other organs. Management of melanoma includes wide excision of the lesion for all patients and administration of Braf kinase inhibitors, such as sorafenib (non-selective) or vemurafenib (selective), for patients with BRAFV600E (substitution of glutamic acid for valine in BRAF gene at codon 600) mutations. Educational Objective: Activating BRAF mutations in chromosome 7 are present in the majority of patients with melanoma, especially among those with no chronic sun exposure. Braf is a serine/threonine protein kinase that activates MAP kinase/ERK signaling pathway. Administration of Braf kinase inhibitors, such as sorafenib (non-selective) or vemurafenib (selective), has demonstrated efficacy for melanoma patients with BRAFV600E (substitution of glutamic acid for valine in BRAF gene at codon 600) mutations. References: Miller AJ, Mihm MC. Melanoma. N Engl J Med. 2006; 355:51-65. Gilchrest BA, Eller MS, Geller AC, et al. The pathogenesis of melanoma induced by ultraviolet radiation. N Engl J Med. 1999;340(17):1341-8. Ascierto PA, Kirkwood JM, Grob JJ, et al. The role of BRAF V600 mutation in melanoma. J Transl Med. 2012;10:85. First Aid 2014 page]]
Approved	Approved::Yes
Keyword	WBRKeyword::Melanoma, WBRKeyword::BRAF, WBRKeyword::Mutation, WBRKeyword::Malignant melanoma, WBRKeyword::Skin cancer, WBRKeyword::Vemurafenib, WBRKeyword::Sorafenib, WBRKeyword::Protein kinase, WBRKeyword::Kinase, WBRKeyword::MAP kinase, WBRKeyword::Nevus
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