1. Which of the following immune checkpoint pathways is represented by relatlimab?
A. Lymphocyte-activation gene 3 (LAG-3)
B. Bispecific T-cell engager (BITE)
C. Cytotoxic T lymphocyte-associated antigen 4 (CTLA-4)
D. Programmed cell death-1 (PD-1)
E. Unsure
2. Please use this CASE to answer Questions 2 & 3
Past medical history (PMH): Noncontributory
Labs: All labs within normal limits
Given his new diagnosis of metastatic melanoma and the results of his mutation testing, there are multiple options to consider in the first-line setting. Which regimen would NOT be appropriate to recommend at this time?
A. Pembrolizumab 400 mg IV q42 days
B. Ipilimumab 3 mg/kg IV + nivolumab 1 mg/kg IV q21 days x 4 doses, followed by nivolumab 480 mg q28 days
C. Nivolumab 480 mg IV q28 days
D. Ipilimumab 3 mg/kg IV q21 days x 4 doses
E. Unsure
3. CASE continues:
A. To block the MAPK pathway, which contributes to tumor progression
B. Targeting different pathways/receptors on T cells that are not functionally redundant, allowing for complementary and synergistic effects on immune response
C. To induce viral-mediated tumor lysis and increase antigen-presenting cells for immune destruction
D. Increase binding of the gp100 peptide on uveal tumor cells to activate T cell-mediated cytotoxicity
E. Unsure
4. Which of the following are patient-specific factors that can be associated with better outcomes in patients with metastatic brain metastases?
A. LDH >2x ULN
B. ECOG Performance Status 0-1
C. Age <70 years old
D. <10 metastatic brain lesions
E. Unsure
5. Based on available data from the DREAMseq (EA6134) trial in metastatic melanoma patients with BRAF V600 mutations, what is the optimal sequencing of BRAF-MEK inhibitor targeted therapy and checkpoint inhibitor therapy for frontline and second-line therapies, respectively?
A. Dabrafenib + trametinib as frontline therapy, at progression switch to ipilimumab + nivolumab
B. Nivolumab as frontline therapy, at progression switch to vemurafenib + trametinib
C. Nivolumab + ipilimumab as frontline therapy, at progression switch to dabrafenib + trametinib
D. Nivolumab + dabrafenib + trametinib (triplet therapy) as frontline, at progression switch to nivolumab + ipilimumab
E. Unsure
6. Please use this case to answer Questions 6 to 8.
BRAF V600E+ mutation
PMH: Asthma, depression, hypertension (HTN), hyperlipidemia
Past surgical history (PSH): Appendectomy, cholecystectomy, melanoma wide local excision and lymph node resection
A. Serious inflammation can occur in any organ system, but are more common in certain areas such as the skin, lungs, liver, and lower gastrointestinal (GI) tract
B. Provide a wallet card that has contact information for the medical team, symptoms to self-monitor for at home, and when to seek urgent medical attention
C. AG should only contact the medical team for possible immune-related symptoms that have not improved on their own after 1 week
D. Discuss that adverse effects can occur after the first treatment, or even weeks/months after therapy has been discontinued, so AG should continue to monitor for and report these symptoms
E. Unsure
7. After cycle 2, AG developed transaminitis with AST 3.5x ULN, ALT 4x ULN (grade 2) with mild nausea, anorexia, fatigue, and myalgias (grade 3). How would you manage her grade 2 transaminitis?
A. Hold ipilimumab + nivolumab and admit to the hospital for IV infliximab
B. Hold nivolumab and continue ipilimumab at a reduced dose
C. Hold both ipilimumab + nivolumab for 3 days, then restart without rechecking labs
D. Hold both ipilimumab + nivolumab, initiate oral prednisone 0.5 mg/kg/day, and recheck labs in 1 week; may resume therapy when steroids have been tapered and AST/ALT are grade 0-1
E. Unsure
8. AG unfortunately experienced worsening of her AST and ALT, and after being escalated to prednisone 2 mg/kg, she plateaus her liver function values. What additional immunosuppressive agent would be appropriate to recommend at this time?
A. Vedolizumab
B. Tocilizumab
C. Mycophenolate mofetil
D. Horse antithymocyte globulin (h-ATG)
E. Unsure
