ASCO GUIDELINES Bundle

Treatment ➤ Recommendation 2.2. For patients with resected stage IIIA/B/C/D disease that is BRAF wild type, the following options should be offered (in no particular order): nivolumab × 52 weeks OR pembrolizumab × 52 weeks. Ipilimumab and high-dose interferon are NOT recommended for routine use in adjuvant therapy. See Table 1 for recommended dosing and scheduling details. (Strong recommendation; EB-B-H) Qualifying Statements: Patients with stage III disease with microscopic sentinel nodal metastasis <1 mm diameter were not included in the randomized trials that studied efficacy of immune checkpoint inhibitors as adjuvant therapy for melanoma. Both nivolumab and pembrolizumab are United States Food and Drug Administration (FDA)-approved as adjuvant treatment for patients with melanoma with lymph node involvement who have undergone complete disease resection. Patients with stage III disease with less than 1 mm involvement in the sentinel lymph node have a relatively better prognosis and lower risk of relapse. Therefore, treatment should be individualized after discussing risk-benefit quotient with these patients. ➤ Recommendation 2.3. For patients with resected stage IIIA/B/C/D BRAF- mutant (V600E/K*) disease, the following therapy options should be offered (in no particular order): nivolumab × 52 weeks OR pembrolizumab × 52 weeks OR dabrafenib plus trametinib × 52 weeks. See Table 1 for reasonable dosing and scheduling details. (Strong recommendation; EB- B-H) Qualifying Statements: See Other Considerations section in full text guideline for discussion of relationship between systemic therapy and resection/CLND/SLNB. Patients with stage III disease with microscopic sentinel nodal metastasis <1 mm diameter were not included in the randomized trials that studied efficacy of immune checkpoint inhibitors as adjuvant therapy for melanoma. Both nivolumab and pembrolizumab are US FDA-approved as adjuvant treatment for patients with melanoma with lymph node involvement who have undergone complete resection of their disease. Patients with stage III disease with less than 1 mm involvement in the sentinel lymph node usually have a good prognosis and low risk of relapse. Therefore, treatment should be individualized after discussing risk-benefit quotient with these patients. ➤ Recommendation 2.4. No recommendation can be made for or against dabrafenib plus trametinib in patients with resected stage III/IV melanoma with BRAF mutations other than V600E/K. (L) ➤ Recommendation 2.5. Patients with resected stage IV melanoma should be offered adjuvant nivolumab. (Strong recommendation; EB-H) Patients with resected stage IV melanoma may be offered pembrolizumab or (in the case of BRAF mutant disease) dabrafenib plus trametinib. (Weak recommendation; IC)

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