18
• Clinical Trials are strongly recommended if available
• Best Supportive Care/Hospice option can be elected at any point
IVA
Other tumor genetics?
e.g., ALK, NTRK, RET
fusions
BRAF
V600E
mut
present?
IVB
Surgery
Resectable?
Y
N
N
N
Y
Y
Encourage definitive-
intention therapy
(because of potential
for long-term survival
for IVA patients)
Rapid BRAF
assessment (IHC,
molecular), parallel
Comprehensive
genetic testing*
• Goal: R0/R1 resection
• Avoid debulking
• Avoid laryngectomy
generally
preferred
else
Dabrafenib
+ Trametinib
Treatment
* Cytotoxic chemotherapy may be started as a 'bridge' while awaiting genomic information or while
awaiting targeted therapy (e.g. dabrafenib and trametinib). Dashed arrows depict circumstances
where competing therapeutic options may be of consideration.
Figure 1. Initial Treatment of Stages IVA and IVB
