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This is a difficult case, with what is clearly a very slow-growing melanoma that has slowly recurred after multiple resections over the course of 10 years. As a medical oncologist, my bias with what is now a 4th recurrence, is to treat systemically. There are two ways to do this- my inclination is to resect the lymph node to NED and then treat adjuvantly with nivolumab or pembrolizumab as per the adjuvant immunothearpy trials. Alternately, you could choose to not resect and treat with either nivolumab alone, pembrolizumab alone, ipi-nivo, or nivo-relatlimab (if/when it becomes available). My bias is also not to treat with BRAF/MEK inhibitor therapy up-front as immune therapy has a greater chance for cure. However, how to sequence BRAF/MEK with ipi/nivo has never been conclusively decided- we are waiting on complete accrual and results from the DREAMseq trial. I would recommend against combination PD-L1+BRAF+MEK as in the IMpsire150 trial despite the positive results and FDA approval as this was compared to BRAF/MEK alone and the correct comparison would have been sequential therapy.
Pending Moderator approval.
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