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Mateusz Gładysz

Pathway read-through · Melanoma

Melanoma: from the report to the recommendation

Mateusz Gładysz · MD · FEBOPRAS · FEBHS

A read-through for a New Zealand regional melanoma and high-risk skin cancer MDM, for the registrar preparing a case and the consultant chairing it. The core line carries the decisions; the closed panels carry the groundwork and the divergences.

Clinical content verified References checked 51 questions 8 MDM cases Version 1.1

All cases are constructed for teaching and describe no real patient. Clinical content verified 1 October 2026. Sources: Aotearoa NZ Melanoma Clinical Guidelines, 4th ed. (Skin Cancer NZ, June 2026) (final; PDF August 2026) · Pharmac Schedule October 2026 · AJCC 8th ed. · NCCN Cutaneous Melanoma V3.2026 (professional content behind login; quotations from V1.2026) · ESMO CPG (Ann Oncol 2025) · EADO/EDF/EORTC 2024.

Not covered: uveal and mucosal melanoma beyond routing and funding notes; paediatric melanoma; immune-related toxicity management in detail. Assumed terms of reference: the MDM in this read-through discusses all melanoma except head and neck melanoma with neck nodal involvement (parotid to supraclavicular) or stage III disease, which goes to a separate Head and Neck MDM. Check your own MDM’s terms of reference.

Skip to MDM cases
SchemaThickness and ulceration give a probability. The probability sets the node, the imaging, the margin, the funding and the follow-up.
Changes in practice since October 2025
  • 1 June 2025 — Pharmac funds perioperative pembrolizumab and adjuvant dabrafenib + trametinib for resectable or resected stage IIIB–IV melanoma.
  • 1 May 2026 — Pharmac funds neoadjuvant nivolumab + ipilimumab (maximum two cycles) for resectable stage IIIB–IV; adjuvant nivolumab afterwards only if required, to 12 months total.
  • June 2026 — Aotearoa NZ Melanoma Clinical Guidelines 4th edition published (PDF posted August 2026). New: GPP 5.1.14 accepts a 3 mm pathological margin for melanoma in situ after discussion; GPP 5.4.1 now treats a sentinel node deposit over 5 mm as “radiologically evident” disease; GPP 5.3.2 now says SNB “should be recommended” after a negative PET-CT at T4b. The guideline still describes neoadjuvant nivolumab + ipilimumab as unfunded, which is out of date.
  • 2025–2026 — Adjuvant relatlimab (RELATIVITY-0981) negative; adjuvant vibostolimab (KEYVIBE-0102) stopped for futility; CheckMate 76K 3-year RFS HR 0.62 (earlier estimate 0.42); INTerpath-001 (individualised mRNA vaccine + pembrolizumab) met its RFS endpoint on 19 August 2026, no hazard ratio released, accrual closed.

WorkupIs the report enough to decide?

Basics: what the diagnostic biopsy and the synoptic report must contain

The diagnostic operation is a narrow complete excision with 2 mm margins, deep enough not to transect the base, orientated along lymphatic flow on a limb (GPP 3.2.6, p28), and closed directly, without flaps or grafts. Partial biopsy is acceptable in select circumstances (face, acral site, very large lesion, low suspicion) and must be flagged on the request form.

The synoptic report (; ICCR 3rd edition, January 2026) carries the items every later decision needs: subtype, to 0.1 mm, , , deep and peripheral margins, , perineural invasion, microsatellites, regression and tumour-infiltrating lymphocytes. Turnaround target: 80% of final reports within 5 working days.

Case
GP referral. Shave biopsy from the upper back: “superficial spreading melanoma, at least 0.6 mm, transected at the base, no ulceration seen, mitoses 1/mm².” Patient 55, fit.
What is the next step?
□ Guess   □ Fairly sure   □ Certain
✗ (a) Treats a truncated depth as a measured one. “At least 0.6 mm” is a floor, not a Breslow thickness; T category, margin and the node question are all undetermined.
✓ (b) Correct. GPP 3.2.5: a narrow-margin excision may be performed when a partial biopsy is inadequate for microstaging, so that thickness, ulceration and the nomogram inputs can be measured before the definitive plan.
✗ (c) Commits to a staging operation without knowing whether the nomogram threshold is met, and a wide excision first would degrade later mapping if it were needed.
✗ (d) The nomogram is a clinician’s calculation, and it cannot be run on a transected specimen: Breslow is unknown.
A base-transected shave sets a lower bound on thickness and nothing else. Everything downstream of T category is unknown until the lesion is fully excised. GPP 3.2.5 allows a narrow excision when a partial biopsy is inadequate for microstaging, but not generally when the partial specimen already meets the criteria for considering SNB. The excision is kept narrow because wide excision and undermining reduce the accuracy of a later SNB (section 3.2).

Rule

Every downstream decision is computed from the report. Before the case is discussed, confirm the specimen was complete or adequately sampled, and that the report states subtype, Breslow to 0.1 mm, ulceration, mitotic rate, LVI and margins. If any of these is missing or the base is transected, the MDM action is a re-excision or an addendum, not a plan.

Narrow-margin excisional biopsy may be performed if an initial partial biopsy is inadequate for diagnosis or microstaging, but it should not generally be performed if the initial specimen meets the criteria for consideration of SNB.

Source: Aotearoa NZ Melanoma Clinical Guidelines, 4th ed. (Skin Cancer NZ, June 2026)3, GPP 3.2.5–3.2.6, p28; biopsy technique 3.2, p27; synoptic reporting GPP 3.3.5, p30.

Rule

BRAF testing is not performed on the primary in the absence of metastatic disease. It is required for every patient with stage III or IV disease, and the practical moment to order it is at the diagnosis of nodal disease, on the metastatic tissue, because it decides the adjuvant choice after a non-response to neoadjuvant therapy.

All patients with resected Stage III – IV melanoma should have tumour BRAF mutation testing.

Source: Aotearoa NZ Melanoma Clinical Guidelines, 4th ed. (Skin Cancer NZ, June 2026)3, GPP 5.6.1, p60; GPP 3.3.8, p30 (no testing of the primary without metastasis; prognostic gene expression profiling discouraged).

Worked case — 5 steps
ReferralExcision biopsy, forearm, 62-year-old woman. Report: nodular melanoma, Breslow 2.6 mm, ulceration present, mitoses 6/mm², LVI absent, peripheral margin 1.5 mm, deep margin clear. No regression. Nodes impalpable.
  1. WorkupReport complete. All nomogram inputs and margin data are present; the specimen was a complete excision. No addendum needed.
  2. StagingT3b, clinical stage IIB. 2.1–4.0 mm with ulceration is T3b; N0 by examination.
  3. StagingBaseline imaging is optional, by age and comorbidity. GPP 3.6.3: at IIB, PET-CT or CT “may be appropriate dependent on patient age and comorbidities”. Not mandatory.GPP 3.6.3
  4. TreatmentPlan 20 mm wide excision with SNB at the same operation. T3 margin is 20 mm; the nomogram will exceed 10% at this thickness and mitotic rate.GPP 5.1.13, 5.3.1
  5. WorkupDo not order BRAF yet. No metastatic disease. Order it on the sentinel node if positive.GPP 3.3.8
What would change this? A transected base or a missing mitotic rate would stop the case at step 1. A palpable node would move the case to the neoadjuvant pathway and BRAF testing now.

Why?

Why is the diagnostic excision narrow, and why is a flap or graft avoided at that stage?

Show answer
A 2 mm margin gives the full lesion for microstaging without disturbing the lymphatics. Wide undermining, flaps and grafts alter lymphatic drainage, so a later sentinel node biopsy maps less reliably. The wide excision and the node are done together once the report has fixed the T category and the nomogram band.
Evidence and other guidelinesNZ ≠ NCCN on shave biopsy

Biopsy type. NZ is stricter than NCCN: the diagnostic operation is a narrow complete excision, with partial biopsy only in select circumstances (3.2); NCCN accepts a deep saucerisation with adequate depth. ESMO: full-thickness complete excision with a minimal margin.

Report content. ICCR 3rd edition (January 2026, TNM9-aligned) made histological subtype a core element. ESMO’s minimum list matches the RCPA protocol and adds that mitotic rate “should also be reported”.

Molecular. NZ discourages prognostic gene expression profiling outside a trial (GPP 3.3.8); NCCN V1.2026 allows the CP-GEP assay to support omitting in T1b–T2a; ESMO does not recommend routine use. Follow NZ. ESMO also suggests BRAF testing “should be considered” at clinical IIB–IIC, which has no funded consequence here.

Timeliness. 62 days; specialist assessment within 14 days; diagnostic excision within 14 days; result to patient within 10 days; first treatment within 31 days of the decision to treat (NZ 2.1, p21).

StagingDoes a T1 melanoma need the sentinel node?

Basics: T1a, T1b, sentinel node biopsy and the MIA nomogram

T1a is under 0.8 mm and not ulcerated. T1b is under 0.8 mm with , or 0.8–1.0 mm with or without it. Mitotic rate was removed from T1 staging in AJCC 8 but remains a reporting item and a nomogram input.

SNB maps the first draining node with radiocolloid, SPECT and blue dye, removes it and examines it with levels and immunohistochemistry. It is a staging operation. MSLT-I4 made it the strongest single prognostic factor; MSLT-II5 showed that acting on a positive result with completion dissection does not improve survival.

The MIA nomogram converts age, , subtype, , ulceration and into a predicted probability that the node is positive (Lo et al., JCO 2020; predictive accuracy 73.9% in the development cohort, C-statistic 75.0% on external validation).

Case
Three complete excision biopsies, all invasive melanoma, nodes impalpable. Classify each.
□ Guess   □ Fairly sure   □ Certain
T1b. Under 0.8 mm, ulceration alone makes it T1b.
T1b. 0.8–1.0 mm is T1b with or without ulceration.
T1a. Under 0.8 mm and not ulcerated is the only T1a combination.
Thickness alone does not separate T1a from T1b. The 0.8 mm line and ulceration interact: a 0.7 mm ulcerated lesion and a 0.95 mm non-ulcerated lesion are both T1b, and both open the sentinel node question.

Rule

The T1a/T1b line decides whether the node question is opened. The margin is 10 mm for both. For T1b N0 the staging basis changes the stage group: pathological stage IA after a negative , clinical stage IB if no SNB is done. The NZ follow-up schedule follows the stage group, so record which basis the MDM used.

Source: AJCC 8th ed.6; Aotearoa NZ Melanoma Clinical Guidelines, 4th ed. (Skin Cancer NZ, June 2026)3, GPP 6.1.5, p68 (IA annual; IB 6-monthly for 2 years) and GPP 5.3.11, p49 (no SNB → 6-monthly ultrasound for 2 years).

Rule

From T1b upward the node is decided by the nomogram percentage, not the T category. If any of the six inputs is missing, the rule cannot be applied: request an addendum. If SNB is not performed in a T1b or thicker melanoma, offer ultrasound surveillance of the basin 6-monthly for 2 years with a baseline scan.

SNB staging is considered for all patients who could benefit from the procedure, with melanoma T1b or thicker and a sentinel node risk of >5% on the Melanoma Institute of Australia sentinel node metastasis risk prediction tool… If <5%, SNB is not recommended. When 5-10% risk, SNB should be considered. At a risk of >10% SNB is recommended.

Source: Aotearoa NZ Melanoma Clinical Guidelines, 4th ed. (Skin Cancer NZ, June 2026)3, GPP 5.3.1, p49; GPP 5.3.11, p49; GPP 6.4.2, p80. MIA nomogram: Lo SN et al., J Clin Oncol 2020;38:27197.

T1a<0.8 mm, not ulceratedT1b<0.8 mm ulcerated, or 0.8–1.0 mm
Stage, pathological / clinicalIA / IAIA / IB
Margin10 mm10 mm
Sentinel nodeNot recommendedRun the nomogram
Follow-upAnnual, 10 yearsAnnual after negative SNB; 6-monthly × 2 y + ultrasound if no SNB
Check
Which row differs between T1a and T1b whichever staging basis is used?
□ Guess   □ Fairly sure   □ Certain
✓ (a) Correct. The node question opens at T1b on either basis.
✗ (b) Follow-up differs only when no SNB is done (clinical IB). After a negative SNB both are pathological IA and annual.
✗ (c) Both are 10 mm. Ulceration and the 0.8 mm line do not move the T1 margin.
Breslow thickness and ulceration classify the tumour as T1a or T1b. For T1a the NZ nomogram rule does not apply. For T1b and thicker, first check that all six nomogram inputs are reported; if any is missing, request a pathology addendum. If all are present, run the MIA nomogram: under 5 percent, sentinel node biopsy is not recommended; 5 to 10 percent, it should be considered; over 10 percent, it is recommended. Breslow + ulcerationfrom the report T1a T1b or thicker NZ nomogram rule does not applyselect cases only; validity less certain All six inputs reported? no Request addendum yes MIA nomogram < 5%not recommended 5–10%consider > 10%recommended Six inputs: age, Breslow, subtype,mitotic rate, ulceration, LVIGPP 5.3.1, p49 Breslow + ulcerationfrom the report T1a T1b or thicker NZ nomogram rule does not apply select cases only; validity less certain All six inputs reported? no yes Request addendum MIA nomogram < 5%not recommended 5–10%consider > 10%recommended Six inputs: age, Breslow, subtype,mitotic rate, ulceration, LVIGPP 5.3.1, p49
The T category opens the question; the percentage answers it.
Worked case — 6 steps
Referral68-year-old, calf. Excision biopsy: superficial spreading melanoma, 0.9 mm, not ulcerated, 1 mitosis/mm², no LVI. MIA nomogram: 6%.
  1. StagingT1b. 0.9 mm is in the 0.8–1.0 mm band; ulceration does not matter here.
  2. WorkupReport complete for the nomogram. All six inputs are stated; the 6% figure can be trusted.
  3. StagingBand 5–10%: “SNB should be considered”. The T category opened the question; the percentage decides.GPP 5.3.1
  4. FundingA positive node would give stage IIIA, below the Pharmac line. Resected stage IIIB is the funding threshold; no funded adjuvant therapy follows from a positive node here.
  5. Follow-upWhat the node buys: prognosis, a more intensive schedule, trial eligibility. If the node is negative, pathological IA and annual review; if not done, clinical IB, 6-monthly with ultrasound.GPP 6.1.5
  6. TreatmentDiscuss, decide with the patient, record the reasoning. If taken, do it at the same operation as the 10 mm wide excision.
What would change this? A nomogram under 5% (not recommended) or over 10% (recommended) removes the discussion. A missing input means defer, not decide.

Why?

Why does the NZ rule gate the node on a calculated percentage rather than on the T category?

Show answer
The T category uses two variables; the nomogram uses six. Two patients reported as T1b can land on opposite sides of 5% on age and mitotic rate, so a T-category rule would take nodes from the wrong patients. Thickness and ulceration matter because they predict occult nodal disease; the percentage is that prediction made explicit.
Evidence and other guidelinesNZ ≠ ESMO at T2a

Where the rules disagree. NZ uses a probability; the others use T category plus features. ESMO: SNB “should be discussed” at pT1b and is “recommended for all patients with clinically node-negative T2a or higher [I, A]”. NICE: consider at 0.8–1.0 mm with ulceration, LVI or mitoses ≥2, and above 1.0 mm; none at stage IA. NCCN: T1b “discuss and consider”, T2a and above “discuss and offer”; V1.2026 also lets the CP-GEP assay support omitting SNB in T1b–T2a, which NZ and ESMO do not. The discordance bites in an older patient with a T2a melanoma whose MIA risk falls below 5%: NZ says not recommended, ESMO says recommended.

T1a. NZ: “a SLN may be indicated in a select group of patients with a T1a melanoma, but the validity of the SLN risk prediction tool in this group is less certain” (5.1, p41). ESMO allows discussion in special cases (e.g. 3 mitoses/mm², a positive deep margin).

How strong is the 5% threshold? In the largest external validation (Swedish registry, n = 10,089; Olofsson Bagge, JAMA Surg 20248) the nomogram added no net benefit at a 5% threshold compared with biopsying everyone; net benefit appeared from about 7% and was greatest at 10% in T2 melanomas. The “5–10% consider” band is where the tool performs least well, which is an argument for a genuine discussion rather than a default.

Internal NZ inconsistency. Appendix 5 applies the calculator to “Stage IB disease and above”; GPP 5.3.1 says “T1b or thicker”. T1b N0 is pathological IA. Follow GPP 5.3.1.

Check
A 34-year-old has a 0.6 mm non-ulcerated melanoma of the neck with 3 mitoses/mm² and LVI present (T1a). You had planned wide excision without discussing SNB. Given these features, discussing SNB with the patient becomes:
much less appropriateunchangedmuch more appropriate
□ Guess   □ Fairly sure   □ Certain
Defensible range +1 to +2. NZ: the rule formally starts at T1b and the tool’s validity at T1a is “less certain”, but the guideline allows a select group. ESMO names mitoses ≥3/mm² as a special case for discussion. NCCN places T1a with adverse features in the discuss-and-consider band. This is an MDM discussion to document, not an automatic no.

StagingT4b: the scan or the node first?

Basics: what baseline imaging each stage gets, and what a positive scan changes

Stages 0, I and IIA: no baseline imaging in asymptomatic patients; ultrasound of the basin only if examination is equivocal. Stage IIB (T3b, T4a): PET-CT or CT “may be appropriate dependent on patient age and comorbidities”. Stage IIC (T4b): PET-CT is recommended. Stage IIIA under observation: no cross-sectional imaging unless adjuvant therapy or dissection is planned. Stage IIIB–D: PET-CT and brain MRI if upstaging would change treatment. Stage IV: CT chest, abdomen and pelvis (± neck) and brain MRI; PET-CT if oligometastatic or equivocal. Low-dose PET-CT does not exclude brain metastases.

Do not stage a patient whose comorbidities preclude any further treatment. Staging imaging should be complete within two weeks.

Case
Excision biopsy, vertex scalp, 59-year-old man: nodular melanoma 5.2 mm, ulcerated, mitoses 12/mm², LVI present. Neck nodes impalpable. Fit, ECOG 0.
What is the next step?
□ Guess   □ Fairly sure   □ Certain
✗ (a) The usual order, applied where NZ inverts it. At T4b the scan comes first: a positive PET-CT changes the whole pathway before any operation.
✓ (b) Correct. GPP 5.3.2: T4b patients “should undergo PET-CT staging prior to undergoing SNB”, and if negative, “SNB should be recommended”.
✗ (c) Omitting SNB at T4b forfeits the pathological staging that decides access to funded adjuvant therapy (N1a → IIIC).
✗ (d) Under the stated terms of reference, head and neck melanoma goes to the Head and Neck MDM only when neck nodes are involved or the disease is stage III. With impalpable nodes this MDM decides the staging order.
At T4b the sentinel node risk frequently exceeds 20%, and a proportion of patients already have radiologically evident nodal or distant disease. Finding that on PET-CT before theatre keeps the neoadjuvant option open. Operating first, then finding disease, closes it.

Rule

For every T category except T4b, the sentinel node comes first and imaging follows only if indicated. For T4b the order is inverted: PET-CT first, then if the scan is negative. The reason is access. A patient with radiologically evident nodal disease is a candidate for funded neoadjuvant immunotherapy only if treatment starts before complete resection; a node found at operation has already been resected, and only the adjuvant route remains.

Clinically suitable patients with a T4b primary melanoma should undergo PET-CT staging prior to undergoing SNB to identify those with radiologically evident nodal disease that are suitable for neoadjuvant immunotherapy. If the PET-CT is negative for metastatic disease SNB should be recommended for even more accurate staging to facilitate access to adjuvant treatments.

Source: Aotearoa NZ Melanoma Clinical Guidelines, 4th ed. (Skin Cancer NZ, June 2026)3, GPP 5.3.2, p49; baseline imaging GPP 3.6.2–3.6.6, p36.

Two timelines. Top: for a T4b primary, PET-CT comes first; if negative, sentinel node biopsy follows; if PET-CT shows nodal disease, the patient goes to medical oncology for neoadjuvant therapy before surgery. Bottom: for clinically detected resectable stage IIIB to IV, biopsy confirmation, staging and an oncology referral come before any theatre date; neoadjuvant immunotherapy is given, then surgery about three weeks after the last dose. Booking theatre first forfeits the neoadjuvant option, because funding requires treatment before complete resection. T4b primary (stage IIC) PET-CT first PET negative →SNB recommended PET shows nodal disease →oncology, neoadjuvant, then surgery GPP 5.3.2, p49 Clinically detected, resectable IIIB–IV Core/FNA, PET-CT,MRI brain, BRAF Medical oncologybefore any theatre date Neoadjuvant ICInivo+ipi ×2 or pembro ×3 Surgery ≈ 3 weeks afterlast dose (GPP 5.5.8) theatre booked first → treatment is no longer “prior to complete surgical resection”→ neoadjuvant funding lost T4b primary (stage IIC) PET-CT first GPP 5.3.2, p49 PET negative →SNB recommended PET shows nodal disease →oncology, neoadjuvant, then surgery Clinically detected, resectable IIIB–IV Core/FNA, PET-CT,MRI brain, BRAF Medical oncologybefore any theatre date Neoadjuvant ICInivo+ipi ×2 or pembro ×3 Surgery ≈ 3 weeks afterlast dose (GPP 5.5.8) theatre booked first → treatment is no longer “prior to complete surgical resection”→ neoadjuvant funding lost
Where access is decided by sequence rather than by stage.
Worked case — 6 steps
ReferralExcision biopsy, thigh, 70-year-old man: melanoma 6.0 mm, ulcerated. Groin impalpable. PET-CT: single FDG-avid ipsilateral inguinal node, 14 mm; no distant disease. ECOG 1, no autoimmune disease.
  1. StagingT4b with radiologically evident nodal disease. Clinical stage IIIC (T4b N1b).
  2. WorkupConfirm with core biopsy or FNA of the node; contrast MRI brain; BRAF on the nodal tissue. GPP 5.5.3 requires tissue confirmation, PET-CT and MRI brain before neoadjuvant therapy; BRAF now, because it decides the adjuvant choice after a non-response.GPP 5.5.3, 5.6.1
  3. TreatmentRefer to medical oncology before any theatre date. The neoadjuvant Special Authority requires treatment prior to complete surgical resection; a booked dissection forfeits it.GPP 2.1.9
  4. FundingFunded: nivolumab + ipilimumab ×2 cycles, or pembrolizumab ×3 doses. Both meet the resectable IIIB–IV criteria; the NZ guideline does not rank them, and the choice is made with medical oncology.
  5. TreatmentTherapeutic dissection about 3 weeks after the last dose; wide excision at the same operation. GPP 5.5.8 and 5.5.1.
  6. Follow-upAdjuvant decision by pathological response. MPR: no adjuvant; partial response: adjuvant offered; non-response: adjuvant considered, BRAF/MEK preferred if BRAF-mutant.GPP 5.5.12
What would change this? A negative PET-CT sends the same patient to wide excision with SNB. Distant disease on PET-CT moves the case to the stage IV pathway. ECOG 3 or active autoimmune disease removes the neoadjuvant option.

Why?

Why does the T4b inversion exist when the guideline itself calls staging PET at T4 “controversial, due to low yield and high false-positive rate”?

Show answer
Because the consequence of a true positive is now large. Before funded neoadjuvant therapy, an occult node found on PET-CT changed little that surgery would not also find. Now it opens a treatment that must start before resection. The rule trades false positives, which are worked up, for the patients who would otherwise lose the neoadjuvant option. It is expert consensus, not trial evidence.
Evidence and other guidelinesNZ ≠ ESMO/NICE at IIB

Stage II imaging. ESMO and EADO recommend CT or PET-CT plus brain MRI from IIB; NICE “consider” whole-body and brain CT at IIB and “offer” at IIC. NZ: IIC PET-CT; IIB optional by age and comorbidity; brain imaging not specified at IIB. The NZ restraint is defensible because a positive result at IIB changes nothing that is funded, other than detecting occult stage IV.

Internal NZ inconsistency. Appendix 5 lists CT head, chest, abdomen and pelvis for IIB with SNB “if above negative”; GPP 3.6.3 makes it optional. Follow the GPP and document the choice.

NCCN has no PET-before-SNB rule; imaging in stage 0–II is for signs and symptoms only.

Do not stage the unfit. NZ 3.6: if comorbidity precludes any further treatment, do not perform routine staging; the same applies to surveillance imaging (GPP 6.3.6).

TreatmentHow wide, measured from what?

Basics: clinical margin, pathological margin and shrinkage

The clinical margin is measured on the skin with a ruler from the edge of the scar or residual lesion. The pathological margin is what the pathologist measures on the fixed, sectioned specimen; it is always smaller because tissue shrinks 10–28% after excision and fixation. Guideline margin tables specify clinical margins. Depth: to, but not including, the deep fascia.

Melanoma in situ and T1a excisions can be done under local anaesthetic in primary care by an appropriately trained clinician (GPP 5.1.3).

Case
Two patients. P: 6.0 mm ulcerated melanoma of the back. Q: 2.5 mm non-ulcerated melanoma of the shoulder. Both nodes impalpable.
What additional clinical margin does each need at wide excision?
□ Guess   □ Fairly sure   □ Certain
✓ (a) Correct. Both are over 2 mm; both are 20 mm. Ulceration and thickness above 2 mm do not widen the margin further.
✗ (b) 10–20 mm is the 1–2 mm row. Q is 2.5 mm.
✗ (c) No NZ margin exceeds 20 mm. Margins above 2 cm have not been shown to influence survival.
✗ (d) Q is over 2 mm thick, which puts it in the 20 mm row. 10 mm is for melanomas of 1 mm or less.
The margin table has a ceiling. Above 2 mm every melanoma gets 20 mm, and ulceration does not change the width at any thickness. The variables that promote the stage group are not the variables that set the margin.

Rule

LesionAdditional clinical margin
Naevus with severe cytological or architectural atypia5 mm
Melanoma in situ, including lentigo maligna5–10 mm
≤1.0 mm (T1)10 mm
>1.0–2.0 mm (T2)10–20 mm
>2.0–4.0 mm (T3)20 mm
>4.0 mm (T4)20 mm

Margins may be modified by site and comorbidity. Where limiting morbidity or disfigurement is a priority, the pathological margin already achieved at biopsy may be deducted from the planned clinical margin, and choosing 1 cm rather than 2 cm is appropriate in the 1–2 mm band.

Source: Aotearoa NZ Melanoma Clinical Guidelines, 4th ed. (Skin Cancer NZ, June 2026)3, GPP 5.1.13 (margin table), p44; GPP 5.1.2, 5.1.5–5.1.7, p43. Rationale p41: margins wider than 2 cm do not appear to influence survival; MelMarT-II9 (1 cm vs 2 cm for pT2b–pT4b) is not expected to report before about 2029.

Rule

Two in situ rules that change practice. A 3 mm pathological margin on the excision biopsy of melanoma in situ may be accepted without further wide excision after a discussion of the increased recurrence risk, with case-by-case pathological review: a clean 3 mm margin is lower risk than one that petered out. For lentigo maligna, margin-controlled surgery (Mohs or staged excision with rushed paraffin sections) is preferred; topical imiquimod is an off-label option under specialist guidance where surgery is not acceptable or feasible.

Pathological margins of 3mm on excision biopsy for in situ melanoma may be accepted without a further wide local excision after a discussion with the patient of increased risk of recurrence and potentially invasive disease.

Source: Aotearoa NZ Melanoma Clinical Guidelines, 4th ed. (Skin Cancer NZ, June 2026)3, GPP 5.1.14, p44; GPP 5.1.8, p43; GPP 5.1.15, p44. Evidence base: retrospective series with short follow-up (Joyce 201510; Moura 202011) in which 11–20% of recurrences were invasive.

Worked case — 5 steps
ReferralExcision biopsy, cheek, 74-year-old woman: lentigo maligna melanoma 1.2 mm, not ulcerated, mitoses 1/mm²; peripheral pathological margin 4 mm at biopsy. Nomogram 4%.
  1. StagingT2a, clinical stage IB; nomogram under 5%. SNB not recommended. Offer ultrasound surveillance of the neck 6-monthly for 2 years.GPP 5.3.1, 5.3.11
  2. TreatmentTable margin 10–20 mm; site favours the lower end. On the face, limiting disfigurement is a priority: GPP 5.1.2 and the rationale support 10 mm.GPP 5.1.7
  3. TreatmentDeduct the 4 mm already achieved: plan about 6 mm clinical margin. The deduction rule applies “in anatomical areas where limiting morbidity or disfigurement is a priority”.GPP 5.1.7
  4. TreatmentConsider margin control because of the lentigo maligna component. Subclinical extension of LM is wide: only 41% of head and neck melanoma in situ cleared at 5 mm in the Moyer staged-excision series cited by the guideline.GPP 5.1.8
  5. Follow-upClinical IB: 6-monthly for 2 years, then annual to 10 years; ultrasound as above. GPP 6.1.5
What would change this? A nomogram over 5% would put SNB on the table at the same operation. An invasive component over 2 mm would fix the margin at 20 mm regardless of site.

Why?

Why is the deduction rule restricted to sites where morbidity matters, rather than applied everywhere?

Show answer
Because the tables were built on clinical margins measured from the lesion, and shrinkage means a pathological millimetre is not a clinical millimetre. Deducting everywhere would systematically under-excise. The guideline accepts that trade only where the extra tissue costs function or appearance, which is where a modest increase in local recurrence risk is a reasonable exchange.
Evidence and other guidelinesNZ ≠ ESMO at 1–2 mm

Margins. ESMO fixes 1 cm for all melanomas ≤2 mm and 2 cm above; NZ and NCCN allow 1–2 cm in the 1–2 mm band. NICE: at least 0.5 cm for stage 0. No trial separates 1 cm from 2 cm for ≤2 mm tumours.

Desmoplastic melanoma. NZ: radiotherapy where unresectable or where “clinical margins are <8 mm”, and for head and neck, marked neurotropism or >4 mm (GPP 5.2.1–5.2.2). ESMO writes the same threshold as a pathological ≥8 mm margin, which triggers RT more often because pathological margins are always smaller.

Subungual melanoma. The NZ text recommends amputation at the next proximal interphalangeal joint for invasive disease and notes emerging evidence for conservative surgery in in situ disease; this is rationale, not a GPP. ESMO accepts reduced margins at acral sites to preserve function.

Timing with . NZ: SNB at the time of the re-excision. In the neoadjuvant pathway the wide excision can be deferred to the nodal operation (GPP 5.5.1).

TreatmentThe sentinel node is positive. Now what?

Basics: what MSLT-II changed, and what the sentinel node report contains

MSLT-II (n = 1,939) randomised sentinel-node-positive patients to completion dissection or ultrasound observation: melanoma-specific survival was identical (86% vs 86% at 3 years), and lymphoedema was 24.1% vs 6.3%. DeCOG-SLT12 found the same. Completion dissection is therefore no longer routine.

The NZ sentinel node report (MIA synoptic, Appendix 4) states the number of nodes, tumour foci, compartment, size of the largest discrete deposit in millimetres, penetrative depth, extranodal spread and nodal naevus, with BRAF VE1 immunohistochemistry. The deposit size drives the next decision.

Case
Wide excision and SNB done. Primary: 1.6 mm, not ulcerated (T2a). Sentinel node: one node, single deposit 1.8 mm, no extranodal spread. Other nodes negative. Patient 52, fit.
What is the recommended management of the node basin?
□ Guess   □ Fairly sure   □ Certain
✗ (a) The pre-2017 standard. MSLT-II showed no survival benefit and quadrupled lymphoedema.
✓ (b) Correct. GPP 5.4.1: deposit under 5 mm and primary T2a or thinner → ultrasound surveillance 6-monthly for 3 years by an experienced sonographer.
✗ (c) T2a N1a is stage IIIA, below the Pharmac line (resected IIIB and above). Not funded.
✗ (d) At IIIA under observation, baseline cross-sectional imaging is not recommended: low true-positive and high false-positive rates (GPP 3.6.4).
Stage IIIA with a small deposit is the group where the trials, the NZ guideline and the funding line all point the same way: no dissection, no funded systemic therapy, structured ultrasound follow-up and an MDM record of the discussion.

Rule

Every positive sentinel node is discussed at the MDM for observation versus adjuvant therapy versus completion dissection. Deposit under 5 mm with a T2a or thinner primary: ultrasound observation 6-monthly for 3 years. Primary T2b or thicker with any deposit: stage IIIB or higher under AJCC 8, so adjuvant therapy is discussed. Deposit over 5 mm: the NZ guideline suggests this “could be considered” radiologically evident disease, staged IIIB or above.

Patients with sentinel node disease of <5 mm and a primary melanoma T2a or thinner are recommended for observation with node field US every 6 months for the first 3 years by an experienced sonographer. If the nodal deposit is >5mm this may have been picked up on preop imaging and thus could be considered as ‘radiologically evident’ disease with a staging of IIIB or above.

Source: Aotearoa NZ Melanoma Clinical Guidelines, 4th ed. (Skin Cancer NZ, June 2026)3, GPP 5.4.1, p53; GPP 5.3.10, p49; MSLT-II: Faries MB et al., NEJM 2017;376:22115.

Rule

Completion dissection remains an option for patients who cannot or do not wish to be followed with ultrasound, or where local control favours it; PET-CT precedes any dissection. A node found at has already been resected: if the stage is IIIB or higher, the route is adjuvant therapy within the funding window, not neoadjuvant therapy.

Source: Aotearoa NZ Melanoma Clinical Guidelines, 4th ed. (Skin Cancer NZ, June 2026)3, GPP 5.4.2, 5.4.4, p53; adjuvant GPP 5.6.1–5.6.4, p60.

Stage IIIAT1–T2a with N1a or N2aStage IIIBT2b/T3a with N1a–N2b; T1a–T2a with N1b, N1c or N2b; T0 with N1b/N1c
How the node was foundSentinel node biopsy (occult)SNB with a thicker primary, or clinically detected
Node basinUltrasound 6-monthly × 3 yUltrasound if SNB-detected; dissection after neoadjuvant therapy if clinically detected
Funded systemic therapyNoneAdjuvant pembrolizumab or D+T; neoadjuvant if clinically detected
Baseline imagingNot recommended under observationPET-CT and brain MRI if it would change treatment
Clinical follow-up4-monthly × 2 y, 6-monthly y3, annual to 10 ySame
Check
A T2a N1a patient becomes IIIB if which single feature changes?
□ Guess   □ Fairly sure   □ Certain
✓ (a) Correct. T2b N1a is IIIB under AJCC 8. Ulceration of the primary, not the node, moves the stage.
✗ (b) Under AJCC 8, deposit size does not change N1a. The NZ 5 mm convention applies above 5 mm and is not an AJCC rule.
✗ (c) T2a N2a is still IIIA.
✗ (d) Age is not a staging variable.
Worked case — 6 steps
ReferralWide excision and SNB done 3 weeks ago. Primary: 2.2 mm, ulcerated (T3b), trunk. Sentinel node: one deposit 3 mm, no extranodal spread. BRAF not yet tested. Patient 58, ECOG 0.
  1. StagingT3b N1a: pathological stage IIIC. T3b or T4a with any N1–N2 is IIIC under AJCC 8.
  2. WorkupOrder BRAF on the sentinel node now; PET-CT and brain MRI before adjuvant therapy. GPP 5.6.1 (all resected III–IV) and GPP 3.6.4 (baseline PET-CT if adjuvant therapy planned).GPP 5.6.1, 3.6.4
  3. TreatmentNo completion dissection; ultrasound observation of the basin. MSLT-II. Dissection only if surveillance is impossible or local control demands it.GPP 5.4.1–5.4.2
  4. FundingResected stage IIIC: adjuvant pembrolizumab for 12 months, or dabrafenib + trametinib for 12 months if BRAF V600E. Special Authority: resected IIIB–IV, ECOG 0–2, start within 13 weeks of the most recent resection.
  5. TreatmentThis is adjuvant, not neoadjuvant. The node has been removed; the neoadjuvant criterion “prior to complete surgical resection” cannot be met.
  6. Follow-upThe clock: NZ says start within 12 weeks; the Special Authority allows 13 weeks from the wide excision and SNB. The 13 weeks run from the most recent resection (primary or lymphadenectomy, Pharmac note b), and the criterion allows delay that is necessary for post-surgery recovery. Pharmac has not stated whether a later margin re-excision resets the clock; confirm before relying on it.GPP 5.6.4
What would change this? A 1.9 mm non-ulcerated primary with the same node is IIIA: same surgery, same ultrasound, no funded systemic therapy. A clinically palpable node before surgery would have made this a neoadjuvant case.

Why?

Why does a positive sentinel node not lead to dissection, when dissection was standard for decades?

Show answer
Because the node had already done its work as a prognostic test. In MSLT-II removing the remaining nodes found disease in about 11% of the basin but did not change melanoma-specific survival, while lymphoedema rose from 6% to 24%. Regional control can be maintained with ultrasound and delayed dissection in the few who relapse. The survival determinants are systemic, and adjuvant therapy now addresses them.
Evidence and other guidelinesNZ ≠ AJCC 8 on deposit size

The >5 mm convention. GPP 5.4.1 extrapolates from ultrasound-detection series (Starritt 200513; Sibon 200714; Pilko 201215). It has not been validated as a staging rule, it is not in AJCC 8, and the Pharmac states stage “as per American Joint Committee on Cancer (AJCC) 8th Edition”.

ESMO: “ is not recommended for patients with a positive SLNB [I, E]”; adjuvant therapy at IIIA with a deposit under 1 mm is “generally not recommended [I, D]”, which aligns with NZ practice; above 1 mm Europe discusses adjuvant therapy and NZ cannot fund it (GPP 5.6.5 names “Stage IIIA (lymph node metastasis >1mm)” as a group that may be considered, unfunded).

Ultrasound frequency. GPP 5.4.1 and 6.1.5 say 6-monthly; GPP 6.4.2 says 4–6-monthly, for 3 years after a positive node and 2 years when SNB was omitted, with a baseline scan. The guideline acknowledges ultrasound “is a limited resource” and that CT may be as effective for torso primaries with several basins.

TreatmentClinically detected stage III: the sequence decides the access

Basics: neoadjuvant versus adjuvant, and what the two funded regimens are

Adjuvant therapy follows complete resection. Neoadjuvant therapy is given first, with the tumour and its draining nodes in place, which appears to generate a broader anti-tumour response and allows the pathological response to be measured. Two regimens are funded for resectable stage IIIB–IV. Nivolumab + ipilimumab: two cycles, surgery about three weeks after the last dose, then adjuvant nivolumab only if the pathological response is inadequate, to 12 months total (NADINA). Pembrolizumab: three doses, surgery, then adjuvant pembrolizumab to 12 months total (SWOG S180116). Neither is funded for uveal melanoma; mucosal melanoma is not excluded.

Response is graded on the resected specimen: pathological complete or near-complete response (≤10% viable tumour) is a major pathological response; 10–50% is partial; over 50% is non-response.

Case
Referral from plastics. 3.1 mm ulcerated melanoma of the back excised 5 weeks ago. Now a 2.5 cm palpable left axillary node, FNA positive for melanoma. PET-CT: axilla only. MRI brain clear. ECOG 0. Axillary dissection is booked for next Tuesday.
What should the MDM recommend?
□ Guess   □ Fairly sure   □ Certain
✗ (a) Targeted therapy is not the funded neoadjuvant regimen. Immunotherapy first for BRAF-mutant and wild-type alike; targeted therapy is held for a non-response or for toxicity.
✗ (b) Loses the neoadjuvant option. Both neoadjuvant Special Authorities require treatment before complete resection, and the trial evidence favours the neoadjuvant sequence.
✗ (c) Same problem. BRAF should be sent now, but the dissection date is the thing to move.
✓ (d) Correct. GPP 5.5.1 (neoadjuvant for resectable clinical IIIB–D), GPP 2.1.9 (start within two weeks of the joint decision), GPP 5.5.8 (surgery ~3 weeks after).
A booked dissection is the single commonest way a patient loses funded neoadjuvant therapy. Stage IIIC (T3b N1b) is inside the Special Authority; the only thing that can put the patient outside it is the order of events. Sending BRAF now on the FNA material costs nothing and decides the adjuvant choice if the response is poor.

Rule

Resectable, clinically or radiologically detected stage IIIB–D and resectable stage IV melanoma is a neoadjuvant case unless contraindicated. Confirm the diagnosis by core or FNA, stage with PET-CT and contrast MRI brain, test BRAF on the metastatic tissue, mark the index node, and refer to medical oncology before any theatre date is set. Surgery is a full therapeutic dissection about three weeks after the last dose, with the wide excision done at the same time if not already done.

Patients with resectable clinical Stage IIIB-D and resectable Stage IV melanoma should be considered for neoadjuvant ICI therapy and discussed in a melanoma multi-disciplinary meeting.

Source: Aotearoa NZ Melanoma Clinical Guidelines, 4th ed. (Skin Cancer NZ, June 2026)3, GPP 5.5.1, 5.5.3, 5.5.6–5.5.9, p58; GPP 2.1.9, p21. The guideline (GPP 5.5.5) still lists nivolumab + ipilimumab as unfunded; Pharmac funded it from 1 May 2026 (SA264217/SA264318).

Rule

After nivolumab + ipilimumab: a major pathological response needs no adjuvant therapy; a partial response should be offered adjuvant immunotherapy; a non-response should be considered for it, with BRAF/MEK preferred in BRAF-mutant disease, and adjuvant radiotherapy may be considered. After neoadjuvant pembrolizumab: adjuvant pembrolizumab to complete 12 months. Adjuvant nivolumab is funded “if required”, to 12 months total including the two neoadjuvant cycles.

Source: Aotearoa NZ Melanoma Clinical Guidelines, 4th ed. (Skin Cancer NZ, June 2026)3, GPP 5.5.11–5.5.14, p58; Pharmac SA2643 renewal criteria (October 2026)18. NADINA: Blank CU et al., NEJM 2024;391:169619 (MPR 59.0%; 12-month EFS 83.7% vs 57.2%, HR 0.32); 2-year EFS 77.3% vs 55.7%, HR 0.40 (ESMO 2025, congress report20).

Before 1 May 2026the habitFrom 1 May 2026the funded position
Neoadjuvant regimen fundedPembrolizumab ×3 onlyNivolumab + ipilimumab ×2, or pembrolizumab ×3
Adjuvant after neoadjuvantPembrolizumab to 12 monthsNivolumab only if required (no MPR), to 12 months total; or pembrolizumab route unchanged
Timing criterionTreatment before complete resectionTreatment before complete resection
Stage criterionResectable IIIB–IV, AJCC 8, ECOG 0–2Resectable IIIB–IV, AJCC 8, ECOG 0–2
Advanced (unresectable) ipilimumabNot fundedNot funded
Check
Which statement about the 1 May 2026 Pharmac change is correct?
□ Guess   □ Fairly sure   □ Certain
✗ (a) It did not. Ipilimumab is funded only in the resectable neoadjuvant setting; the advanced-disease combination remains unfunded.
✗ (b) Adjuvant nivolumab is funded only “if required”; after a major pathological response it is omitted.
✓ (c) Correct. Both regimens are funded; neither the Special Authority nor the NZ guideline ranks them.
✗ (d) Pembrolizumab remains funded and guideline-endorsed; the NZ guideline lists both regimens without ranking, and the choice between them is a medical oncology decision.
Worked case — 6 steps
Referral2.0 mm non-ulcerated melanoma of the scalp excised 6 weeks ago. Now two palpable level II neck nodes, FNA positive. PET-CT: neck only. MRI brain clear. BRAF V600E. ECOG 0, no autoimmune disease.
  1. StagingT2a N2b: stage IIIB, resectable. Clinically detected nodes are N1b/N2b regardless of the T category.
  2. WorkupRouting: head and neck melanoma with neck nodal disease goes to the Head and Neck MDM. Under the stated terms of reference, H&N melanoma with neck nodal involvement (parotid to supraclavicular) or stage III disease is discussed at the H&N MDM.
  3. TreatmentMedical oncology must be at that discussion before a neck dissection date is set. The neoadjuvant criterion is “prior to complete surgical resection”; the H&N route is where surgery-first most easily happens.GPP 2.1.9
  4. FundingFunded neoadjuvant: nivolumab + ipilimumab ×2 or pembrolizumab ×3. Stage IIIB, ECOG 0, no prior therapy: inside the Special Authority.
  5. TreatmentBRAF V600E does not change the first step. Immunotherapy first; dabrafenib + trametinib is held for a non-response or for immune toxicity.GPP 5.5.12–5.5.13
  6. Follow-upRestage before surgery; neck dissection about 3 weeks after the last dose; response-adapted adjuvant plan. GPP 5.5.7–5.5.8
What would change this? Under the stated terms of reference, impalpable nodes with the same primary would keep this patient at the melanoma MDM for SNB. Distant disease on PET-CT would move the case to the stage IV pathway. ECOG 3 or a transplant would remove the immunotherapy route.

Why?

Why does neoadjuvant therapy produce a larger effect than the same drug given after surgery?

Show answer
With the tumour and its draining nodes in place, checkpoint blockade acts on a larger and more diverse population of tumour-reactive T cells, and the response can be measured on the specimen. In NADINA the event-free survival hazard ratio was 0.32 at one year against surgery followed by adjuvant nivolumab, and 59% of patients had a major pathological response and needed no further treatment. Overall survival data are immature; the benefit shown so far is event-free and distant-metastasis-free survival.
Evidence and other guidelinesESMO/NCCN rank nivo+ipi first; NZ does not

Ranking. ESMO: neoadjuvant nivolumab–ipilimumab “should be offered [I, A]”; neoadjuvant plus adjuvant pembrolizumab “also recommended [II, A]”. NCCN 2026 (congress report): neoadjuvant therapy is the preferred initial approach for resectable nodal disease, with nivolumab + ipilimumab category 1. NZ lists both without ranking. There is no head-to-head trial. Reasons to favour pembrolizumab: autoimmune disease, frailty, 2, significant cardiac comorbidity; grade ≥3 systemic toxicity was 29.7% vs 14.7% in NADINA.

Dosing. The criteria for neoadjuvant nivolumab + ipilimumab (SA2642/SA2643) set a maximum of two cycles, not a dose. NADINA gave ipilimumab 80 mg + nivolumab 240 mg 3-weekly ×2 (trial registration NCT0494911321; the NEJM abstract does not state the dose). Use the ACT-NOW regimen library.

Pembrolizumab dose count. The NZ rationale text refers to “a further 18 dose post-operative course”; S180116 gave 3 neoadjuvant + 15 adjuvant doses, and the Special Authority caps the total at 12 months including neoadjuvant doses (18 cycles). Use 3 + 15.

Omitting dissection after MPR (PRADO22: 5-year EFS 71%, OS 86%, phase 2) is not NZ standard; GPP 5.5.9 requires a full therapeutic dissection. MSLT-3 is comparing index-node excision with therapeutic lymph node dissection after neoadjuvant immunotherapy (NCT07049276).

In-transit disease. Resectable in-transit metastases are N1c/N2c/N3c, stage IIIB or higher, and eligible for funded neoadjuvant therapy; unresectable disease is treated systemically first. ILI is provided by Waitematā “after all other treatment options” (GPP 5.7.9). T-VEC is not on the Schedule.

Real-world caution. A small Swiss series23 treating by the NADINA protocol reported in 5 of 18 (28%), well below the trial’s 59%.

FundingWhich stage groups are funded, and which are not

FundingPosition as at the October 2026 Pharmac Schedule, checked 1 October 2026. Funding and Special Authority criteria change often: check the current Schedule before acting on them.

Basics: how a Special Authority works

Pharmac funds medicines against criteria that must all be met at the time of application. The criteria are literal: stage is defined by AJCC 8th edition and timing criteria are enforceable, with one written exception: adjuvant treatment may start more than 13 weeks after resection where the delay is necessary for post-surgery recovery. Otherwise, when the criteria are not met, the routes are a Special Authority waiver (Pharmac’s waiver process24 is for circumstances that meet the intent of a criterion but not its exact wording; Pharmac has said it will consider waivers for system-caused delays in specified situations), a Named Patient Pharmaceutical Assessment, a clinical trial, or self-funding.

Case
Three patients with no prior systemic therapy, all ECOG 0. X: resected T4b N0 (IIC). Y: resected T2a N1a, deposit 2 mm (IIIA). Z: resected T3a N1a (IIIB).
Who is eligible for publicly funded adjuvant immunotherapy?
□ Guess   □ Fairly sure   □ Certain
✗ (a) IIC has a worse 5-year outlook than IIIA in AJCC 8 data, and international guidelines offer adjuvant therapy at IIC, but the Special Authority starts at IIIB.
✓ (b) Correct. Resected stage IIIB, IIIC, IIID or IV. IIB, IIC and IIIA are not funded.
✗ (c) Nodal disease is not the criterion; IIIA is excluded whatever the deposit size under AJCC 8.
✗ (d) X (IIC) and Y (IIIA) are below the line. Prognosis does not decide funding; the stage label does.
The funding line is a stage label, not a risk estimate. Stage IIC carries a higher risk of death than stage IIIA, and ESMO grades adjuvant therapy at IIB–IIC as [I, A], yet in New Zealand IIC is unfunded and IIIB is funded. The MDM should record the discussion and the options (self-funding, trial, observation) for every IIB, IIC and IIIA patient.

Rule

Funded perioperative therapy begins at resected or resectable stage IIIB (AJCC 8). Below the line sit IIB, IIC and IIIA, for which the NZ guideline says adjuvant therapy “may be considered” and notes it is “not currently Pharmac funded”. For advanced disease the funded options are anti-PD-1 monotherapy (pembrolizumab or nivolumab) and dabrafenib + trametinib. Ipilimumab + nivolumab is not funded for unresectable or metastatic disease, including asymptomatic brain metastases; nivolumab + relatlimab and tebentafusp are not on the Schedule.

Other groups that may be considered for adjuvant systemic treatment include selected patients with resected Stage IIB, IIC and Stage IIIA (lymph node metastasis >1mm) melanoma (not currently Pharmac funded for these indications).

Source: Aotearoa NZ Melanoma Clinical Guidelines, 4th ed. (Skin Cancer NZ, June 2026)3, GPP 5.6.5, p61; Pharmac Schedule October 202625 (SA263126, SA264217, SA264318; dabrafenib/trametinib per the 9 May 2025 decision27). See the funding table at the end of this document.

A horizontal ladder of AJCC 8 stage groups from IA to IV. Perioperative immunotherapy is publicly funded from resected or resectable stage IIIB upward. Stages IIB, IIC and IIIA sit below the line despite international guidelines offering adjuvant therapy at IIB and IIC and, for larger nodal deposits, IIIA. IA IB IIA IIB IIC IIIA IIIB IIIC IIID IVresectable → neoadjuvant Pharmac line: resected or resectable IIIB and above ESMO / NCCN / EADO offer adjuvant anti-PD-1 at IIB–IIC (RFS benefit; no OS benefit shown) IIIA with deposit >1 mm: discussed in Europe; unfunded here Neoadjuvant nivo+ipi or pembrolizumab;adjuvant pembrolizumab or D+T Special Authority stages: AJCC 8th edition. October 2026 Schedule. IA IB IIA IIB IIC IIIA ESMO / NCCN / EADO offer adjuvant anti-PD-1 at IIB–IIC (RFS benefit; no OS benefit shown) IIIA with deposit >1 mm: discussed in Europe; unfunded here Pharmac line: resected or resectable IIIB and above IIIB IIIC IIID IVresectable → neoadjuvant Neoadjuvant nivo+ipi or pembrolizumab;adjuvant pembrolizumab or D+T Special Authority stages: AJCC 8th edition. October 2026 Schedule.
Three stage groups sit on the wrong side of a line their prognosis does not draw.
Worked case — 5 steps
ReferralResected T4a N0 (IIB), SNB negative, back, 49-year-old woman, ECOG 0. Asks about “the immunotherapy my friend in Australia had”.
  1. StagingStage IIB, pathologically staged. T4a N0.
  2. FundingAdjuvant pembrolizumab or nivolumab: not funded in NZ. The Special Authority begins at resected IIIB.
  3. TreatmentWhat the evidence supports: recurrence-free survival benefit, no overall survival benefit shown. KEYNOTE-716 4-year RFS HR 0.62, DMFS HR 0.59; progression-free survival after next-line therapy HR 0.75 with a CI crossing 1. CheckMate 76K 3-year RFS HR 0.62.
  4. TreatmentOptions to record: observation with NZ surveillance; self-funded pembrolizumab 200 mg 3-weekly ×17; clinical trial if one is open. No stage II trial is recruiting in NZ; INTerpath-001 has closed to accrual and KEYVIBE-010 was stopped.
  5. Follow-up4-monthly review for 2 years, 6-monthly in year 3, annual to 10 years; no routine imaging at IIB. GPP 6.1.5, 6.3.1
What would change this? Ulceration (T4b, IIC) adds PET-CT at baseline and CT with brain imaging 6-monthly for 3 years, but does not cross the funding line. A positive sentinel node would have made this IIIC and funded.
Evidence and other guidelinesESMO [I, A] at IIB–IIC; unfunded here

Stage II. ESMO: adjuvant pembrolizumab or nivolumab for 12 months “should be considered for patients with stage IIB-IIC disease… RFS benefit but lack of mature OS data [I, A]”. NCCN and EADO agree. KEYNOTE-71628 at 4 years: RFS HR 0.62 (0.50–0.78), DMFS HR 0.59, PRFS2 HR 0.75 (0.56–1.01). CheckMate 76K at 3 years: RFS HR 0.62 (0.47–0.80), DMFS HR 0.72 (0.52–1.00); the earlier HR of 0.42 was the first interim estimate.

Stage III adjuvant, what is proven. No anti-PD-1 adjuvant trial has shown an overall survival benefit: CheckMate 23829 5-year OS 76% vs 72% against ipilimumab (full-text HR 0.86, 95% CI 0.66–1.12, not significant); KEYNOTE-05430 OS not reported (the 7-year analysis31 gives RFS HR 0.63 and DMFS HR 0.64, and no OS in its abstract). COMBI-AD32 final OS HR 0.80, p = 0.06 (V600E subgroup 0.75, exploratory). ESMO advises against targeted adjuvant therapy in V600K; the Special Authority says only “confirmed BRAF mutation”; follow NZ GPP 5.6.3 (V600E).

Advanced disease. ESMO prefers ipilimumab–nivolumab first line “regardless of BRAF status” when it can be delivered safely; CheckMate 06733 at 10 years: median OS 71.9 vs 36.9 (nivolumab) vs 19.9 months (ipilimumab), though the trial was not powered to compare the combination with nivolumab alone. In NZ the funded first-line choice is anti-PD-1 monotherapy or dabrafenib + trametinib, and after anti-PD-1 failure a BRAF wild-type patient has no funded immunotherapy option.

Second use of anti-PD-1. The Special Authority allows funded anti-PD-1 for advanced disease after perioperative anti-PD-1 only if there was no recurrence on treatment or within six months of finishing it.

Uveal and mucosal. Uveal melanoma is excluded from every melanoma Special Authority; tebentafusp is neither Medsafe-approved nor funded (5-year OS 16% vs 8%; Piperno-Neumann S et al., Ann Oncol 202634). Mucosal melanoma is not excluded.

Timing. NZ GPP 5.6.4 and ESMO: start adjuvant therapy within 12 weeks; the Special Authority allows 13 weeks from the most recent resection, or longer where delay is necessary for post-surgery recovery. Plan to 12.

Follow-upSurveillance: which schedule, and on which staging basis?

Basics: what a follow-up visit contains, and who does it

Each visit: symptom review, the scar and surrounding skin, regional and distant node basins, the in-transit pathway between the primary site and the draining basin, a head-to-toe skin check with dermoscopy, and lymphoedema monitoring after nodal surgery. Patients are taught self-examination (ABCDEFG or SCAN) and encouraged to photograph lesions; those with additional risk factors self-examine 3-monthly. Appendix 6 hands routine review to the GP after the specialist phase, with a written plan and a named lead clinician.

Case
Two patients, both 0.9 mm non-ulcerated melanoma (T1b), both wide excision done. U had a sentinel node biopsy: negative. V declined the sentinel node biopsy.
What follow-up does the NZ guideline set for each?
□ Guess   □ Fairly sure   □ Certain
✗ (a) U is pathological stage IA and annual. V has no pathological node status and is clinical stage IB: 6-monthly with ultrasound.
✓ (b) Correct. GPP 6.1.5 (IA annual; IB 6-monthly ×2 years; no SNB → 6-monthly ultrasound ×2 years) and GPP 5.3.11.
✗ (c) U is pathological IA after a negative node and follows the annual schedule.
✗ (d) Reversed and wrong tier. 4-monthly is the IIB and above schedule.
The staging basis decides the schedule. T1b N0 is pathological stage IA after a negative sentinel node and clinical stage IB without one. The MDM record should say which applies, because the follow-up letter to the GP depends on it.

Rule

StageClinical reviewImaging
0 (in situ)Annual, long termNone
IAAnnual for at least 10 yearsNone
IB, IIA6-monthly × 2 years, then annual to year 10None; ultrasound of the basin 6-monthly × 2 years if no SNB
IIB4-monthly × 2 years, 6-monthly year 3, annual to year 10None routinely
IICAs IIBCT chest/abdomen/pelvis ± neck + brain MRI or CT 6-monthly × 3 years; consider annual in years 3–5
IIIAAs IIBCT (± neck) at 6 and 12 months, then annually to year 3; ultrasound of the remaining basin 6-monthly × 3 years
IIIB–D, resected IVAs IIB; stage IV with extra visits as neededCT ± neck + brain 3–6-monthly × 3 years, annual in years 3–5

Beyond 10 years, continue for stage I (about a quarter of stage I melanoma deaths occur after 10 years), prior in situ melanoma, keratinocyte cancer, age over 65, acral, scalp or neck primaries and nodular subtype; lifelong for multiple melanomas, atypical mole syndrome or more than 100 naevi.

Source: Aotearoa NZ Melanoma Clinical Guidelines, 4th ed. (Skin Cancer NZ, June 2026)3, GPP 6.1.5–6.1.7, p68; GPP 6.3.1–6.3.2, p76; GPP 6.4.2, p80. Appendix 6 (p100) adds a CT at 3 months for IIC and above and hands over to the GP after year 2 or 3; where it differs from the GPPs, document which schedule the MDM chose.

Worked case — 5 steps
ReferralResected stage IIIC (T3b N1a) 4 months ago, on adjuvant pembrolizumab. Baseline PET-CT clear. Left axilla. Patient 58.
  1. Follow-upClinical review 4-monthly for 2 years, 6-monthly in year 3, annual to year 10. GPP 6.1.5.
  2. Follow-upCT chest/abdomen/pelvis with brain MRI 3–6-monthly for 3 years, then annually in years 3–5. GPP 6.3.2. Oncology usually times these with treatment.
  3. Follow-upUltrasound of the remaining axillary basin 6-monthly for 3 years. Positive sentinel node under observation, no dissection.GPP 5.4.1
  4. Follow-upEach visit includes the in-transit pathway from the primary to the axilla and a full skin check. Second primaries are commoner after any melanoma.GPP 6.1.3
  5. Follow-upWritten plan to patient and GP; named lead clinician; self-examination taught. GPP 6.1.8–6.1.9, 6.2.1
What would change this? Had the node been negative (IIB), imaging would stop entirely and the visit schedule would be the same. Had the patient been IIIA, CT would run at 6 and 12 months then annually to year 3, without brain imaging.

Why?

Why does the NZ schedule stop routine imaging at IIB yet image IIC six-monthly, when both are 4-monthly clinically?

Show answer
Because the yield and the consequence differ. At IIC (T4b) the risk of occult distant disease is high enough that finding it changes the pathway, and the same patient would have had baseline PET-CT. At IIB the guideline judges the true-positive rate too low against the false positives, and finding stage IV early has no funded systemic consequence that clinical review would not also reach. The imaging schedule tracks funded consequences as much as risk; both are expert consensus, not trial evidence.
Evidence and other guidelinesNZ 10 years vs NICE 1–5 years

Duration. NZ follows every stage to 10 years; NICE discharges stage IA after one year and IB–IV after five; ESMO says national guidance applies, “particularly after 3 years”; NCCN tapers after 5 years and stops routine imaging at 3–5 years. The NZ rationale rests on late deaths (Lo et al. 201835) and second primaries; MELFO36 (randomised) showed reduced schedules are safe for IB–IIC. There is no high-quality evidence that surveillance imaging improves survival.

Internal NZ inconsistencies. Appendix 6 lists a CT at 3 months for IIC and above that GPP 6.3.2 does not; ultrasound frequency is “6 monthly” in GPP 5.4.1 and 6.1.5 but “4–6 monthly” in GPP 6.4.2. Pick one and document it.

Modality. NICE: do not routinely use PET-CT in follow-up; MRI instead of CT for under-25s and in pregnancy. NZ: MRI preferred for the brain; low-dose PET-CT does not exclude brain metastases.

FundingNZ funding position at October 2026 Schedule (verified 1 October 2026)

FundingPosition as at the October 2026 Pharmac Schedule, checked 1 October 2026. Funding and Special Authority criteria change often: check the current Schedule before acting on them.

The single reference for every funding statement in this document. Stage is AJCC 8th edition throughout. Every melanoma criterion excludes uveal melanoma; mucosal melanoma is not excluded.

SettingAgentFunded?Conditions
Resectable IIIB–IV, neoadjuvantNivolumab + ipilimumabYes, from 1 May 2026SA2643/SA2642. ECOG 0–2; no prior funded perioperative therapy; treatment before complete resection; maximum two cycles. Adjuvant nivolumab afterwards only “if required”, within 13 weeks of complete resection (or later if delay is necessary for post-surgery recovery), to 12 months total including the two neoadjuvant cycles.
Resectable IIIB–IV, neoadjuvantPembrolizumabYes, since 1 June 2025SA2631. Treatment before complete resection; monotherapy; 200 mg 3-weekly; 12 months total including neoadjuvant doses (18 cycles).
Resected IIIB–IV, adjuvantPembrolizumabYesSA2631. Start within 13 weeks of the most recent resection (primary or lymphadenectomy), unless delay is necessary for post-surgery recovery; ECOG 0–2; 12 months.
Resected IIIB–IV, adjuvant, BRAF-mutantDabrafenib + trametinibYesConfirmed BRAF mutation (NZ guideline and ESMO: V600E); within 13 weeks of resection, unless delay is necessary for post-surgery recovery; 12 months. Also fundable after neoadjuvant anti-PD-1 “if required” (confirm with Pharmac).
Resected IIB, IIC, IIIA, adjuvantAnyNoNo Special Authority indication; no open consultation found.
Unresectable / metastatic, first linePembrolizumab or nivolumab monotherapyYesECOG 0–2; baseline tumour burden documented. Re-use after perioperative anti-PD-1 only if no recurrence on treatment or within six months of finishing. Renewals beyond 24 months allowed for melanoma.
Unresectable / metastaticDabrafenib + trametinibYesFirst or second line; BRAF-mutant.
Unresectable / metastatic, including brain metastasesIpilimumab + nivolumabNoIpilimumab is funded only in the resectable neoadjuvant setting.
Unresectable / metastaticNivolumab + relatlimab; encorafenib + binimetinibNot listedNot on the Schedule.
Metastatic uvealTebentafuspNoNot Medsafe-approved; no application received (Pharmac, April 2026).
In-transit diseaseT-VECNot listedILI provided by Waitematā after other options (GPP 5.7.9).
Steroid-refractory immune toxicityInfliximab, tocilizumabYes, since 1 June 2025Abatacept via Rapid NPPA only.

Sources: Pharmac decisions 9 May 2025 (amended 1 July 2025)27 and 7 April 202637; Special Authority forms SA263126, SA264217, SA264318 (October 2026). Pharmac has said it will consider Special Authority waivers for system-caused delays in specified situations (people resected in the three months before 1 June 2025; adjuvant nivolumab after neoadjuvant therapy); apply through the waiver process24.

MDM listEight referrals, in the order they arrive

Each step reveals the next. The final step asks for the two-sentence directive.

Case 1 · GP referral, calf

Referral62-year-old woman. Excision biopsy calf: superficial spreading melanoma, Breslow 0.85 mm, no ulceration, margins clear, LVI absent, subtype stated. Mitotic rate: “not assessable”. Nodes impalpable. Fit.
Step 1
What is the T category and stage?
□ Guess   □ Fairly sure   □ Certain
✓ (a) Correct. Clinical staging applies until a sentinel node result exists.
✗ (b) Pathological IA needs a negative sentinel node; none has been done.
✗ (c) 0.85 mm is in the 0.8–1.0 mm band: T1b.

Case 2 · Plastics referral, back — theatre already booked

Referral48-year-old man. 4.4 mm ulcerated melanoma of the back excised 3 weeks ago (T4b). CT chest/abdomen/pelvis: two enlarged left axillary nodes, largest 22 mm. No other disease. No brain imaging yet. ECOG 0. Axillary dissection booked in 8 days.
Step 1
What is missing before a treatment decision?
□ Guess   □ Fairly sure   □ Certain
✓ (a) Correct. All four, and they can be done within the fortnight.
✗ (b) Sentinel node biopsy is not used when nodes are radiologically evident; sample the node directly.
✗ (c) Tissue confirmation, PET-CT and contrast MRI brain are required before neoadjuvant therapy (GPP 5.5.3).

Case 3 · Positive sentinel node, small deposit

Referral44-year-old man. Wide excision and SNB, shoulder. Primary 1.3 mm, not ulcerated, mitoses 2/mm². One sentinel node with a 0.9 mm subcapsular deposit; second node negative; no extranodal spread. ECOG 0.
Step 1
Stage?
□ Guess   □ Fairly sure   □ Certain
✗ (a) IIIC needs T3b/T4a with any N, or higher N burden.
✓ (b) Correct. T2a N1a.
✗ (c) IIIB would need a T2b or thicker primary, or a clinically detected node.

Case 4 · Head and neck primary with a neck node

Referral71-year-old man. 2.6 mm ulcerated melanoma of the right temple excised 4 weeks ago. Now a 2 cm right level II node, FNA positive. ECOG 1. Referred to this MDM.
Step 1
Where should this case be discussed?
□ Guess   □ Fairly sure   □ Certain
✗ (a) Any theatre booking before oncology input risks the neoadjuvant option.
✗ (b) This MDM takes most melanoma, but under the stated terms of reference head and neck melanoma with neck nodal involvement goes to the Head and Neck MDM.
✓ (c) Correct. Under the stated terms of reference, H&N melanoma with neck nodal involvement (parotid to supraclavicular) or stage III disease goes to the Head and Neck MDM; medical oncology must be at that discussion before a neck dissection date is set.

Case 5 · Melanoma in situ, nose

Referral79-year-old woman. Excision biopsy nasal sidewall: lentigo maligna (melanoma in situ), peripheral pathological margins 3 mm all round, clear cut. No residual pigment. Anticoagulated, mild dementia.
Step 1
What are the options the NZ guideline supports?
□ Guess   □ Fairly sure   □ Certain
✓ (a) Correct. GPP 5.1.13, 5.1.14, 5.1.8.
✗ (b) Off-label and reserved for lesions where surgery is not acceptable or feasible.
✗ (c) GPP 5.1.14 now allows acceptance of a 3 mm pathological margin after discussion.

Case 6 · Resected IIIC, referred late

Referral55-year-old woman. Groin dissection for a palpable node (T3a primary, thigh) done privately 10 weeks ago; no neoadjuvant therapy. Pathology: 2 of 12 nodes, extranodal spread. BRAF pending. No staging since surgery. ECOG 0.
Step 1
What is the funding situation?
□ Guess   □ Fairly sure   □ Certain
✗ (a) The disease has been resected; the neoadjuvant criterion cannot be met.
✓ (b) Correct. About 3 weeks remain; a later start is allowed only if the delay is necessary for post-surgery recovery.
✗ (c) The Special Authority allows 13 weeks from the dissection (longer only where delay is necessary for post-surgery recovery); the NZ 12-week target is a plan, not the funding rule.

Case 7 · Stage IV, BRAF wild-type

Referral63-year-old man. Prior IIIB melanoma, completed adjuvant pembrolizumab 14 months ago. Now lung and adrenal metastases, no brain disease, LDH normal, ECOG 0. BRAF wild-type.
Step 1
Which systemic options are publicly funded for him?
□ Guess   □ Fairly sure   □ Certain
✗ (a) BRAF wild-type.
✗ (b) ESMO-preferred, but ipilimumab is not funded for advanced disease.
✓ (c) Correct. The Special Authority allows re-use if there was no recurrence on treatment or within six months of finishing.

Case 8 · Solitary thin melanoma, nothing more needed

Referral38-year-old woman. Excision biopsy forearm: superficial spreading melanoma 0.5 mm, no ulceration, mitoses 0/mm², margins clear, complete report. Nodes impalpable. Wide excision 10 mm completed, histology clear. No family history; 30 naevi.
Step 1
Stage and node question?
□ Guess   □ Fairly sure   □ Certain
✓ (a) Correct. Under 0.8 mm, not ulcerated.
✗ (b) The rule applies from T1b; at T1a the tool’s validity is “less certain” and SNB is for a select group only.
✗ (c) Mitotic rate is not a T1 staging variable in AJCC 8.

NumbersThresholds that change a decision

Number
The T1a/T1b thickness line, below which a non-ulcerated melanoma is T1a: ___ mm
mm
□ Guess   □ Fairly sure   □ Certain
0.8 mm. Decides whether the nomogram rule applies (GPP 5.3.1).
Number
Under the NZ rule, SNB is not recommended when the MIA nomogram risk is below ___ %
%
□ Guess   □ Fairly sure   □ Certain
5%. Below it, not recommended; 5–10%, considered; above 10%, recommended.
Number
Wide excision margin for a 1.0 mm melanoma: ___ mm
mm
□ Guess   □ Fairly sure   □ Certain
10 mm for T1 (≤1.0 mm). GPP 5.1.13.
Number
A pathological margin of ___ mm on the excision biopsy of melanoma in situ may be accepted without further excision after discussion
mm
□ Guess   □ Fairly sure   □ Certain
3 mm. GPP 5.1.14; a clean margin is lower risk than one that petered out.
Number
Pharmac requires adjuvant therapy to start within ___ weeks of the most recent complete resection
weeks
□ Guess   □ Fairly sure   □ Certain
13 weeks (Special Authority), extendable where delay is necessary for post-surgery recovery; the NZ guideline plans for 12.
Number
Funded neoadjuvant nivolumab + ipilimumab: maximum ___ cycles before resection
cycles
□ Guess   □ Fairly sure   □ Certain
Two. Then surgery about 3 weeks after the last dose.
Number
Surgery after neoadjuvant immunotherapy is planned about ___ weeks after the last dose
weeks
□ Guess   □ Fairly sure   □ Certain
About 3 weeks (GPP 5.5.8).
Number
A sentinel node deposit over ___ mm is treated by the NZ guideline as possibly “radiologically evident” (IIIB or above)
mm
□ Guess   □ Fairly sure   □ Certain
5 mm (GPP 5.4.1). Not an AJCC 8 rule; the Special Authority uses AJCC 8.
Number
Without SNB, a T1b or thicker melanoma has ultrasound of the basin 6-monthly for ___ years
years
□ Guess   □ Fairly sure   □ Certain
2 years, with a baseline scan (GPP 5.3.11, 6.4.2).
Number
Major pathological response: ___ % or less viable tumour in the resected specimen
%
□ Guess   □ Fairly sure   □ Certain
10% (INMC). MPR after nivolumab + ipilimumab means no adjuvant therapy.
Number
Desmoplastic melanoma: radiotherapy is recommended where clinical margins are under ___ mm
mm
□ Guess   □ Fairly sure   □ Certain
8 mm (GPP 5.2.1). ESMO writes the same number as a pathological margin.
Number
The Faster Cancer Treatment target from referral to first treatment: ___ days
days
□ Guess   □ Fairly sure   □ Certain
62 days; melanoma in situ is excluded. First specialist assessment within 14 days.

Your answersCounts only

Answer key

GlossaryTerms used in this document

Breslow thickness
Depth from the granular layer to the deepest invasive cell, to 0.1 mm. The primary T-category variable.
CLND
Completion lymph node dissection after a positive sentinel node. No longer routine after MSLT-II.
ECOG
Performance status 0 (fully active) to 4. Pharmac melanoma criteria require ECOG 0–2.
FCT
Faster Cancer Treatment indicator: 62 days from referral to first treatment; excludes melanoma in situ.
ICI
Immune checkpoint inhibitor: anti-PD-1 (pembrolizumab, nivolumab) with or without anti-CTLA-4 (ipilimumab).
LVI
Lymphovascular invasion: tumour within lymphatic or vascular channels. A nomogram input (optional in the online tool).
MIA nomogram
Melanoma Institute Australia calculator at melanomarisk.org.au predicting sentinel node positivity from six inputs.
MPR
Major pathological response: 10% or less viable tumour in the resected specimen after neoadjuvant therapy (INMC definition).
NPPA
Named Patient Pharmaceutical Assessment: Pharmac’s individual funding route when Special Authority criteria are not met.
PDEMA
Peripheral and deep en face margin assessment (complete margin control), including Mohs and staged excision with en face sections.
RCPA protocol
Royal College of Pathologists of Australasia structured report for melanoma, reproduced as Appendix 3 of the NZ guideline; equivalent to the ICCR dataset.
SNB
Sentinel node biopsy: mapping and removing the first draining node(s). A staging operation, not a treatment.
Special Authority
Pharmac’s criteria-based funding approval. Criteria are literal; stage is defined by AJCC 8th edition.
deduction rule
Subtracting the pathological margin already achieved at biopsy from the planned clinical margin, where morbidity matters (GPP 5.1.7).
in-transit metastasis
Dermal or subcutaneous tumour more than 2 cm from the primary, before the regional nodes. Counts as N1c, N2c or N3c.
irAE
Immune-related adverse event. Endocrine irAEs (hypophysitis, adrenal insufficiency, thyroiditis) are often permanent.
mitotic rate
Mitoses per mm² in the dermal hot spot. Removed from AJCC 8 T1 staging; still a reporting item and a nomogram input.
ulceration
Full-thickness loss of epidermis over the tumour on histology, not a clinical impression and not biopsy artefact. Moves “a” to “b” within a T category.

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  51. Long GV, Atkinson V, Lo SN, Guminski AD, Sandhu SK, Brown MP, et al. Ipilimumab plus nivolumab versus nivolumab alone in patients with melanoma brain metastases (ABC): 7-year follow-up of a multicentre, open-label, randomised, phase 2 study. Lancet Oncol. 2025;26(3):320-330. PubMed DOI ABC
  52. Merck and Moderna Announce Phase 3 INTerpath-001 Trial of Intismeran Autogene Plus KEYTRUDA® Met Endpoints of Recurrence-Free Survival (RFS) and Distant Metastasis-Free Survival (DMFS) in Patients With Completely Resected Stage IIB-IV Melanoma. Merck & Co. and Moderna (press release). 2026. Available at: https://news.modernatx.com/merck-and-moderna-announce-phase-3-interpath-001-trial-of-intismeran-plus-keytruda-met-endpoints-of-rfs-and-dmfs-in-melanoma. INTerpath-001; press announcement 19 August 2026
  53. SACT Regimen Library. Te Aho o Te Kahu (ACT-NOW programme). 2026. Available at: https://srl.org.nz/.

Unresolved as of 1 October 2026. Whether NCCN V3.2026 changed any statement quoted here from V1.2026. The exact NADINA dose regimen adopted in the ACT-NOW library. Whether adjuvant dabrafenib + trametinib after neoadjuvant nivolumab + ipilimumab is accepted under the “PD-1/PD-L1 inhibitor” clause. Whether any Pharmac application is pending for stage IIB/IIC adjuvant therapy or for nivolumab + relatlimab.