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Mateusz Gładysz

Pathway read-through · Axillary and groin dissection

Axilla and groin: the dissection after neoadjuvant immunotherapy

Mateusz Gładysz · MD · FEBOPRAS · FEBHS

A read-through for a New Zealand regional melanoma and high-risk skin cancer MDM, for the registrar consenting and operating on a therapeutic nodal dissection and the consultant planning it. The core line carries the decisions; the closed panels carry the anatomy, the trial detail and the divergences.

Clinical content verified References checked 52 questions 6 MDM cases Version 1.1

All cases are constructed for teaching and describe no real patient. Clinical content verified 1 October 2026. Sources: NADINA (Blank, NEJM 2024; 2-year update ESMO 2025) · PRADO (Reijers, Nat Med 2022; 3-year Eur J Cancer 2025; 5-year Nat Med 2026) · Aotearoa NZ Melanoma Clinical Guidelines (4th edition, June 2026) · NCCN Cutaneous Melanoma V1.2026 (ME-G; all NCCN wording on this page is quoted from V1.2026, since superseded; later versions were not re-checked because NCCN guidelines need a login) · Cancer Council Australia melanoma guideline (MAGICapp, 2024) · ESMO (Ann Oncol 2025) · EADO 2024 · Spillane node-count standards (2009, 2011) · ANZMTG 01.02/TROG 02.01 · EAGLE FM · MSLT-3 and OMIT registrations.

Scope: therapeutic dissection of the axilla and groin for clinically or radiologically evident melanoma, with notes on nodal cSCC and Merkel cell carcinoma. The choice of systemic regimen, Special Authority wording and follow-up schedules are in the Melanoma read-through; neck dissection is not covered. In this read-through, the MDM’s terms of reference are assumed to send neck dissection and head and neck cSCC to a separate Head and Neck MDM; check your own MDM’s terms of reference.

Companion pages: Melanoma · cSCC · BCC Pathway Read-throughs

Skip to MDM casesVideos and links
SchemaMark the largest node before the first dose. At week 6 the index node carries the response; in New Zealand the whole basin still comes out until MSLT-3 reports.
Changes in practice since June 2024
  • June 2024 — NADINA presented at the ASCO plenary and published (Blank, NEJM 2024;391:16961): two doses of ipilimumab 80 mg + nivolumab 240 mg, TLND in week 6 for every patient, adjuvant therapy only without a major pathological response. 12-month EFS 83.7% vs 57.2%.
  • 1 June 2025 — Pharmac funds perioperative pembrolizumab and adjuvant dabrafenib + trametinib for resectable or resected stage IIIB–IV melanoma.
  • 1 October 2025 — MSLT-3 (NCT07049276), randomising index-node excision against TLND after neoadjuvant therapy, starts recruiting; no New Zealand site was listed on the registry at 1 October 2026.
  • October 2025 — ESMO 20252: NADINA 24-month EFS 77.3% vs 55.7%, HR 0.40. OMIT (NCT06754904, single arm, TLND omitted after MPR) recruiting in the Netherlands.
  • 28 January 2026 — PRADO 5-year results (Hoeijmakers, Nat Med 2026;32:9523): EFS 71%, OS 86%.
  • 2026 — NCCN Cutaneous Melanoma V1.2026: level III axillary dissection “has historically been recommended” but is untested with neoadjuvant or adjuvant therapy; pelvic dissection decided on imaging and by the MDT. INMC pathology protocol updated (Rawson, Ann Oncol 20264).
  • 1 May 2026 — Pharmac funds neoadjuvant nivolumab + ipilimumab (maximum two doses) for resectable stage IIIB–IV; adjuvant nivolumab afterwards only if required.
  • June 2026 — NZ Melanoma Clinical Guidelines 4th edition published; GPP 5.5.9 keeps “a full therapeutic nodal dissection of the involved lymph node basin” after neoadjuvant therapy, as in the consultation draft. Its GPP 5.5.5 still describes ipilimumab + nivolumab as “not funded”; Pharmac has funded the combination since 1 May 2026.

WorkupTherapeutic, completion or index node only: which operation is on the table?

Basics: four operations with similar names

Therapeutic lymph node dissection () clears a basin that holds clinically or radiologically evident melanoma: palpable, PET-positive or measurable on imaging, and confirmed by core biopsy or FNA. In NZ it follows neoadjuvant immunotherapy in suitable patients.

Completion lymph node dissection () clears a basin after a positive sentinel node when nothing is clinically evident. After MSLT-II and DeCOG-SLT it is no longer routine.

Index lymph node () excision removes only the node marked before neoadjuvant therapy. It is the PRADO operation and the experimental arm of MSLT-3.

Sentinel node biopsy stages a clinically node-negative basin. It is not a treatment for evident disease.

Case
Three patients reach a regional Melanoma & HRSC MDM. Which operation, and when?
□ Guess   □ Fairly sure   □ Certain
Neoadjuvant ICI, then TLND. Clinically detected, resectable stage III: the NZ default is ICI first (GPP 5.5.1).
Ultrasound surveillance. A small sentinel deposit from a T2a primary is observed with 6-monthly node-field ultrasound (NZ GPP 5.4.1).
Upfront TLND. Checkpoint inhibitors risk graft rejection; only patients who can safely receive ICI and surgery enter the neoadjuvant pathway (GPP 5.5.4).
How the disease was found decides the operation. Clinically or radiologically evident nodes go to neoadjuvant therapy and then a therapeutic dissection. A small sentinel-node deposit is watched. Upfront dissection is kept for patients who cannot safely have ICI.

Rule

A basin with clinically or radiologically evident melanoma is cleared therapeutically, and in suitable patients neoadjuvant immunotherapy comes first. A sentinel-node-positive basin is usually watched. Removing the index node alone is a trial operation in New Zealand, not a standard one.

An oncological therapeutic lymphadenectomy is offered to all patients with clinically or radiologically evident nodal disease after appropriate staging and discussion at a melanoma MDM. This should be preceded by neoadjuvant immunotherapy unless contraindicated.

Source: NZ Melanoma Clinical Guidelines5, 4th edition (June 2026), 5.4 Description and GPP 5.4.1–5.4.4, 5.5.1, 5.5.4. Faries MB et al., NEJM 20176 (MSLT-II); Leiter U et al., Lancet Oncol 20167 (DeCOG-SLT).

Rule

Clinically detected nodal disease is always stage IIIB or higher in AJCC 8 (N1b, N2b or N3b; even T0 N1b is IIIB), so every such patient meets the stage criterion for funded neoadjuvant therapy. What removes access is the order of events: the neoadjuvant Special Authorities require treatment before complete resection. An open excision biopsy or a dissection booked first closes the route.

Source: AJCC Cancer Staging Manual, 8th ed.; Pharmac SA26428/SA26439 and the pembrolizumab neoadjuvant criteria (SA2631; detail in the Melanoma Pathway Read-through), verified 2 October 2026 (October 2026 Schedule).

Worked case — 5 steps
Referral58-year-old woman. 3.5 cm left groin mass, 18 months after a 1.8 mm non-ulcerated calf melanoma with a negative sentinel node. GP ultrasound: two abnormal inguinal nodes. No biopsy yet.
  1. WorkupConfirm with an image-guided core biopsy, not an excision. A core gives the diagnosis and tissue for BRAF and leaves the node in place to be marked.GPP 5.5.3
  2. WorkupStage with PET-CT and contrast MRI brain; send BRAF on the core. Stage III needs BRAF status before the adjuvant decision.GPP 5.5.3
  3. GroinRecord the pelvis on the baseline PET-CT now. Pelvic uptake or biopsy-proven pelvic disease makes the later operation ilio-inguinal.GPP 5.4.10
  4. SequenceRefer to medical oncology before any theatre date; mark the largest node before dose 1. The marker lets the node be found and graded at week 6.GPP 5.5.6
  5. SequencePlan the groin dissection about three weeks after the last dose. Extent follows the baseline scan, not the restaging scan (this read-through’s reading of GPP 5.5.8–5.5.9, consistent with the S1801 design).GPP 5.5.8–5.5.9
What would change this? An open excision of the only abnormal node would leave nothing to treat before surgery. The neoadjuvant route would close, and the MDM question would become clearance of the basin plus adjuvant therapy.

Why?

Why is a palpable node confirmed by core biopsy rather than excised?

Show answer
Excision removes the disease the neoadjuvant drugs would act on, removes the node whose response would be graded, and scars the basin before the definitive dissection. A core gives the diagnosis and tissue for BRAF and leaves the index node in place to be marked.
Evidence and other guidelinesNCCN lists nodal recurrence as neoadjuvant

Neoadjuvant first. ESMO (Ann Oncol 2025): neoadjuvant nivolumab–ipilimumab followed by surgery “should be offered”, and neoadjuvant plus adjuvant pembrolizumab “is also recommended”. EADO 2024: neoadjuvant ipilimumab + nivolumab followed by complete resection “can be offered”. NCCN V1.2026 lists as candidates clinically evident resectable nodal disease, isolated resectable in-transit disease, resectable oligometastatic stage IV, and clinically evident recurrence in a basin after a formal dissection.

Cautions (NCCN). No proven overall survival benefit yet; radiological response does not always match pathology; progression or toxicity can prevent curative surgery. In NADINA 2.4% progressed before surgery; the NZ guideline quotes 2–8% across trials.

Completion dissection. ESMO: “CLND is not recommended for patients with a positive SLNB [I, E]”. The NZ guideline keeps it for MDM discussion when ultrasound follow-up is not possible or the balance between local control and the morbidity of surgery favours local control (GPP 5.4.2); its rationale adds that dissection for local control should be discussed when adjuvant immunotherapy is not an option.

WorkupThe index node: which one, marked with what, and when?

Basics: what the marker is for, and the options

The index lymph node is the largest involved node at baseline. It is marked under ultrasound before the first dose so that it can be found at surgery even after a complete clinical response, and so that the pathologist can identify it and report its response.

Markers in use: a metallic clip (needs its own localisation on the day: wire, seed or intraoperative ultrasound); a magnetic seed found with a handheld magnetometer (Sentimag); a radioactive iodine-125 seed found with a gamma probe (the technique from breast surgery, with radiation-safety handling); hydrogel and nitinol markers seen on ultrasound. In PRADO: magnetic seed 52%, nitinol 34%, I-125 9%, hydrogel 4%.

Case
Neoadjuvant nivolumab + ipilimumab planned; first dose next week.
Ultrasound shows three involved axillary nodes: 3.2 cm (level I), 1.8 cm (level II) and 1.1 cm (level I). Which should be marked before neoadjuvant therapy?
□ Guess   □ Fairly sure   □ Certain
✓ (a) Correct. The index node is the largest involved node; the concordance data were collected on that definition.
✗ (b) Level II is cleared in a TLND anyway. The marker is for response grading, not for completeness.
✗ (c) One marked dominant node is the protocol standard; more markers add localisation work without adding to response assessment.
✗ (d) Even with a full dissection the pathologist needs the marker to find and grade the index node, and the surgeon needs it after a complete clinical response.
Mark the largest involved node, once, before dose 1. It is the deposit most likely to hold residual tumour, and its response represents the basin in 99% of cases.

Rule

Mark the largest involved node (and any in-transit deposit) under ultrasound before the first dose. Record the marker type and position in the MDM outcome so theatre and pathology know what to look for.

Pre-operative marking of the index lymph node (largest involved node) or in-transit disease should be performed to allow accurate identification during surgery and to guide targeted pathological analysis of site of disease that was dominant prior to commencing neoadjuvant ICI therapy.

Source: NZ Melanoma Clinical Guidelines5, 4th edition (June 2026), GPP 5.5.6. Marker proportions: PRADO (Reijers, Nat Med 202210), as reported by BJS Academy (Dedeilia & Boland, 202211).

Rule

The index node represents the basin. In 82 patients from OpACIN and OpACIN-neo its response matched the whole TLND specimen in 81 (99%) and every individual node in 79 (96%). The clinically important discordance is residual tumour outside a responding index node: in NeoACTIVATE arm C, 2 of 30 patients had a pCR in the index node but disease in other nodes (false-negative rate 13.3%); in the OpACIN cohorts two patients had an 80%-viable non-index node despite a partial response in the index node.

Source: Reijers ILM et al., JAMA Surg 2022;157:33512; Hieken TJ et al., Ann Surg Oncol 202613 (NeoACTIVATE arm C: false-negative rate of an index-node pCR 13.3%).

Timeline in weeks from the first dose. Before week 0: core biopsy, PET-CT, MRI brain and BRAF. Week 0: the index node is marked and dose 1 is given. Week 3: dose 2. About week 5: restaging PET-CT or CT. Week 6: therapeutic lymph node dissection, removing the marked index node first, about three weeks after dose 2. Weeks 7 to 8: pathology grades the response by INMC criteria and sets the adjuvant plan. In NADINA the median time from first dose to surgery was 45 days. Nivolumab + ipilimumab × 2: the surgeon’s calendar Wk 012Wk 34Wk 5Wk 678 after core, PET-CT, MRI brain, BRAF Index node marked Dose 1 Dose 2 Restage (PET-CT/CT) TLND, index node first ≈3 weeks after dose 2 Pathology: INMC grade sets the adjuvant plan NADINA planned surgery for week 6; median 45 days (IQR 42–49) from the first dose. NZ GPP 5.5.7–5.5.8: restage before surgery; operate about three weeks after the last dose. Nivolumab + ipilimumab × 2: the surgeon’s calendar Wk 0 1 2 Wk 3 4 Wk 5 Wk 6 7 8 after core, PET-CT, MRI brain, BRAF Index node marked Dose 1 Dose 2 Restage (PET-CT/CT) TLND, index node first ≈3 weeks after dose 2 Pathology: INMC grade sets the adjuvant plan NADINA planned surgery for week 6; median 45 days (IQR 42–49) from the first dose. NZ GPP 5.5.7–5.5.8: restage before surgery; operate about three weeks after the last dose.
The marker goes in before dose 1; the operation sits three weeks after dose 2.
MarkerFound at surgery withPractical points
ClipSeparate localisation (wire, seed or ultrasound)Cheap and widely stocked; the commonest choice in an international survey (30%).
Magnetic seedMagnetometer probe (Sentimag)No radiation; metal instruments disturb the probe, so polymer instruments help. Magseed in melanoma: localised 20/20, in the specimen 19/20.
I-125 seed (MARI)Gamma probeRadiation licensing, storage and tracking of the seed.
Hydrogel, nitinolUltrasoundDepends on intraoperative ultrasound.

Sources: Schermers B et al., BJS 2019;106:51914 (MeMaLoc); Krabbe et al., EJSO 2026;52:11194715; Novis et al., Ann Surg Oncol 2026;33:257116 (survey, full text: clip 30%, magnetic seed 17%, radioactive seed 14%); Donker M et al., Ann Surg 201517 (MARI).

Worked case — 5 steps
ReferralNeoadjuvant nivolumab + ipilimumab planned for a 2.8 cm left axillary node. Oncology clinic tomorrow; first dose next week. No marker requested.
  1. WorkupRequest ultrasound-guided marking of the largest node before dose 1. After the first dose the chance to mark the baseline index node is lost.GPP 5.5.6
  2. WorkupUse the marker that the local service can localise in theatre. Record the type and position in the MDM outcome.
  3. SequenceRestage before surgery. PET-CT or contrast CT looks for progression.GPP 5.5.7
  4. AxillaAt week 6, find and remove the index node first, label it separately, then complete levels I–III. The OpACIN-neo approach: index node as specimen A.
  5. AftercareTell the pathologist: neoadjuvant therapy given, marker type, index node labelled. INMC sampling and grading follow.GPP 3.3.7
What would change this? A complete clinical response by week 6 does not change the operation in New Zealand. It is the case in which an unmarked index node is hardest to find.

Why?

Why is the index node defined as the largest node rather than the most accessible one?

Show answer
The largest deposit carries the most tumour and is the one most likely to hold residual viable tumour. If it has a major pathological response, the smaller deposits almost always have too, and the concordance data were collected on that definition. A small node chosen for convenience could overstate the response.
Evidence and other guidelinesNCCN: index-node surgery still investigational

NCCN V1.2026 (ME-G) notes that clinical trials are evaluating response-directed treatment after resection of the index node, and footnotes that studies are ongoing to determine whether index-node removal or a limited dissection could replace TLND after a major pathological response.

INMC. The 2018 pathology consensus (Tetzlaff, Ann Oncol 201818) recommends a clip at the diagnostic biopsy. The 2026 update (Rawson, Ann Oncol 2026;37:2064) examines nodes ≤3 cm in their entirety and at least a full transverse slice of larger involved nodes.

Practice survey (Novis, Ann Surg Oncol 2026): 74% regard neoadjuvant therapy as standard; 27% think the data are enough to adopt index-node-guided surgery.

SequenceNADINA: what the protocol asked of the surgeon

Basics: the NADINA design in one paragraph

Phase 3, 423 patients, resectable macroscopic stage III melanoma: at least one pathologically proven node that was palpable, PET-positive or measurable on imaging, and up to three in-transit metastases. Neoadjuvant arm: ipilimumab 80 mg + nivolumab 240 mg, two doses three weeks apart, then TLND (and resection of in-transit disease) in week 6. A major pathological response (, ≤10% viable tumour) received no further treatment; partial or non-response received dabrafenib + trametinib for 46 weeks if BRAF V600E/K, otherwise 11 more cycles of nivolumab. Adjuvant arm: TLND, then 12 cycles of nivolumab. Primary endpoint: event-free survival ().

Case
Three patients in the NADINA neoadjuvant arm after the week-6 TLND. What does the protocol give next?
□ Guess   □ Fairly sure   □ Certain
No adjuvant therapy. MPR, whatever the BRAF status.
Adjuvant nivolumab, 11 cycles every 4 weeks.
Dabrafenib + trametinib for 46 weeks: BRAF V600E or V600K without MPR.
NADINA put the surgical specimen in charge of the adjuvant plan. MPR (≤10% viable) stops treatment; any lesser response gets adjuvant therapy chosen by BRAF status. Radiotherapy was allowed except after MPR.

Rule

Every NADINA patient had a therapeutic dissection, whatever the response: 197 TLNDs and one index-node procedure in the neoadjuvant arm, 207 TLNDs in the adjuvant arm. NADINA answered a question about drug sequence. It did not test less surgery.

therapeutic lymph-node dissection and, if applicable, resection of the in-transit metastases in week 6

Source: Blank CU et al., N Engl J Med 2024;391:16961 (methods and results; the procedure counts are from the supplementary appendix as extracted).

Rule

Surgery ran to time and was no more dangerous after immunotherapy. Median 45 days from the first dose to surgery; 81.8% within a week of schedule. Five patients progressed and three had toxicity that prevented surgery. Median node yield 18 (neoadjuvant) vs 17 (upfront). Grade ≥3 surgery-related adverse events 14.1% vs 14.4%. The basins (supplementary Table 1): axilla 40.8%, groin 31.3%, neck about a quarter.

Source: Blank CU et al., NEJM 2024;391:16961 and supplementary Table 1 as extracted; 2-year update Lucas MW, ESMO 2025 LBA572 (surgery-related AEs any grade 75.9% vs 81.2%; ESMO 2025 presentation, not in the printed abstract).

A single bar representing the 212 patients in the neoadjuvant arm. Pathological complete response 47.2 percent and near-complete response 11.8 percent together make the major pathological response of 59.0 percent, which received no adjuvant therapy. Partial response 8.0 percent. Non-response 26.4 percent. Progression before surgery 2.4 percent and surgery not yet performed or omitted 4.2 percent. Two-year relapse-free survival by category, from the ESMO 2025 presentation: pCR 95.1 percent, near-pCR 81.2 percent, partial response 69.4 percent, non-response 48.4 percent. NADINA neoadjuvant arm (n = 212): response on the week-6 specimen MPR 59.0% → no adjuvant therapy pCR 47.2% near-pCR 11.8% pPR 8.0% pNR 26.4% no surgery 6.6% 2-year RFS 95.1%81.2%69.4%48.4% Response by INMC criteria. RFS from the ESMO 2025 presentation (median follow-up 25.2 months). NADINA neoadjuvant arm (n = 212): response on the week-6 specimen MPR 59.0% → no adjuvant therapy 2-year RFS pCR 47.2% 95.1% near-pCR 11.8% 81.2% pPR 8.0% 69.4% pNR 26.4% 48.4% no surgery 6.6% Response by INMC criteria. RFS from the ESMO 2025 presentation (median follow-up 25.2 months).
The specimen sorts the patients: MPR stops treatment; everyone else goes on to adjuvant therapy.
Neoadjuvant armipi + nivo × 2, TLND week 6Adjuvant armTLND, then nivolumab × 12
Before surgeryTwo doses of ipilimumab + nivolumabNothing
OperationTLND (in-transit disease resected)TLND
Median nodes removed1817
Grade ≥3 surgery-related AEs14.1%14.4%
Adjuvant therapyOnly without MPR, by BRAFNivolumab for all
12-month EFS83.7%57.2%
Check
Which row shows that neoadjuvant therapy did not make the dissection more hazardous?
□ Guess   □ Fairly sure   □ Certain
✓ (a) Correct. 14.1% vs 14.4%.
✗ (b) That is the oncological benefit, not the surgical risk.
✗ (c) That is what the specimen decides after surgery.
Worked case — 5 steps
ReferralWeek 6 after two doses of ipilimumab 80 mg + nivolumab 240 mg. Left inguinal TLND done. Pathology: index node 0% viable tumour with fibrosis and melanophages; 0 of 14 other nodes with viable tumour. BRAF V600E.
  1. AftercarePathological complete response: an MPR. INMC grading on the whole specimen.
  2. AftercareNo adjuvant systemic therapy. NADINA; NZ GPP 5.5.12.GPP 5.5.12
  3. AftercareNo radiotherapy. NADINA excluded MPR from radiotherapy; NZ considers it only after non-response.GPP 5.5.14
  4. AftercareStage III surveillance with imaging. Schedule in the Melanoma Pathway Read-through.
  5. AftercareLymphoedema therapist review. Groin dissection: quote 20–30%.GPP 5.4.13
What would change this? A specimen with 30% viable tumour (pPR) would open adjuvant therapy: dabrafenib + trametinib in NADINA for BRAF V600E, whereas the NZ guideline says adjuvant immunotherapy should be offered after pPR.

Why?

Why did NADINA keep the full dissection in both arms?

Show answer
It was testing when to give the drugs, so the operation had to be the same in both arms; changing the surgery as well would have made any EFS difference uninterpretable. The full specimen also produced the response grade that drove the adjuvant plan. Whether the dissection itself can be dropped is a separate question, which MSLT-3 is now asking.
Evidence and other guidelinesNADINA ≠ NZ on pPR in BRAF-mutant disease

Updates. ESMO 202419 (18 months; as presented, reported in The ASCO Post): EFS 80.8% vs 53.9%. ESMO 2025 (median follow-up 25.2 months): 24-month EFS 77.3% vs 55.7%, HR 0.40 (95% CI 0.28–0.57); DMFS 82.8% vs 63.9%. Overall survival not yet reported. Grade ≥3 systemic AEs 31.1% vs 15.9%.

Quality of life. Blank (ASCO Post, 202420): “The major quality of life impairment came from the surgery.” This is the argument for testing less surgery, not evidence that less surgery is safe.

SWOG S1801 (Patel, NEJM 202321): pembrolizumab × 3, then surgery whose “type and extent … were prespecified” and done “regardless of radiologic response”; surgery-related grade 3–4 AEs 7% vs 4%; 2-year EFS 72% vs 49%.

OpACIN-neo surgical outcomes (NKI, Zijlker, EJC 202322): complications 31.8% after neoadjuvant therapy vs 36.8% upfront; lymphoedema 22.7% vs 13.2%.

Toxicity before surgery. NZ 5.5 rationale, after van Akkooi et al., Ann Surg Oncol 202223 (INMC surgical considerations): check endocrine, liver and cardiac function before surgery, and postpone patients needing steroids until the adverse event is improving to grade 1.

Not published in the main paper: how NADINA defined the extent of dissection in each basin (axillary levels, when the pelvis was cleared). The supplementary protocol was not accessible for this document.

SequencePRADO: stop at the index node?

Basics: what PRADO did, and why it is older than it looks

PRADO was the extension cohort of the OpACIN-neo trial: 99 patients with clinical stage IIIB–D nodal melanoma, ipilimumab 1 mg/kg + nivolumab 3 mg/kg for two doses, the index node marked at baseline and excised at week 6. The index-node response decided everything after it. It was published in 2022, before NADINA; what is new is the 5-year follow-up (January 2026) and the randomised trial it led to, MSLT-3.

Case
Three index-node results at week 6 in PRADO. What followed for each?
□ Guess   □ Fairly sure   □ Certain
No TLND, no adjuvant therapy: MPR.
TLND only: pPR, >10 to ≤50%.
TLND plus adjuvant systemic therapy, ± synchronous radiotherapy: pNR.
PRADO had three tiers set at 10% and 50% viable tumour in the index node. Only MPR skipped the dissection; pPR had the dissection without adjuvant therapy; pNR had both.

Rule

PRADO showed that stopping at the index node is feasible: index-node MPR 61%; TLND omitted in 59 of 60; 2-year RFS 93% (MPR), 64% (pPR), 71% (pNR); DMFS 98%, 64%, 76%. Omitting the dissection cut surgery-related adverse events from 84% to 46% and lymphoedema from 39% to 5%, with better physical and role functioning, less fatigue and less pain.

TLND was omitted in 59 of 60 patients with MPR, resulting in significantly lower surgical morbidity and better quality of life

Source: Reijers ILM et al., Nat Med 2022;28:117810. Surgery-related adverse events (46% vs 84%) as reported by van Akkooi in the SSO Great Debate (Ann Surg Oncol 2025)24 and BJS Academy (2022)11; lymphoedema (5% vs 39%) from the SSO Great Debate.

Rule

Five years on: EFS 71%, RFS 74%, DMFS 79%, OS 86% for all 99 patients. In the MPR group 6 of 60 recurred; four were local or regional recurrences within 20 months and were treated with surgery plus systemic therapy. The design is a single-arm phase 2 cohort. It shows the strategy is feasible and that nodal recurrences after omission can often be salvaged; it does not show that omission is non-inferior to dissection. That is MSLT-3’s question.

Source: Hoeijmakers LL et al., Nat Med 2026;32:9523 (5-year abstract); recurrence detail from the Research Square preprint (July 2025)25. MSLT-3: NCT0704927626.

New Zealand position

Not standard. GPP 5.5.9: “Surgery should involve a full therapeutic nodal dissection of the involved lymph node basin, or complete resection of the in-transit disease.” The NZ guideline names MSLT-3 as the trial that will decide; no NZ site was listed on the registry at 1 October 2026. Offer the trial where it is open, not the omission.

At week 6 the marked index node is excised. If it shows a major pathological response, 10 percent or less viable tumour, seen in 61 percent, no dissection and no adjuvant therapy follow; 2-year relapse-free survival 93 percent. Partial response, more than 10 up to 50 percent viable: dissection only; 2-year RFS 64 percent. Non-response, more than 50 percent viable: dissection plus adjuvant systemic therapy with or without radiotherapy; 2-year RFS 71 percent. The dissection was omitted in 59 of 60 patients with MPR. Surgery-related adverse events 46 percent with index node only versus 84 percent with dissection; lymphoedema 5 versus 39 percent. Week 6: excise the marked index node PRADO, ipilimumab 1 mg/kg + nivolumab 3 mg/kg × 2 MPR: ≤10% viable61% of 99No TLND, no adjuvant2-year RFS 93% pPR: >10–50% viableTLND only2-year RFS 64% pNR: >50% viableTLND + adjuvant ± RT2-year RFS 71% TLND omitted in 59 of 60 MPR patients. Surgery-related AEs 46% (index node only) vs 84% (with TLND); lymphoedema 5% vs 39%. 5-year (Nat Med 2026): EFS 71%, OS 86% for all 99 patients. Single-arm phase 2. Not NZ standard: GPP 5.5.9 requires full TLND; MSLT-3 randomises index node vs TLND. Week 6: excise the marked index node PRADO, ipilimumab 1 mg/kg + nivolumab 3 mg/kg × 2 MPR: ≤10% viable 61% of 99 No TLND, no adjuvant 2-year RFS 93% pPR: >10–50% viable TLND only 2-year RFS 64% pNR: >50% viable TLND + adjuvant ± RT 2-year RFS 71% TLND omitted in 59 of 60 MPR patients. Surgery-related AEs 46% (index node only) vs 84% (with TLND); lymphoedema 5% vs 39%. 5-year (Nat Med 2026): EFS 71%, OS 86% for all 99 patients. Single-arm phase 2. Not NZ standard: GPP 5.5.9 requires full TLND; MSLT-3 randomises index node vs TLND.
PRADO used the index node to decide both the surgery and the adjuvant therapy.
NADINArandomised phase 3, n = 423PRADOsingle-arm phase 2, n = 99
Neoadjuvant drugsipi 80 mg + nivo 240 mg × 2ipi 1 mg/kg + nivo 3 mg/kg × 2
Operation at week 6TLND for everyoneIndex node for everyone; TLND only without MPR
After MPRBasin already cleared; no adjuvantNo TLND; no adjuvant
After pPRAdjuvant by BRAF statusTLND; no adjuvant
After pNRAdjuvant by BRAF ± RTTLND + adjuvant ± RT
DesignRandomised against upfront surgeryNo comparison arm for the surgery
Check
Which row explains why PRADO has not changed the NZ standard?
□ Guess   □ Fairly sure   □ Certain
✗ (a) The two doses are close to equivalent for an 80 kg adult.
✗ (b) Both do a dissection plus adjuvant therapy.
✓ (c) Correct. The omission of TLND has never been compared with TLND in a randomised trial.

Why?

Why might omitting the TLND after MPR be worth a small risk of regional recurrence?

Show answer
The morbidity difference is large (lymphoedema 5% vs 39%; surgery-related AEs 46% vs 84%) and lifelong, while regional recurrences after MPR were few and mostly salvageable by delayed dissection. The size of that regional risk, and how often salvage succeeds, is unknown without a randomised comparison, which is the trade MSLT-3 measures.
Evidence and other guidelinesSurvey: 27% would adopt index-node surgery now

3-year comparison with OpACIN-neo (Eur J Cancer 2025;214:11514127, post hoc): after MPR, 3-year RFS 93% without TLND vs 96% with (p = 0.47); DMFS 98% vs 96%. After pNR, 3-year RFS 64% with adjuvant systemic therapy vs 35% without (p = 0.10).

Regional recurrence. At about 28 months, 4 of the 60 MPR patients without TLND had recurred; 3 were in the basin and managed by delayed TLND (Novis survey16, full text, citing PRADO). In the SSO Great Debate, Ariyan puts nodal recurrence after index-node-only surgery at 7% and argues that the co-primary endpoint was not met.

Trials. MSLT-3 (NCT07049276, Melanoma Institute Australia): randomised index-node excision vs TLND after neoadjuvant therapy, non-inferiority on 2-year RFS; recruiting since 1 October 2025, with no NZ site listed on the registry at 1 October 2026; primary result expected around 2030. OMIT (NCT06754904, Erasmus MC): single-arm phase 2, n = 213, TLND omitted after index-node MPR; recruiting.

Guidelines. ESMO (Ann Oncol 2025) recommends neoadjuvant therapy but does not specify the extent of surgery. EADO 2024 describes PRADO without a graded recommendation. NCCN V1.2026: “Randomized studies are planned to assess whether TLND can be safely omitted.”

AxillaTherapeutic axillary dissection: levels I–III, and what stays

Basics: the walls, the levels and the nerves

Walls. Apex: clavicle, first rib and upper border of the scapula. Medial: serratus anterior on the chest wall. Anterior: pectoralis major and minor. Posterior: subscapularis, teres major and latissimus dorsi. Lateral: the intertubercular groove, coracobrachialis and biceps. The axillary vein is the superior limit of the dissection.

Levels are defined by pectoralis minor: level I lateral to or below it, level II behind it, level III medial to or above it, up to the apex.

Nerves. The long thoracic nerve runs on serratus anterior (injury: winging of the scapula). The thoracodorsal nerve and vessels run on subscapularis to latissimus dorsi. The pectoral nerves are named for their cords, not their position: the medial pectoral nerve runs lateral, through or around pectoralis minor; the lateral pectoral nerve runs medial, with the thoracoacromial vessels, to pectoralis major. The crosses the axilla to the upper inner arm.

Case
Structures met in a level I–III therapeutic axillary dissection for melanoma. What is the default for each?
□ Guess   □ Fairly sure   □ Certain
Preserve: injury wings the scapula.
Usually divided; the patient is warned about numbness of the upper inner arm.
Retracted, divided or removed as needed to clear level III (CCA: the level 1–3 lymphadenectomy “may include resection of the pectoralis minor muscle”).
Motor nerves and the vein stay unless tumour involves them. The intercostobrachial nerve usually goes. Pectoralis minor is the door to level III: retract it if you can, divide or remove it if you must.

Rule

For clinically evident melanoma the axillary TLND clears levels I, II and III. Level III needs pectoralis minor retracted, divided or removed. The long thoracic nerve, thoracodorsal bundle and axillary vein are preserved unless involved; the intercostobrachial nerve is usually divided.

A therapeutic axillary lymphadenectomy includes levels I–III.

Source: NZ Melanoma Clinical Guidelines5, 4th edition (June 2026), GPP 5.4.8. Cancer Council Australia melanoma guideline28 (MAGICapp; numbered 12.3.2 in the former wiki version): “complete level 1-3 lymphadenectomy which may include resection of the pectoralis minor muscle … intercosto-brachial nerve(s) and usually medial pectoral nerve dependent on the extent of disease and body habitus.”

Rule

Level III is where palpable disease hides. With palpable axillary melanoma, level III nodes were involved in 16.9% (0% after a positive sentinel node), and level III involvement carried worse survival. NCCN V1.2026 notes that the need for level III has not been re-tested with neoadjuvant or adjuvant therapy; a 2024 series found level III positive in 7.3%, with more treatment necrosis in levels I–II than in level III.

Source: Mahvi et al., Ann Surg Oncol 201929 (n = 71 palpable); Parker et al., J Surg Oncol 202430 (Moffitt, n = 95); NCCN Cutaneous Melanoma V1.2026, ME-G.

Rule

Count the nodes and name the boundaries. Axillary dissections should reach at least 10 nodes with a mean of 21. The operation note states the anatomical boundaries and the levels removed; mark the apex for the pathologist.

Source: Spillane AJ et al., Ann Surg 2009;249:47331 (quality standards); NZ Melanoma Clinical Guidelines5, 4th edition (June 2026), GPP 5.4.6; NCCN V1.2026 ME-G footnote: anatomic boundaries described in the operative report.

Schematic strip of the axilla from the apex on the left to the lateral border on the right, under the axillary vein, which is the superior limit. Level III lies medial to pectoralis minor and runs up to the apex at the costoclavicular ligament. Level II lies behind pectoralis minor. Level I lies lateral to pectoralis minor, out to latissimus dorsi. The long thoracic nerve runs on serratus anterior on the medial wall and is preserved. The thoracodorsal bundle runs on subscapularis to latissimus dorsi and is preserved. The intercostobrachial nerve crosses levels I and II to the upper inner arm and is usually divided. Levels are named by their relation to pectoralis minor Axillary vein: superior limit Level IIImedial to pec minorup to the apex PectoralisminorLevel IIbehind it Level Ilateral to pec minorout to latissimus Apex: costoclavicular (Halsted’s) ligament Latissimus dorsi: lateral limit Long thoracic nerve, on serratus anterior (medial wall): preserve Thoracodorsal bundle, on subscapularis to latissimus: preserve Intercostobrachial nerve, across levels I–II to the inner arm: usually divided Levels are named by their relation to pectoralis minor Axillary vein: superior limit Level III medial to pec minor up to the apex Pectoralis minor Level II behind it Level I lateral to pec minor out to latissimus Apex: costoclavicular (Halsted’s) ligament Latissimus dorsi: lateral limit Long thoracic nerve, on serratus anterior (medial wall): preserve Thoracodorsal bundle, on subscapularis to latissimus: preserve Intercostobrachial nerve, across levels I–II to the inner arm: usually divided
Schematic, not to scale: the strip runs from the apex (left) to the lateral border (right). A melanoma TLND clears all three levels.
Worked case — 5 steps
Referral52-year-old man. Right axillary TLND at week 6 after nivolumab + ipilimumab; magnetic seed in the 3 cm level I index node. Restaging clear.
  1. AxillaConsent for numbness, seroma and drain, wound infection, shoulder stiffness, lymphoedema about 1 in 10, and winging if the long thoracic nerve is injured. MIA consent figures.
  2. AxillaLocalise the seed; remove the index node first and label it separately. Specimen X-ray confirms the seed.
  3. AxillaDefine the axillary vein superiorly and latissimus laterally; keep the thoracodorsal bundle and the long thoracic nerve in view. Clear levels I and II en bloc.
  4. AxillaRetract or divide pectoralis minor and clear level III to the apex; mark the apex with a suture. GPP 5.4.8.
  5. AftercareDrain; operation note with boundaries, levels and specimen orientation. Expect at least 10 nodes.GPP 5.4.6
What would change this? If level III disease is fixed to the vein or plexus, the margin there is the limit of the resection. Record it: an involved or close margin and extranodal extension are radiotherapy questions.

Why?

Why is level III routinely cleared for melanoma when a breast axillary dissection usually stops at level II?

Show answer
Palpable melanoma nodes extend to level III in about one in six patients, and apical recurrence against the vein and plexus is hard to salvage. Breast axillary dissection is usually done for lower-volume disease in a disease where radiotherapy routinely covers the undissected apex and supraclavicular field. The breast atlas rule, levels I–II unless level III is palpable, does not transfer.
Evidence and other guidelinesNCCN: level III untested with neoadjuvant therapy

NCCN V1.2026 (ME-G): for clinically involved axillary disease, dissection of levels I–III “has historically been recommended”, but the need for level III “has not been formally evaluated” with neoadjuvant or adjuvant approaches. An anatomically complete dissection of the involved basin is required, with boundaries in the operation note.

Breast practice (VUMC Open Manual, Bird): “If there is no grossly palpable disease in Level III, an axillary dissection should only include Levels I and II.” Useful for technique, not for extent in melanoma.

Node counts. Spillane 2009: axilla mean 21.9, median 21; 90% of dissections had ≥10 nodes. Validated at MIA (Read, EJSO 201532): counts fell below the standard in 4 of 409 self-reported dissections.

Lymphoedema after axillary surgery. MIA consent information: about 10%. Queensland series (Theodore 201733): moderate–severe lymphoedema 8% after axillary CLND. Prospective perometry (Hyngstrom 201334): 13% had a limb volume change over 10% at 12 months.

GroinGroin: inguinal, or ilio-inguinal?

Basics: the femoral triangle, Cloquet’s node and the pelvis

Femoral triangle. Superior: inguinal ligament. Lateral: medial border of sartorius. Medial: medial border of adductor longus. Floor: iliopsoas, pectineus, adductor longus. Roof: fascia lata with the cribriform fascia.

Inguinal (superficial and deep inguinal, “inguinofemoral”) dissection removes the fat and nodes of the triangle, skeletonising the femoral vessels, with the pudendal nodes and the nodes on the external oblique aponeurosis (the Emory template: about 5 cm above the ligament), and from the femoral canal, medial to the femoral vein under the inguinal ligament.

Ilio-inguinal dissection adds the external iliac and obturator nodes through an extraperitoneal approach, from at least the common iliac bifurcation to the inguinal ligament, skeletonising the iliac vessels and the obturator nerve.

Case
Three groin patients after neoadjuvant therapy. Which dissection does the NZ guideline point to?
□ Guess   □ Fairly sure   □ Certain
Ilio-inguinal. PET-CT-positive pelvic nodes (NZ GPP 5.4.10).
Inguinal. Nothing in the pelvis on imaging.
Either. NZ reserves the pelvis for imaging or biopsy evidence; CCA allows it for extensive inguinal disease; NCCN says bulky inguinal disease raises the risk of occult pelvic nodes and leaves the decision to imaging and the MDT.
Imaging decides the pelvis. NZ reserves ilio-inguinal dissection for PET-positive or biopsy-proven pelvic disease, or an iliac second-tier node after a positive SNB. NCCN and CCA agree on imaging but leave room for extensive inguinal disease. Cloquet’s node alone is a weak guide.

Rule

The inguinal dissection skeletonises the femoral vessels and removes the pudendal nodes, the nodes on the external oblique and Cloquet’s node. The pelvis is added for PET-positive or biopsy-proven pelvic disease, or when an iliac node is the second-tier node of a positive sentinel node that is not being observed.

A therapeutic inguinal lymphadenectomy involves skeletonisation of the femoral vessels and removal of pudendal nodes, nodes anterior to the external oblique and Cloquet’s nodes in the femoral canal. … An ilioinguinal node dissection is performed for PET-CT positive or for biopsy-proven melanoma metastases in inguinal and pelvic nodes in the absence of distant disease.

Source: NZ Melanoma Clinical Guidelines5, 4th edition (June 2026), GPP 5.4.9–5.4.10.

Rule

Imaging decides, and imaging misses. The NZ guideline quotes pelvic node involvement in 30–39% of ilio-inguinal dissections for macroscopic disease and 9.3% after a positive sentinel node only; in Spillane 2011 the 39% covered all ilio-inguinal dissections. PET-CT for pelvic nodes: sensitivity 25%, specificity 95.6%, NPV 87.8% (EAGLE FM substudy). Cloquet’s node picks up about half of pelvic disease (sensitivity 54%); CCA calls intraoperative assessment by Cloquet’s node “unreliable”.

Source: Spillane AJ et al., Ann Surg Oncol 201135; Russell M et al. (EAGLE FM PET/CT substudy), EJSO 2026;52:11116336; Strobbe et al., Ann Surg Oncol 200137; NZ 5.4 rationale; CCA melanoma guideline28 (MAGICapp; 12.3.3 in the former wiki numbering).

Rule

Node counts: inguinal and ilio-inguinal dissections should reach a minimum of 7 nodes with a mean of 14 (Spillane 2009). Split by extent (Spillane 2011): inguinal median 11, 90% with ≥8; ilio-inguinal median 21.5, 90% with ≥14. Plan the extent from the baseline scan: a pelvic node that shrinks on restaging still gets cleared.

Source: Spillane AJ et al., Ann Surg 2009;249:47331 and Ann Surg Oncol 201135; SWOG S180121 (surgery prespecified and done “regardless of radiologic response”); NZ GPP 5.5.9.

Decision diagram. A groin node confirmed on core biopsy with a baseline PET-CT. If pelvic nodes are PET-positive or biopsy-proven, perform an ilio-inguinal dissection, adding external iliac and obturator nodes up to the common iliac bifurcation. If there is no pelvic disease on PET-CT, perform an inguinal dissection, skeletonising the femoral vessels and removing the pudendal nodes, the nodes on the external oblique and Cloquet's node. Also ilio-inguinal in New Zealand: an iliac second-tier node after a positive sentinel node biopsy that is not being observed. For extensive inguinal disease the Cancer Council Australia guideline allows ilio-inguinal dissection; NCCN leaves it to imaging and the multidisciplinary team. Groin node confirmed on core biopsy baseline PET-CT read for the pelvis Pelvic nodes PET-positive or biopsy-proven No pelvic disease on PET-CT Ilio-inguinal dissection + external iliac and obturator nodes, to the common iliac bifurcation Inguinal dissection femoral vessels skeletonised; pudendal, external oblique and Cloquet’s nodes Also ilio-inguinal (NZ): an iliac second-tier node after a positive SNB that is not being observed. Extensive inguinal disease: CCA allows ilio-inguinal; NCCN leaves it to imaging and the MDT. Groin node confirmed on core biopsy baseline PET-CT read for the pelvis Pelvic nodes PET-positive or biopsy-proven Ilio-inguinal dissection + external iliac and obturator nodes, to the common iliac bifurcation No pelvic disease on PET-CT Inguinal dissection femoral vessels skeletonised; pudendal, external oblique and Cloquet’s nodes Also ilio-inguinal (NZ): an iliac second-tier node after a positive SNB that is not being observed. Extensive inguinal disease: CCA allows ilio-inguinal; NCCN leaves it to imaging and the MDT.
The baseline scan, not the restaging scan and not Cloquet’s node, sets the extent.
Inguinalfemoral triangle + Cloquet’s nodeIlio-inguinal+ external iliac and obturator
Minimum node count7 (90% reach ≥8)7 (90% reach ≥14)
Overall survival (ANZMTG subgroup)No significant differenceHR 0.75 (0.40–1.40), P = 0.43
Limb volume increase (ANZMTG subgroup)9.9%13.4% (P = 0.35)
Lymphoedema at 18 months (EAGLE FM, n = 88)18.8%41.4% (difference not significant)
Randomised evidenceEAGLE FM closed at 88 of 634Survival endpoint unpublished
Check
Which statement do the rows support?
□ Guess   □ Fairly sure   □ Certain
✓ (a) Correct. Two small data sets, neither powered for survival.
✗ (b) The 18.8% vs 41.4% gap was not statistically significant in 88 patients.
✗ (c) HR 0.75 with a confidence interval from 0.40 to 1.40.

Sources: ANZMTG groin subgroup: Henderson MA et al., Ann Surg Oncol 2019;26:466338 (46 inguinal, 23 ilio-inguinal; median follow-up 73 months). EAGLE FM: Lee TS et al., Ann Surg Oncol 2024;31:406139.

Worked case — 5 steps
Referral64-year-old woman. Right groin after nivolumab + ipilimumab. Baseline PET-CT: three inguinal nodes, largest 3.4 cm (marked); no pelvic uptake. Restaging: smaller, nothing new.
  1. GroinInguinal dissection: the pelvis is not indicated by imaging. NZ GPP 5.4.10.
  2. GroinFind and remove the marked index node first; label it. Then clear the triangle en bloc.
  3. GroinSend Cloquet’s node separately labelled. A positive Cloquet’s node reopens the pelvic question at the MDM.
  4. GroinCover the femoral vessels if the skin flaps are thin: sartorius transposition is an option, not a rule. The evidence is weak (see Complications).
  5. AftercareDrain; lymphoedema therapist before and after; audit the complications. GPP 5.4.13–5.4.14.
What would change this? A PET-avid external iliac node at baseline would make this an ilio-inguinal dissection, even if the node had shrunk on restaging: the extent follows the baseline disease.

Why?

Why is the extent of groin surgery set by the baseline scan rather than the week-5 restaging scan?

Show answer
Response to neoadjuvant therapy is measured on pathology, not on imaging: radiology underestimates it, and a shrinking iliac node may still hold viable tumour. The trials prespecified the operation from baseline disease (S1801 “regardless of radiologic response”), and NZ GPP 5.5.9 asks for a full dissection of the involved basin; reading “involved” as involved at baseline is this read-through’s interpretation, consistent with S1801. Planning from the baseline scan keeps the operation therapeutic for everything present at the start.
Evidence and other guidelinesNCCN (2016) sent Cloquet’s node to the pelvis; CCA calls it unreliable

NCCN V1.2026: an inguinofemoral dissection is the anatomic dissection for clinical groin disease; iliac and obturator dissection “may be considered” if imaging shows resectable pelvic lymphadenopathy. Clinically positive inguinofemoral nodes, ≥3 microscopically positive nodes or a positive Cloquet’s node “may increase the likelihood” of occult pelvic disease, and the decision should rest on preoperative imaging and be made jointly by the MDT. The 2016 version had indicated iliac and obturator dissection for a positive Cloquet’s node (category 2B).

CCA (former wiki section 12.3.3): most authorities recommend inguinal and pelvic lymphadenectomy “only for proven pelvic involvement or the presence of extensive inguinal disease”.

NZ 5.4 rationale: less iliac dissection is being done; no difference in lymphoedema between the procedures in MSLT-II; PET-CT “is not sensitive to small volume disease”; lymphoscintigraphy before SNB shows where the second-tier nodes lie.

Data. Rotterdam (van der Ploeg 201140): deep nodes positive in 24.8%, 5-year OS 12% vs 40%, CT NPV 91%, no difference in survival or local control between superficial and combined dissection. Pasquali 201441: pelvic metastases 26.7% overall (17.3% micrometastatic, 36.8% macrometastatic); in micrometastatic disease Cloquet’s node NPV 95.5%. EAGLE FM (Lee, Ann Surg Oncol 2024): lymphoedema highest at 6 months, 45.9% vs 54.1%.

AftercareSeroma, wound and lymphoedema: what to promise and what helps

Basics: complication definitions and what a drain is for

Seroma or lymphocele: lymph collecting under the flaps once the drain is out. Wound complications: infection, flap edge necrosis, dehiscence; commoner in the groin. Lymphoedema: usually defined as an inter-limb volume difference over 10% or a rise in bioimpedance (L-Dex) over 10; it peaks in the first months and partly settles. The consensus (Sotelo, BJS Open 202442) standardises how groin-dissection complications are reported.

Drains (MIA consent information): axilla for several days and up to several weeks; groin usually 5–10 days, sometimes up to six weeks.

Case
A 64-year-old is consented for an inguinal TLND. She asks how likely lasting leg swelling is. Which figure is the best estimate to give?
□ Guess   □ Fairly sure   □ Certain
✗ (a) That is PRADO’s rate after index-node excision alone, without a dissection.
✓ (b) Correct. MIA consent figure for groin dissection; moderate–severe lymphoedema after groin CLND 20% (Theodore 2017); 20.9% across TLNDs in a systematic review.
✗ (c) Close to the measured prevalence at 6 months in EAGLE FM (46–54%), which falls later; not the lasting figure.
✗ (d) Far too low for any groin dissection.
Quote groin and axilla separately, and say the swelling is often worst in the first months. Groin: about 20–30%. Axilla: about 10%. Radiotherapy to the groin roughly doubles leg volume change.

Rule

Quote the basins separately. Lymphoedema: axilla about 1 in 10, groin 2–3 in 10. Early complications: axillary TLND 33%, groin TLND 43%. Across TLND series: any complication 39.3%, wound infection or breakdown 25.4%, seroma 20.4%, lymphoedema 20.9%.

Source: MIA clinical brochures (axillary43 and groin dissection44); Theodore et al., ANZ J Surg 201733 (916 axillae, 605 groins); Moody et al., EJSO 201745 (systematic review, TLND n = 1627).

Rule

NZ asks for three things around every dissection: access to a lymphoedema therapist before and after surgery, an operation note that names the boundaries and levels, and a data system that audits complications.

Patients must have access to a lymphoedema therapist to prescribe and fit compression garments and provide education about pre- and post-operative lymphoedema management.

Source: NZ Melanoma Clinical Guidelines5, 4th edition (June 2026), GPP 5.4.6, 5.4.13, 5.4.14. NCCN V1.2026 ME-G adds referral of refractory lymphoedema to a specialist in lymphovascular procedures, preferably within a trial.

Rule

Neoadjuvant immunotherapy makes the operation slower but has not made it more complicated. Complications after neoadjuvant therapy vs upfront: NKI 31.8% vs 36.8%; MIA 55% vs 51%; Karolinska 63.2% vs 80.6% (19 neoadjuvant patients, all on anti-PD-1 monotherapy, vs 62 upfront; longer operations). NADINA grade ≥3 surgery-related AEs 14.1% vs 14.4%. Surgeons rated the dissection harder in 46% and easier in 17% (neo-ACTIVATE).

Source: Zijlker et al., EJC 202322 and Ann Surg Oncol 202446; Lytchiér et al., EJSO 202647; Blank CU et al., NEJM 20241; Hieken 202248 as cited in the NZ 5.5 rationale.

Open inguinal dissectionstandardVideoscopic (MILND / VIL)minimally invasive
Nodes retrieved8 (two-centre comparison, 28 open vs 13 MILND: Abbott, Ann Surg Oncol 201349)11
Wound dehiscence14% (same series; P = 0.07)0%
Same-basin recurrence5.9% (MSLT-II, open)4.4% (8.2% for clinical nodes)
Randomised evidence—RCT (NCT01526486) stopped for poor accrual
Learning curve—Proficient within about 6 cases (83% of surgeons; Jakub, J Am Coll Surg 201650)
Check
Which row is the main argument for the videoscopic approach?
□ Guess   □ Fairly sure   □ Certain
✗ (a) The two-centre series called MILND an equivalent lymphadenectomy (11 vs 8 nodes); node yield is not the argument for it.
✓ (b) Correct. The groin wound is where open dissection does worst.
✗ (c) There is none, which is the argument against.

Why?

Why does the groin carry more wound and lymphoedema morbidity than the axilla?

Show answer
All the lymph from the leg passes through a small field, and the leg is dependent. The skin flaps over the femoral triangle are thin and poorly perfused, sit in a moist crease that flexes with every step, and lie directly over the femoral vessels. Obesity and diabetes add to each of these.
Evidence and other guidelinesNo RCT for sartorius transposition or MILND

Sartorius transposition (NSQIP, n = 38151): wound complications 10% vs 14% unmatched (P = 0.39); 8% vs 23% after matching for operating time (P = 0.05). Saphenous vein sparing: small series only. A review calls both manoeuvres controversial (Sarnaik AA et al., Cancer Control 200952).

Videoscopic groin dissection. Emory (Delman 201153; melanoma and other cancers): 45 procedures, median 11 nodes, wound complications 18%. SAFE-MILND54 (87 patients): 88.5% completed minimally invasively, median 12 nodes, any adverse event 71%, grade 3 in 26%. Mayo (Jakub 202255): same-basin recurrence 4.4%. Padua videoscopic ilio-inguinal (Sommariva, BJS 201656): 24 procedures, median 21 nodes, 4 conversions.

Immediate lymphatic reconstruction (lymphaticovenous bypass at the time of dissection) has been described after melanoma axillary and ilio-inguinal dissection (Cleveland Clinic, with instructional videos57); melanoma-specific outcome data are limited.

Radiotherapy after TLND increases leg lymphoedema (ANZMTG58: leg volume increase 15.0% vs 7.7%, p = 0.014) but not arm volume.

AftercareAfter the specimen: response grade, adjuvant therapy, radiotherapy

Basics: INMC response grading

The grades the treated tumour bed (viable tumour plus necrosis, melanophages and fibrosis). pCR: no viable tumour. Near-pCR: viable tumour >0% and ≤10%. Together these are the MPR. pPR: >10% to ≤50%. pNR: >50%.

The request form must say that neoadjuvant immunotherapy was given (NZ GPP 3.3.7) and name the marker. The 2026 INMC update4 examines nodes ≤3 cm in their entirety and at least a full transverse slice of larger nodes.

Case
Three TLND specimens after neoadjuvant immunotherapy. Grade each.
□ Guess   □ Fairly sure   □ Certain
pCR.
Near-pCR: >0 and ≤10%, so an MPR.
pPR: >10% to ≤50%.
Two cut-points carry the decisions: 10% (MPR or not) and 50% (partial or non-response).

Rule

After nivolumab + ipilimumab the specimen sets the adjuvant plan: MPR, no adjuvant therapy; pPR, adjuvant immunotherapy offered; pNR, adjuvant therapy considered, with BRAF/MEK inhibitors preferred in BRAF-mutant disease, and radiotherapy considered if the radiotherapy criteria are met. After neoadjuvant pembrolizumab, adjuvant pembrolizumab completes a year whatever the response. NADINA 2-year RFS (ESMO 2025 presentation): 95.1% (pCR), 81.2% (near-pCR), 69.4% (pPR), 48.4% (pNR).

Adjuvant radiotherapy could be considered in those with a pathological non-response (<50% pathological response) in accordance with current criteria for radiotherapy in melanoma. Both concurrent and sequential delivery of radiotherapy with immunotherapy are acceptable strategies.

Source: NZ Melanoma Clinical Guidelines5, 4th edition (June 2026), GPP 5.5.11–5.5.14. Funding detail in the Melanoma Pathway Read-through. NADINA ESMO 2025 update2 (2-year RFS by response: presentation data, not in the printed abstract).

Rule

Nodal radiotherapy criteria (ANZMTG 01.02/TROG 02.01, as quoted by NZ): palpable disease in ≥1 parotid, ≥2 neck or axillary, or ≥3 groin nodes; extranodal spread; or a largest node ≥3 cm in the neck or ≥4 cm in the axilla or groin. NZ GPP 5.6.7 lists these criteria for use if neoadjuvant or adjuvant therapy is not appropriate or unavailable; after neoadjuvant immunotherapy, GPP 5.5.14 applies current criteria to a pathological non-response. Radiotherapy (48 Gy in 20 fractions) cut lymph-node field relapse from 36% to 21% (adjusted HR 0.52) without improving relapse-free or overall survival, and increased leg volume (15.0% vs 7.7%).

Source: NZ Melanoma Clinical Guidelines5, 4th edition (June 2026), GPP 5.6.7; Burmeister BH et al., Lancet Oncol 2012;13:58959; Henderson MA et al., Lancet Oncol 2015;16:104958.

pPR>10% to ≤50% viablepNR>50% viable
Adjuvant systemic therapy (NZ)Immunotherapy “should be offered”Should be “considered”; BRAF/MEK preferred if BRAF-mutant
Adjuvant radiotherapy (NZ)Not listedCould be considered if criteria met
NADINA 2-year RFS69.4%48.4%
Surgery already doneFull TLNDFull TLND
Check
Which row brings a new treatment modality into the discussion for pNR?
□ Guess   □ Fairly sure   □ Certain
✗ (a) Systemic therapy is on the table in both (offered in pPR, considered in pNR); the drug preference changes.
✓ (b) Correct. Only non-response opens the radiotherapy question in the NZ guideline.
✗ (c) A prognosis, not a treatment.

Why?

Why can adjuvant therapy be dropped after a major pathological response but not after a complete radiological response?

Show answer
Pathology counts viable tumour directly; imaging does not, and it underestimates response (OpACIN-neo: 52% radiological vs 74% pathological). Without further treatment, a pCR carries a 2-year RFS of 95% and a near-pCR 81% in NADINA (ESMO 2025 presentation); at 12 months the whole MPR group had 95% RFS (NEJM 2024). No equivalent outcome data exist for a radiological complete response.
Evidence and other guidelinesNCCN uses ≥3 cm for the axilla; NZ uses ≥4 cm

Node size for radiotherapy. NZ GPP 5.6.7 quotes ≥3 cm in the neck and ≥4 cm in the axilla or groin, for use if neoadjuvant or adjuvant therapy is not appropriate or unavailable. NCCN V1.2026 lists ≥3 cm for cervical or axillary nodes and ≥4 cm for inguinofemoral nodes. Check the ANZMTG protocol wording before quoting either to a patient.

ESMO (Ann Oncol 2025): adjuvant radiotherapy “is not routinely recommended [III, D]”; it could be discussed after R1 resection or resection of bulky nodes [III, C].

NADINA allowed adjuvant radiotherapy in both arms except after MPR (trial protocol; not stated in the abstract).

AftercareNot melanoma: cSCC and Merkel cell nodes in the axilla or groin

Basics: how nodal cSCC and MCC differ from melanoma

cSCC reaching the axilla or groin comes from trunk or limb primaries, often in older or immunosuppressed patients, and is usually bulky with extranodal extension. There is no funded neoadjuvant or adjuvant systemic therapy for cSCC in NZ; surgery and radiotherapy carry the treatment (see the cSCC Pathway Read-through).

Merkel cell carcinoma is radiosensitive and often presents with nodal disease from an unknown primary. Both dissection and radiotherapy are primary options for clinically evident nodes.

Case
76-year-old with a 4 cm cSCC of the forearm excised 7 months ago. Now a 3 cm axillary mass; core biopsy: SCC. PET-CT: axilla only. ECOG 1.
What is the standard plan?
□ Guess   □ Fairly sure   □ Certain
✗ (a) That is the melanoma regimen; it has no role in cSCC.
✓ (b) Correct. NCCN: regional dissection preferred for surgical candidates; after trunk or limb dissection consider nodal radiotherapy, especially with multiple nodes or ENE.
✗ (c) An option only for patients who are not surgical candidates.
✗ (d) The node is already clinically involved.
Nodal cSCC is treated with dissection and usually radiotherapy. Neoadjuvant cemiplimab (51% complete histological response in one study) and adjuvant cemiplimab after surgery and radiotherapy (C-POST) are not funded in NZ.

Rule

cSCC: regional dissection is preferred for surgical candidates; after dissection of trunk or limb nodes, consider radiotherapy to the nodal bed, especially with multiple nodes or extranodal extension. In a Peter Mac series of 78 patients (64 axilla, 14 groin), 81% had ENE, 69% had surgery plus radiotherapy, 5-year overall survival was 33%, and radiotherapy was associated with longer survival (HR 0.5).

Source: NCCN Squamous Cell Skin Cancer V2.2026 (algorithm footnote and discussion MS-16); Bucknell NW et al. (Peter MacCallum), Australas J Dermatol 2022;63:4360; EADO 2026 Part 261: macroscopic nodal disease discussed individually at the tumour board. Neoadjuvant cemiplimab: Gross ND et al., NEJM 2022;387:155762; adjuvant cemiplimab (C-POST): Rischin D et al., NEJM 2025;393:77463.

Rule

Merkel cell carcinoma: dissection is the recommended initial therapy for clinically evident nodes, followed by radiotherapy if indicated; definitive radiotherapy is an alternative. Use caution with groin radiotherapy in patients with existing lymphoedema or high risk of it (high BMI, groin basin, smoking).

Source: NCCN Merkel Cell Carcinoma V2.2026 (radiotherapy principles, footnotes h and i); EADO 2022 MCC guideline64: macroscopic nodes, “complete lymph nodes dissection potentially followed by post-operative RT”.

Why?

Why does the NADINA sequence not transfer to nodal cSCC?

Show answer
The drug evidence is different: cSCC data are for cemiplimab, not ipilimumab + nivolumab, and neither the neoadjuvant nor the adjuvant use is funded in NZ. Radiotherapy has a larger established role in nodal control of cSCC, and the patients are older, with more comorbidity and immunosuppression.

PositionNZ position at 1 October 2026

The single reference for every “NZ standard” statement on this page. Funding detail sits in the Melanoma Pathway Read-through.

QuestionNZ positionSource
Neoadjuvant ICI before TLND, resectable clinical IIIB–DStandard; funded. Pembrolizumab × 3 (from 1 June 2025) or nivolumab + ipilimumab × 2 (from 1 May 2026)GPP 5.5.1; Pharmac Special Authorities
Index node marked before dose 1RecommendedGPP 5.5.6
Timing of surgeryAbout 3 weeks after the last dose, after restagingGPP 5.5.7–5.5.8
Extent after neoadjuvant therapyFull therapeutic dissection of the involved basinGPP 5.5.9
Index node only after MPR (PRADO)Not standard. Trial only: MSLT-3 (no NZ site listed at 1 October 2026)NZ 5.5 rationale; NCT07049276
AxillaLevels I–IIIGPP 5.4.8
GroinInguinal; ilio-inguinal for PET-positive or biopsy-proven pelvic disease, or an iliac second-tier node after a positive SNB that is not observedGPP 5.4.9–5.4.10
Minimum node countNo NZ number. Spillane standard: axilla ≥10, groin ≥7Ann Surg 2009
Operation noteBoundaries and levels removedGPP 5.4.6
Adjuvant radiotherapyMDM decision on ANZMTG criteria; after nivolumab + ipilimumab only for pNR; publicly fundedGPP 5.5.14, 5.6.7
Lymphoedema therapistRequired access, before and after surgeryGPP 5.4.13
Complication auditRequiredGPP 5.4.14
Videoscopic groin dissectionNo NZ data found; availability unconfirmed—
Nodal cSCC or MCC systemic therapyNot funded for cSCC; surgery ± radiotherapycSCC Pathway Read-through

Sources: NZ Melanoma Clinical Guidelines5, 4th edition (June 2026); Pharmac Special Authorities SA2631, SA2642 and SA2643, verified 2 October 2026 (October 2026 Schedule), with funding detail in the Melanoma Pathway Read-through. The 4th edition’s GPP 5.5.5 still describes ipilimumab + nivolumab as “not funded”; Pharmac has funded the combination since 1 May 2026 (SA2642/SA2643), and this table follows the Special Authorities on funding.

MDM listSix referrals, in the order they arrive

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

Case 1 · Groin melanoma with an avid iliac node

Referral61-year-old man. 2.9 mm ulcerated melanoma of the left calf excised 8 months ago; sentinel node negative. Now a 3.8 cm left inguinal mass. Core biopsy: melanoma. PET-CT: two avid left inguinal nodes and a 1.4 cm avid left external iliac node; nothing distant. MRI brain clear. BRAF wild type. ECOG 0.
Step 1
What is the stage and the first step?
□ Guess   □ Fairly sure   □ Certain
✗ (a) Pelvic nodes in continuity with an involved groin are treated as regional; the NZ guideline dissects inguinal plus pelvic disease “in the absence of distant disease”.
✓ (b) Correct. T3b with clinically detected nodes is IIIC. Mark the largest node, then ICI (GPP 5.5.1, 5.5.6).
✗ (c) Surgery first closes the neoadjuvant route.
✗ (d) The stage is IIIC, and PET-CT positivity already meets the NZ criterion for the pelvis.

Case 2 · Axilla after a complete radiological response

Referral47-year-old woman. Right axillary 2.6 cm node, core-confirmed melanoma, no primary found. Magnetic seed placed; two doses of nivolumab + ipilimumab completed three weeks ago. Restaging CT: no measurable axillary node. She asks whether she still needs an operation.
Step 1
What does the NZ guideline recommend?
□ Guess   □ Fairly sure   □ Certain
✗ (a) CT does not measure viable tumour; the specimen does (GPP 5.5.9).
✗ (b) The PRADO operation; in NZ a trial option (MSLT-3), not the standard.
✓ (c) Correct. Full therapeutic dissection of the involved basin.
✗ (d) No evidence supports surveillance in place of resection here.

Case 3 · Transplant recipient with a groin node

Referral69-year-old man, renal transplant 9 years ago, on tacrolimus and mycophenolate. 1.9 cm right inguinal node, core-confirmed melanoma; 1.1 mm non-ulcerated thigh melanoma excised two years ago. PET-CT: two avid right inguinal nodes; pelvis clear. BRAF V600E. ECOG 1.
Step 1
What is the operative plan?
□ Guess   □ Fairly sure   □ Certain
✗ (a) Checkpoint inhibitors risk graft rejection; GPP 5.5.4 limits the neoadjuvant pathway to patients who can safely receive ICI.
✓ (b) Correct. Surgery alone controls the basin without the graft risk.
✗ (c) Not a standard operation, and nothing here justifies less surgery.
✗ (d) Reserved for patients unfit for surgery.

Case 4 · Bulky axilla, non-response

Referral72-year-old woman. Left axilla: 5 cm matted nodes, core-confirmed melanoma; PET-CT axilla only. Index node marked; nivolumab + ipilimumab × 2; level I–III TLND at week 6. Pathology: index node 75% viable; 6 of 24 nodes involved; extranodal extension. BRAF wild type.
Step 1
How is the response graded?
□ Guess   □ Fairly sure   □ Certain
✗ (a) Viable tumour is present.
✗ (b) That needs ≤10% viable tumour.
✗ (c) That is >10% to ≤50%.
✓ (d) Correct. More than 50% viable tumour.

Case 5 · The biggest node was excised elsewhere

Referral55-year-old man. A private surgeon excised a 3 cm right groin node two weeks ago as an “excision biopsy”: melanoma, extranodal extension, margin involved. PET-CT now: two further avid right inguinal nodes (1.5 cm and 1.2 cm); pelvis clear. MRI brain clear. 2.2 mm non-ulcerated leg primary excised last year. BRAF wild type. ECOG 0.
Step 1
Is the neoadjuvant route still open?
□ Guess   □ Fairly sure   □ Certain
✗ (a) Measurable disease remains, and the basin has not been completely resected.
✓ (b) Correct. Two PET-avid nodes are resectable clinically evident disease (GPP 5.5.1).
✗ (c) The basin is still resectable by dissection.
✗ (d) Resectable stage III before complete resection meets the funding criteria.

Case 6 · Nodal cSCC in the axilla

Referral81-year-old man with chronic lymphocytic leukaemia. 3.5 cm poorly differentiated cSCC of the right forearm excised 7 months ago. Now a 4 cm right axillary mass; core biopsy: SCC. PET-CT: axilla only. ECOG 1.
Step 1
On the terms of reference assumed in this read-through, which MDM, and what first-line plan?
□ Guess   □ Fairly sure   □ Certain
✗ (a) On the assumed terms of reference, the Head and Neck MDM takes head and neck cSCC and neck dissection; a forearm cSCC with axillary disease stays with the Melanoma & HRSC MDM.
✓ (b) Correct. NCCN: regional dissection preferred for surgical candidates, then consider nodal radiotherapy.
✗ (c) A melanoma regimen.
✗ (d) The node is clinically involved.

NumbersFigures that change a decision or a consent form

Number
NZ: surgery about ___ weeks after completing neoadjuvant ICI
weeks
□ Guess   □ Fairly sure   □ Certain
3 weeks (GPP 5.5.8): week 6 from the first of two doses.
Number
A major pathological response is ___ % or less viable tumour
%
□ Guess   □ Fairly sure   □ Certain
10% (INMC). MPR stops adjuvant therapy after nivolumab + ipilimumab.
Number
Index node response matched the whole TLND specimen in ___ % of patients
%
□ Guess   □ Fairly sure   □ Certain
99% (81 of 82; Reijers, JAMA Surg 2022).
Number
Spillane: axillary dissections should reach a minimum of ___ nodes
nodes
□ Guess   □ Fairly sure   □ Certain
At least 10, with a mean of 21.
Number
Spillane: inguinal and ilio-inguinal dissections should reach a minimum of ___ nodes
nodes
□ Guess   □ Fairly sure   □ Certain
At least 7, with a mean of 14.
Number
Pelvic nodes are positive in ___ % of ilio-inguinal dissections after a positive sentinel node only
%
□ Guess   □ Fairly sure   □ Certain
9.3%. The NZ guideline quotes 30–39% for macroscopic groin disease; Spillane 2011’s 39% covered all ilio-inguinal dissections.
Number
PRADO: lymphoedema after index-node excision alone, ___ %
%
□ Guess   □ Fairly sure   □ Certain
5%, against 39% with TLND.
Number
PRADO: TLND was omitted in ___ of 60 patients with MPR
patients
□ Guess   □ Fairly sure   □ Certain
59 of 60.
Number
NADINA 12-month EFS in the neoadjuvant arm: ___ %
%
□ Guess   □ Fairly sure   □ Certain
83.7% vs 57.2% (HR 0.32).
Number
ANZMTG radiotherapy criterion: ___ or more involved groin nodes
nodes
□ Guess   □ Fairly sure   □ Certain
3 groin nodes (2 neck or axillary; 1 parotid).
Number
Lymphoedema after axillary dissection: quote about ___ %
%
□ Guess   □ Fairly sure   □ Certain
About 10% (MIA); moderate–severe 8% after CLND.
Number
PRADO 5-year overall survival: ___ %
%
□ Guess   □ Fairly sure   □ Certain
86% (Nat Med 2026).

ResourcesWatch and read

Links checked 29 September 2026. “Free” means no login; journal videos follow the journal’s access. No full operative video of an open melanoma groin or axillary TLND from a major centre was found on an open platform; the animations and minimally invasive videos below cover the anatomy and steps.

Operative videos and animations

Talks: NADINA, PRADO and surgery after neoadjuvant therapy

Key papers

Guidelines and trials

Anatomy refreshers

  • AnatomyThe axillaTeachMeAnatomy · freeWalls, apex and contents.
  • AnatomyThe femoral triangleTeachMeAnatomy · freeBorders, floor, roof and contents.
  • AnatomyAxillary lymph nodesRadiopaedia · freeLevels I–III on imaging relative to pectoralis minor.
  • AnatomyFemoral triangleRadiopaedia · freeCross-sectional anatomy; Cloquet’s node in the femoral canal.
  • TechniqueAxillary dissection (P. Bird)VUMC Open Manual of Surgery · free PDFStep-by-step nerve preservation; breast extent (levels I–II).

Consent and patient information

Your answersCounts only

Answer key

GlossaryTerms used in this document

ANZMTG 01.02/TROG 02.01
Randomised trial of adjuvant nodal radiotherapy (48 Gy in 20 fractions) after TLND in patients at high risk of field relapse. Halved field relapse; no survival benefit; more leg lymphoedema.
CALI
Consensus classification for reporting complications after groin (inguinal and ilio-inguinal) lymph node dissection (BJS Open 2024).
CLND
Completion lymph node dissection: clearance of a basin after a positive sentinel node without clinical disease. No longer routine after MSLT-II and DeCOG-SLT.
Cloquet’s node
The highest deep inguinal node, in the femoral canal medial to the femoral vein under the inguinal ligament; removed and labelled in an inguinal dissection. A weak predictor of pelvic disease.
DMFS
Distant metastasis-free survival.
EAGLE FM
Randomised trial of inguinal vs ilio-inguinal dissection. Closed at 88 of 634 planned patients; lymphoedema data published, survival not.
EFS
Event-free survival. In NADINA: progression to unresectable disease before surgery, recurrence, or death from melanoma or treatment.
ENE
Extranodal extension: tumour through the node capsule. A criterion for adjuvant nodal radiotherapy.
ILN
Index lymph node: the largest involved node at baseline, marked before neoadjuvant therapy so it can be found and graded at surgery.
INMC
International Neoadjuvant Melanoma Consortium: sets the pathology sampling and response-grading rules for neoadjuvant specimens.
intercostobrachial nerve
Sensory nerve from T2 crossing the axilla to the upper inner arm; usually divided in a level I–III dissection, leaving numbness.
MARI
Marking Axillary lymph nodes with Radioactive Iodine seeds: an I-125 seed placed in the node before neoadjuvant therapy and found with a gamma probe (breast surgery origin).
MILND
Minimally invasive (videoscopic) inguinal lymph node dissection, also VIL or VEIL.
MPR
Major pathological response: 10% or less viable tumour (pCR plus near-pCR). Stops adjuvant therapy after nivolumab + ipilimumab.
MSLT-3
Randomised trial of index-node excision vs TLND after neoadjuvant therapy (NCT07049276); non-inferiority on 2-year RFS; recruiting since October 2025, with no NZ site listed at 1 October 2026.
NADINA
Phase 3 trial of neoadjuvant ipilimumab + nivolumab then TLND vs TLND then adjuvant nivolumab in macroscopic stage III melanoma (NEJM 2024).
near-pCR
Viable tumour greater than 0% and 10% or less of the tumour bed.
OMIT
Dutch single-arm phase 2 trial omitting TLND after index-node MPR (NCT06754904).
pCR
Pathological complete response: no viable tumour in the resected specimen.
pNR
Pathological non-response: more than 50% viable tumour.
pPR
Pathological partial response: more than 10% and up to 50% viable tumour.
PRADO
Phase 2 extension cohort of OpACIN-neo: index node excised at week 6; TLND and adjuvant therapy omitted after MPR (Nat Med 2022; 5-year 2026).
RFS
Relapse-free survival.
Special Authority
Pharmac’s criteria-based funding approval; the neoadjuvant criteria require treatment before complete resection.
TLND
Therapeutic lymph node dissection: anatomically complete clearance of a basin with clinically or radiologically evident disease.

References

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Unresolved as of 1 October 2026. How the NADINA protocol defined the extent of dissection in each basin (the supplementary protocol was not accessible). The PRADO MPR recurrence count (the preprint’s 12 + 47 does not sum to 60) and the exact regional recurrence rate after omission. When MSLT-3 will open at an NZ site (none listed on the registry at 1 October 2026). The ANZMTG protocol wording on axillary node size (NZ quotes ≥4 cm; NCCN ≥3 cm). EAGLE FM survival results (unpublished). Availability of videoscopic groin dissection in NZ.

Companion pages. Melanoma Pathway Read-through (staging, systemic therapy, funding, follow-up) · cSCC Pathway Read-through · BCC Pathway Read-through.