Getting warmer.

Were you confused by where the newest guidelines were guiding you in the management of nodal dissection for localized melanoma? A surg onc and two med oncs from Mass Gen and City of Hope have put their heads together to create clear and concise guidelines (nicely outlined in a single figure) on how to approach the systemic treatment of metastatic melanoma. The highlights: Start off with immune checkpoint inhibition to give the best chance of durable response in anyone who can tolerate it, even in patients with BRAF-mutated tumors. The exception here is rapidly growing BRAF-mutated disease where BRAF-targeted agents may produce a quicker response. What’s more, they recommend starting with single agent PD-1 inhibition considering it produces similar disease outcomes when compared with combo immunotherapy but with better tolerability. TBL: A clear and well-reasoned upfront approach to treating metastatic melanoma is single agent PD-1 inhibition, reserving BRAF-targeted agents and/or second-line CTLA-4 inhibition for progression or those who can’t tolerate it. | Kaufman, JAMA Oncol 2018