derm.melanoma.core.v1PRODUCTION

derm.melanoma.core.v1

Cutaneous melanoma (dermatology lens)

dermatologysubacutechronicadult

Hard-required inputs

0 / 9

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as a NOT-TO-MISS: the dermatology engine owns recognition → diagnostic excisional biopsy → histopath-driven AJCC8 staging → wide local excision + SLNB + surveillance, and ROUTES advanced/adjuvant systemic therapy to oncology by engine_id (onc.melanoma-systemic.core.v1) while co-managing checkpoint-inhibitor cutaneous toxicity. Early thin melanoma is highly curable; the failure mode is delayed recognition/biopsy and the amelanotic/nodular/subungual misses (AAD 2019 PMID 30392755).

Inputs

Actions

Advance rule

Set

Advance when

derm-scope set; systemic-therapy + NMSC + irAE routes noted by engine_id

Patient inputs (17)

dermoscopy_findings*symptom • CONTEXT

Atypical pigment network, blue-white veil, irregular streaks/dots/globules, regression structures, negative network raise melanoma probability and outperform naked-eye exam in trained hands (AAD 2019 PMID 30392755)

ugly_duckling_and_total_body_context*symptom • CONTEXT

A lesion that deviates from the patient’s nevus signature ("ugly duckling") plus a total-body skin exam contextualises an isolated lesion and finds synchronous primaries (AAD 2019 PMID 30392755)

melanoma_risk_factors*history • CONTEXT

not present

Fair skin/UV burden, ≥50 nevi or atypical-nevus syndrome, personal/family melanoma, CDKN2A/CDK4, immunosuppression set the pre-test prior and surveillance intensity (AAD 2019 PMID 30392755)

special_site_features*symptom • CONTEXT

Acral (sole/palm) and subungual (Hutchinson, longitudinal melanonychia) presentations are commonly delayed in skin of colour and need a dedicated biopsy pathway (AAD 2019 PMID 30392755)

lesion_abcde_and_change_history*symptom • ENTRY

Asymmetry, Border irregularity, Colour variegation, Diameter >6 mm, Evolution + a documented changing lesion are the core recognition signal driving the biopsy decision (AAD 2019 PMID 30392755)

biopsy_breslow_ulceration_mitoses_subtype*history • INITIAL_WORKUP

not present

Definitive histopathology — Breslow thickness, ulceration, dermal mitotic rate, subtype, microsatellites, margins — is the single determinant of T-category, SLNB candidacy and WLE margin (AJCC8; AAD 2019 PMID 30392755)

amelanotic_or_bleeding_nodular_lesion*symptom • RED_FLAGS

Amelanotic/pink, rapidly growing, bleeding nodular lesions defeat ABCDE — a not-to-miss requiring a low biopsy threshold (AAD 2019 PMID 30392755)

regional_node_or_in_transit_signs*symptom • RED_FLAGS

Palpable regional nodes, satellite/in-transit lesions, or a fixed mass change staging and trigger urgent staging + oncology referral (AJCC 8th edition; AAD 2019 PMID 30392755)

metastatic_systemic_or_neuro_symptoms*symptom • RED_FLAGS

Visceral symptoms, weight loss, or neurologic deficit/headache (brain metastasis) escalate to urgent oncology ± neuro and modify imaging (AJCC8; AAD 2019 PMID 30392755)

staging_imaging_by_stageimaging • BRANCHING_WORKUP

not present

Nodal ultrasound, CT/PET-CT, and brain MRI are stage-directed — not for low-risk stage I, indicated for node-positive/high-stage disease (AAD 2019 PMID 30392755)

braf_nras_ckit_molecularlab • BRANCHING_WORKUP

BRAF V600 (and NRAS, c-KIT in acral/mucosal) testing on resectable stage III–IV / unresectable disease selects targeted therapy and is routed with the patient to oncology (AAD 2019 PMID 30392755)

cbc_with_differentiallab • INITIAL_WORKUP

Baseline + on-treatment monitoring for routed BRAF/MEK (cytopenias) and checkpoint-inhibitor irAE work-up (AAD 2019 PMID 30392755; CheckMate 067 PMID 31562797)

lftlab • INITIAL_WORKUP

Baseline + monitoring — immune hepatitis (checkpoint irAE) and BRAF/MEK hepatotoxicity in routed systemic therapy (AAD 2019 PMID 30392755; CheckMate 067 PMID 31562797)

ldhlab • RISK_STRATIFICATION

Elevated serum LDH up-stages M1 (M1[0] vs M1[1]) and is prognostic in metastatic disease (AJCC 8th edition; AAD 2019 PMID 30392755)

pregnancy_statushistory • TREATMENT

Wide excision/SLNB are safe in pregnancy; staging imaging is modified and systemic immuno/targeted therapy is generally deferred — gates the management arc (AAD 2019 PMID 30392755)

immunosuppression_or_transplanthistory • TREATMENT

not present

Solid-organ-transplant/immunosuppressed patients have higher melanoma risk and worse outcomes, and checkpoint-inhibitor immunotherapy carries graft-rejection risk — modifies routed systemic choice (AAD 2019 PMID 30392755)

creatininelab • TREATMENT

CKD-EPI 2021 race-free eGFR for contrast-imaging staging risk and renal dose context if routed systemic therapy is given (AAD 2019 PMID 30392755; Inker NEJM 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement

informationallife_threateningcheckpoint_inhibitor_severe_irAE_emergency
Patient on routed checkpoint-inhibitor therapy with Grade 3–4 immune-related colitis, hepatitis, pneumonitis, myocarditis, or endocrine crisis (CheckMate 067 PMID 31562797)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningmetastatic_visceral_or_brain_disease
Distant metastatic disease — visceral symptoms, elevated LDH, or neurologic deficit/headache suggesting brain metastasis (AJCC 8th edition; AAD 2019 PMID 30392755)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereclinically_suspicious_lesion_do_not_delay_biopsy
A pigmented or amelanotic lesion clinically/dermoscopically suspicious for melanoma (ABCDE, ugly-duckling, blue-white veil, atypical network, regression) (AAD 2019 PMID 30392755)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverenodal_or_in_transit_or_thick_ulcerated_disease
Palpable regional nodes, satellite/in-transit metastases, or thick (>4 mm) / ulcerated primary on histopathology (AJCC 8th edition)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereamelanotic_or_nodular_rapidly_growing_bleeding_lesion
Rapidly growing, elevated, firm, amelanotic/pink or bleeding nodular lesion (EFG) that defeats ABCDE (AAD 2019 PMID 30392755)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatesubungual_hutchinson_sign
Longitudinal melanonychia with proximal-nail-fold / periungual pigment spread (Hutchinson sign), or a nail-unit pigmented/destructive lesion (AAD 2019 PMID 30392755)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatebraf_wildtype_braf_inhibitor_contraindication
Consideration of BRAF-inhibitor therapy without confirmed BRAF V600 mutation (AAD 2019 PMID 30392755)
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENToptionalDrives dose adjustment

Loading…

Recommended regimen

Cutaneous melanoma — stage-directed ladder (AAD 2019 + AJCC8; systemic routed to oncology)

axis: melanoma_stage_directed_ladderstep 1 - Step 1 — Localised disease: wide local excision ± SLNB (dermatology-owned)

Selected step "Step 1 — Localised disease: wide local excision ± SLNB (dermatology-owned)" — AJCC8 stage 0 (in situ) through resectable stage I–II ± clinically node-negative stage III by positive SLN

wide_local_excision_stage_based_margins
first line
definitive_surgery
triggers: biopsy_confirmed_melanoma
AAD 2019 (PMID 30392755) — definitive treatment of primary cutaneous melanoma: clinical margins by Breslow — in situ 0.5–1.0 cm; ≤1.0 mm → 1 cm; >1–2 mm → 1–2 cm; >2 mm → 2 cm — excised to (not through) deep fascia.
sentinel_lymph_node_biopsy
first line
staging_procedure
triggers: T1b_breslow_ge_0_8mm_or_ulcerated, all_T2_to_T4, discuss_at_T1b
AAD 2019 (PMID 30392755) / MSLT-I (Morton/Faries NEJM 2014 PMID 24521106) — SLNB is the most powerful prognostic stratifier; offer/discuss at ≈T1b (≥0.8 mm or <0.8 mm with ulceration) and all ≥T2; performed at the same setting as WLE.
nodal_ultrasound_surveillance_instead_of_completion_lymphadenectomy
first line
surveillance_procedure
triggers: positive_sentinel_node
MSLT-II (Faries NEJM 2017 PMID 28591523) — immediate completion lymphadenectomy did NOT improve melanoma-specific survival vs nodal ultrasound surveillance for SLN+; nodal US surveillance is the default, completion dissection reserved for selected cases.
staged_or_mohs_excision_for_lentigo_maligna
second line
definitive_surgery
triggers: lentigo_maligna_head_neck, wide_margins_unfeasible_cosmetic_site
AAD 2019 (PMID 30392755) — staged excision / Mohs with exhaustive margin assessment for lentigo maligna at anatomically constrained head/neck sites where standard wide margins are unfeasible.
imiquimod
second line
topical_immune_response_modifier
5% cream • topical • 5×/week ×12 wk (regimens vary) (max: per tolerance/site reaction)
triggers: lentigo_maligna_nonsurgical_candidate, positive_or_close_margin_adjunct
AAD 2019 (PMID 30392755) — off-label topical imiquimod is an option for lentigo maligna when surgery is declined/unfeasible or as a margin adjunct; lower clearance than surgery, requires close follow-up.
rxcui 59943
definitive_radiotherapy_for_lentigo_maligna
second line
radiotherapy
triggers: lentigo_maligna_nonsurgical_candidate, elderly_surgically_unfit
AAD 2019 (PMID 30392755) — definitive radiotherapy is an accepted non-surgical option for lentigo maligna in patients who are not surgical candidates.

outpatient playbook — drug actions (4)

1. wide local excision with AJCC8/AAD stage-based margins (definitive, dermatology-owned)
in situ 0.5–1 cm; ≤1 mm 1 cm; >1–2 mm 1–2 cm; >2 mm 2 cm • surgical • single definitive procedure
trigger: Biopsy-confirmed primary cutaneous melanoma (AAD 2019 PMID 30392755)
Stage-based margin WLE is the curative cornerstone of localised melanoma
2. imiquimod 5% (lentigo maligna, non-surgical candidate / margin adjunct)
rxcui 59943
5% cream • topical • 5×/wk ×12 wk
trigger: Lentigo maligna where surgery declined/unfeasible (AAD 2019 PMID 30392755)
Off-label topical option for lentigo maligna; lower clearance than surgery — close follow-up
3. adjuvant anti-PD-1 (nivolumab / pembrolizumab) — ROUTED to oncology
rxcui 1547545
pembrolizumab 200 mg q3wk • IV • q3wk ×~1 yr
trigger: Resected stage III or high-risk IIB/IIC (KEYNOTE-716 PMID 35367007; CheckMate 238 PMID 37058595)
Adjuvant anti-PD-1 reduces recurrence; delivered by oncology, derm co-manages cutaneous irAE
4. advanced systemic (ipilimumab+nivolumab / BRAF-MEK) — ROUTED to oncology
rxcui 1094833
ipilimumab 3 mg/kg + nivolumab induction • IV • q3wk ×4 then maintenance
trigger: Unresectable / metastatic disease (CheckMate 067 PMID 31562797; COMBI-d/v PMID 31166680)
Combination immunotherapy / BRAF-MEK by oncology; dermatology co-manages cutaneous toxicity and surveils for second primaries

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: New, changing, or symptomatic pigmented lesion meeting ABCDE / ugly-duckling criteria (AAD 2019 primary cutaneous melanoma PMID 30392755); Rapidly growing elevated firm nodule (EFG) — incl. amelanotic/pink nodular melanoma which classically defeats ABCDE (AAD 2019 PMID 30392755); Pigmented nail band with proximal-nail-fold pigment spread (Hutchinson sign) → subungual melanoma until biopsy proven otherwise (AAD 2019 PMID 30392755).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cutaneous melanoma (dermatology lens)** (derm.melanoma.core.v1).
Phenotype framing: Terminal pigmented-lesion differential with named pivots: melanoma vs benign acquired nevus (symmetric, stable, regular network pivot) vs dysplastic/atypical nevus (mild irregularity, monitor-vs-excise pivot) vs seborrheic keratosis (stuck-on, milia-like cysts + comedo-like openings pivot) vs pigmented basal cell carcinoma (arborising vessels + leaf-like areas, route derm.actinic-keratosis-nmsc.core.v1) vs solar lentigo / ink-spot lentigo (uniform fingerprint pattern pivot) vs blue nevus (homogeneous steel-blue, long-stable pivot) vs dermatofibroma (central white scar-like patch + dimple sign pivot) vs subungual haematoma (resolving, moves out with growth, no Hutchinson — vs subungual melanoma) vs pyogenic granuloma (rapid friable vascular nodule — vs amelanotic nodular melanoma) vs angiokeratoma (dark vascular lacunae pivot). When in doubt, biopsy — recognition errors are the dominant harm.
Scope: Frame as a NOT-TO-MISS: the dermatology engine owns recognition → diagnostic excisional biopsy → histopath-driven AJCC8 staging → wide local excision + SLNB + surveillance, and ROUTES advanced/adjuvant systemic therapy to oncology by engine_id (onc.melanoma-systemic.core.v1) while co-managing checkpoint-inhibitor cutaneous toxicity. Early thin melanoma is highly curable; the failure mode is delayed recognition/biopsy and the amelanotic/nodular/subungual misses (AAD 2019 PMID 30392755).

No severity triggers fired against current inputs.

Plan

Regimen axis: **Cutaneous melanoma — stage-directed ladder (AAD 2019 + AJCC8; systemic routed to oncology)** — step "Step 1 — Localised disease: wide local excision ± SLNB (dermatology-owned)".
1. wide_local_excision_stage_based_margins (definitive_surgery, first line) — AAD 2019 (PMID 30392755) — definitive treatment of primary cutaneous melanoma: clinical margins by Breslow — in situ 0.5–1.0 cm; ≤1.0 mm → 1 cm; >1–2 mm → 1–2 cm; >2 mm → 2 cm — excised to (not through) deep fascia.
2. sentinel_lymph_node_biopsy (staging_procedure, first line) — AAD 2019 (PMID 30392755) / MSLT-I (Morton/Faries NEJM 2014 PMID 24521106) — SLNB is the most powerful prognostic stratifier; offer/discuss at ≈T1b (≥0.8 mm or <0.8 mm with ulceration) and all ≥T2; performed at the same setting as WLE.
3. nodal_ultrasound_surveillance_instead_of_completion_lymphadenectomy (surveillance_procedure, first line) — MSLT-II (Faries NEJM 2017 PMID 28591523) — immediate completion lymphadenectomy did NOT improve melanoma-specific survival vs nodal ultrasound surveillance for SLN+; nodal US surveillance is the default, completion dissection reserved for selected cases.
4. staged_or_mohs_excision_for_lentigo_maligna (definitive_surgery, second line) — AAD 2019 (PMID 30392755) — staged excision / Mohs with exhaustive margin assessment for lentigo maligna at anatomically constrained head/neck sites where standard wide margins are unfeasible.
5. imiquimod 5% cream topical 5×/week ×12 wk (regimens vary) (topical_immune_response_modifier, second line) — AAD 2019 (PMID 30392755) — off-label topical imiquimod is an option for lentigo maligna when surgery is declined/unfeasible or as a margin adjunct; lower clearance than surgery, requires close follow-up.
6. definitive_radiotherapy_for_lentigo_maligna (radiotherapy, second line) — AAD 2019 (PMID 30392755) — definitive radiotherapy is an accepted non-surgical option for lentigo maligna in patients who are not surgical candidates.

Setting playbook (outpatient) — Recognise the suspicious pigmented/amelanotic lesion, perform a diagnostic excisional biopsy, assign AJCC8 stage from synoptic histopathology, deliver wide local excision ± SLNB with correct stage-based margins, route advanced/adjuvant systemic therapy to oncology, and establish lifelong stage-stratified surveillance (AAD 2019 PMID 30392755; AJCC 8th edition)
7. wide local excision with AJCC8/AAD stage-based margins (definitive, dermatology-owned) in situ 0.5–1 cm; ≤1 mm 1 cm; >1–2 mm 1–2 cm; >2 mm 2 cm surgical single definitive procedure — Biopsy-confirmed primary cutaneous melanoma (AAD 2019 PMID 30392755) (Stage-based margin WLE is the curative cornerstone of localised melanoma)
8. imiquimod 5% (lentigo maligna, non-surgical candidate / margin adjunct) 5% cream topical 5×/wk ×12 wk — Lentigo maligna where surgery declined/unfeasible (AAD 2019 PMID 30392755) (Off-label topical option for lentigo maligna; lower clearance than surgery — close follow-up)
9. adjuvant anti-PD-1 (nivolumab / pembrolizumab) — ROUTED to oncology pembrolizumab 200 mg q3wk IV q3wk ×~1 yr — Resected stage III or high-risk IIB/IIC (KEYNOTE-716 PMID 35367007; CheckMate 238 PMID 37058595) (Adjuvant anti-PD-1 reduces recurrence; delivered by oncology, derm co-manages cutaneous irAE)
10. advanced systemic (ipilimumab+nivolumab / BRAF-MEK) — ROUTED to oncology ipilimumab 3 mg/kg + nivolumab induction IV q3wk ×4 then maintenance — Unresectable / metastatic disease (CheckMate 067 PMID 31562797; COMBI-d/v PMID 31166680) (Combination immunotherapy / BRAF-MEK by oncology; dermatology co-manages cutaneous toxicity and surveils for second primaries)

Non-pharmacologic actions:
- Diagnostic narrow-margin excisional biopsy (or full-thickness punch/incisional through the thickest area) — never a superficial shave for a deep/uncertain pigmented lesion (AAD 2019 PMID 30392755)
- Sentinel lymph node biopsy at the same setting per AJCC8/MSLT-I criteria (PMID 24521106)
- Nodal ultrasound surveillance instead of completion lymphadenectomy for SLN+ (MSLT-II PMID 28591523)
- Staged/Mohs excision or definitive radiotherapy for lentigo maligna where wide margins are unfeasible (AAD 2019 PMID 30392755)
- Multidisciplinary tumour-board referral for stage ≥III; oncology shared-care for any systemic therapy
- Structured skin self-examination + photoprotection + familial/CDKN2A counselling education (AAD 2019 PMID 30392755)

AVOID / contraindication checks:
- Braf mek targeted only if braf v600 mutant (BRAF inhibitor MONOTHERAPY in BRAF wildtype melanoma can paradoxically activate MAPK and accelerate growth — molecular testing is mandatory before any BRAFi; always partnered with a MEK inhibitor when used)
- Checkpoint inhibitor autoimmune and solid organ transplant caution (high risk of irAE flare / allograft rejection — checkpoint immunotherapy decisions are oncology led with transplant/rheumatology input; recognised and routed, not initiated here)
- Checkpoint inhibitor severe irAE is an emergency (Grade 3–4 colitis/hepatitis/pneumonitis/myocarditis/endocrinopathy → emergent oncology hold + systemic corticosteroids; not managed by escalating melanoma therapy)
- Systemic immuno and targeted therapy generally deferred in pregnancy (wide local excision and SLNB are safe; staging imaging modified; systemic therapy deferred/oncology MFM led — AAD 2019 PMID 30392755)
- Do not monitor a high suspicion pigmented lesion (a clinically/dermoscopically suspicious lesion warrants prompt diagnostic excisional biopsy — short interval digital dermoscopy is only for low suspicion equivocal lesions, never to defer biopsy of a suspicious one — AAD 2019 PMID 30392755)
- No superficial shave for a deep or uncertain pigmented lesion (a transected base prevents accurate Breslow/staging; use narrow excisional or full thickness punch/incisional through the thickest area — AAD 2019 PMID 30392755)

Monitoring

Regimen monitoring:
- stage-stratified total-body skin + regional-node exam: q6–12mo stage 0–I; q3–6mo stage II–IV yr1–2 then lengthen (AAD 2019 PMID 30392755)
- nodal ultrasound surveillance for SLN-positive patients managed without completion lymphadenectomy (MSLT-II PMID 28591523)
- stage-directed cross-sectional / brain imaging + serum LDH for node-positive / high-stage / metastatic disease (AJCC8; AAD 2019 PMID 30392755)
- checkpoint-inhibitor irAE surveillance (skin, thyroid, hepatitis, colitis, pneumonitis, hypophysitis, myocarditis) for routed-systemic patients — derm co-monitors skin, escalates severe irAE to oncology (CheckMate 067 PMID 31562797)
- BRAF/MEK toxicity surveillance (pyrexia, ocular, cardiac LVEF, cutaneous SCC/keratoacanthoma) per oncology for BRAF-mutant patients on targeted therapy (COMBI-d/v PMID 31166680)
- lifelong skin self-examination + second-primary vigilance (elevated lifetime second-melanoma risk) (AAD 2019 PMID 30392755)

Setting (outpatient) monitoring:
- Stage-stratified total-body skin + node exam (q6–12mo stage 0–I; q3–6mo stage II–IV yr1–2) (AAD 2019 PMID 30392755)
- Nodal US for SLN+ on observation; stage-directed imaging + LDH for high stage (MSLT-II PMID 28591523; AJCC8)
- Cutaneous irAE + BRAF/MEK toxicity co-monitoring for routed-systemic patients (CheckMate 067 PMID 31562797)

Follow-up plan: Lifelong derm continuity: scheduled total-body skin exams (second-primary risk is elevated for life — ~ up to 5–10% lifetime second melanoma), structured skin self-examination + partner-assisted nail/scalp/acral checks, photoprotection counselling, surveillance imaging cadence by stage, and first-degree-relative + CDKN2A familial counselling (incl. pancreatic-cancer surveillance discussion in CDKN2A kindreds). Re-stage and re-route to oncology on recurrence/in-transit/new-primary; reconcile any checkpoint-inhibitor cutaneous irAE with derm.drug-eruption.core.v1.
- Close-out criterion: lifelong surveillance + self-exam + photoprotection + familial counselling documented; recurrence/second-primary re-entry path defined

Monitoring phase: Stage-stratified surveillance (AAD 2019 PMID 30392755): history + total-body skin + regional-node exam every 6–12 mo for low-risk stage 0–I, every 3–6 mo for stage II–IV (years 1–2) extending intervals over time, lifelong skin self-exam education; nodal ultrasound for SLN+ on observation (MSLT-II PMID 28591523); stage-directed cross-sectional/brain imaging + LDH for higher stages. For patients on routed systemic therapy, dermatology co-monitors immune cutaneous toxicity and surfaces severe irAE (thyroid/hepatitis/colitis/pneumonitis/dermatitis/myocarditis) for emergent oncology routing; BRAF/MEK toxicity (pyrexia, ocular, cardiac, cutaneous) per oncology.

Disposition

Current setting: outpatient — Recognise the suspicious pigmented/amelanotic lesion, perform a diagnostic excisional biopsy, assign AJCC8 stage from synoptic histopathology, deliver wide local excision ± SLNB with correct stage-based margins, route advanced/adjuvant systemic therapy to oncology, and establish lifelong stage-stratified surveillance (AAD 2019 PMID 30392755; AJCC 8th edition)

Disposition criteria:
- In situ / thin node-negative melanoma → outpatient WLE + lifelong surveillance, no systemic therapy (AAD 2019 PMID 30392755)
- Stage III / high-risk II / IV → MDT + oncology shared-care; systemic therapy routed to onc.melanoma-systemic.core.v1 by engine_id
- Inpatient/urgent only for bulky surgical disease, symptomatic metastasis, brain metastasis, or severe irAE

Escalation triggers (move to higher acuity):
- Clinically/dermoscopically suspicious lesion → urgent diagnostic excisional biopsy — do NOT monitor (AAD 2019 PMID 30392755)
- Palpable nodal / satellite / in-transit / thick-ulcerated disease → urgent staging + oncology/MDT referral (AJCC 8th edition)
- Metastatic visceral or brain-metastasis symptoms → urgent oncology ± neurosurgery, route by engine_id (AAD 2019 PMID 30392755)
- Severe checkpoint-inhibitor irAE (Grade 3–4 colitis/hepatitis/pneumonitis/myocarditis) → emergent oncology hold + systemic immunosuppression (CheckMate 067 PMID 31562797)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Patient on routed checkpoint-inhibitor therapy with Grade 3–4 immune-related colitis, hepatitis, pneumonitis, myocarditis, or endocrine crisis (CheckMate 067 PMID 31562797)
- [LIFE_THREATENING] Distant metastatic disease — visceral symptoms, elevated LDH, or neurologic deficit/headache suggesting brain metastasis (AJCC 8th edition; AAD 2019 PMID 30392755)
- [SEVERE] A pigmented or amelanotic lesion clinically/dermoscopically suspicious for melanoma (ABCDE, ugly-duckling, blue-white veil, atypical network, regression) (AAD 2019 PMID 30392755)

Citations

- AAD 2019 Guidelines of care for the management of primary cutaneous melanoma (Swetter et al, JAAD; PMID 30392755, DOI 10.1016/j.jaad.2018.08.055) + AJCC 8th edition cutaneous-melanoma staging (Gershenwald) + MSLT-I final report (Morton/Faries, NEJM 2014; PMID 24521106) + MSLT-II (Faries, NEJM 2017; PMID 28591523) + CheckMate 067 5-yr (Larkin/Wolchok, NEJM 2019; PMID 31562797) + KEYNOTE-006 (Robert, NEJM 2015; PMID 25891173; 7-yr PMID 37348035) + COMBI-d/v 5-yr pooled (Robert, NEJM 2019; PMID 31166680) + CheckMate 238 adjuvant 5-yr (Larkin, CCR 2023; PMID 37058595) + KEYNOTE-716 adjuvant stage IIB/C (Luke, Lancet 2022; PMID 35367007) + SWOG S1801 neoadjuvant (Patel, NEJM 2023; PMID 36856617) [PMID:30392755](https://pubmed.ncbi.nlm.nih.gov/30392755/)
- Cited evidence (PMID 24521106) [PMID:24521106](https://pubmed.ncbi.nlm.nih.gov/24521106/)
- Cited evidence (PMID 28591523) [PMID:28591523](https://pubmed.ncbi.nlm.nih.gov/28591523/)
- Cited evidence (PMID 31562797) [PMID:31562797](https://pubmed.ncbi.nlm.nih.gov/31562797/)
- Cited evidence (PMID 25891173) [PMID:25891173](https://pubmed.ncbi.nlm.nih.gov/25891173/)

Last reconciled with current guidelines: 2026-05-22.

References

AAD 2019 Guidelines of care for the management of primary cutaneous melanoma (Swetter et al, JAAD; PMID 30392755, DOI 10.1016/j.jaad.2018.08.055) + AJCC 8th edition cutaneous-melanoma staging (Gershenwald) + MSLT-I final report (Morton/Faries, NEJM 2014; PMID 24521106) + MSLT-II (Faries, NEJM 2017; PMID 28591523) + CheckMate 067 5-yr (Larkin/Wolchok, NEJM 2019; PMID 31562797) + KEYNOTE-006 (Robert, NEJM 2015; PMID 25891173; 7-yr PMID 37348035) + COMBI-d/v 5-yr pooled (Robert, NEJM 2019; PMID 31166680) + CheckMate 238 adjuvant 5-yr (Larkin, CCR 2023; PMID 37058595) + KEYNOTE-716 adjuvant stage IIB/C (Luke, Lancet 2022; PMID 35367007) + SWOG S1801 neoadjuvant (Patel, NEJM 2023; PMID 36856617) — PMID:30392755
Cited evidence (PMID 24521106) — PMID:24521106
Cited evidence (PMID 28591523) — PMID:28591523
Cited evidence (PMID 31562797) — PMID:31562797
Cited evidence (PMID 25891173) — PMID:25891173