Patient
BMA-KRAS_Q61_MELANOMA · Algorithm: ALGO-MELANOMA-METASTATIC-1L
Clinical significance of mutations (ESCAT)
Tumor-board context — the engine does not use these tiers to rank tracks
| Biomarker | Variant | ESCAT | Evidence | Clinical significance | Drugs | Sources |
|---|
| BIO-RAS-MUTATION | KRAS Q61X | IIB | | KRAS Q61 (rare in melanoma; NRAS Q61 is more common) — MEKi monotherapy modest activity (binimetinib in NRAS-mut melanoma NEMO trial; KRAS Q61 cells extrapolated). | — | |
| BIO-RAS-MUTATION | NRAS G12 | IIIA | | NRAS G12/G13 — rarer than Q61 mutations in melanoma. Same MEKi/ICI rationale extrapolated. | anti-PD1-based ICI | |
| BIO-RAS-MUTATION | NRAS G13 | IIIA | | NRAS G13 in melanoma — limited data; treat per NRAS-mut algorithm. | anti-PD1-based ICI | |
| BIO-RAS-MUTATION | NRAS Q61K | IB | | NRAS Q61K — same therapeutic rationale as Q61R. ICI 1L; binimetinib NEMO subgroup. | anti-PD1-based ICI
binimetinib (off-label) | |
| BIO-RAS-MUTATION | NRAS Q61R | IB | | NRAS Q61R is the most common NRAS hotspot in melanoma (~20% of cutaneous melanomas). Binimetinib (MEKi) monotherapy improved PFS vs dacarbazine in NEMO (Dummer et al. Lancet Oncol 2017) — modest benefit; not FDA-approved as monotherapy. ICI (anti-PD1 ± anti-CTLA4) is the standard 1L for NRAS-mut metastatic melanoma. MEKi+CDK4/6i combos under investigation. | nivolumab + ipilimumab (1L preferred)
binimetinib (NEMO; investigational/off-label) | - SRC-NCCN-MELANOMA-2025
- SRC-ESMO-MELANOMA-2024
|
Treatment options (4 tracks)
- Indication
- IND-MELANOMA-METASTATIC-1L-NIVO-IPI
- Regimen
- Nivolumab + ipilimumab (melanoma, 1L metastatic)
- Drugs + NSZU
- Nivolumab (DRUG-NIVOLUMAB) 1 mg/kg IV induction → 480 mg flat IV q4w maintenance · Induction with ipi cycles 1-4 · IV ✓ NSZU covered
- Ipilimumab (DRUG-IPILIMUMAB) 3 mg/kg IV (higher than RCC) · Days 1 of cycles 1-4 · IV ✓ NSZU covered
- Reason
- Engine default per algorithm ALGO-MELANOMA-METASTATIC-1L: {'step': 4, 'outcome': False, 'branch': {'result': 'IND-MELANOMA-METASTATIC-1L-NIVO-IPI'}, 'fired_red_flags': [], 'winner_red_flag': None}
- Indication
- IND-MELANOMA-ADJUVANT-PEMBRO-STAGE-III
- Regimen
- Pembrolizumab adjuvant (resected stage III/IV melanoma; KEYNOTE-054)
- Drugs + NSZU
- Pembrolizumab (DRUG-PEMBROLIZUMAB) 200 mg IV q3w (or 400 mg IV q6w) · Day 1 every 3 weeks (or q6w), for up to 18 cycles (~12 months total) starting within 12 weeks of definitive surgery · IV ✓ NSZU covered
- Reason
- Alternative track presented for HCP consideration
- Indication
- IND-MELANOMA-BRAF-METASTATIC-1L-DABRA-TRAME
- Regimen
- Dabrafenib + trametinib (BRAF V600E+ NSCLC)
- Drugs + NSZU
- Dabrafenib (DRUG-DABRAFENIB) 150 mg PO BID · Continuous · PO ✓ NSZU covered
- Trametinib (DRUG-TRAMETINIB) 2 mg PO once daily · Continuous · PO ✓ NSZU covered
- Reason
- Alternative track presented for HCP consideration
- Indication
- IND-MELANOMA-METASTATIC-1L-PEMBRO-MONO
- Regimen
- Pembrolizumab monotherapy (advanced/metastatic melanoma, 1L; KEYNOTE-006)
- Drugs + NSZU
- Pembrolizumab (DRUG-PEMBROLIZUMAB) 200 mg IV q3w (or 400 mg IV q6w) · Day 1 every 3 weeks (or q6w), for up to 35 cycles (~2 years) or until progression / unacceptable toxicity · IV ✓ NSZU covered
- Reason
- Alternative track presented for HCP consideration
Pre-treatment investigations
Investigations before treatment start · critical / standard / desired · merged across tracks
| ID | Name | Priority | Category | Where to order | Needed for |
|---|
| TEST-CECT-CAP | CECT chest/abdomen/pelvis | Critical | imaging | — | all tracks |
| TEST-LDH | Lactate Dehydrogenase | Critical | lab | — | standard |
| TEST-BRAIN-MRI-CONTRAST | Brain MRI with contrast | Standard | — | — | all tracks |
Red flags — PRO / CONTRA aggressive
PRO-AGGRESSIVE
Triggers that push toward the aggressive track
- Symptomatic CNS metastases — ICI doublet (nivo+ipi) intracranially active; BRAFi+MEKi for visceral crisis.RF-MELANOMA-TRANSFORMATION-PROGRESSION
CONTRA-AGGRESSIVE
Hard contraindications to escalation
What NOT to do
Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity
Standard plan (IND-MELANOMA-ADJUVANT-PEMBRO-STAGE-III)
- Do not start adjuvant IO without negative baseline brain MRI with contrast — occult cerebral metastases are a frequent finding.
- Do not skip baseline TSH / cortisol / glucose — endocrine irAE are the most frequent, and pre-existing endocrinopathies change management.
- Do not start later than 12 weeks from surgery — KEYNOTE-054 window is shorter; benefit poorly characterized after that.
- Do not continue with gr ≥3 irAE without reassessing benefit/risk — adjuvant is curative intent, threshold for permanent discontinuation lower than metastatic.
- Do not combine with immunosuppression or live vaccines.
- Do not skip pre-treatment counseling — irAE may be permanent (endocrinopathies) and impact quality of life more than relapse in some scenarios.
Standard plan (IND-MELANOMA-METASTATIC-1L-PEMBRO-MONO)
- Do not start pembrolizumab without baseline TSH / cortisol / glucose — endocrine irAE are the most frequent.
- Do not ignore active autoimmune disease — relative contraindication, assess risk/benefit with rheumatologist.
- Do not skip baseline brain MRI with contrast — cerebral metastases are often asymptomatic in melanoma.
- Do not continue with gr ≥3 irAE without high-dose steroids (1-2 mg/kg prednisolone-equivalent) — delay in management can be fatal.
- Do not combine with immunosuppressants / live vaccines during treatment.
- Do not prescribe with ECOG ≥3 — limited data, palliative approach more appropriate.
Timeline
Treatment timeline — derived from regimen + monitoring schedule
Standard plan
Induction · Nivolumab + ipilimumab (melano
21-day cycles × 4 induction; nivo maintenance until progression OR 2 years
Standard plan
Induction · Pembrolizumab adjuvant (resect
21-day cycles × 18 cycles (~12 months) per KEYNOTE-054 protocol
Aggressive plan
Induction · Dabrafenib + trametinib (BRAF
28-day cycles × Continuous until progression
Standard plan
Induction · Pembrolizumab monotherapy (adv
21-day cycles × Up to 35 cycles (~2 years) or until progression
MDT brief
Skills (recommended) — for consideration (2)
- Clinical pharmacist recommended
Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.
skill: clinical_pharmacistv0.1.0reviewed 2026-04-25STUBsign-offs: 0lead: TBD
- Molecular geneticist / molecular oncologist recommended
Indication references an actionable genomic biomarker — mutation / target / actionability interpretation needed.
skill: molecular_geneticistv0.1.0reviewed 2026-04-25STUBsign-offs: 0lead: TBD
Open questions (1, 0 blocking)
Data quality
- Unevaluated RedFlags: RF-MELANOMA-BRAF-V600-ACTIONABLE, RF-MELANOMA-HIGH-RISK-BIOLOGY, RF-MELANOMA-INFECTION-SCREENING, RF-MELANOMA-IO-RESISTANT, RF-MELANOMA-KIT-MUT-ACTIONABLE, RF-MELANOMA-NF1-MUT-CANDIDATE, RF-MELANOMA-ORGAN-DYSFUNCTION, RF-MELANOMA-STAGE-III-RESECTED, RF-MELANOMA-TRANSFORMATION-PROGRESSION, RF-UVEAL-MELANOMA-BAP1-MUT-CANDIDATE
Skill catalog (2/16 activated in this plan)
All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).
| Specialist | skill_id | Version | Last reviewed | Sign-offs | Domain |
|---|
| Cellular therapy specialist (CAR-T) | cellular_therapy_specialist | v0.1.0 | 2026-04-25 | 0 | cellular_therapy |
| Clinical pharmacist | clinical_pharmacist | v0.1.0 | 2026-04-25 | 0 | clinical_pharmacy |
| Hematologist / oncohematologist | hematologist | v0.1.0 | 2026-04-25 | 0 | hematology_oncology |
| Hematopathologist (lymphoma / leukemia / myeloma) | hematopathologist | v0.1.0 | 2026-04-25 | 0 | hematopathology |
| Infectious disease / hepatology | infectious_disease_hepatology | v0.1.0 | 2026-04-25 | 0 | infectious_diseases |
| Medical oncologist (solid-tumor chemotherapist) | medical_oncologist | v0.1.0 | 2026-04-25 | 0 | solid_oncology |
| Molecular geneticist / molecular oncologist | molecular_geneticist | v0.1.0 | 2026-04-25 | 0 | molecular_oncology |
| Palliative care | palliative_care | v0.1.0 | 2026-04-25 | 0 | palliative_care |
| Pathologist (general) | pathologist | v0.1.0 | 2026-04-25 | 0 | pathology |
| Primary care / family physician | primary_care | v0.1.0 | 2026-04-25 | 0 | primary_care |
| Psycho-oncologist | psychologist | v0.1.0 | 2026-04-25 | 0 | psychosocial |
| Radiation oncologist | radiation_oncologist | v0.1.0 | 2026-04-25 | 0 | radiation_oncology |
| Radiologist | radiologist | v0.1.0 | 2026-04-25 | 0 | diagnostic_imaging |
| Social worker / case manager | social_worker_case_manager | v0.1.0 | 2026-04-25 | 0 | psychosocial |
| Surgical oncologist | surgical_oncologist | v0.1.0 | 2026-04-25 | 0 | surgical_oncology |
| Transplant specialist (BMT) | transplant_specialist | v0.1.0 | 2026-04-25 | 0 | cellular_therapy |
Sources cited
- SRC-CHECKMATE-067-LARKIN-2019: Five-Year Survival with Combined Nivolumab and Ipilimumab in Advanced Melanoma (2019)
- SRC-CHECKMATE-238-WEBER-2017: Adjuvant Nivolumab versus Ipilimumab in Resected Stage III or IV Melanoma (2017)
- SRC-COMBI-D-LONG-2014: Combined BRAF and MEK Inhibition versus BRAF Inhibition Alone in Melanoma (2014)
- SRC-ESMO-MELANOMA-2024: ESMO Cutaneous Melanoma (2024)
- SRC-KEYNOTE-006-ROBERT-2015: Pembrolizumab versus Ipilimumab in Advanced Melanoma (2015)
- SRC-KEYNOTE-054-EGGERMONT-2018: Adjuvant Pembrolizumab versus Placebo in Resected Stage III Melanoma (2018)
- SRC-NCCN-MELANOMA-2025: NCCN Cutaneous Melanoma (2025.v2)
Experimental options (clinical trials)
Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-05-04.
| NCT | Title | Phase | Status | Sponsor | UA | Eligibility (excerpt) |
|---|
| NCT06229340 | Leflunomide or Combination of MEK Inhibitor and Hydroxychloroquine for Refractory Patients With RAS Mutations | PHASE2 | RECRUITING | — | |
| NCT03454035 | Ulixertinib/Palbociclib in Patients With Advanced Pancreatic and Other Solid Tumors | PHASE1 | RECRUITING | — | |
| NCT05379985 | Study of RMC-6236 in Patients With Advanced Solid Tumors Harboring Specific Mutations in RAS | PHASE1 / PHASE2 | RECRUITING | — | |
| NCT06326411 | A Study to Investigate the Safety and Efficacy of NST-628 Oral Tablets in Subjects With Solid Tumors | PHASE1 | RECRUITING | — | |
Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.
Option availability in Ukraine
Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).
| Option | UA registration | NSZU | Cost orientation | Access pathway |
|---|
| Standard plan Nivolumab + ipilimumab (melanoma, 1L metastatic) (REG-NIVO-IPI-MELANOMA) | ✓ registered | ✓ covered | ₴-? — verify pathway | NSZU formulary |
| Standard plan Pembrolizumab adjuvant (resected stage III/IV melanoma; KEYNOTE-054) (REG-PEMBRO-ADJUVANT-MELANOMA) | ✓ registered | ✓ covered | ₴-? — verify pathway | NSZU formulary |
| Aggressive plan Dabrafenib + trametinib (BRAF V600E+ NSCLC) (REG-DABRAFENIB-TRAMETINIB-NSCLC) | ✓ registered | ✓ covered | ₴-? — verify pathway | NSZU formulary |
| Standard plan Pembrolizumab monotherapy (advanced/metastatic melanoma, 1L; KEYNOTE-006) (REG-PEMBRO-MONO-MELANOMA) | ✓ registered | ✓ covered | ₴-? — verify pathway | NSZU formulary |
| Trial · NCT06229340 Leflunomide or Combination of MEK Inhibitor and Hydroxychloroquine for Refractory Patients With RAS Mutations No UA site listed — international referral required | — unknown | — unknown | self-pay: ₴0/course | Trial sponsor |
| Trial · NCT03454035 Ulixertinib/Palbociclib in Patients With Advanced Pancreatic and Other Solid Tumors No UA site listed — international referral required | — unknown | — unknown | self-pay: ₴0/course | Trial sponsor |
| Trial · NCT05379985 Study of RMC-6236 in Patients With Advanced Solid Tumors Harboring Specific Mutations in RAS No UA site listed — international referral required | — unknown | — unknown | self-pay: ₴0/course | Trial sponsor |
| Trial · NCT06326411 A Study to Investigate the Safety and Efficacy of NST-628 Oral Tablets in Subjects With Solid Tumors No UA site listed — international referral required | — unknown | — unknown | self-pay: ₴0/course | Trial sponsor |
Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-05-04.