Synthetic educational example. Do not self-treat: a qualified treating physician must verify the sources, patient data, contraindications, and final plan.
Patient
MELANOMA-ADJ-PEMBRO-STAGE3-001 · 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 |
|---|
| No clinically actionable variants matched in this profile. |
| Biomarker | Status |
|---|
| BIO-BRAF-V600E | Excluded (negative) |
| BIO-BRAF-V600K | Excluded (negative) |
| BIO-NRAS | Not in KB — ask clinician to verify |
| BIO-KIT | BIO definition in KB; no ESCAT BMA entry — verify with clinician |
Primary current-line option
- 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
- Primary current-line option selected by ALGO-MELANOMA-METASTATIC-1L at step 0; branch-driving red flag: RF-MELANOMA-STAGE-III-RESECTED.
Other current-line alternatives (3 tracks)
Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.
- 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
- Current-line alternative 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
- Current-line alternative 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
- Current-line alternative presented for HCP consideration
Why this branch was chosen
Triggers from the patient profile that fired and drove the chosen branch.
Step 0 → branch IND-MELANOMA-ADJUVANT-PEMBRO-STAGE-III
- RF-MELANOMA-STAGE-III-RESECTED ★ winner: Resected stage III cutaneous melanoma — adjuvant-eligible biology (positive sentinel-lymph-node biopsy or clinically detected nodal disease, surgically resected via wide local excision ± completion lymphadenectomy or therapeutic neck/inguinal dissection per surgical judgment). Treatment-defining: shifts the patient out of the metastatic 1L pathway into adjuvant immunotherapy (KEYNOTE-054 pembrolizumab × 12 months, CheckMate-238 nivolumab × 12 months) or adjuvant BRAFi+MEKi (COMBI-AD dabrafenib + trametinib) for BRAF V600 mutants. Adjuvant therapy initiated within 12 weeks of definitive surgery per the registration trials.
SRC-NCCN-MELANOMA-2025SRC-ESMO-MELANOMA-2024SRC-KEYNOTE-054-EGGERMONT-2018SRC-CHECKMATE-238-WEBER-2017SRC-COMBI-AD-LONG-2017
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
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 · Pembrolizumab adjuvant (resected stage III/IV melanoma; KEYNOTE-054)
21-day cycles × 18 cycles (~12 months) per KEYNOTE-054 protocol
Standard plan
Induction · Nivolumab + ipilimumab (melanoma, 1L metastatic)
21-day cycles × 4 induction; nivo maintenance until progression OR 2 years
Aggressive plan
Induction · Dabrafenib + trametinib (BRAF V600E+ NSCLC)
28-day cycles × Continuous until progression
Standard plan
Induction · Pembrolizumab monotherapy (advanced/metastatic melanoma, 1L; KEYNOTE-006)
21-day cycles × Up to 35 cycles (~2 years) or until progression
MDT brief
Discussion questions (1, 0 blocking)
MDT talk tree (3 steps)
| # | Owner | Topic | Action |
|---|
| 1 | hematologist | Staging / disease burden | What is the current LDH? Marker of tumor burden and transformation. |
| 2 | clinical_pharmacist | Specialist review | Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication. |
| 3 | molecular_geneticist | Specialist review | Indication references an actionable genomic biomarker — mutation / target / actionability interpretation needed. |
Skills (recommended) — for consideration (2)
- Clinical pharmacist recommended
Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.
- Molecular geneticist / molecular oncologist recommended
Indication references an actionable genomic biomarker — mutation / target / actionability interpretation needed.
Data quality
Usable with caveats. No critical default-track gap was found, but the MDT should review the listed caveats before final sign-off.
- Biomarker coverage: 1/1 known (100%), 0 missing, 0 default-track gaps
- Unevaluated RedFlags: RF-ACTIVE-AUTOIMMUNE-DISEASE-ICI-RISK, RF-BAP1-CONFIRMED-CARRIER, RF-CDKN2A-SPECIFIC-PDAC-CARRIER, RF-ENVIRONMENTAL-OUTDOOR-UV-SKIN-PREVENTION, RF-FAMMM-CONFIRMED-CARRIER, RF-LIFESTYLE-UV-EXPOSURE-PREVENTION, RF-MELANOMA-BRAF-V600-ACTIONABLE, RF-MELANOMA-INFECTION-SCREENING, RF-MELANOMA-IO-RESISTANT, RF-MELANOMA-KIT-MUT-ACTIONABLE, RF-MELANOMA-NF1-MUT-CANDIDATE, RF-MELANOMA-ORGAN-DYSFUNCTION, RF-OCC-FIREFIGHTER-PREVENTION, RF-UVEAL-MELANOMA-BAP1-MUT-CANDIDATE, RF-WERNER-CONFIRMED-CARRIER
Technical MDT skill metadata (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: 2026-08-17.
| NCT | Title | Phase | Status | Sponsor | UA | Signals | Eligibility (excerpt) |
|---|
| NCT06332755 | Study to Evaluate LB-LR1109, Administered Alone for the Treatment of Solid Tumor and in Combination With Atezolizumab for the Treatment of NSCLC | PHASE1 | RECRUITING | — | Phase 1 only Single country | |
| NCT03315468 | French Clinical Datbase of Melanoma Patients (RIC-Mel) | N/A | RECRUITING | — | Single country | |
| NCT06199713 | Correlating Early FDG PET/CT and ctDNA in Immune Checkpoint Inhibitor (ICI)-Treated Melanoma Patients | N/A | RECRUITING | — | Small N (<50) Surrogate endpoint only Single country | |
| NCT07244835 | A Study of DEG6498 in Participants With Solid Tumors | PHASE1 | RECRUITING | — | Phase 1 only Single country | |
| NCT06172478 | A Study of HER3-DXd in Subjects With Locally Advanced or Metastatic Solid Tumors | PHASE2 | RECRUITING | — | Surrogate endpoint only | |
| NCT05379985 | Study of RMC-6236 in Patients With Advanced Solid Tumors Harboring Specific Mutations in RAS | PHASE1 / PHASE2 | RECRUITING | — | Single country | |
| NCT03702309 | Liquid Biopsy Evaluation and Repository Development at Princess Margaret | N/A | RECRUITING | — | Single country | |
| NCT07749586 | A Study to Evaluate ARV-6723 Alone and With Pembrolizumab in Participants With Advanced Solid Tumors | PHASE1 / PHASE2 | RECRUITING | — | Surrogate endpoint only Single country | |
| NCT07092670 | MELAFERT: Impact of Adjuvant Therapy on FERTility in Patients With Resected MELAnoma at High Risk of Relapse. | N/A | RECRUITING | — | Single country | |
| NCT05373823 | MySmartSkin Online Skin Self-exam Intervention for Melanoma Survivors | NA | RECRUITING | — | Single country | |
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 Pembrolizumab adjuvant (resected stage III/IV melanoma; KEYNOTE-054) (REG-PEMBRO-ADJUVANT-MELANOMA) | ✓ registered | ✓ covered | ₴-? — verify pathway | NSZU formulary |
| Standard plan Nivolumab + ipilimumab (melanoma, 1L metastatic) (REG-NIVO-IPI-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 · NCT06332755 Study to Evaluate LB-LR1109, Administered Alone for the Treatment of Solid Tumor and in Combination With Atezolizumab for the Treatment of NSCLC No UA site listed — international referral required | — unknown | — unknown | self-pay: ₴0/course | Trial sponsor |
| Trial · NCT03315468 French Clinical Datbase of Melanoma Patients (RIC-Mel) No UA site listed — international referral required | — unknown | — unknown | self-pay: ₴0/course | Trial sponsor |
| Trial · NCT06199713 Correlating Early FDG PET/CT and ctDNA in Immune Checkpoint Inhibitor (ICI)-Treated Melanoma Patients No UA site listed — international referral required | — unknown | — unknown | self-pay: ₴0/course | Trial sponsor |
| Trial · NCT07244835 A Study of DEG6498 in Participants With Solid Tumors No UA site listed — international referral required | — unknown | — unknown | self-pay: ₴0/course | Trial sponsor |
| Trial · NCT06172478 A Study of HER3-DXd in Subjects With Locally Advanced or Metastatic 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 · NCT03702309 Liquid Biopsy Evaluation and Repository Development at Princess Margaret No UA site listed — international referral required | — unknown | — unknown | self-pay: ₴0/course | Trial sponsor |
| Trial · NCT07749586 A Study to Evaluate ARV-6723 Alone and With Pembrolizumab in Participants With Advanced Solid Tumors No UA site listed — international referral required | — unknown | — unknown | self-pay: ₴0/course | Trial sponsor |
| Trial · NCT07092670 MELAFERT: Impact of Adjuvant Therapy on FERTility in Patients With Resected MELAnoma at High Risk of Relapse. No UA site listed — international referral required | — unknown | — unknown | self-pay: ₴0/course | Trial sponsor |
| Trial · NCT05373823 MySmartSkin Online Skin Self-exam Intervention for Melanoma Survivors 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: 2026-08-17.