Resected stage III cutaneous melanoma — adjuvant-eligible biology (positive sentinel-lymp...

Deterministic view of the source YAML entity. Clinical authority remains with the cited source IDs and reviewer sign-off state.

ID	`RF-MELANOMA-STAGE-III-RESECTED`
Type	Red flag
Status	reviewed 2026-04-30 \| pending_clinical_signoff
Diseases	`DIS-MELANOMA`
Sources	`SRC-CHECKMATE-238-WEBER-2017` `SRC-COMBI-AD-LONG-2017` `SRC-ESMO-MELANOMA-2024` `SRC-KEYNOTE-054-EGGERMONT-2018` `SRC-NCCN-MELANOMA-2025`

Red Flag Origin

Definition	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.
Clinical direction	intensify
Category	high-risk-biology
Shifts algorithm	ALGO-MELANOMA-METASTATIC-1L, ALGO-MELANOMA-ADJUVANT-1L

Trigger Logic

{
  "all_of": [
    {
      "finding": "stage_iii",
      "value": true
    },
    {
      "finding": "stage_iv",
      "value": false
    },
    {
      "any_of": [
        {
          "finding": "resection_status",
          "value": "R0_resected"
        },
        {
          "finding": "resection_status",
          "value": "R1_resected"
        },
        {
          "finding": "wide_local_excision_completed",
          "value": true
        }
      ]
    }
  ],
  "type": "stage_resection_composite"
}

Notes

Engine wiring: when resected-stage-III biology is detected on a patient profile that lacks `disease_state` (so the metastatic-1L algorithm is the only line=1 algorithm available by load-order fallback), this RedFlag fires inside ALGO-MELANOMA-METASTATIC-1L step 0 to redirect the engine to the adjuvant indication (IND-MELANOMA-ADJUVANT-PEMBRO-STAGE-III) instead of the metastatic-1L default. Once curated patient JSONs migrate to set `disease_state: "adjuvant"`, ALGO-MELANOMA-ADJUVANT-1L picks them up directly and this step 0 becomes redundant (still safe — it's additive). KEYNOTE-054 BRAF-WT and BRAF-mut both eligible — adjuvant pembro is the standard-track default; aggressive-track substitution to dabra+trame (COMBI-AD) is BRAF-mut subgroup only.

Used By

Algorithms

ALGO-MELANOMA-ADJUVANT-1L - ALGO-MELANOMA-ADJUVANT-1L
ALGO-MELANOMA-METASTATIC-1L - ALGO-MELANOMA-METASTATIC-1L