How do you approach patients with very low risk stage IIIA cutaneous melanoma for adjuvant immunotherapy?

Although it may seem that Stage 3A is a higher stage than Stage 2B and 2C, it must be kept in mind that according to AJCC 8 criteria, 2B and 2C melanomas are thicker (with to without ulceration), and a 3A melanoma is by definition a thinner melanoma. A thin melanoma (<2mm) is called a 3A melanoma because of the lymph node deposit that is found on sentinel node biopsy. The risk of 'systemic' recurrence in such patients is extremely low compared to someone with thicker melanoma, even without a lymph node deposit.

Such patients (as mentioned here) were not a part of any trial. KEYNOTE 054 included patients with lymph node deposits >1mm. Hence, ideally, such patients should not be offered adjuvant checkpoint inhibition. However, there is a confl...