How do you treat an isolated in-transit recurrence of melanoma without evidence of clinical nodal involvement in a patient with a history of previously resected primary melanoma?

TVEC is an option.

I could also agree on NADINA or pembrolizumab, depending on the patient's other comorbidities.

Resection is also a possibility, but then would need a discussion of adjuvant therapy.

Indeed, there are many options, and none has been studied in detail.

I like neoadjuvant, as it gives an...

If the patient does not have a clinical lymph node, then neither of those two trials is applicable. We treat "isolated" in-transit metastasis with T-VEC first. Surgical resection can be done later if there is less than a complete pathologic response.