Objectives: To describe the scientific evidence regarding adjuvant treatment for stage III and IV cutaneous melanoma and the unresolved issues in this setting. Methods: This review examines the main studies on adjuvant medical therapies approved over the years by the Food and Drug Administration and European Medicines Agency together with the main evidence related to the treatments referred to in the National Comprehensive Cancer Network and European Society of Clinical Oncology guidelines at the time of submission (May 2026) for stage III and IV cutaneous melanoma. A particular focus on immunotherapy (interferon, ipilimumab, and anti-PD-1 antibodies, both as monotherapy and in combination) and targeted therapy with anti-BRAF agents, either as monotherapy or in combination with MEK inhibitors, is given. Besides that, this work also evaluates the role of radiation therapy and addresses some unresolved issues, such as adjuvant therapy in stage IIIA and treatment selection in BRAF-mutated melanoma. Results: Adjuvant therapy for stage III and IV cutaneous melanoma has evolved over the years, starting with interferon and progressing to the use of immunocheckpoint inhibitors and targeted therapy. However, not all treatments that have proven effective in metastatic disease have subsequently played a role in the adjuvant setting. Conclusions: Currently, adjuvant treatment for stage III and IV cutaneous melanoma involves the use of anti-PD-1 antibodies (nivolumab and pembrolizumab) and dabrafenib plus trametinib if the patient has a BRAF V600 mutation. It was not possible to identify the adjuvant therapy of choice for BRAF-mutated melanoma, and several factors must be considered when deciding between immunotherapy and targeted therapy. The role of radiation therapy remains controversial and could be discussed by the multidisciplinary team as part of the adjuvant strategy in selected patients. Likewise, adjuvant therapy for stage IIIA melanoma should be carefully evaluated in light of the risk–benefit ratio.

Background: Melanoma disproportionately affects older adults, who account for a growing share of cases as populations age. Its incidence rises with age, and the number of ultra-octogenarians (≥85 years) is expected to triple by 2050, particularly in high-incidence regions such as Australia, North America and Europe. Moreover, older adults frequently present with substantial comorbidities, making management complex and complicating treatment decisions. Methods: This comprehensive review summarizes evidence concerning the clinicopathological characteristics, treatment patterns, systemic therapy outcomes, and geriatric considerations relevant to patients aged 75 years or older with melanoma. PubMed/MEDLINE was searched from January 2000 to March 2026. Reference lists of eligible articles and relevant reviews were examined to identify additional studies. Priority was given to studies reporting age-stratified outcomes for patients aged at least 75 years. Because relatively few studies reported outcomes specifically for patients aged ≥75 years, evidence using thresholds of ≥65, ≥70, or ≥80 years was included when directly relevant. Age thresholds are reported for each study and should not be considered interchangeable. Results: Most evidence specific to patients aged ≥75 years derives from retrospective cohorts and registries. Compared with younger patients, elderly patients more often present with melanomas of the head, neck, hands and feet, a higher prevalence of the nodular subtype, greater Breslow thickness, higher mitotic rates and lower tumor-infiltrating lymphocyte density. Diagnosis is frequently delayed due to difficulties with self-examination, visual impairment, benign age-related skin changes and social factors. Despite presenting such a high-risk disease, older patients are less likely than their younger counterparts to receive immunotherapy or BRAF/MEK-targeted agents. This treatment gap may reflect comorbidities, altered pharmacokinetics, concerns about toxicity, under-representation in pivotal trials, and limited caregiver support. Available real-world data suggest that the efficacy of immune checkpoint inhibitors and targeted therapies is comparable to that in younger adults, although treatment selection, discontinuation, hospitalization, and dose modification differ across studies. Conclusions: Melanoma in older adults has distinct clinical and pathological patterns, but treatment evidence for patients aged ≥75 years remains limited and subjected to selection bias. Tailored, geriatric-informed treatment strategies integrating tumor biology, comorbidity, functional status and patient preferences are needed to optimize outcomes for patients aged 75 years and older.

Melanoma adjuvant therapy has substantially improved recurrence-free and distant metastasis-free survival in patients with resected high-risk disease, and more recently these advances have extended to earlier stages. However, important unmet needs remain, including the management of stage IIIA disease, the optimal treatment strategy after relapse on adjuvant therapy, and the identification of biomarkers capable of refining patient selection. This review summarizes recent advances and unresolved questions in the adjuvant and neoadjuvant treatment of melanoma. We discuss novel systemic strategies, including immune checkpoint inhibitor combinations and personalized neoantigen mRNA vaccines, together with the expanding role of neoadjuvant approaches. We also examine prognostic and predictive tools - such as clinicopathologic models, circulating tumor DNA, serum biomarkers, tumor microenvironment features, and gene expression profiling – that may help better define recurrence risk and therapeutic benefit. Current evidence suggests that although modern therapies have changed the natural history of resected melanoma, a substantial proportion of patients are still overtreated or undertreated when treatment decisions are based on stage alone. Future progress will depend on integrating biological risk stratification with clinical staging and on optimizing treatment sequencing across adjuvant and neoadjuvant settings.

Melanoma adjuvant therapy has substantially improved recurrence-free and distant metastasis-free survival in patients with resected high-risk disease, and more recently, these advances have extended to earlier stages. However, important unmet needs remain, including the management of stage IIIA disease, the optimal treatment strategy after relapse on adjuvant therapy, and the identification of biomarkers capable of refining patient selection. This review summarizes recent advances and unresolved questions in the adjuvant and neoadjuvant treatment of melanoma. We discuss novel systemic strategies, including immune checkpoint inhibitor combinations and personalized neoantigen mRNA vaccines, together with the expanding role of neoadjuvant approaches. We also examine prognostic and predictive tools—such as clinicopathologic models, circulating tumor DNA, serum biomarkers, tumor microenvironment features, and gene expression profiling—that may help better define recurrence risk and therapeutic benefit. Current evidence suggests that although modern therapies have changed the natural history of resected melanoma, a substantial proportion of patients are still overtreated or undertreated when treatment decisions are based on stage alone. Future progress will depend on integrating biological risk stratification with clinical staging and optimizing treatment sequencing across adjuvant and neoadjuvant settings.

Melanoma has long represented a unique challenge in oncology. In its early stages, it can often be cured with surgery alone, resulting in excellent survival outcomes. Its biology is complex and heterogeneous, often including mutations such as BRAF and NRAS, which partly explain its high immunogenicity but also its capacity to relapse. For many decades, the standard approach in resectable stage III melanoma was surgery first, followed by adjuvant therapy. In the last decade, the development of immune checkpoint inhibitors created the opportunity to treat patients before surgery. The neoadjuvant approach is based on the hypothesis that treatment of the intact tumor may enhance antitumor immune priming and activation. The first prospective neoadjuvant studies, including OpACIN and OpACIN-neo, showed high pathological response rates with ipilimumab plus nivolumab and introduced pathological response as an early marker of long-term benefit. The PRADO study showed that treatment response could guide the extent of surgery required. The SWOG S1801 trial demonstrated better event-free survival with perioperative pembrolizumab compared to adjuvant therapy alone. Lastly, the phase III NADINA trial showed that neoadjuvant ipilimumab plus nivolumab followed by response-adapted adjuvant therapy significantly improves outcomes. Biomarkers such as PD-L1, IFN-γ signature, tumor mutational burden and imaging (PET scan) appear promising to predict response, but none have been sufficiently validated for routine clinical practice.

The role of adjuvant therapy in stage III melanoma is well established in clinical practice. Because stage IIB–IIC melanoma carries a risk of recurrence and melanoma-specific mortality comparable to that of stage III disease, adjuvant approaches have also been developed for patients with thick stage II tumors. Both pembrolizumab and nivolumab have demonstrated efficacy in reducing the risk of local and distant recurrence in patients with high-risk stage II melanoma, whereas evidence supporting the use of BRAF-MEK inhibitors in this setting remains inconclusive. Combinations of immune checkpoint inhibitors, as well as immunotherapy combined with mRNA-based vaccines, are currently under investigation in clinical trials. However, given the non-trivial risk of immune-related adverse events, careful selection of patients with stage II disease who are most likely to derive meaningful benefit from adjuvant therapy is essential. In this context, several clinicopathologic variables and gene expression profiling-based prognostic tools have been proposed to refine risk stratification. To date, however, none of these instruments have been incorporated into routine clinical practice, and no validated predictive biomarkers are available. Accordingly, optimal patient selection for adjuvant therapy remains an important unmet clinical need in early-stage melanoma.