Variation in the practice of wide local excision for melanoma in Ireland and the UK: a questionnaire survey

Abstract

Background Wide local excision (WLE) is standard practice in the management of melanoma, but no national or international guidelines exist regarding its technique. Objectives The aims of this study were to assess variation in the practice of WLE and to explore the effect of clinicians’ specialty and grade on such variation. Methods This was an international, anonymized, cross-sectional study. An online questionnaire was distributed to the Irish Association of Dermatologists, British Association of Dermatologists, British Association of Plastic and Reconstructive and Aesthetic Surgeons, Melanoma Focus, and BioGenoMEL members. Results Of 128 respondents, 57% were dermatologists and 38% plastic surgeons. Most (80%) were consultants. Almost all clinicians learned their technique from colleagues (99%) “on the job”, while 21% also used textbooks/media as part of WLE training. There was significant variation in planning and performing WLE: 59% considered margins already achieved, 71% marked margins with the skin relaxed. For 1 cm WLE, 84% delineated 1 cm from the scar edge; with plastic surgeons more likely to mark from the scar midpoint (p < 0.05). Most followed a longitudinal/oblique axis on the limbs for WLE (81%). Only 40% sent “dog ears” for histology. Most (71%) incised along the marked line, 27% incised outside it. Most (79%) excised to deep fascia, 19% to the next biological margin. Conclusion This study demonstrates significant variation among clinicians performing WLE, an essential component of melanoma management. We postulate that this could impact on patient outcomes. A consensus statement should be developed, to achieve more consistency in the practice of WLE.