Mohs surgery: Difference between revisions

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Revision as of 12:11, 21 April 2009

Editor-In-Chief: Michel C. Samson, M.D., FRCSC, FACS [1]

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Overview

Mohs surgery, also known as chemosurgery, created by a general surgeon, Dr. Fredrick E. Mohs, is microscopically controlled surgery that is highly effective for common types of skin cancer, with a cure rate cited by most studies between 97% and 99.8%^[1] for primary basal cell carcinoma, the most common type of skin cancer. Mohs procedure is also used for squamous cell carcinoma, but with a lower cure rate. Two isolated studies reported cure rate for primary basal cell cancer as low as 95% and 96% (see discussion on "Why is the Cure Rate so Varied?).^[2]^[3]^[4] Recurrent basal cell cancer has a lower cure rate with Mohs surgery, more in the range of 94%.^[5] It has been used in the removal of melanoma-in-situ (cure rate 77% to 98% depending on surgeon), and certain types of melanoma (cure rate 52%).^[6]^[7] Another study of melanoma-in-situ revealed Mohs cure rate of 95% for frozen section Mohs, and 98 to 99% for fixed tissue Mohs method.^[8]^[9] Other indications for Mohs surgery include dermatofibrosarcoma protuberans, keratoacanthoma, spindle cell tumors, sebaceous carcinomas, microcystic adnexal carcinoma, merkel cell carcinoma, Pagets's disease of the breast, atypical fibroxanthoma, leimyosarcoma, and angiosarcoma.^[10] Because the Mohs procedure is micrographically controlled, it provides precise removal of the cancerous tissue, while healthy tissue is spared. Mohs surgery is relatively expensive when compared to other surgical modalities.^[11] However, in anatomically important areas (eyelid, nose, lips), tissue sparing and low recurrence rate makes it a procedure of choice by many physicians.

History

Originally, Dr. Mohs used an escharotic agent made of zinc chloride and bloodroot (the root of the plant Sanguinaria canadensis, which contains the alkaloid sanguinarine). The original ingredients were 40.0 gm Stibnite, 10.0 gm Sanguinaria canadensis, and 34.5 ml of saturated zinc chloride solution.^[12] This paste is very similar to "Hoxsey's paste" (see Hoxsey Therapy). Harry Hoxsey, a lay cancer specialist was developing a herbal tonic and paste designed to treat internal and external cancers. Hoxsey recommended applying paste to the affected area and within days to weeks, the area would necrose (cell death), separate from surrounding tissue and fall out. Dr. Mohs applied a very similar paste after experimenting with a number of compounds to the wound of his skin cancer patients. They were to leave the paste on the wound overnight, and the following day, the skin cancer and surrounding skin would be anesthetic, and ready to be removed. The specimen was then excised, and the tissue examined under the microscope. If cancer remained, more paste was applied, and the patient would return the following day. Later, local anesthetic and frozen section histopathology applied to fresh tissue allowed the procedure to be performed the same day, with less tissue destruction, and similar cure rate.^[13] The term "chemosurgery" remains today, and is used synonymously with Mohs micrographic surgery.

Mohs Surgery Case Studies

Photos courtesy of Dr. B. Cowan

CASE STUDY 1: Left Nasal Rim Skin Cancer

File:Mohs surgery case study 1.png
Click to view complete slide-show and the surgeon's comments for the Left Nasal Rim Skin Cancer case study

CASE STUDY 2: Right Lower Lip Skin Cancer

File:Mohs surgery case study 2.png
Click to view complete slide-show and the surgeon's comments for the Right Lower Lip Skin Cancer case study

CASE STUDY 3: Left Temple Basal Cell Cancer

File:Mohs surgery case study 3.png
Click to view complete slide-show and the surgeon's comments for the Left Temple Basal Cell Cancer case study

About Mohs surgeons

The Mohs surgeon must understand the biologic behavior of several types of skin tumors in order to provide comprehensive management of cutaneous oncology. The Mohs surgeon must have extensive training in the surgical removal of skin cancer, the microscopic analysis (pathology) of the tumor, and reconstructive surgery of the skin and underlying structures. In addition, Medicare requires that the same physician serve as surgeon and pathologist. All Mohs surgeons must have a CLIA certified laboratory.

The American College of Mohs Micrographic Surgery and Cutaneous Oncology was established in 1967 and named after Frederic Mohs, who first developed the technique in the 1940s. This organization's members are board certified dermatologists who have become proficient and experienced in the use of Mohs micrographic surgery. In order to become a member of this college, member physicians must be board certified in a field of medicine or surgery (usually dermatology) and then complete an additional 1 to 2 years of post-residency fellowship training, with exposure to complex tumors and reconstructive plastic surgery of the skin. These College sponsored fellowships are not recognized by the The Accreditation Council for Graduate Medical Education. The College has grown to nearly 800 members.

The American Society for Mohs Surgery is a non-profit professional medical society of over 800 dermatologists, pathologists, and Mohs technicians. Founded in 1990, the ASMS is dedicated to the highest quality patient care and education relative to Mohs surgery as a specialized surgical treatment for skin cancer. This organization's Fellows are board certified dermatologists who have become proficient and experienced in the use of Mohs micrographic surgery. Some ASMS Fellows have completed an ACMMSCO sponsored Mohs fellowship, but most received their Mohs training during Dermatology Residency and post-residency training and experience. ASMS requires yearly peer case review of its Fellow members.

The Board of Medical Subspecialities considers Mohs micrographic surgery as part of the field of dermatology and does not recognize it as a separate subspeciality.

The American Academy of Dermatology is the largest organization of board certified dermatologists, many of whom perform dermatologic and Mohs micrographic surgery. With a membership of over 15,000, it represents virtually all practicing dermatologists in the United States and Canada and has specific member information regarding those performing Mohs micrographic surgery.

The American Society of Dermatologic Surgery founded in 1970 is the largest organization of board certified dermasurgeons with nearly 4000 members who perform dermatologic surgeries including Mohs micrographic surgery. The mission of the Society is to promote excellence in the subspecialty of dermatologic surgery and foster the highest standards of patient care.

The official medical journal for Mohs surgery, Dermatologic Surgery, is published by the American Society for Dermatologic Surgery and is the official journal of The American College of Mohs Micrographic Surgery and Cutaneous Oncology and the official publication for the American Society for Dermatologic Surgery.

The The Accreditation Council for Graduate Medical Education is responsible for the accreditation of post-MD medical training programs within the United States. Accreditation is accomplished through a peer review process and is based upon established standards and guidelines. Starting in 2005, and ACGME recognized and accredited Procedural Dermatology fellowships have started in the U.S. to train fellows. There is no additional ABMS board certification of dermatologists who have completed a Procedural Dermatology fellowship.

The Association of Academic Dermatologic Surgoens has board certified dermasurgeon professors who have faculty appointments at major teaching hospitals and universities and are engaged in training medical students and residents in the practice of dermatologic surgery and Mohs micrographic surgery.

Patients who desire Mohs surgery for removal of skin cancer should contact a Mohs surgeon for evaluation and treatment of the biopsied lesion.

References

Bowen G, White G, Gerwels J (2005). "Mohs micrographic surgery". Am Fam Physician. 72 (5): 845–8. PMID 16156344.Full text

External links

nl:Mohs' chirurgie Template:WikiDoc Sources

↑ George, R. Mohs Micrographic Surgery. 1991, W.B. Saunders Co., p. 13.
↑ Smeets NW, et al. Surgical excision vs Mohs' micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial. Lancet. November 13, 2004-19;364(9447):1766-72.
↑ http://www.ncbi.nlm.nih.gov/pubmed/15541449?dopt=Abstract
↑ Wennberg, AM., et al. Five-year results of Mohs' micrographic surgery for aggressive facial basal cell carcinoma in Sweden. Acta Derm Venereol. 1999 Sep;79(5):370-2.
↑ George, R. Mohs Micrographic Surgery. 1991, W.B. Saunders Co., p. 7.
↑ Mikhail, G. Mohs Micrographic Surgery. 1991, W.B. Saunders. p 4.
↑ Gross, K.G., et al. Mohs Surgery, Fundamentals and Techniques. 1999, Mosby. pp.211-220
↑ Bene, NI, et al. Mohs micrographic surgery is accurate 95.1% of the time for melanoma in situ: a prospective study of 167 cases Dermatol Surg. 2008 May;34(5):660-4.
↑ Am J Clin Dermatol. 2005;6(3):151-64.Links Lentigo maligna: prognosis and treatment options. Stevenson O, Ahmed I.
↑ Gross, K.G., et al. Mohs Surgery, Fundamentals and Techniques. 1999, Mosby. pp. 193-203.
↑ http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Treatment_of_Basal_Cell_Carcinoma_51.asp
↑ Mohs, F. Chemosurgery, Microscopically Controlled Surgery for Skin cancer. 1978, Charles C. Thomas Publisher. ISBN 0-398-03725-6. pp. 3-6.
↑ Mikhail, G. Mohs Micrographic Surgery. 1991, Saunders. pp. 3-4.

[1] George, R. Mohs Micrographic Surgery. 1991, W.B. Saunders Co., p. 13.

[2] Smeets NW, et al. Surgical excision vs Mohs' micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial. Lancet. November 13, 2004-19;364(9447):1766-72.

[3] ttp://www.ncbi.nlm.nih.gov/pubmed/15541449?dopt=Abstract

[4] Wennberg, AM., et al. Five-year results of Mohs' micrographic surgery for aggressive facial basal cell carcinoma in Sweden. Acta Derm Venereol. 1999 Sep;79(5):370-2.

[5] George, R. Mohs Micrographic Surgery. 1991, W.B. Saunders Co., p. 7.

[6] Mikhail, G. Mohs Micrographic Surgery. 1991, W.B. Saunders. p 4.

[7] Gross, K.G., et al. Mohs Surgery, Fundamentals and Techniques. 1999, Mosby. pp.211-220

[8] Bene, NI, et al. Mohs micrographic surgery is accurate 95.1% of the time for melanoma in situ: a prospective study of 167 cases Dermatol Surg. 2008 May;34(5):660-4.

[9] Am J Clin Dermatol. 2005;6(3):151-64.Links Lentigo maligna: prognosis and treatment options. Stevenson O, Ahmed I.

[10] Gross, K.G., et al. Mohs Surgery, Fundamentals and Techniques. 1999, Mosby. pp. 193-203.

[11] ttp://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Treatment_of_Basal_Cell_Carcinoma_51.asp

[12] Mohs, F. Chemosurgery, Microscopically Controlled Surgery for Skin cancer. 1978, Charles C. Thomas Publisher. ISBN 0-398-03725-6. pp. 3-6.

[13] Mikhail, G. Mohs Micrographic Surgery. 1991, Saunders. pp. 3-4.

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@@ Line 15: / Line 15: @@
-== Mohs procedure ==
+==History==
-Mohs surgery is performed by a Mohs skin cancer surgeon in four steps:
+Originally, Dr. Mohs used an [[eschar]]otic agent made of zinc chloride and [[bloodroot]] (the root of the plant Sanguinaria canadensis, which contains the alkaloid [[sanguinarine]]). The original ingredients were 40.0 gm Stibnite, 10.0 gm Sanguinaria canadensis, and 34.5 ml of saturated zinc chloride solution.<ref>Mohs, F. Chemosurgery, Microscopically Controlled Surgery for Skin cancer. 1978, Charles C. Thomas Publisher. ISBN 0-398-03725-6. pp. 3-6.</ref> This paste is very similar to "Hoxsey's paste" (see [[Hoxsey Therapy]]). Harry Hoxsey, a lay cancer specialist was developing a herbal tonic and paste designed to treat internal and external cancers. Hoxsey recommended applying paste to the affected area and within days to weeks, the area would necrose (cell death), separate from surrounding tissue and fall out. Dr. Mohs applied a very similar paste after experimenting with a number of compounds to the wound of his skin cancer patients. They were to leave the paste on the wound overnight, and the following day, the skin cancer and surrounding skin would be anesthetic, and ready to be removed. The specimen was then excised, and the tissue examined under the microscope. If cancer remained, more paste was applied, and the patient would return the following day. Later, local anesthetic and frozen section histopathology applied to fresh tissue allowed the procedure to be performed the same day, with less tissue destruction, and similar cure rate.<ref>Mikhail, G. Mohs Micrographic Surgery. 1991, Saunders. pp. 3-4.</ref> The term "chemosurgery" remains today, and is used synonymously with Mohs micrographic surgery.
-*  Surgical removal of tissue (Surgical Oncology)
-*  Mapping the piece of tissue, freezing and cutting the tissue between 5 and 10 [[micrometre]]s using a [[cryostat]], and staining with H&E or other stains (including T. Blue)
-* Interpretation of microscope slides (Pathology)
-*  Reconstruction of the surgical defect (Reconstructive Surgery)
-After each surgical removal of tissue, the specimen is processed ([http://www.biomedcentral.com/content/supplementary/1471-5945-6-10-s1.ppt look here for a clay animation of tissue processing]), cut on the cryostat and placed on a slides, stained with H&E and then read by the Mohs surgeon who examines the sections for cancerous cells.  If cancer is found, its location is marked on the map (drawing of the tissue) and the surgeon removes the indicated cancerous tissue from the patient.  This procedure is repeated until no further cancer is found.
-Thus, Mohs surgery requires expertise in frozen section microscopic interpretation and in the surgical technique of excising the cancer and  repairing the defect in a cosmetically acceptable manner.  Some  Mohs training is done during many dermatology residencies.  As with other subspecialties, many Mohs surgeons complete an additional 1 to 2 years of post-residency fellowship.
-Some physicians believe that frozen section histology is the same as Mohs micrographic surgery, and it is not.  Standard histology processing is a random tissue sampling technique, examining less than 10% of the total surgical margin (imagine pulling 5 slices of bread out of a whole loaf of sliced bread and examing only 5 slices to visualize the whole loaf).  In Mohs processing, the entire surgical margin is examined (imagine one who examined the entire outside crust of the same loaf of bread).  In statistic term, the more slices of bread one examine, the lower the "false negative" rate will be come.  False negative occurs when a pathologist read cancer excision as "free of residual carcinoma", eventhough cancer might be present in the wound and missed because of the random sampling.  In reality, most pathology lab examine only 3 to 8 sections of this "loaf" in their margin determination.  While a diligent pathologist can cut and process a standard excision to get the same margin control as Mohs surgery, it is seldom done, as tissue processing is very difficult in practice.  The alternative to Mohs surgery is when a pathologist request the processing to be done by "cutting through the block".  Again, this method approaches that of Mohs surgery, but still is not as good.  Cutting through the block will result in the random discarding of many slices, but does greatly decrease the incidence of "false negative" reports.   Dr. Mohs perfected a simple and efficient way to "flatten" and examine the entire surgical margin.
 == Mohs Surgery Case Studies ==

v t e Plastic surgery
Techniques	Incision • Excision • Microsurgery • Chemosurgery • Electrosurgery • Laser surgery • Dermabrasion • Liposuction
Common procedures	Autograft • Allograft • Xenograft
Cosmetic surgery	Abdominal etching • Abdominoplasty • Blepharoplasty• Mammoplasty (Breast augmentation • Breast reduction • Breast lift) • Buttock Augmentation • Chemical peel • Labiaplasty • Rhinoplasty • Otoplasty • Rhytidectomy • Suction-Assisted Lipectomy • Chin augmentation • Cheek augmentation • Collagen / fat / hyaluronic acid and other tissue filler injections • Laser skin resurfacing
Sub-specialties	Craniofacial surgery • Hand surgery • Microsurgery • Cosmetic surgery • Pediatric plastic surgery • Burn surgery
Common functional impairments treated	Burns • Traumatic injuries (e.g. facial bone fractures • Congenital abnormalities (e.g. Cleft palate) • Developmental abnormalities • Infection or Disease • Removal of cancers or tumors (e.g. mastectomy for a breast cancer)