What is Micrograpic surgery
Mohs surgery
New treatments for skin cancer are appearing and evolving rapidly in recent years. However, one surgical technique has more than stood the test of time. Developed by Dr. Frederick Mohs in the 1930s, Mohs micrographic surgery has, with a few refinements, come to be embraced over the past decade by an increasing number of surgeons for an ever-widening variety of skin cancers. Today, Mohs surgery has come to be accepted as the single most effective technique for removing Basal Cell Carcinoma and Squamous Cell Carcinoma(BCCs and SCCs), and many other types of skin cancer. It accomplishes the nifty trick of sparing the greatest amount of healthy tissue while also most completely expunging cancer cells; cure rates for BCC and SCC are an unparalleled 98 percent or higher with Mohs, significantly better than the rates for standard excision or any other accepted method.
Mohs surgery or Mohs micrographic surgery (MMS) is a surgical technique for the removal of certain skin cancers by taking special horizontal sections of skin tissue and examining them under a microscope. It differs from other surgical excision techniques which normally involve examination of vertical sections. The technique was first developed by Dr Frederic E Mohs in the 1930s and has been refined and perfected over the last 50 years, although the unique process of examining horizontal tissue sections, colour coding excised specimens and creating a map to identify location of remaining cancer cells to be excised remains the cornerstone of the procedure.
The cure rate for MMS is very high (up to 99%) compared with other treatments for skin cancer, thus MMS has become the treatment of choice for basal cell carcinomas (BCC) and squamous cell carcinomas (SCC) with high risk for recurrence.
A number of different forms of micrographic surgery other than Mohs surgery are practiced. Examples include the margin strip method (“Tübingen torte”) and the “Munich” method. All variants have the same goal; radical tumour removal with optimal sparing of surrounding tumour-free tissue. They differ, however, in the technique of tumour excision, the preparation of the histological specimens and the interpretation of the slides. Many surgeons carry out simply “frozen section pathology” without true mapping of the tumour.
It is important to understand that these techniques whilst acceptable in many situations are not the same as Mohs and do not have the same degree of accuracy nor the same depth of evidence-base supporting their use. Mohsis by far the most widely used and accepted micrographic surgery technique.
What does the procedure involve?
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Mohs micrographic surgery involves a specific sequence of surgery and pathological investigation. An outline of the process is shown below:
The visible tumour is outlined with a marker pen.
A local anaesthetic is injected into the area.
Once the anaesthetic has taken effect (several minutes) the visible portion of the tumour including a small safety margin is surgically removed.
The tissue is divided into sections, which are colour-coded with tissue dyes. Reference marks are made on the skin to show the site of these sections.
A map of the surgical site and the sections of removed tissue is drawn.
The tissue is processed by a specialist histotechnologist, who applies certain chemicals, freezes the specimen, and sections it into tiny slices with a microtome.
The undersurface and edges of each section are microscopically examined by the dermatologist for evidence of cancer cells.
If cancer cells are found their location is marked on the map and another layer of cancerous tissue can be precisely removed from the patient according to the map. By using this technique only areas with cancer cells are sequentially removed and normal healthy tissue is preserved.
The removal process continues layer by layer until microscopically there is no longer any evidence of cancer remaining in the surgical site.
Depending on the size of the resulting wound it may be left to heal on its own, closed with stitches, or reconstructed with a skin graft or flap.The procedure usually takes about 3 hours to complete but in some cases where the tumour is large may take a whole day or longer.
How effective is Mohs micrographic surgery?
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Mohs micrographic surgery is very effective at completely removing skin cancers while sparing normal healthy tissue. Cure rates have been found to exceed 99% for new (primary) cancers and 95% for recurrent cancers. Five-year recurrence rates for the different treatments of primary and recurrent basal cell carcinoma are shown in the table below.
Five-year recurrence rates for the different treatments of primary and recurrent basal cell carcinoma*
| Treatment | Primary BCC, % recurrence rate | Recurrent BCC, % recurrence rate |
|---|---|---|
| Mohs migrographic surgery | 1.0 | 5.6 |
| Surgical excision | 10.1 | 17.4 |
| Radiotherapy | 9.7 | 9.8 |
| Cryotherapy | 7.5 | 13.0 |
| Curettage and cautery | 7.7 | 40.0 |
*Medscape Reference at www.emedicine.medscape.com. Acessed 18 November 2008.
Who is suitable for Mohs micrographic surgery?
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Skin cancers may form with undefined edges and lengthy rootlike extensions that can grow deeply or laterally from the clinically visible lesion. The MMS technique allows almost 100% of the tumour margins to be microscopically examined, very much moree than traditional histological methods. Hence MMS is particularly suitable for the treatment of difficult skin cancers because it is able to identify and remove all cancer tissue including that found in finger-like extensions. This allows higher cure rates and less scarring. MMS is primarily used to treat basal and squamous cell carcinomas, but can be used to treat less common skin cancers including melanoma. It is particularly useful in the following circumstances.
Recurrent or incompletely excised BCC and SCC
Primary BCC and SCC where the edges of the cancer cannot be clearly defined
BCC and SCC in an area where it is important to preserve healthy tissue for maximum functional and cosmetic result, such as eyelids, nose, ears, lips, genitals, hands, feet
BCC and SCC that is large (> 2cm in diameter) or growing rapidly.
Cancer arising in scars or in sites of previous radiation therapy
High risk or aggressive types of SCC (e.g. infiltrative histology, poorly differentiated)
MMS is also recommended where a patient may have multiple, small, less aggressive tumours situated in the same surgical area, and in young patients who may expect to have further skin cancers on the face in future. However, most BCC and SCC are clearly defined tumours in low risk sites, and can be dealt with by simple excisional surgery or other methods.
What are the complications of Mohs micrographic surgery?
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As with all surgical procedures there is a risk of complications. For MMS possible complications include:
Bleeding – bleeding risks should be identified preoperative medical history. Patients should stop medications that increase the risk of bleeding, e.g. warfarin, aspirin, unless this is medically risky for them.
Nerve damage resulting in skin numbness – small sensory nerve fibres in the skin may be severed during removal of tissue layers. Usually the problem is temporary as new nerve fibres grow back. The surgeon will work cautiously around nerves controlling movement to avoid damaging them, unless absolutely necessary in order to completely remove the tumour.
Infection – rare if the area being treated is kept clean. Oral antibiotics may be required for patients with large wounds or with co-existing medical conditions, e.g. diabetes.
Postoperative problems, e.g. bleeding, clots under the tissue, death of the skin used to repair the wounds, graft failure.
Who is suitable for Mohs micrographic surgery?
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A specially trained dermatologist or dermatologic surgeon performs Mohs micrographic surgery. The MMS surgeon needs to have skills in dermatology, oncology, pathology and reconstructive surgery. Occasionally, other specialist practitioners may be called in to assist, e.g. plastic surgeon to reconstruct the wound, head/neck surgeon to treat the deep component of the tumour. Consult your doctor or dermatologist to find a suitable MMS surgeon.
What you must ask your surgeon
Are you a dermatologist?
The vast majority of trained Mohs surgeons are board certified dermatologists with training in Mohs surgery
Do you have a one-year accredited fellowship?
Most Mohs surgeons now should have undertaken a 12 month fellowhip in Mohs surgery and procedural dermatology in an accreditted training centre after completing their dermatology residency. Those who qualified over 8 years ago may have had less formal training but Mohs will be expected to be the main part of their job and their experience in this field may compensate.
Do you analyse the cancer yourself /"Do you read your own pathology slides"?
Mohs surgeons remove tumours, mark them map them to your body site and analyse the pathology themselves. This is the true Mohs technique and this is how it is performed in all the leading centres to acheive the highest cure rates. Some European countries such as France do not permit non-pathologists to carry out pathological examinations for historical and political reasons. Because of this the Mohs technique is not practiced there. Dermatologists in these countries do carry out micrographic surgery in conjunction with a pathologist but this is not the same as Mohs. Where dermatologists are permitted by law to carry out their own pathology they must do so if they are to call themselves Mohs surgeons.
How many cases do you perform per year?
Mohs surgeons are required to perform a certain number of cases per year to maintain their accreditation.
Why is a dermatologist the best person for Mohs?
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Mohs surgery and other forms of micrographic surgery are being carried out in an unregulated way in many parts of the world. The ESMS is devoted at setting high standards for these procedures to ensure that patients are treated by appopriately qualified professionals and get the highest quality of care.
Mohs and other forms of skin cancer micrographic surgery are always best carried out by a board-certified dermatologist with additional training in these techniques (also called dermatological surgeons). Pathologists and other surgeons are highly valued colleagues whom we work with very closely. They may be an important part of your care but if you are having Mohs micrographic surgery then your dermatological suregeon should be leading it.
This is because board-certified dermatologists learn about skin cancer, the ultrastructure of the skin and its pathology throughout their post-graduate training. It is core to their training and not just a peripheral part of it, as it is in other specialties. They practice skin surgery throughout their training and dermatological surgeons concentrate purely on reconstructing the skin and its underlying structures and this is what makes them expert in it. They do not operate on other organs unlike many other surgical specialties. This combined with the specialised training in Mohs allows them to accurately remove the tumour, examine it under a microscope and then map it to your face or body so that we can remove the tumur with the greatest accuracy
With the diffferent array of doctors treating skin we are increasingly seeing skin cancers that have been inappropriately treated. Some have been overtreated therefore leading to unnecessary scars whilst others have been undertreated leading to higher than average recurrence rates and tumour enalrgment. Dermatologists have a deep understanding of skin structure and will have had had experience in multiple non-surgical treatments for skin cancer such as cream treatments, and photodynamic therapy. They can therefore choose the most appropriate treatment for your particular skin cancer and your particular skin.
What is a dermatologist?
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If you look on the internet and magazines there are many people who claim to be ‘skin experts’ or ‘dermatologists’ and currently there is no law or regulation governing who can use these titles. In the medical profession in Europe to acquire full accreditation of the medical board of the country as a true specialist in skin disease doctors must go through rigourous training and exams. This is combined with many years of practical training.
United Kingdom
In the UK a board certified dermatologist is known as a Consultant Dermatologist and will always be listed on the General Medical Specialist register which is found here
Further information on training in other European countries will appear here shortly.