Management of Cutaneous Tumors with Mohs Micrographic Surgery

Abstract

Since the inception of Mohs micrographic surgery in the 1930s, this technique has proved its utility in the treatment of cutaneous tumors. This review describes the technique of Mohs micrographic surgery and the various indications for which it is used. We discuss the use of Mohs micrographic surgery for the following cutaneous tumors: basal cell carcinoma, squamous cell carcinoma, melanoma in situ, dermatofibrosarcoma protuberans, Merkel cell carcinoma, microcystic adnexal carcinoma, atypical fibroxanthoma, and sebaceous carcinoma. Mohs micrographic surgery is cost effective in the U.S. health care system because billing for the surgeon-pathologist and laboratory processing is bundled together. However, Mohs micrographic surgery may be more expensive in European systems because the Mohs technique surgeon, pathologist, and laboratory fees may be billed separately. KEYWORDS: Mohs micrographic surgery, cutaneous oncology, skin cancerIn the early 1930s, Dr. Frederic Mohs developed the procedure that bears his name while working as an assistant in a cancer research laboratory during medical school. 1 While studying rats implanted with skin cancer, he noticed that the carcinomatous tissue, when fixed in 20% zinc chloride, maintained its histologic architecture after extirpation, thus aiding in microscopic examination. 2 To ensure margin clearance, he formulated the technique of chemical fixation, excision by saucerization, and microscopic examination of horizontal sections. 2 In 1936, he started using this technique in patients deemed incurable. He would apply the 20% zinc chloride paste on the skin cancer in vivo and leave it overnight to fixate the skin. While painful for the patient, this was quite effective in preserving the microscopic anatomy of the skin. Only one stage could be taken per day because the tissue was processed using paraffin sections. Subsequent stages could be taken depending on the microscopic results. The presence of zinc chloride on the skin forced Dr. Mohs to allow the wounds to heal by secondary intention as the inflammation left the wound bed inhospitable to reconstructive techniques. With this protocol, he was able to successfully treat most of his patients.Because Dr. Mohs was formally trained as a general surgeon, he first reported his success in using this technique in 440 patients in the Archives of Surgery in 1941. 3 However, the reception within the surgical community was modest at best. His technique diverged so dramatically from the accepted procedure that the presence of purulent-looking, open wounds and the associated pain served to confirm the suspicion of his colleagues that this technique was unacceptable. 2 Over time, the impressive cure rate and acceptable cosmetic outcome of granulation slowly improved the medical community's impression of his technique.In 1946, Dr. Mohs presented his technique at the American Academy of Dermatology annual meeting in

Dermatofibrosarcoma protuberans: Our experience of 59 cases

“…MMS is a surgical procedure characterized by precise histological resection margin control. According to Dim-Jamora and Perone (49), MMS should be the first choice for DFSP treatment. The most important technical aspect in MMS is continual sequential horizontal sectioning (5-7 µm) with immediate microscopic examination of the frozen sections of the resected tissue until a clear margin is obtained.…”

A Practical Update of Surgical Management of Merkel Cell Carcinoma of the Skin

“…Mohs micrographic surgery is cost effective in the American health care system because billing for the surgeon-pathologist and laboratory processing is bundled together [65]. However, Mohs micrographic surgery may be more expensive in European systems because the surgeon, pathologist, and laboratory may bill separately.…”

Skin Cancers of the Hand and Upper Extremity

“…The process of excision, mapping, and histologic examination is repeated until all margins are clear of cancer. 32 Following excision, closure options include primary closure, secondary intention, local skin flaps, or skin grafts.…”