Mohs surgery for melanoma: rationale, advances and possibilities

Abstract

Mohs surgery (MS) is an effective technique for the removal of a variety of cutaneous neoplasms by virtue of its thorough assessment of margins. It has yet to become widely accepted for melanoma because recognizing melanocytes histologically in frozen section can be problematic. Recently, 'rapid' methods of immunohistochemistry have been developed that resolve this issue by staining the melanocytes in frozen section. In addition, some of the immunohistochemistry protocols that previously required up to 1 h now take 19 min or less. These technological enhancements for MS have removed some of the obstacles towards the acceptance of MS as a legitimate option for removal of melanomas, especially poorly demarcated lesions and lesions from the head and neck, the distal extremities and the genitalia. Experience thus far with MS for melanoma has shown lower recurrence rates and improved disease-specific survival compared with historical controls for standard excision, while at the same time minimizing the sacrifice of normal tissue.

Current perspectives on Mohs micrographic surgery for melanoma

“… 22 In fact, one of the strongest arguments for the use of MMS in LM/LMM in particular is the issue of subclinical spread. 3 , 8 , 10 , 13 , 16 , 18 , 24 , 25 , 28 , 37 , 50 Subclinical spread occurs in 12%–71% of LM cases and refers to the microscopic extension of the tumor beyond the clinically apparent borders. 24 , 26 , 50 , 51 …”

Mistaken Conclusions in a Nonmelanoma Skin Cancer Article Published in JAMA

“…First, patient safety is paramount and is ensured (in almost all cases) through avoidance of general anesthesia and with the use of local anesthesia, particularly in patients with LLE . Second, 100% microscopic examination of tissue margins from resected tissue ensures the highest cure rate for NMSC and melanoma . Because of the elegant tissue preparation and microscopic mapping, precious tissue surrounding the tumor is spared .…”

“…49,[54][55][56] Second, 100% microscopic examination of tissue margins from resected tissue ensures the highest cure rate for NMSC and melanoma. 32,33,[57][58][59][60] Because of the elegant tissue preparation and microscopic mapping, precious tissue surrounding the tumor is spared. 61 Through tissue conservation, smaller defects are encountered, which frequently translates to less-onerous reconstructions and better cosmetic outcomes.…”