Say Goodbye
to Cancer, One
Layer at a
Time: Mohs
Surgery for
Skin Cancer
Jamie L. McGinness, MD
www.SpringfieldClinic.com
Meet my family…
Mohs Surgery
Objectives
• What is Mohs surgery?
• How is Mohs different from other
surgical techniques?
• How effective is Mohs and for...
Take home message…..
• When properly performed, MMS is the gold standard
for skin cancer therapy
– Complete margin control...
Who is Jamie McGinness?
• Born and raised in Potosi, MO
• 1994-1998 Undergraduate School -
BS, Biochemistry University of
...
What is Mohs Surgery?
• Mohs Micrographic
Surgery is an
advanced surgical
treatment for skin
cancers.
Mohs Surgery
• Dr Frederick Mohs
History
• Developed by Frederic E. Mohs, M.D. in
the 1930s, Mohs Micrographic Surgery
has been refined and perfected for m...
History
• He developed a unique technique of
– color coding excised specimens
– creating a mapping process to accurately
i...
History
• The technique evolved and was refined
with fresh tissue frozen histology
– Excise tumor
– Examine tissue with fr...
Mohs Surgery is the Gold
Standard for Surgical Tumor
Clearance
Why??
Copyright: Tri H Nguyen, MD,
FACMS
Advantages of Mohs Surgery
1. Excellent tumor cure rates
2. Tissue sparing
3. Outpatien...
Principles of MMS
Complete margin control
Higher cure rates (100% margin evaluated)
Tissue sparing
Tissue conservation (ou...
What is Mohs?
• Mohs is a precisely controlled process
– ensures accuracy during tumor tissue
removal
– accuracy and integ...
What is Mohs?
• Skin cancer roots can be accurately
traced and removed while preserving
healthy tissue
Mohs Surgery Procedure
• Tumor marked with margin
Mohs Surgery Procedure
• Tumor debulked
Mohs Surgery Procedure
• Incision with 1-2 mm margins
• Knicks made for orientation
Mohs Surgery Procedure
• Tissue removed
Mohs Surgery Procedure
• Tissue grossed and mapped
Mohs Surgery Procedure
• Section color coded for orientation
Mohs Surgery Procedure
• Tissue embedded for horizontal sections
Mohs Surgery Procedure
• Sections cut and put on slides.
Mohs Surgery Procedure
• Sections stained and read.
Mohs Surgery Procedure
• Pathology read and mapped.
• Process repeated until margins clear.
Principles of MMS
Complete margin control
Higher cure rates (100% margin evaluated)
Tissue sparing
Tissue conservation (ou...
Myth
As long as margins are
negative, the method of
margin control is irrelevant
Why not?
Margin Control Techniques
Conventional Vertical Sections
Intraoperative Frozen Section Control
Mohs Micrographic Surgery
B...
Wide Local Excision
Paraffin Processing
(Conventional Vertical
Sections)
• Wide excision
• Wound closed
• Patient discharg...
Copyright: Tri H Nguyen, MD,
FACMS
In both forms of WLE (paraffin & IOFS),
the resecting surgeon usually does not ink
the ...
BA DC E
Conventional Sectioning
• Breadloaf sections Extension of tumor not
represented in sections
A-E.
B
A
D
C E
F
G
MARGINS NEGATIVE
Right??
WRONG
Why?
<1% of tissue is examined in
standard histologic sections
B
A
D
C E
F
G
...
Mohs Sectioning
• 100% of peripheral and deep margin
examined
Extension of tumor
would be seen with
Mohs section.
Mohs Sectioning
Mohs Sectioning
• Tissue is layed down and cut horizontally
– Peripheral margin and deep margin in 1 plane.
• How is this done?
Relaxing incisions made
Epidermis
Dermis
Fat
Peripheral and deep margin now in 1 plane
EpidermisEpidermis Dermis DermisFat
1 2
Mohs Sectioning
Mohs Sectioning
Mohs Sectioning
1 2
Mohs Sectioning
Mohs Sectioning
Myth
Mohs Surgery is just like
Intraoperative Frozen Section
Control (IOFSC)
Both Mohs surgery & IOFSC
are forms of margin control
using frozen sections
But there are critical differences inBut there...
Traditional Sections
SurgeonSurgeon TechnicianTechnician PathologistPathologist
Paraffin SectionParaffin Section
Processing
SurgeonSurgeon TechnicianTechnician PathologistPathologist
Intraoperative Frozen SectionIntraoperative Frozen S...
Mohs Processing
SurgeonSurgeon TechnicianTechnician PathologistPathologist
Mohs SurgeryMohs Surgery
Intraoperative Frozen ...
Principles of MMS
Complete margin control
Higher cure rates (100% margin evaluated)
Tissue sparing
Tissue conservation (ou...
How is Mohs Different?
• Ability to remove less since 100%
margin is evaluated
• Meticulous mapping: tissue
– color coded ...
Principles of MMS
Complete margin control
Higher cure rates (100% margin evaluated)
Tissue sparing
Tissue conservation (ou...
Copyright: Tri H Nguyen, MD,
FACMS
Mohs surgery: The
philosophy of ONE (Mohs
surgeon = surgeon & pathologist)
• When Surge...
Copyright: Tri H Nguyen, MD,
FACMS
Mohs surgery: The philosophy of
ONE (Mohs surgeon = surgeon &
pathologist)
• More integ...
Mohs Processing
SurgeonSurgeon TechnicianTechnician PathologistPathologist
Mohs SurgeryMohs Surgery
Intraoperative Frozen ...
Copyright: Tri H Nguyen, MD,
FACMS
Mohs surgery: The philosophy of
ONE (Mohs surgeon = surgeon &
pathologist)
• More integ...
Ensuring tissue integrity
Missing epidermis Tissue hole
Copyright: Tri H Nguyen, MD,
FACMS
Mohs surgery: The philosophy of
ONE (Mohs surgeon = surgeon &
pathologist)
• More integ...
Tissue Sparing
• Precise margin control saves healthy
tissue.
• If tumor is seen only tumor-involved tissue
is precisely r...
MMS: Tissue Conservation
Standard Excision
• Should be at least 4 mm
margins for low risk basal cell
and squamous cell can...
Traditional Excision
4-6 mm Margins4-6 mm Margins
4 mm margins (low risk)4 mm margins (low risk)
6-10 mm margins (high6-10...
Mohs Removal
1-2 mm Margins1-2 mm Margins
Sometimes smaller margins are
taken…
• Margins of 1-3 mm are
inadequate for
– Small, well-demarcated
primary basal cell
cancers on the face.
– These should be
...
What Tumors are Treated with
Mohs?
• Most common skin cancer treated
– Basal cell carcinoma
– Squamous cell carcinoma
– pr...
How effective is Mohs surgery?
Myth
Mohs surgery has comparable cure rates
with other therapies
Copyright: Tri H Nguyen, MD, FACMS
5-yr Cure Rates Primary BCC
90
92
92.5
91.3
99
84 86 88 90 92 94 96 98 100
EDC
Excision...
Copyright: Tri H Nguyen, MD, FACMS
5-yr Cure Rates Recurrent BCC
60
82.6
83.6
94.4
0 10 20 30 40 50 60 70 80 90 100
EDC
Ex...
Copyright: Tri H Nguyen, MD,
FACMS
Excision: Primary BCC & Size
Excision: 5-yr Cure Rates primary BCC & size
92
91
96.8
90...
Excision & BCC Location
Excision: 5-yr Cure Rates & BCC Location
93.4
99.3
90
91
92
93
94
95
96
97
98
99
100
Head Other
si...
Copyright: Tri H Nguyen, MD, FACMS
SCC of the Lip
5-yr Cure Rates Primary SCC of Lip
98
90
0
10
20
30
40
50
60
70
80
90
100
Non-MOHS Mohs Surgery
*
Rowe. Et ...
Recurrent SCC
5-yr Cure Rates
92
77
0
10
20
30
40
50
60
70
80
90
100
Excision Mohs Surgery
Rowe. Et al. J Am Acad Dermatol...
The BEST chance to cure skin
cancer, is your FIRST chance
Recurrent skin cancers have a
lower cure rate than primary skin
...
Disadvantages
• Time consuming
– Tissue turnover time: at least 30-60 minutes per
layer (sometimes longer)
• Dependent on ...
Is it worth it?
Cost Comparison
Head/ Neck
$
Trunk
$
Extremities
$
Office excision with
Permanent sections
1201 905 1125
Mohs Micrographic...
MMS is 7% more expensive than routine excisions
but 11% less expensive than office excision with
frozen sections
Significa...
Copyright: Tri H Nguyen, MD,
FACMS
Outpatient Surgery
Mohs is an outpatientMohs is an outpatient
procedure, performed unde...
Outpatient Surgery
• Mohs is performed under local
anesthesia, which allows patients to
return home immediately
• Patients...
Cook J. Arch Dermatol 2003;139:143-
52
• 1358 Mohs cases (1052 patients)
– Prospective evaluation
– 99% in-house reconstru...
Indications for MMS
MMS: Indications
• Histologically aggressive
tumors
• Large tumors (>2cm) in
any location
• Incompletely excised
tumors
Tumor Indications
• Basal cell carcinoma
• Squamous cell carcinoma
• Lentigo maligna/melanoma
• Dermatofibrosarcoma protub...
Special Patients
• Organ transplant
patients
• Basal cell nevus
syndrome patients
Not every tumor needs or
qualifies for Mohs…When is
Mohs Not Indicated?
• Small localized
tumors
• Tissue conservation
les...
When is Mohs Not Indicated?
• Difficult tumor
Locations
• Local anesthesia
• When tumor is too
large for complete
margin c...
Mohs surgeon: Training matters
Who may perform Mohs
Surgery?
Requirements
Surgical expertise
and
Frozen section pathology
Training of a Mohs Surgeon
• Dermatology Residency
– Medical & surgical
dermatology
– Dermatopathology part of
Board Certi...
Not everyone who performs
Mohs surgery is fellowship
trained
Mohs College & Mohs Society
What is the difference?
Mohs College
• 1-2 year fellowships
after Dermatology
• Minimum 500 cases
– Diversity
– Complexity...
After Mohs tumor
clearance, defects are
then reconstructed
The Magic after MohsThe Magic after Mohs
SurgerySurgery
Non Mohs Defect
1 week follow-up
1 week follow-up
Take home message…..
• When properly performed, MMS is the gold standard
for skin cancer therapy
– Complete margin control...
More Resources
Find videos, handouts and more
resources at
www.SpringfieldClinic.com/DoctorIsIn
Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer
Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer
Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer
Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer
Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer
Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer
Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer
Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer
Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer
Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer
Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer
Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer
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Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer

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Skin cancer is the most common form of cancer in the United States. In fact, according to studies, one in five Americans will be diagnosed with skin cancer at some point in their lives. Mohs micrographic surgery is an advanced treatment for skin cancer, offering the highest cure rate available. Please join Dr. Jamie McGinness as he discusses this innovative and successful procedure—one that could save your skin…and life.

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  • As both the surgeon and the pathologist, I can determine if the tissue slide is complete and represents what was resected, mapped, and oriented…then order recuts if a margin is missing or remove another layer if needed.
  • Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer

    1. 1. Say Goodbye to Cancer, One Layer at a Time: Mohs Surgery for Skin Cancer Jamie L. McGinness, MD
    2. 2. www.SpringfieldClinic.com
    3. 3. Meet my family…
    4. 4. Mohs Surgery
    5. 5. Objectives • What is Mohs surgery? • How is Mohs different from other surgical techniques? • How effective is Mohs and for what tumors? • What are the indications for Mohs? • What are the limitations of Mohs? • Who performs Mohs surgery?
    6. 6. Take home message….. • When properly performed, MMS is the gold standard for skin cancer therapy – Complete margin control. – Superior Cure rate. – Tissue Sparing • Mohs is not appropriate for every tumor • Mohs alone is not the cure-all for some tumors • MMS success depends on a philosophy of one – Surgeon = Pathologist – Surgical expertise + Histologic interpretation
    7. 7. Who is Jamie McGinness? • Born and raised in Potosi, MO • 1994-1998 Undergraduate School - BS, Biochemistry University of Missouri Columbia (Columbia, MO) • 1998-2002 Medical School - MD, University of Missouri Columbia (Columbia, MO) • 2002-2003 Internship - Internal Medicine, University of Missouri Columbia Hospital and Clinics (Columbia, MO) • 2003-2006 Residency - Dermatology, University of Virginia (Charlottesville, VA) • 2006-2007 Fellowship - Dermatology & Skin Cancer Center (Leawood, KS) • 2010-2011 Advanced Mohs and Reconstructive surgery training in Houston, TX
    8. 8. What is Mohs Surgery? • Mohs Micrographic Surgery is an advanced surgical treatment for skin cancers.
    9. 9. Mohs Surgery • Dr Frederick Mohs
    10. 10. History • Developed by Frederic E. Mohs, M.D. in the 1930s, Mohs Micrographic Surgery has been refined and perfected for more than half a century.
    11. 11. History • He developed a unique technique of – color coding excised specimens – creating a mapping process to accurately identify the location of remaining cancerous cells. – Used zinc chloride paste.
    12. 12. History • The technique evolved and was refined with fresh tissue frozen histology – Excise tumor – Examine tissue with frozen histology immediately – Chemosurgical technique developed by Dr. Mohs no longer used.
    13. 13. Mohs Surgery is the Gold Standard for Surgical Tumor Clearance Why??
    14. 14. Copyright: Tri H Nguyen, MD, FACMS Advantages of Mohs Surgery 1. Excellent tumor cure rates 2. Tissue sparing 3. Outpatient surgery
    15. 15. Principles of MMS Complete margin control Higher cure rates (100% margin evaluated) Tissue sparing Tissue conservation (out with the bad in with the good) Philosophy of ONE (Mohs surgeon = surgeon & pathologist)
    16. 16. What is Mohs? • Mohs is a precisely controlled process – ensures accuracy during tumor tissue removal – accuracy and integrity during tissue processing – precise and complete histologic evaluation of margins
    17. 17. What is Mohs? • Skin cancer roots can be accurately traced and removed while preserving healthy tissue
    18. 18. Mohs Surgery Procedure • Tumor marked with margin
    19. 19. Mohs Surgery Procedure • Tumor debulked
    20. 20. Mohs Surgery Procedure • Incision with 1-2 mm margins • Knicks made for orientation
    21. 21. Mohs Surgery Procedure • Tissue removed
    22. 22. Mohs Surgery Procedure • Tissue grossed and mapped
    23. 23. Mohs Surgery Procedure • Section color coded for orientation
    24. 24. Mohs Surgery Procedure • Tissue embedded for horizontal sections
    25. 25. Mohs Surgery Procedure • Sections cut and put on slides.
    26. 26. Mohs Surgery Procedure • Sections stained and read.
    27. 27. Mohs Surgery Procedure • Pathology read and mapped. • Process repeated until margins clear.
    28. 28. Principles of MMS Complete margin control Higher cure rates (100% margin evaluated) Tissue sparing Tissue conservation (out with the bad in with the good) Philosophy of ONE (Mohs surgeon = surgeon & pathologist)
    29. 29. Myth As long as margins are negative, the method of margin control is irrelevant Why not?
    30. 30. Margin Control Techniques Conventional Vertical Sections Intraoperative Frozen Section Control Mohs Micrographic Surgery But how do these techniques differ?
    31. 31. Wide Local Excision Paraffin Processing (Conventional Vertical Sections) • Wide excision • Wound closed • Patient discharged • Tissue vertically sectioned (breadloaf) • Paraffin sections & results about 1-2 weeks later Intraoperative Frozen Sections • Wide excision • Wound open • Tissue vertically sectioned (breadloaf) • Frozen sections read intraoperatively by pathology • Wound closed if Negative • Paraffin sections to confirm
    32. 32. Copyright: Tri H Nguyen, MD, FACMS In both forms of WLE (paraffin & IOFS), the resecting surgeon usually does not ink the tissue, map the tissue, or read the pathology Sections are processed vertically (breadloaf)
    33. 33. BA DC E Conventional Sectioning • Breadloaf sections Extension of tumor not represented in sections A-E.
    34. 34. B A D C E F G MARGINS NEGATIVE Right?? WRONG Why? <1% of tissue is examined in standard histologic sections B A D C E F G C-1
    35. 35. Mohs Sectioning • 100% of peripheral and deep margin examined Extension of tumor would be seen with Mohs section.
    36. 36. Mohs Sectioning
    37. 37. Mohs Sectioning
    38. 38. • Tissue is layed down and cut horizontally – Peripheral margin and deep margin in 1 plane. • How is this done?
    39. 39. Relaxing incisions made Epidermis Dermis Fat Peripheral and deep margin now in 1 plane EpidermisEpidermis Dermis DermisFat
    40. 40. 1 2 Mohs Sectioning
    41. 41. Mohs Sectioning
    42. 42. Mohs Sectioning
    43. 43. 1 2 Mohs Sectioning
    44. 44. Mohs Sectioning
    45. 45. Myth Mohs Surgery is just like Intraoperative Frozen Section Control (IOFSC)
    46. 46. Both Mohs surgery & IOFSC are forms of margin control using frozen sections But there are critical differences inBut there are critical differences in tissue processing, mapping, &tissue processing, mapping, & orientation.orientation.
    47. 47. Traditional Sections SurgeonSurgeon TechnicianTechnician PathologistPathologist Paraffin SectionParaffin Section
    48. 48. Processing SurgeonSurgeon TechnicianTechnician PathologistPathologist Intraoperative Frozen SectionIntraoperative Frozen Section
    49. 49. Mohs Processing SurgeonSurgeon TechnicianTechnician PathologistPathologist Mohs SurgeryMohs Surgery Intraoperative Frozen SectionIntraoperative Frozen Section
    50. 50. Principles of MMS Complete margin control Higher cure rates (100% margin evaluated) Tissue sparing Tissue conservation (out with the bad in with the good) Philosophy of ONE (Mohs surgeon = surgeon & pathologist)
    51. 51. How is Mohs Different? • Ability to remove less since 100% margin is evaluated • Meticulous mapping: tissue – color coded mapping of excised specimens • Margin examination – thorough microscopic examination • This allows precise localization and removal of tumor if needed. – Saves normal skin
    52. 52. Principles of MMS Complete margin control Higher cure rates (100% margin evaluated) Tissue sparing Tissue conservation (out with the bad in with the good) Philosophy of ONE (Mohs surgeon = surgeon & pathologist)
    53. 53. Copyright: Tri H Nguyen, MD, FACMS Mohs surgery: The philosophy of ONE (Mohs surgeon = surgeon & pathologist) • When Surgeon & Pathologist are one: – tissue integrity and superior tumor clearance are achieved.
    54. 54. Copyright: Tri H Nguyen, MD, FACMS Mohs surgery: The philosophy of ONE (Mohs surgeon = surgeon & pathologist) • More integrity of tissue processing • More effective tumor management – Ensure tissue integrity microscopically • More accuracy in tissue orientation & mapping • Accurate histologic tumor identification • More tissue conservation
    55. 55. Mohs Processing SurgeonSurgeon TechnicianTechnician PathologistPathologist Mohs SurgeryMohs Surgery Intraoperative Frozen SectionIntraoperative Frozen Section
    56. 56. Copyright: Tri H Nguyen, MD, FACMS Mohs surgery: The philosophy of ONE (Mohs surgeon = surgeon & pathologist) • More integrity of tissue processing • More effective tumor management – Ensure tissue integrity microscopically • More accuracy in tissue orientation & mapping • Accurate histologic tumor identification • More tissue conservation
    57. 57. Ensuring tissue integrity Missing epidermis Tissue hole
    58. 58. Copyright: Tri H Nguyen, MD, FACMS Mohs surgery: The philosophy of ONE (Mohs surgeon = surgeon & pathologist) • More integrity of tissue processing • More effective tumor management – Ensure tissue integrity microscopically • More accuracy in tissue orientation & mapping • Accurate histologic tumor identification • More tissue conservation
    59. 59. Tissue Sparing • Precise margin control saves healthy tissue. • If tumor is seen only tumor-involved tissue is precisely removed to cure the skin cancer – Cancer roots are resected one layer at a time until clear • Saves as much healthy tissue as possible • Smallest defect possible • Maximal cure rate
    60. 60. MMS: Tissue Conservation Standard Excision • Should be at least 4 mm margins for low risk basal cell and squamous cell cancer • More for high risk skin cancers – National comprehensive Cancer Network (NCCN guidelines) • 90% 5-year cure rate for primary BCC • 83% 5-year cure rates for recurrent BCC Mohs Surgery • 1-2 mm margins per layer • 99% 5-year cure rates for primary BCC • 94% 5-year cure rates for recurrent BCC
    61. 61. Traditional Excision 4-6 mm Margins4-6 mm Margins 4 mm margins (low risk)4 mm margins (low risk) 6-10 mm margins (high6-10 mm margins (high risk)risk)
    62. 62. Mohs Removal 1-2 mm Margins1-2 mm Margins
    63. 63. Sometimes smaller margins are taken…
    64. 64. • Margins of 1-3 mm are inadequate for – Small, well-demarcated primary basal cell cancers on the face. – These should be treated with standard 4 mm margins or Mohs. • Higher chance of positive margins • Higher risk of recurrence
    65. 65. What Tumors are Treated with Mohs? • Most common skin cancer treated – Basal cell carcinoma – Squamous cell carcinoma – primary tumors • (cancers that have not been treated before) – Recurrent tumors • (cancers that have returned despite previous treatment) – Other non common tumors
    66. 66. How effective is Mohs surgery? Myth Mohs surgery has comparable cure rates with other therapies
    67. 67. Copyright: Tri H Nguyen, MD, FACMS 5-yr Cure Rates Primary BCC 90 92 92.5 91.3 99 84 86 88 90 92 94 96 98 100 EDC Excision Cryosurgery Radiation Mohs % Rowe. Et al. J Dermatol Surg Oncol 1989;15:315-328
    68. 68. Copyright: Tri H Nguyen, MD, FACMS 5-yr Cure Rates Recurrent BCC 60 82.6 83.6 94.4 0 10 20 30 40 50 60 70 80 90 100 EDC Excision Radiation Mohs % Caccialanza M. Eur J Dermatol 2001 Jan-Feb;11(1):25-8
    69. 69. Copyright: Tri H Nguyen, MD, FACMS Excision: Primary BCC & Size Excision: 5-yr Cure Rates primary BCC & size 92 91 96.8 90 92 94 96 98 100 0-5 mm 6-9 mm >10 mm Lesion Size % Silverman. Et al. J Dermatol Surg Oncol 1991;17:720-726
    70. 70. Excision & BCC Location Excision: 5-yr Cure Rates & BCC Location 93.4 99.3 90 91 92 93 94 95 96 97 98 99 100 Head Other sites percentage Silverman. Et al. J Dermatol Surg Oncol 1991;17:720-726
    71. 71. Copyright: Tri H Nguyen, MD, FACMS
    72. 72. SCC of the Lip 5-yr Cure Rates Primary SCC of Lip 98 90 0 10 20 30 40 50 60 70 80 90 100 Non-MOHS Mohs Surgery * Rowe. Et al. J Am Acad Dermatol 1992;26:976-990
    73. 73. Recurrent SCC 5-yr Cure Rates 92 77 0 10 20 30 40 50 60 70 80 90 100 Excision Mohs Surgery Rowe. Et al. J Am Acad Dermatol 1992;26:976-990
    74. 74. The BEST chance to cure skin cancer, is your FIRST chance Recurrent skin cancers have a lower cure rate than primary skin cancers
    75. 75. Disadvantages • Time consuming – Tissue turnover time: at least 30-60 minutes per layer (sometimes longer) • Dependent on tissue integrity and need for recuts of tissue – Immunostains add additional time • Cost – more expensive than traditional standard excisions (but higher cure rates) • Labor intensive
    76. 76. Is it worth it?
    77. 77. Cost Comparison Head/ Neck $ Trunk $ Extremities $ Office excision with Permanent sections 1201 905 1125 Mohs Micrographic surgery 1278 964 993 Office excision with Frozen sections 1438 1117 1136 Excision in ASC with Frozen sections 2012 1694 1620 (ASC: Ambulatory Surgical Center) Cook J.et al. J American Acad Dermatol 98:39; 698-703
    78. 78. MMS is 7% more expensive than routine excisions but 11% less expensive than office excision with frozen sections Significantly less expensive than ASC based surgical excision (Not calculating intrinsic value of superior cure rates and tissue conservation)
    79. 79. Copyright: Tri H Nguyen, MD, FACMS Outpatient Surgery Mohs is an outpatientMohs is an outpatient procedure, performed underprocedure, performed under local anesthesialocal anesthesia Mohs patients continue all theirMohs patients continue all their medications, includingmedications, including anticoagulation regimens. All areanticoagulation regimens. All are ambulatory home.ambulatory home. Mohs surgery is very well toleratedMohs surgery is very well tolerated under local anesthesia.under local anesthesia.
    80. 80. Outpatient Surgery • Mohs is performed under local anesthesia, which allows patients to return home immediately • Patients do not have to discontinue their medications. • Patients recover more quickly, which is important since most skin cancers occur in the elderly
    81. 81. Cook J. Arch Dermatol 2003;139:143- 52 • 1358 Mohs cases (1052 patients) – Prospective evaluation – 99% in-house reconstruction – Local anesthesia +/- anxiolysis • Incidence of complications = 1.64% – No deaths, no hospitalizations, no resuscitations – Majority of incidents related to Postop bleeding
    82. 82. Indications for MMS
    83. 83. MMS: Indications • Histologically aggressive tumors • Large tumors (>2cm) in any location • Incompletely excised tumors
    84. 84. Tumor Indications • Basal cell carcinoma • Squamous cell carcinoma • Lentigo maligna/melanoma • Dermatofibrosarcoma protuberans • Sebaceous carcinoma • Microcystic adnexal carcinoma • Atypical Fibroxanthoma • Extramammary Pagets disease
    85. 85. Special Patients • Organ transplant patients • Basal cell nevus syndrome patients
    86. 86. Not every tumor needs or qualifies for Mohs…When is Mohs Not Indicated? • Small localized tumors • Tissue conservation less of an issue – trunk • Superficial BCC & SCC – unless recurrent • Topical therapy • Photodynamic therapy • Cryotherapy • Curettage & electrodessication • Laser ablation • Excision with margins
    87. 87. When is Mohs Not Indicated? • Difficult tumor Locations • Local anesthesia • When tumor is too large for complete margin control • When tumors become non-contiguous
    88. 88. Mohs surgeon: Training matters
    89. 89. Who may perform Mohs Surgery? Requirements Surgical expertise and Frozen section pathology
    90. 90. Training of a Mohs Surgeon • Dermatology Residency – Medical & surgical dermatology – Dermatopathology part of Board Certification in dermatology • Mohs Fellowship (1-2 years) – Frozen section dermatopathology – Cutaneous oncology – Reconstruction
    91. 91. Not everyone who performs Mohs surgery is fellowship trained Mohs College & Mohs Society
    92. 92. What is the difference? Mohs College • 1-2 year fellowships after Dermatology • Minimum 500 cases – Diversity – Complexity – Under supervision of experienced ACMS approved Mohs surgeon • Only approved ACMS programs allowed to train. Mohs Society • Intense instructional courses • No fellowship • Minimum 75 cases • Submit 2 cases for review • Passed a written and practical exam on Mohs • Annual QA
    93. 93. After Mohs tumor clearance, defects are then reconstructed
    94. 94. The Magic after MohsThe Magic after Mohs SurgerySurgery
    95. 95. Non Mohs Defect
    96. 96. 1 week follow-up
    97. 97. 1 week follow-up
    98. 98. Take home message….. • When properly performed, MMS is the gold standard for skin cancer therapy – Complete margin control. – Superior Cure rate. – Tissue Sparing • Mohs is not appropriate for every tumor • Mohs alone is not the cure-all for some tumors • MMS success depends on a philosophy of one – Surgeon = Pathologist – Surgical expertise + Histologic interpretation
    99. 99. More Resources Find videos, handouts and more resources at www.SpringfieldClinic.com/DoctorIsIn
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