Is Mohs Surgery Necessary For Squamous Cell Carcinoma

Why Is Mohs Surgery Performed

Mohs surgery commonly addresses skin cancer that:

• Is located on any sensitive area where it is important to minimize the removal of normal healthy tissue, such as the head and neck, fingers, toes or genitals

• Is of an aggressive subtype

• Develops in patients with suppressed immune systems

• Was previously treated and has come back

• Is growing quickly

• Is large

Review Exceptions And Special Cases

An exception to this rule may occur if a pathologist had performed a biopsy with a confirmed cancer diagnosis, which results in a same-day Mohs micrographic surgery procedure. The AMAs CPT® Assistant advises the physician may need a new biopsy before performing Mohs micrographic surgery if:

• A biopsy report is not available with reasonable efforts
• A biopsy has been done more than 90 days before surgery
• The original biopsy is ambiguous

Answer: Mohs For Small Basal Cell Cancers

Mohs is a very specialized surgery which is indicated for treatment of certain skin cancers based on their size, biologic behavior, location, and if they are in high risk areas or are already recurrent. Alternative treatments may be appropriate for a BCC if it does not fit the guidelines. You will need to discuss these with your dermatolgist and make an informed decision based on information received. As much as I love 5FU for treatment of precancerous actinic keratoses I have never been inclined to encourage patients to use 5FU for BCCs unless they are very superficial and in an area where the 5FU can be used for longer periods of time and sometimes under occlusion if it is possible.

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Disadvantages Of Mohs Surgery

Disadvantages of Mohs surgery include the following:

• The procedure may become tedious and prolonged for the patient especially if the case is difficult or complex.

• An inability to remove a large or difficult tumor in one day may preclude immediate reconstruction after complete excision.

• The procedure requires a specially trained dermatologist and ancillary personnel.

• Multiple injections of local anesthetic can cause patient discomfort.

Mohs surgery is usually an outpatient procedure and takes 3 hours to complete, on average. However, some very complex cases may take an entire day or longer, and additional time may also be required when tumors are more extensive than usual. Furthermore, if a complex case requires reconstruction by a different specialist, the resulting wound may require delayed closure .

Mohs surgery is cost effective owing to its high cure rate and because it is usually performed with local anesthesia on an outpatient basis. The cost of Mohs surgery compares favorably with that of excision with frozen-section interpretation, but Mohs surgery results in superior cure rates owing to the complete review of the surgical margin with horizontally oriented tissue processing, and it requires only one specialized provider to serve as the surgical oncologist, pathologist, and reconstructive surgeon. However, if Mohs surgery is used in skin cancers that could adequately be treated with routine modalities , it no longer remains cost effective.

Mohs Surgery For The Newly Diagnosed: What You Need To Know

If youre reading this, you or someone you care about was probably diagnosed with skin cancer, and a doctor may have recommended Mohs surgery as the best treatment option.

Youre not alone. More than 5 million cases of basal cell carcinoma and squamous cell carcinoma are treated in the U.S. each year. Of these skin cancers, approximately 80 percent occur on the head and neck, locations that get significant sun exposure. Mohs surgery may be recommended by doctors for treating skin cancers in these cosmetically challenging locations, as well as other areas of the body.

The good news is that when detected and treated early, the vast majority of skin cancers are curable. At the same time, words like cancer and surgery can be frightening. Learning what you need to know about your condition and treatment can help put your mind at ease.

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What Are The Steps In The Procedure

The Mohs procedure involves a layer-by-layer removal of skin that contains cancer cells. Here are the typical steps in the procedure:

• The skin around the cancer cells is numbed with an injected anesthetic.
• Any visible, raised area of the tumor is removed first.
• A thin layer of tissue is removed from the involved site, with attempt to preserve as much healthy, normal skin as possible.
• The tissue is marked in a manner to identify right, left, top, and bottom, which is also marked on a map of the patient.
• The removed tissue is immediately frozen, cut, and stained in the doctor’s office. This process takes approximately one hour, but this time varies from case to case.
• The entire bottom and outer edges of the removed tissue layer are examined under a microscope by the Mohs surgeon.
• If any cancer cells are seen under the microscope, their location is identified , and an additional thin layer of tissue is removed only from the area where cancer cells remain.
• The process of microscopic examination and removal of additional layers of tissue continues until no more cancer cells are seen under the microscope.

Since the Mohs surgical technique only removes diseased tissue in the specific area in which it resides, more of the surrounding normal tissue can be saved. Another advantage of the Mohs technique is that the microscopic examination and removal method reveals the skin cancer down to its roots, allowing for complete removal of the cancer.

What Does Squamous Cell Carcinoma Look Like

Squamous cell carcinomas most often affect areas with lot of sun exposure such as the face, scalp, neck, ears, backs of hands, forearms, and shins. Squamous cell carcinomas can occur in many other areas of the skin. Squamous cell carcinoma often looks like a rough scaly spot, scab or sore that just will not heal. They tend to bleed easier than normal skin.

Scabs and scratches typically heal within 4 weeks. Skin cancer does not heal because the cells are abnormal. If you have a non-healing scab or sore, and it has been more than 4 weeks you should call your dermatologist to have this spot examined.

It is very important to note that while these characteristics are some of the most common signs of squamous cell carcinoma, there is no substitute for your skin concern being examined in person by a Board-Certified Dermatologist. This is the gold standard for having any of your skin concerns addressed. Your Board-Certified Dermatologist will perform a comprehensive examination and is the expert when it comes to diagnosis and treating skin cancers.

What causes squamous cell carcinoma?

How is squamous cell carcinoma diagnosed?

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What Happens During Mohs Surgery

The procedure is done in stages, all in one visit, while the patient waits between each stage. After removing a layer of tissue, the surgeon examines it under a microscope in an on-site lab. If any cancer cells remain, the surgeon knows the exact area where they are and removes another layer of tissue from that precise location, while sparing as much healthy tissue as possible. The doctor repeats this process until no cancer cells remain.

Step 1: Examination and prep

Depending on the location of your skin cancer, you may be able to wear your street clothes, or you may need to put on a hospital gown. The Mohs surgeon examines the spot where you had your biopsy and may mark it with a pen for reference. The doctor positions you for best access, which may mean sitting up or lying down. A surgical drape is placed over the area. If your skin cancer is on your face, that may mean you cant see whats happening, but the doctor talks you through it. The surgeon then injects a local anesthesia, which numbs the area completely. You stay awake throughout the procedure.

Step 2: Top layer removal

Using a scalpel, the surgeon removes a thin layer of visible cancerous tissue. Some skin cancers may be the tip of the iceberg, meaning they have roots or extensions that arent visible from the surface. The lab analysis, which comes next, will determine that. Your wound is bandaged temporarily and you can relax while the lab work begins.

Step 3: Lab analysis

Step 4: Microscopic examination

Basal Cells And Squamous Cells: How They Differ

To understand the difference between BCCs and SCCs, we should look at the uniqueness of the cells in the skin. The epidermis, the top layer of the skin, is made up of melanocytes, basal cells, and squamous cells. Squamous cells live in the outermost layer of the skin. Lower beneath the surface are basal cells, which eventually come to the surface to replace squamous cells that are shed naturally. So, basal cells transform into squamous cells as they move up to the outer layer of the epidermis. Melanocytes are the cells that add color to the skin.

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How Fast Do Squamous Cell Carcinomas Spread

Squamous cell carcinomas typically spread slowly, and they have a low rate of metastasis . When caught in its early stages, a squamous cell carcinoma is highly curable, but approximately 2-6% of squamous cell carcinomas metastasize. Most of the time, these lesions only break down the skin and tissues where they have developed. However, if a squamous cell carcinoma presents in a high-risk locationsuch as on the lips, ears, genital region, or within a scaror has the chance to grow significantly larger and deeper, this can increase the chance of spreading. Those with suppressed immune systems are also at an increased risk of having their skin cancer spread.

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What Is Different About Mohs Surgery

The procedure is different to other surgical techniques because at the time of tumour removal the complete tumour margin is mapped and examined under the microscope . This ensures that tumour is not present at the edges of the removed skin.

We draw a map of the operation site if tumour is still present we can identify where by using the map. If there is tumour present at the edge then a further piece of skin needs to be removed, at that specific site. This process is repeated until no tumour is found.

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Are There Risk Factors For Developing Merkel Cell Carcinoma

• Merkel cell polyomavirus infection This virus was first discovered in 2008, and its still somewhat of a mystery. This virus is found in the cancer cells of 80 percent of people with Merkel cell carcinoma.
• UV light exposure Exposure to the ultraviolet rays is the major risk factor . This exposure can come from the sun, tanning beds, or from UV light treatments for psoriasis.
• Fair skin Nearly 90 of Merkel cell carcinomas occur in white people.
• Old age This form of skin cancer is very rare in people under the age of 50. Over 80 percent of cases form in those over 70. This is probably due to a combination of accumulating UV exposure and a weakening immune system.
• Males Men are twice as likely to get this skin cancer, although again that can simply be a factor that men get more sun exposure.
• Weakened immune system Our immune systems not only fight germs and viruses, they also help the body fight cancer. When these systems are weakened, the patient becomes more likely to develop some types of cancer, including Merkel cell carcinoma.

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How Does Mohs Micrographic Surgery Work

The procedure is done in stages. After the affected area has been numbed with local anesthesia, the doctor uses a scalpel to excise the cancer in a disklike shape, says Dr. Leffell. When using the standard technique of simple excision, the surgeon must remove the tumor and cut a wide margin around it to ensure that she is removing as many of the abnormal cells as possible.

But with Mohs surgery, the doctor can start with a narrower excision and use a scalpel to remove just what is visible and can then later remove more if necessary.

The specimen is then brought to a laboratory that is a part of the Mohs unit. The specimen is divided into pieces and carefully mapped using different colors of ink. The tissue pieces are then processed in the lab and studied under the microscope by the Mohs surgeon, who can check the margins around the edges and underneath the tumor. Then the surgeon returns to the patient and removes another layer of cancerous tissue, if needed. In about 50 percent of cases, only one layer is needed to clear the cancer.

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How Aggressive Is Squamous Cell Carcinoma

Squamous cell carcinoma is not often considered to be life threatening. This form of skin cancer that affects the squamous cells tends to create slow-growing tumors. Although squamous cell carcinoma is more likely to invade deeper layers of the skin and spread to other parts of the body than basal cell carcinoma, this is still uncommon.

Only about 5 to 10 percent of squamous cell carcinoma tumors are considered to be aggressive.

Additional Information About Treatments For Sccs

In cases where SCC has spread, invaded the deep layers of the skin, caused severe local damage, are large in size, or has resisted a variety of treatments, more extensive treatment is likely to be necessary.

If you have been treated for, diagnosed with, or suspect that you have a Squamous Cell Carcinoma, the best first step toward effective treatment is to schedule a consultation at one of our dermatology clinics in The Villages or Leesburg. As one of the top Mohs Surgeons in the country, Dr. Gurgen has effectively treated hundreds of SCC patients. Contact us for a consult today.

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Surgery For Basal And Squamous Cell Skin Cancers

Surgery is a common treatment for basal cell and squamous cell skin cancers. Different surgical techniques can be used. The options depend on the type of skin cancer, how large the cancer is, where it is on the body, and other factors. Most often the surgery can be done in a doctors office or hospital clinic using a local anesthetic . For skin cancers with a high risk of spreading, surgery sometimes will be followed by other treatments, such as radiation or chemotherapy.

Skin Grafting And Reconstructive Surgery

After surgery to remove a large basal or squamous cell skin cancer, it may not be possible to stretch the nearby skin enough to stitch the edges of the wound together. In these cases, healthy skin can be taken from another part of the body and grafted over the wound to help it heal and to restore the appearance of the affected area. Other reconstructive surgical procedures, such as moving ‘flaps’ of nearby skin over the wound, can also be helpful in some cases.

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Surgical Procedures For Basal & Squamous Cell Skin Cancers

Basal or squamous cell skin cancers may need to be removed with procedures such as electrodessication and curettage, surgical excision, or Mohs surgery, with possible reconstruction of the skin and surrounding tissue.

Squamous cell cancer can be aggressive, and our surgeons may need to remove more tissue. They may also recommend additional treatments for advanced squamous cell cancer, such as medications or radiation therapyenergy beams that penetrate the skin, killing cancer cells in the body.

Basal cell cancer is less likely to become aggressive, but if it does, our doctors may use surgery and other therapies to treat it.

Dermatologists Defend Mohs Surgery As Effective And Cost

Brett M. Coldiron, MD

Mohs has a success rate approaching 99% for difficult-to-treat basal and squamous cell cancers and is a very cost-effective treatment option for nonmelanoma skin cancer.Brett M. Coldiron, MD

To clarify, the Mohs appropriate use criteria do not say that Mohs should be used for certain skin cancers, rather, that in some instances Mohs can be an appropriate choice, and in others it is not.Brett M. Coldiron, MD

The headline, Patients Costs Skyrocket, Specialists Incomes Soar, aptly encapsulates the theme of a recent article in TheNew York Times,1 part of a series entitled, Paying Till It Hurts.

Oncologists benefit from the ability to mark up each dose of chemotherapy they administer in private offices, according to the article, which also pointed out rising incomes for oncologists, gastroenterologists, and dermatologists over the past several years. But particular scrutiny was leveled at dermatologists use of Mohs micrographic surgery for treating skin cancers.

Use of the surgery has skyrocketed in the United Statesover 400 percent in a little over a decadeto the point that last summer Medicare put it at the top of its potentially misvalued list of overused or overpriced procedures, the Times article declared.

A Wonderful Tool

Most Procedures in Office

Determining Factors

Appropriate Use Criteria

Unfairly Targeted?

Disclosure: Dr. Coldiron reported no potential conflicts of interest.

References

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Mohs Surgery Is Very Precise

During Mohs surgery, a dermatologic surgeon like Maher removes skin from a skin cancer site one stage at a time. First, a dermatologic surgeon outlines the lesion with ink to map the tumor. After a local anesthetic is injected, the doctor removes the thinnest possible layer of cancerous tissue. While the patient waits, that layer is processed in an onsite pathology lab. After processing, the dermatologic surgeon can then examine the entire margin of removed tissue under the microscope to determine whether any cancer remains. If skin cancer persists, the dermatologic surgeon can identify the precise location of the remaining cancerous cells. At that point, the patient returns to the operating room so that the surgeon can take another layerand the process is repeated until all cancerous tissue has been removed. Roughly 80 percent of patients only need a single layer of skin removed in order to remove all the cancerous tissue. This layer-by-layer approach keeps the incision as small as possible to reduce scarring and promote healing.

Because of the way we process these tissue samples, looking at 100 percent of the margin, we can know for certain when weve removed all of the cancer, Maher said.