What Is The Purpose Of Mohs Surgery
Mohs surgery is a painstaking procedure. It requires microscopic analysis of tissue cells while the surgery is taking place. The borders of each thin layer of tissue are analyzed for potential malignancy as they are removed horizontally. This technique is designed to remove the entire tumor with minimal amounts of healthy tissue. This results in less disfigurement. For this reason, Mohs surgery is ideal for removing skin cancers from the face, ears, or genitals.
The procedure is highly effective for skin cancers that have high rates of recurrence. Its also effective on aggressive or large lesions. Mohs surgery is also used when lesions have ill-defined borders.
Mohs And Melanoma: A Step
- Posted on: Jan 15 2017
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Any skin cancer diagnosis can be heartbreaking for a patient. So many questions come to mind that it may be difficult to articulate them right away. Patients rely on their physicians for answers sometimes to questions they dont even know they have. For instance, todays dermatologist is expected to know about Mohs surgery. More specifically, how to perform this meticulous procedure, and in what situations.
Historically, Mohs has been performed primarily on basal cell and squamous cell carcinomas that are located in highly visible places on the body. Lesions within scar tissue, or related to skin cancer recurrence are also best treated with the layer by layer approach taken during the Mohs procedure.
But what about melanoma? This is the most concerning skin cancer diagnosis a patient can receive one with a stubbornly consistent mortality rate. One would think that the proven track record of Mohs would match well with the need for full removal of melanoma cancer cells.
The fact is, the transition has been slow. Fortunately, it has been steady.
Can Melanoma Lead To Other Cancers
The research on this is not extensive, but studies have pointed to a link. The biggest risk for patients who have had a previous melanoma that was treated and removed is to develop another melanoma. The risk for patients who had a previous melanoma for developing a second case is nine times greater than the general populations risk of developing melanoma.
There is also an increase in other cancers. The most common second cancers after a person have had melanoma were breast, prostate, and non-Hodgkins lymphoma.
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What Are The Types Of Melanoma
Most people assume there is just melanoma. There are actually four different types of this most dangerous form of skin cancer.
- Superficial spreading melanoma This is the most common form. It can arise in an existing mole or appear as a new lesion. When it forms in a mole already on the skin, it tends to grow on the surface for a period of time before penetrating more deeply. It is most likely to occur on the torso in men, the legs in women, and the upper back in both sexes. Superficial spreading melanoma appears as flat or slightly raised and discolored, asymmetrical patches with uneven borders.
- Lentigo maligna This form of melanoma often develops in older people. It also grows close to the surface skin in the beginning. This form typically develops on sun-damaged areas of the face, ears, arms, and upper torso. Lentigo maligna appears as flat or slightly raised, blotchy patches with uneven borders.
- Acral lentiginous melanoma This is the most common form of melanoma found in people with darker skin tones, including those with African ancestry. It often forms in areas that are not easy to spot under the fingernails or toenails, on the soles of the feet, or on the palms of the hands. It appears as a black or brown area.
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.
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Mohs Surgery: Still The Gold Standard Sometimes Too Much Of A Good Thing
For years, Mohs micrographic surgery , more concisely known as Mohs surgery, has worn the unofficial mantle of gold standard for the treatment of the keratinocyte cancers, basal cell and cutaneous squamous cell carcinoma . In this issue, Mark Teich, The Skin Cancer Foundations scientific director, interviews Mohs expert C. William Hanke, MD, discussing what makes Mohs surgery the optimal treatment for many skin cancer patients and how it has evolved and improved over the years. Dr. Hanke also sounds a note of caution about how Mohs can be overused, entailing greater costs in time and resources for simpler cases that dont require it. For those not familiar with the Mohs technique, Dr. Hanke explains the basics, below.
Basics of Mohs Surgery
Mohs surgery gives you the highest cure rate and lowest recurrence rate of any skin cancer treatment, while preserving the maximum amount of normal tissue. In many cases it allows for less complex reconstructions and provides superior cosmesis.
Why such a difference in cure rates? The bottom line is, Mohs surgeons can evaluate 100 percent of the surgical margin compared with only about 1 percent using standard surgical excision. So, they are assured of locating nearly all residual cancer cells with Mohs, whereas standard excision amounts to an educated guessing game.
How Is Mohs Surgery Performed
Mohs surgery is always performed in a medical facility that houses a laboratory.
An anesthetic will be injected into the area where the tumor is located, numbing it completely and making the procedure painless. Your surgeon will use a scalpel to gently remove the tumor, along with one layer of tissue from around it. The tumor and tissue will be taken to the lab for analysis while you wait. This waiting period may last up to an hour or longer, but youll be able to use the restroom if you need to. If the tumor is not next to your mouth, youll also be able to have a light snack or something to drink.
In the lab, the tissue sample will be sectioned and analyzed. If cancer is found, an additional layer of tissue will be removed in the exact area where the malignancy was located. This process continues until no more cancer cells are detected.
If you have malignant melanoma, its vitally important that your surgeon remove every single microscopic melanoma cell. This reduces the chance of cancer spreading to other parts of your body. New technologies, including stains that highlight malignant cells under a microscope and other immunohistochemistry techniques, help to further diminish this risk.
If the procedure is very long, you may require an additional injection of anesthesia.
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Surgery For Metastatic Melanoma
If melanoma has spread from the skin to other organs such as the lungs or brain, the cancer is very unlikely to be curable by surgery. Even when only 1 or 2 areas of spread are found by imaging tests such as CT or MRI scans, there are likely to be others that are too small to be found by these scans.
Surgery is sometimes done in these circumstances, but the goal is usually to try to control the cancer rather than to cure it. If 1 or even a few metastases are present and can be removed completely, this surgery may help some people live longer. Removing metastases in some places, such as the brain, might also help prevent or relieve symptoms and improve a personâs quality of life.
If you have metastatic melanoma and your doctor suggests surgery as a treatment option, be sure you understand what the goal of the surgery would be, as well as its possible benefits and risks.
What Is The Cure Rate For Melanoma
If caught early, the success rate for treating melanoma is very high. Thats why yearly skin cancer screenings are so important, particularly for people with fair skin. The estimated five-year survival rate for patients whose melanoma is detected early is about 99 percent in the U.S. But when cancer has spread to the lymph nodes, the five-year survival rate falls to 63 percent. If cancer has spread to distant organs, this rate falls to just 20 percent.
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What Is The Difference Between Mohs Surgery And Standard Excision
In standard excision, the tissue sample is sent off for histological processing while the wound is closed. The processing takes a number of days during which cross sections are created at various distances through the sample and are microscopically assessed by a pathologist. The pathologist looks for skin cancer at the margins of each section, but these are only a fraction of the actual excision margin.
In Mohs surgery, the histological processing takes place on the day of surgery and the wound is only closed after it has been confirmed that the entire cancer has been removed. The excision margin is examined by an embedding technique that allows horizontal sections to be cut involving all the deep and radial excision margins. If any tumour is visible in these sections, it means that the excision is incomplete and the patient requires a further Mohs stage.
A mapping process and colour coding system is used during Mohs surgery to precisely localise any remaining cancer, and tissue is only removed if it contains cancer. This process preserves healthy tissue.
Mohs surgery yields higher clearance rates than standard excision, and smaller wounds therefore better cosmetic results.
Are There Risks Associated With Mohs Surgery
The complications associated with the Mohs surgery itself are very low however, risks are unique to each individual. Please discuss your particular health issues and any concerns about the Mohs procedure with your surgeon. Listed below are the usual risks associated with Mohs surgery:
- Scar formation at the site of tumor removal.
- Larger than expected wound created upon removal of the skin cancer.
- Poor wound healing, which may be due to the patient’s underlying health conditions or failure of the wound repair method.
- Excessive bleeding from the wound, which could affect wound healing and/or result in the need for more office visits.
- Wound that becomes infected .
- Loss of nerve function if a tumor invades a nerve, which can be temporary or permanent.
- Regrowth of tumor after removal .
- Cosmetic or functional deformities if tumor is near or on an important structure such as eyes, eyelids, nose, ears, lips, forehead, scalp, fingers, or genital area.
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Mohs Surgery For Melanoma In Situ Where We Stand
You were just diagnosed with stage 0 melanoma, or melanoma in situ, on the tip of your ear. You learn that you are lucky and that your melanoma was detected before it had time to spread throughout your body. A surgery to remove the melanoma is quickly scheduled, and you take a deep breath and try not to think of what you narrowly avoided.
The most widely performed surgery to treat melanoma in situ is called a wide local excision where a surgeon removes the tumor with a margin of clear-looking skin of .5 1 cm. The wound is then stitched together. This technique has proven to be effective at curing melanoma in situ in most patients.
While effective and time tested, the procedure can cause significant scarring and even loss of function when performed in delicate areas. For non-melanoma skin cancers, such as basal cell carcinomas and squamous cell carcinomas, an alternative tissue-sparing procedure is frequently performed called Mohs Micrographic Surgery. Mohs Micrographic Surgery, frequently shortened to just Mohs surgery, was developed in the 1930s by Dr. Frederic Mohs, Professor of Surgery at the University of Wisconsin.
While more time consuming, Mohs surgery is more precise and allows surgeons to confirm that all tumor is removed before stitching the wound. This preserves more tissue and leaves smaller scars. In some cases and at some locations the procedure is also being used to treat melanoma in situ.
Can The Cancer Come Back
Mohs surgery has the highest cure rate of all treatments for basal cell and squamous cell carcinomas — more than 99% for new skin cancers and 95% if the cancer comes back.
Your doctor will want to schedule regular follow-ups with you to check your skin for new cancers. Twice a year is normal, but you may need them more often if the cancer is an aggressive type thatâs more likely to come back. You and your doctor will decide on the right schedule.
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What Treatment Options Are Available For Advanced Cases Of Melanoma
If a patients melanoma has spread beyond the surface skin, treating it is more difficult. Here are some methods and what is involved.
- Surgery to remove affected lymph nodes This surgery, clinically known as lymphadenectomy, is done to remove melanoma that has spread only to the lymph nodes. This can prevent it from spreading to other areas of the body.
Since the lymph nodes usually affected by melanoma are near the surface of the skin, this is not a difficult surgery or recovery. If the lymph nodes in question are located in more difficult areas to access, recovery correspondingly will be more involved. Lymphedema may develop after the removal of the lymph nodes. This is an accumulation of lymphatic fluid that collects in the area where the lymph nodes were removed.
- Chemotherapy Because chemotherapy uses drugs that course through your entire body to get to the cancer cells, it usually is not the best treatment for isolated melanoma. These drugs can damage your nerves and cause pain, burning, tingling, or weakness and sensitivity to hot and cold. Other side effects include hair loss, mouth sores, infection, and bruising or bleeding.
- Radiation In advanced melanoma, radiation may be used to kill any cancer cells that may have been left behind after surgery or if the melanoma has spread to the brain or the bones.
Melanoma Removal And Why Mohs Surgery Isnt Suitable
It doesnt matter how popular a skin cancer surgery is, even if it has the success rate of Mohs surgery, there are distinct reasons it isnt suitable for melanoma outside scarring.
The main reason is that melanoma is a far more aggressive form of cancer, and even after removal, there are chances it can reoccur. Reasons for this being that the removed tissue may not catch all the cancer cells.
Besides this, melanoma cancer cells can be a lot harder for the surgeon to detect, hence the reason they remove so much tissue. If there is a reoccurrence, it can prove fatal for the patient if undetected.
Mohs Micrographic Surgery For Digital Melanoma And Nonmelanoma Skin Cancers
Dr. Husain is from the Division of Dermatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York. Dr. Allawh is from the Department of Dermatology, Drexel University, Philadelphia, Pennsylvania. Dr. Hendi is in private practice, Chevy Chase, Maryland, and also is from the Department of Dermatology, Georgetown University Hospital, Washington, DC.
The authors report no conflict of interest.
Correspondence: Zain Husain, MD, Montefiore Medical Center, Division of Dermatology, 111 E 210th St, Bronx, NY 10467 .
Treatment of digital skin cancers is challenging due to various functional and cosmetic implications. Traditionally, routine treatment includes radical amputation, but digital skin cancers are increasingly being treated with more conservative, tissue-sparing methods such as Mohs micrographic surgery , which provides excellent tissue conservation and margin control when used to treat melanoma and nonmelanoma skin cancers . In this study, we conducted a retrospective chart review to evaluate clinical outcomes following MMS for treatment of digital melanoma and NMSCs.
- Melanoma and nonmelanoma skin cancers of the digits traditionally have been treated with wide local surgical excision and even amputation.
- Conservative tissue sparing techniques such as Mohs micrographic surgery can be used to treat digital skin cancers with high cure rates and improved functional and cosmetic results.
What Is Mohs Surgery And When Is It Used
Mohs surgery is a precise, intricate, highly effective procedure, considered the gold standard for treating many BCCs and SCCs, including those in cosmetically and functionally important areas around the eyes, nose, lips, ears, scalp, fingers, toes or genitals. Mohs is also recommended for BCCs or SCCs that are large, aggressive or growing rapidly, that have indistinct edges or have recurred after previous treatment.
Some surgeons are also successfully using Mohs surgery on certain cases of melanoma.
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Answer: Moh’s Can Be Usedbut
Being a board-certified facial plastic surgeon as well as a board certified dermatologist , I have had discussions with Moh’s surgeons about using Moh’s for melanoma. Understand that Moh’s surgery allows the surgeon to remove a tumor with taking the least amount of normal tissue and insuring that all of the margins are clear. They do a great job and it certainly has its place. It is my belief that I do not want to be “close” when I resect a melanoma. I want to have very clear margins and this requires taking more “normal” skin and going deeper then I might with another type of tumor. So the answer is “yes” Moh’s surgery can be used for resecting a melanoma, but I do not see the value over having it resected with “close” margins. I always ask the pathologist “how clear were my margins”. This is an on-going discussion. To date there has been no definitive study that proves that Moh’s surgery has any greater success in treating melanoma then frozen sections or a wide resection.