Abstract
Mohs micrographic surgery (MMS) provides the highest cure rate for skin cancer while maximally sparing surrounding healthy tissue. False negatives and false positives are avoided by histologic studies of 100 % of the tumour margins and by sophisticated processing of horizontal sections during surgery, respectively. By sparing noncancerous tissue, MMS offers a solution to the dilemma of removing a tumour in its entirety while preserving as much tissue as possible intact. Since interactive microscopic control of removed tissue means that the neoplasm can be eliminated in stages, cure is theoretically confirmed by the end of surgery, depending on the type and characteristics of the removed tumour.
MMS success mainly depends on correctly performing a number of steps between removing the cancerous tissue and obtaining samples for histologic study. Errors in technique and microscopic interpretation are particularly relevant to cases of tumour recurrence after MMS. Therefore, in addition to mastering the basic principles of surgical dermatology, the Mohs surgeon needs to be trained in advanced MMS.
MMS is underpinned by two basic principles. The first principle is that microscopic confirmation of tumour-free surgical margins immediately on removing the tumour is far more specific than any visual inspection. The second principle concerns the need for coordination, as MMS is a single procedure performed in stages. Since a number of disciplines are involved, successful MMS requires one person—the Mohs surgeon—to assume responsibility for organising the procedure and ensuring effective communication when different tasks are carried out by different professionals. The Mohs surgeon thus needs to be knowledgeable about all the steps so as to oversee them and intervene interactively when necessary. Each of the MMS stages is reviewed in detail.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Swanson NA, Taylor WB, Tromovitch TA. The evolution of Mohs surgery. J Dermatol Surg Oncol. 1982;8:650–4.
Hruza GJ. Mohs micrographic surgery local recurrences. J Dermatol Surg Oncol. 1994;20:573–7.
Brodland DG, Amonette R, Hanke CW, Robbins P. The history and evolution of Mohs micrographic surgery. Dermatol Surg. 2000;26(4):303–7.
Benedetto PX, Poblete-Lopez C. Mohs micrographic surgery technique. Dermatol Clin. 2011;29(2):141–51,vii. Review.
Thornton SL, Beck B. Setting up the Mohs surgery laboratory. Dermatol Clin. 2011;29(2):331–40, xi. Review.
Hetzer MR. The Mohs laboratory. In: Snow SN, Mikhail GR, editors. Mohs micrographic surgery. 2nd ed. Madison: University of Wisconsin Press; 2004. p. 329–37.
Trost LB, Bailin PL. History of Mohs surgery. Dermatol Clin. 2011;29(2):135–9, vii.
Tromovitch T, Stegman S. Microscopically controlled excision of skin tumors: chemosurgery (Mohs) fresh tissue technique. Arch Dermatol. 1974;110:231–2.
Morgan M, Bowland T. Mohs and frozen section overview. In: Morgan MB, Hamill JR, Spencer JM, editors. Atlas of Mohs and frozen section cutaneous pathology. New York: Springer; 2009. p. 3–8.
Otley C, Roenigk R. Mohs surgery. In: Bolognia J, Jorizzo J, Rapini R, editors. Dermatology. 2nd ed. St Louis: Mosby; 2008. p. 2269–79.
Stranahan D, Cherpelis BS, Glass LF, Ladd S, Fenske NA. Immunohistochemical stains in Mohs surgery: a review. Dermatol Surg. 2009;35:1023–34.
Chung VQ, Bernardo L, Jiang SB. Presurgical curettage appropriately reduces the number of Mohs stages by better delineating the subclinical extensions of tumor margins. Dermatol Surg. 2005;31(9 Pt 1):1094–9 [discussion: 1100].
Miller LJ, Argenyi ZB, Whitaker DC. The preparation of frozen sections for micrographic surgery. J Dermatol Surg Oncol. 1993;19:1023–9.
Silapunt S, Peterson SR, Alcalay J, et al. Mohs tissue mapping and processing: a survey study. Dermatol Surg. 2004;30(6):961.
Humphreys TR, Nemeth A, McCrevey S, et al. A pilot study comparing toluidine blue and hematoxylin and eosin staining of basal cell and squamous cell carcinoma during Mohs surgery. Dermatol Surg. 1996;22:693–7.
Bouzari N, Olbricht S. Histologic pitfalls in the Mohs technique. Dermatol Clin. 2011;29(2):261–72, ix. Review.
Walling HW, Swick BL. Identifying a tissue floater on Mohs frozen sections. Dermatol Surg. 2009;35:1009–10.
Mogensen M, Jemec GB. Diagnosis of nonmelanoma skin cancer/keratinocyte carcinoma: a review of diagnostic accuracy of nonmelanoma skin cancer diagnostic tests and technologies. Dermatol Surg. 2007;33(10):1158–74.
Bobadilla F, Wortsman X, Munoz C, et al. Presurgical high resolution ultrasound of facial basal cell carcinoma: correlation with histology. Cancer Imaging. 2008;8:163–72.
Redondo P, Marquina M, Pretel M, et al. Methyl-ALA-induced fluorescence in photodynamic diagnosis of basal cell carcinoma prior to Mohs micrographic surgery. Arch Dermatol. 2008;144(1):115–7.
Nguyen DH, Siegel DM, Zell D, et al. Quality assurance. In: Morgan MB, Hamill JR, Spencer JM, editors. Atlas of Mohs and frozen section cutaneous pathology. New York: Springer; 2009. p. 9–14.
Leshin B, Prichard EH, White WL. Dermal granulomatous inflammation to cornified cells. Significance near cutaneous squamous cell carcinoma. Arch Dermatol. 1992;128(5):649–52.
Requena C et al. Dermatofibrosarcoma protuberans: clinical, pathological, and genetic (COL1A1-PDGFB) study with therapeutic implications. Histopathology. 2009;54(7):860–72.
Rapini RP. Pitfalls of Mohs micrographic surgery. J Am Acad Dermatol. 1990;22:681–6.
Swanson NA. Mohs surgery. Technique, indications, applications, and the future. Arch Dermatol. 1983;119(9):761–73.
Siegel DM. Mohs surgery for large and difficult tumors and in special clinical situations. In: Gross KG, Steinmann HK, Rapini RP, editors. Mohs surgery fundamentals and techniques. St Louis: Mosby; 1999. p. 231–8.
El Tal AK, Abrou AE, Stiff MA, et al. Immunostaining in Mohs micrographic surgery: a review. Dermatol Surg. 2010;36(3):275–90.
Whalen J, Leone D. Mohs micrographic surgery for the treatment of malignant melanoma. Clin Dermatol. 2009;27(6):597–602.
Temple CL, Arlette JP. Mohs micrographic surgery in the treatment of lentigo maligna and melanoma. J Surg Oncol. 2006;94:287–92.
Zalla MJ, Lim KK, Dicaudo DJ, et al. Mohs micrographic excision of melanoma using immunostains. Dermatol Surg. 2000;26(8):771–84.
Chang KH, Finn DT, Lee D, Bhawan J, Dallal GE, Rogers GS. Novel 16-minute technique for evaluating melanoma resection margins during Mohs surgery. J Am Acad Dermatol. 2011;64(1):107–12.
Levine H, Bailin P, Wood B, et al. Tissue conservation in treatment of cutaneous neoplasms of the head and neck. Combined use of Mohs’ chemosurgical and conventional surgical techniques. Arch Otolaryngol. 1979;105(3):140–4.
Ducic Y, Marra DE, Kennard C. Initial Mohs surgery followed by planned surgical resection of massive cutaneous carcinomas of the head and neck. Laryngoscope. 2009;119(4):774–7.
Bakhtar O, Close A, Davidson TM, Baird SM. Tissue preparation for MOHS’ frozen sections: a comparison of three techniques. Virchows Arch. 2007;450(5):513–8.
Hanke CW, Leonard AL, Reed AJ. Rapid preparation of high-quality frozen sections using a membrane and vacuum system embedding machine. Dermatol Surg. 2009;34(1):20–5.
Miller CJ, Sobanko JF, Zhu X, Nunnciato T, Urban CR. Special stains in Mohs surgery. Dermatol Clin. 2011;29(2):273–86, ix. Review.
Butler DF, Parekh PK, Lenis A. Imiquimod 5 % cream as adjunctive therapy for primary, solitary, nodular nasal basal cell carcinomas before Mohs micrographic surgery: a randomized, double blind, vehicle-controlled study. Dermatol Surg. 2009;35(1):24–9.
Han A, Chen EH, Niedt G, Sherman W, Ratner D. Neoadjuvant Imatinib therapy for dermatofibrosarcoma protuberans. Arch Dermatol. 2009;145(7):792–6.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Glossary
- Cryostat
-
is a device used to maintain low temperatures of samples
- MART-1
-
Melanoma antigen recognised by T-cells
- MMS
-
Mohs micrographic surgery
- NMSC
-
Non-melanoma skin cancer
- OCT
-
Optimal cutting temperature
Rights and permissions
Copyright information
© 2014 Springer Science+Business Media New York
About this chapter
Cite this chapter
Garcés, J.R. (2014). Mohs Micrographic Surgery. In: Baldi, A., Pasquali, P., Spugnini, E. (eds) Skin Cancer. Current Clinical Pathology. Humana Press, New York, NY. https://doi.org/10.1007/978-1-4614-7357-2_21
Download citation
DOI: https://doi.org/10.1007/978-1-4614-7357-2_21
Published:
Publisher Name: Humana Press, New York, NY
Print ISBN: 978-1-4614-7356-5
Online ISBN: 978-1-4614-7357-2
eBook Packages: MedicineMedicine (R0)