MOHS MICROGRAPHIC SURGERY

ADVANTAGES OF MOHS MICROGRAPHIC SURGERY

Dr. Ken Gross Presents:

INDICATIONS
FOR
MOHS
MICROGRAPHIC SURGERY

Excellent technique for treatment of many cutaneous &

Tissue conservation

mucosal tumors
Well suited for skin tumors with:
continguous growth patterns
ill-defined subclinical spread
cosmetic & functional significance
high recurrence rate (treated by other modalities)

Accurate histologic margin evaluation

Highest cure rate of all treatment modalities
Coordination of surgery & pathology
Outpatient surgery (usually) with safety of local

anesthetics

Slides were originally compiled by LYNN PROCTOR

SHIPMAN, M.D.

DISADVANTAGES OF MOHS
MICROGRAPHIC SURGERY

RECURRENCE RATES OF
STANDARD TREATMENT MODALITIES

FIVE YEAR RECURRENCE RATES FOR BASAL CELL

CARCINOMA
(Rowe et al J. Dermatol Surg Oncol 1989;15)

No prospective data with controlled patient /tumor

Tedious & time-consuming

Expensive modality (staff/equipment)
Surgical/pathologic training required

variables comparing treatment modalities

Statistics skewed lower for Radiation and Mohs which
tend to treat more difficult tumors
No 5 year data on recent treatment modalities:
photodynamic dye therapy and Aldara
Recurrent tumors have expected higher recurrence rates

Curettage & electrosurgery

Primary

Recurrent

BCC

BCC

7.7 %

40.0 %

10.1 %

17.4 %

Cryosurgery

7.5 %

13.0 %

Radiation therapy

8.7 %

9.8 %

Mohs micrographic excision

1.0 %

5.6 %

Surgical excision

Five Year Recurrence Rates for Squamous Cell

Carcinoma
(Rowe et al J Am Acad Dermatol 1992:26)

INDICATIONS FOR MOHS TREATMENT OF BASAL

CELL CARCINOMA & SQUAMOUS CELL CARCINOMA

OBJECTIVES
IN THE MANAGEMENT OF
SKIN CANCERS (5 CS)

Primary BCCs / SCCs

Specific criteria

Cure
Primary SCC

Recurrent

SCC

First treatment offers highest chance of cure

Complications

Curettage
g & electrosurgery
g y

3.7 %

-------

Surgical excision

8.1 %

23.3 %

Cryosurgery

3.2%

-------

Radiation therapy

10.0 %

-------

Mohs micrographic excision

3.1 %

6.7-10 %
6.7-

Medical status of patient

Preservation of function

Cosmesis
Never compromise cure for cosmesis

Convenience
Cost

VARIABLES TO EXAMINE
FOR SELECTION OF MOHS FOR
PRIMARY BCCS & SCCS

MORPHEAFORM BCC

Preoperative tissue biopsy important

Subtypes of BCC/SCC may not be reported: look at slide!!!
slide
May have >1 subtype present at same location

Morpheaform BCC
Histologic margins extend well beyond clinical margin.
Salasche reports avg. 7.2mm subclinical extension
Metatypical BCC
Squamous differentiation and keratinization within a tumor
that is predominant basal cell carcinoma
High risk of recurrence (1230 %); risk of metastases
(<9.7%)

PRE--OP
PRE

Histologic
Anatomic
Size
Border
Tumor behavior
Immunocompromised pts, basal cell nevus
syndrome or irradiated skin
Incompletely excised BCCs / SCCs
Specific criteria
Recurrent BCCs / SCCs
Strongly indicated

RECURRENT METATYPICAL BCC

INTRA--OP
INTRA

HISTO

Histologic Subtypes

PRE--OP
PRE
POST--OP
POST

METATYPICAL BCC
BCC

SCC DIFFERENTIATION

HISTOLOGIC SUBTYPES (CONT)

ANATOMIC LOCATION
High Risk for Recurrence

Infiltrating & micronodular BCCs

Poorly differentiated & acantholytic SCCs
Perineural
Perineural,, p
perivascular , & deep
p tissue involvement

PERINEURAL

MASK OR H-ZONE

Perineural tumor found in 64% of SCCs >2.5 cm in

size
Tumor can advance several cms beyond initial site
of perineural entry and gain access into intracranial
space
Tumor depth >4mm

 
  
  

Mask or H zone on Head

x nasolabial folds, upper and mucosal lips,
vermillion,, columella,, nose,, medial & lateral
canthi, temples, pre and post auricular skin,
helices, tragi, conchae, ear canals
Cosmetic or Functionally significant sites
nose, eyelid, entire face in some patients, digits,
penis

Aggressive Biologic Behavior or Rapid

Growth

Size of BCC/SCC

Direct correlation between tumor size &

recurrence
Tumor diameter >2 cm consider Mohs
Indistinct Clinical Border
Field-fire BCC with multicentric
discontinuous foci due to carcinogen,
previous irradiation or treatment with
liquid N2

METASTATIC RATES FOR SCCS

Cutaneous SCC
SCCss
Mucocutaneous SCCs
Scar/Inflammatory SCCs

26%
10 11 %
10 30 %

IMMUNOCOMPROMISED PATIENTS

SCC > 2CM

IN IMMUNOSUPPRESSED PATIENT
PRE--OP
PRE

PRE--OP
PRE

DEFECT

Increased risk for aggressive tumor behavior

Basal Cell Nevus syndrome patients

Radiation therapy may aggravate growth

Treat aggressive growing tumors with Mohs

4 :1 ratio of SCC / BCC

CLL is the worst

--- worse than transplant or HIV

Indications for Mohs Surgery

HISTO

Previously irradiated skin

EARLY POSTPOST-OP

Clear margin is different than normal patients

INCOMPLETELY EXCISED BCC/SCC

(IMMEDIATE POST-OP)

RECURRENT BCC/SCC

RECURRENT BCC
PRE--OP
PRE

Do not recommend watch & wait policy for tumor

recurrence if positive margins reported by pathology

after excision
Immediate re-excision with Mohs surgery if:
Deep positive surgical margins involved
Orientation of surgical specimen unknown
Skin flap was used initially to close the surgical
defect

Strongest indication for Mohs surgery

Recurrent BCCs/SCCs may have unpredictable

multifocal
u t oca tumor
tu o growth
g o t underneath
u de eat p
previous
e ous scar
sca
ear, nose, temple, scalp locations permit
widespread occult growth in perichondrium or
periosteum
Mohs surgery not (?) recommended for recurrent oral
or pharyngeal / laryngeal tumors (Terry Davidson
M.D.)

DEFECT

PRE--OP CLOSEPRE
CLOSE-UP

ADDITIONAL CUTANEOUS TUMORS

TREATED WITH MOHS SURGERY
The following cutaneous tumors can also be treated by

Mohs micrographic surgery in critical areas:

Recurrent, aggressive or mutilating
keratoacanthomas
Microcystic adnexal carcinoma
Desmoplastic trichoepitheliomas

ADDITIONAL CUTANEOUS TUMORS TREATED WITH

MOHS SURGERY (CONT)

CAVEATS: MANY OF THE PREVIOUS TUMORS MAY

REQUIRE:

Atypical fibroxanthomas

Adjunctive therapies

Verrucous carcinomas

sentinel lymph node biopsies, radiation,

chemotherapy, paraffin embedded sections with
immunohistochemical stains to ensure tumor
erradication
Evaluations
pathologists, oncologists, radiation-oncology,
plastic, ENT, ophthalmologic & general surgeons
Presentation
hospital tumor boards

Dermatofibrosarcoma protuberans
Bowens disease of genitalia
Melanoma particularly lentigo maligna on facial skin
Merkel cell carcinoma
Sebaceous carcinoma
Pagets & extramammary Pagets disease
Malignant fibrous histiocytoma
Squamous Cell Carcinoma of Head & Neck with Metastases