Synoptic reporting in Mohs micrographic surgery

There is currently no standardised reporting format for Mohs surgery with its operation reports mostly written in a narrative form making them prone to unintentional errors and omission of necessary data. Synoptic histology reporting is used to describe excised skin cancers such as melanomas and, more recently, squamous cell and basal cell carcinomas. Since Mohs surgery is utilised as the gold standard treatment for locally invasive squamous and basal cell carcinomas, we propose the use of our model of synoptic reporting to ensure the completeness and consistency of Mohs surgery operation reports.     

Formalin-fixed tissue Mohs surgery (slow Mohs) for basal cell carcinoma: 5-year follow-up data

Background Mohs surgery using a formalin‐fixed tissue technique (slow Mohs) was used to treat 1090 basal cell carcinomas (BCCs) occurring in 1000 patients without Gorlin syndrome in a prospective, open nonrandomized trial of therapy carried out in a university dermatology department. Objectives To record outcomes and 5‐year cure rates in these patients. Results Five multirecurrent BCCs could not be cleared and Mohs surgery was abandoned. In the remaining 1085 BCCs, after debulking, clearance was achieved with a mean of 1·7 stages and 7·7 blocks. Logistic regression analysis showed that large tumour size and position on the nose were the only factors that significantly predicted the risk of tumour excision requiring more than two Mohs stages. Wounds were managed by the Mohs surgeon (n = 917), by an oculoplastic surgeon (n = 117) and by a plastic or other surgeon (n = 56). The mean interval between the first Mohs excision and Mohs clearance, regardless of the closure technique, was 4·2 days (range 0–44) and the mean interval between tumour clearance and defect closure was 1·9 days (range 0–49). Reconstruction of 117 periocular defects by the oculoplastic surgeon was done at a mean of 0·8 days (range 0–6) after Mohs clearance. Reconstruction by the plastic surgeon was done at a mean of 10 days (range 0–49) after Mohs clearance. Five‐year follow up was possible in 750 BCCs. Within this group 21 tumour recurrences were identified, giving a 5‐year cure rate of 97·2% for all patients, 97·8% for primary BCC and 95·3% for recurrent BCC. The mean tumour recurrence time was 2·5 years (range 0·6–4·99) following Mohs excision. There was a higher risk of recurrence for big (four of 78; 5%) and recurrent (nine of 193; 5%) BCCs compared with other indications for Mohs surgery. Conclusions The essential difference between frozen sections and formalin‐fixed sections is the greater use of an automated laboratory system to process the smaller size and greater number of blocks produced using the latter process. An effective Mohs service based on formalin‐fixed sections requires a minimum of three half‐day operating sessions together with a pathology laboratory able to provide results routinely within 24–48 h. A formalin‐fixed tissue Mohs service is useful for certain skin tumours and requires less technician time than a frozen section service but this advantage may not outweigh the inconvenience to the patient.     

Mohs显微外科手术75例回顾分析

目的 分析Mohs显微外科手术的意义及特点.方法 对75例Mohs显微外科手术病例进行回顾性分析.结果 手术病例中多为老年人,基底细胞癌、Bowen病等为最常见的受治病种.部分肿瘤经多次扩大切除才被切净,最终切除面积大于常规方法切除的面积.68%为头面部手术,头面部缺损多需要应用复杂成形修复.手术缺损最终大小与患者年龄及皮肤肿瘤发生部位无关.结论 对于切除皮肤肿瘤,Mohs显微外科手术比常规切除方法更彻底,有助于切除后手术缺损的成形修复.     

改良Mohs显微描记手术治疗Merkel细胞癌二例

【摘要】 Mohs显微描记手术是切除皮肤肿瘤的理想术式。本文2例Merkel细胞癌患者行改良Mohs显微描记手术切除肿瘤，随访1年余，肿瘤未复发。与传统扩大切除术相比，改良Mohs手术是Merkel 细胞癌患者更好的选择。     

A Case of Trichilemmal Carcinoma Treated with Mohs Micrographic Surgery

Trichilemmal carcinoma is a cutaneous adnexal tumor originating from the outer root sheath of hair follicle, and it was first described by Headington in 1976. Clinically, it usually occurs as an asymptomatic solitary papule, nodule or mass on the face or scalp. This neoplasm is a malignant counterpart of trichilemmoma, and it has been reported in the literature as trichilemmal carcinoma, tricholemmal carcinoma, malignant trichilemmoma, and tricholemmocarcinoma. Although histologically, trichilemmal carcinoma frequently has maliganant features, it has a relatively benign clinical behavior. We think Mohs micrographic surgery is a useful treatment modality in trichilemmal carcinoma because the final skin defect is smaller than a wide excision. We report a case of primary trichilemmal carcinoma which had developed on the face, treated with Mohs micrographic surgery.     

Surgical Tip: The Double-Bladed Scalpel in Mohs Micrographic Surgery

Mohs micrographic surgery is applied as the primary method of treatment for various cutaneous neoplasms. Many other methods that are modified applications of Mohs micrographic surgery have also been suggested. We introduce a technique, which is a modified vertical method of Mohs micrographic surgery using the double-bladed scalpel.     

Mohs surgery for squamous cell carcinoma

Cutaneous squamous cell carcinoma (SCC) is the second most common human cancer and can behave aggressively. Mohs micrographic surgery offers the highest cure rates for high-risk SCCs and is particularly useful for SCCs on challenging anatomic sites.     

Mohs micrographic surgery pearls

Mohs micrographic surgery has evolved over the last 60 years from fixed-tissue chemosurgery with secondary intention healing to fresh-tissue surgical excision utilizing advanced histotechnology and reconstructive techniques. This evolution has occurred while preserving the fundamental characteristics of Mohs surgery: microscopically controlled tumor excision by one surgeon acting as pathologists to ensure complete tumor extirpation while maximally conserving tissue. Refinements, modifications, and clinical pearls will be outlined that uphold these tenets and enhance the quality of patient care.     

Histologic pitfalls in the Mohs technique

The success of the Mohs procedure depends on the reliability of each step in the technique. Pitfalls in histologic preparation of the tissue specimens may occur during debulking, excising, orienting, creating the map, sectioning, inking, tissue flattening and freezing, cutting, slide fixation, staining, and mapping the tumor. Challenges are also present in interpreting the slides. Diagnostic pitfalls include floaters, inflammatory conditions resembling tumor, and perineural invasion. The technique requires time, teaching, and a sufficient quantity of cases from which to learn, as well as attention to the pitfalls that occur while processing tissue specimens and interpreting and mapping the histology.     

改良Mohs显微描记手术26例分析

目的　观察改良Mohs显微描记手术治疗皮肤癌的临床疗效。方法　沿皮损外约2mm～4mm切除病灶,用数码相机拍下切除组织的位置及形状,并即时打印,将送检的组织在打印图纸上及病人身上相对应的位置作相同的记号。然后按Mohs显微描记手术其他步骤进行。结果　26例患者经改良Mohs显微描记手术治疗,所有切口均Ⅰ期愈合,皮片或皮瓣均成活,随访1个月～2年,除一例头皮复发性鳞状细胞癌术后一月复发外,余患者均治愈,肿瘤无复发。结论　改良Mohs显微描记手术可指导手术医生更精确地控制扩大切除的范围,在根治肿瘤的同时最大限度的保留正常组织,为下一步的成形修复创造最佳条件。     

Treatment of 208 extensive basal cell carcinomas with Mohs micrographic surgery

Aim With the rapidly increasing number of basal cell carcinomas in Europe, a close look at Mohs Micrographic Surgery (MMS) is timely. Subject We report the results of MMS in the Netherlands, as treatment for extensive basal cell carcinomas. Methods Patients (n= 198) with extensive basal cell carcinoma (n= 208) were treated with MMS. The mean follow up period was 6.4 years. Results Four of 208 BCCs recurred. Conclusions Considering a recurrence rate of only 2% for the treatment of extensive and mainly recurrent basal cell carcinomas, we suggest that MMS provides the best prospect for total tumour removal.     

Mohs micrographic surgery technique

This article provides a protocol for the systematic approach to the technique of Mohs micrographic surgery. Each step, from tumor excision and tissue mapping, to specimen processing and histologic interpretation, through wound closure and postoperative management, is covered. The advantages of Mohs surgery over other treatment modalities are observed histologic margin control, superior cure rates, and maximal tissue-sparing potential. The increased preservation of normal tissue leads to smaller surgical defects, optimal reconstructive results, and diminished risk of poor surgical outcomes. Overall, the risks of the procedure are few, the benefits numerous, and the outcomes worth the time and effort spent in learning the technique.     

Setting up the Mohs surgery laboratory

Mohs micrographic surgery has the highest cure rate for skin cancer. Accurate and precise preparation of horizontal frozen sections in the laboratory is essential for the success of Mohs micrographic surgery. Key considerations in developing the Mohs surgery laboratory are careful planning and design, selection of proper equipment and supplies, training of laboratory personnel, adherence to regulatory standards of Clinical Laboratory Improvement Amendments (CLIA), and execution of an effective daily routine. The method of tissue processing used in the laboratory must yield optimal results for processing skin in an efficient manner.     

Mohs surgery histopathology concordance in Australia

Background: Mohs micrographic surgery is an important technique for dealing with difficult non‐melanoma skin cancers. The ability of the Mohs surgeon to correctly interpret the histopathology is crucial to the practice of this surgery. This study sought to assess the concordance between a Mohs surgeon and a dermatopathologist in the reading of Mohs section histopathology slides. Methods: This study was a retrospective study of Mohs frozen section histopathology slides of patients from a private Mohs practice. The slides were provided for assessment by a dermatopathologist who had to interpret the histopathology and mark on a Mohs map the location of the tumour. Results: We demonstrate a 95% agreement between the Mohs surgeon and the dermatopathologist in the interpretation of Mohs frozen section histopathology slides. Conclusion: An Australian Mohs surgeon is capable of correctly identifying and interpreting histopathology in non‐melanoma skin cancers, and this compares favourably to an overseas study.     

Angiomyxoma of the nasal dorsum treated by Mohs surgery

Cutaneous angiomyxomas are myofibroblastic neoplasms with locally aggressive behaviour and a high risk of recurrence. We describe a case of a solitary cutaneous angiomyxoma presenting on the nasal dorsum of a 28‐year‐old man, excised with Mohs surgery using permanent section control and repaired with an advancement flap. Histology showed myxoid nests of bland CD34‐positive and vimentin‐positive stellate and spindled cells in the deep dermis and abundant thin‐walled blood vessels. An echocardiogram, performed to rule out the possibility of a cardiac myxoma with cutaneous embolisation, was normal.