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A patient with recurrent adenoid cystic carcinoma of the skin managed by Mohs surgery is reported. The histopathologic features and differential diagnosis of this tumor are reviewed. Mohs surgery appears to be an ideal way to manage this neoplasm since recurrences after routine excision are common and metastases are uncommon.
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Mohs surgery, as it has evolved since its inception by Dr. Mohs, is a technique for removal of certain cancers using careful, precise microscopic marginal control. The contemporary technique using fresh tissue is detailed, illustrating advantages that include maximal conservation of normal surrounding tissue and structures, an extremely high cure rate, and a tumor-free defect which can be reconstructed immediately. The indications and applications for Mohs surgery, once limited to large recurrent basal cell carcinomas, have expanded to include several cutaneous and paracutaneous neoplasms. These, with an emphasis on certain basal cell carcinomas, are discussed in detail. With better understanding of the Mohs technique, its indications, applications, and advantages, an interdisciplinary approach to certain cutaneous and paracutaneous neoplasms is proposed.
Mohs' surgery often requires multiple dressing changes in a single day. The innovative dressing method described here provides a reproducible, visually acceptable dressing with minimal damage to the patient's uninvolved skin. It also allows speedy removal and a smooth flow of events for the health care team.
Mohs' micrographic surgery (MMS) is the recommended treatment for large basal cell carcinomas (BCCs) of the nose. This 5-year follow-up study attempts to evaluate whether curettage-cryosurgery (CC) could be an alternative therapy in a country where optimal resources for MMS are lacking. All patients with a primary nasal or perinasal BCC, 10 mm or larger in diameter, were assessed at a skin tumour clinic. Sixty-one BCCs of non-morphoeiform type were treated with CC. Most of the tumour was removed by careful curettage with different sized curettes. The tumour area was then frozen with liquid nitrogen in a double freeze-thaw cycle. Fifty patients were followed for at least 5 years with only one recurrence. The cosmetic result was good or acceptable in all patients. A thorough curettage followed by cryosurgery could be a safe and inexpensive alternative therapy even for large primary non-morphoeiform BCCs of the nose.
PURPOSE: Mohs micrographic surgery has been advocated as the optimal management of nonmelanoma skin cancer in the periocular region. It is a technique that is ideally suited to the removal of skin tumours with a contiguous growth pattern such as basal cell carcinoma and squamous cell carcinoma, allowing examination of 100% of the surgical margin. As a result of this total margin control, the technique offers an unsurpassed curve rate combined with maximal preservation of normal tissue. Following excision of a periocular tumour by a Mohs surgeon, the resulting defect usually requires reconstruction. Our objective was to determine whether the size of defect produced by Mohs surgery and the type of reconstruction required differed from the results we would have expected from standard surgery with a 3 mm excision margin. METHODS: A Mohs surgery service with a combined dermatological and oculoplastic approach was set up in Manchester in 1994. We reviewed 60 of our patients who underwent Mohs surgery and compared the size of defect produced as well as the type of reconstruction required with the results we would have predicted for standard excisional surgery with a 3 mm margin. RESULTS: Although a minority of patients required larger reconstructions than would have been anticipated (20%), many had smaller reconstructions than we had predicted (37%). This latter group often had important structures preserved, and therefore had the benefit of less extensive reconstructive surgery. CONCLUSIONS: Excision of a periocular tumour by Mohs surgery may occasionally identify extensive subclinical tumour extension and so produce an unexpectedly large defect for reconstruction. Many patients, however, require less extensive reconstructive surgery than would have been predicted. This produces benefits in terms not only of improved cosmesis and eyelid function, but also reduced operating theatre costs.
For Mohs surgical wounds that show exposed bone (ie, bone denuded of periosteum), healing by secondary intention may be preferable to surgical reconstruction. To determine the appropriateness of secondary intention healing, we reviewed surgical outcome in 205 patients with Mohs wounds of the scalp and forehead that had healed by secondary intention. Of these patients, 38 had Mohs wounds showing exposed bone. The mean area of exposed bone was 1074 mm(2); the mean area of exposed soft tissue was 1575 mm(2). The mean time for wounds with intact periosteum to epithelialize was 7 weeks; the mean time for bare bone to epithelialize was 13 weeks. All wounds healed without infection or tissue breakdown. We conclude that secondary intention healing of scalp and forehead wounds showing exposed bone is a safe and effective method of wound management after Mohs surgery.
Extensive Mohs surgery for carcinomas of the forehead and scalp occasionally requires the removal of periosteum. The exposed bone presents a wound management problem. One method, if healing by secondary intention is a viable option, is to chisel bone to stimulate granulation tissue and promote healing. A case is presented that describes this procedure in an elderly patient.
BACKGROUND: Many Mohs procedures involve the handling and manipulating of thin, fragile skin tissue, particularly eyelid skin. After excision of such tissue, proper handling of the tissue becomes critical for tissue orientation and histologic processing. OBJECTIVE: The authors present a novel way to handle thin, friable tissue after excision in Mohs surgery with the direct application of cyanoacrylate onto freshly excised tissue. METHODS: Nonsterile generic cyanoacrylate can be applied along the epidermal surface edge to excised thin tissue sections before inking the margins, sectioning, and processing. CONCLUSIONS: The superglue increases tissue rigidity and provides for easier handling while staining and orienting the tissues. The added glue does not alter tissue integrity and shows minimal artifact upon histologic examination. This technique furthermore is inexpensive and adds little time to the Mohs procedure. Clinical photographs and histologic pictures are presented.
In micrographic (Mohs') surgery, routine haematoxylin and eosin stains may present difficulties in interpretation of infiltrative (morphoeic) basal cell carcinoma. To supplement these routine stains rapid immunoperoxidase and immunofluorescence techniques are described using cytokeratin markers Dako LP34, MNF 116 or Novocastra NCL-Pan CK on frozen sections to help in the histological evaluation of these tumours.
Mohs' surgery in the face has established itself as the optimal technique for a high cure rate of basal cell and squamous cell carcinoma occurring in the skin of the face. However, after the resection in Mohs' surgery, the defects, when extensive, require careful, planned reconstruction in order to produce a good cosmetic result. Although flap reconstruction is available for smaller lesions, larger defects can be covered often by expansion techniques. The expansion technique involves placing a silastic expander of various size and designs underneath the adjacent skin and, over a period of weeks, injecting saline into the expander in order to increase the amount of skin available for future flap reconstruction. This usually represents a two-stage procedure consisting of the insertion of the expander and, some weeks later, removal of the filled expander when there is sufficient tissue, and using this tissue to reconstruct the initial Mohs' defect by a flap. When defects are greater than half the aesthetic unit of the face, or greater than one-third in the forehead, or over 6 cm in the scalp, expansion techniques should be considered for reconstruction.
Defects following Mohs surgery that cannot be closed primarily or with single flaps may often be reconstructed using the concept of defect subdivision. This involves mentally fragmenting the wound into smaller portions. Each subsegment is reconstructed with a small transposition flap. The closures of the donor sites of these flaps are designed so that each taps into a separate and distinct area of skin laxity. In this way efficient and optimal use is made of available matching regional skin for reconstruction.
BACKGROUND: Examination of Mohs surgery frozen sections may lead to discovery of incidental benign neoplasms such as syringomas. OBJECTIVE: An unusual occurrence of numerous subclinical syringomatous proliferations discovered during Mohs surgery for a basal cell carcinoma that posed a diagnostic and management dilemma is reported. METHODS: Clinical records and histologic sections are examined. RESULT: Multiple syringomatous proliferations were noted around a basal cell carcinoma during Mohs surgery. A few foci were atypical appearing and focally extending into the deep dermis causing a diagnostic dilemma. All atypical syringomatous proliferations were excised. Evaluation of final Mohs margins by permanent sections and biopsies of normal-appearing facial skin showed multiple benign syringomas. CONCLUSION: Although solitary subclinical syringomas have been described in association with basal cell carcinomas, the occurrence of multiple syringomas and syringomatous proliferations has not been previously reported. Dermatologists should be aware of the existence of this phenomenon and consider permanent section evaluation to better determine nature of unusual incidental tumors identified in frozen sections during Mohs surgery.
The Mohs fresh tissue technique has provided a high rate of cure in cases of malignant tumors in the orbital region. However, in some patients, tumor may persist after Mohs surgery if margins are falsely negative or if the Mohs surgeon elects to terminate the procedure with known positive margins. We report six patients who had residual tumor present in the periorbital region after Mohs surgery. These patients have a serious prognosis associated with subsequent morbidity. Accurate communication between the Mohs surgeon and subsequent treating surgeons, combined with aggressive tumor management, may help to minimize morbidity and improve mortality.
PURPOSE: Mohs surgery (micrographically controlled excision) has been advocated as an effective method of dealing with infiltrative periorbital skin tumours. It has been shown to have high rates of tumour clearance with minimal loss of normal tissue, thus making oculoplastic reconstruction easier and functional preservation better. The aim of the present study was to confirm this. Guidelines for the selection of patients for Mohs surgery are discussed. METHODS: We retrospectively reviewed 24 cases of primary (n = 18) and recurrent (n = 6) periorbital basal and squamous cell carcinomas managed by Mohs micrographic excision and plastic reconstruction who presented to the Royal Perth Hospital between 1992 and 1996. RESULTS: Our high rate of tumour clearance (100%) was similar to that of previous studies, although our follow-up period was only 14.6 months. The fact that 50% of our patients with lid involvement had an intact posterior lamella after Mohs excision correlates with the high level of normal tissue preservation. The low rate of postoperative symptomatic problems suggests good maintenance of function. The infiltrative nature of these tumours was highlighted by the substantial proportion of cases (37.5%) that had a much larger excision defect than what was expected prior to excision. CONCLUSIONS: Our analysis confirms that Mohs excision and subsequent oculoplastic reconstruction is an effective method to use when managing periorbital infiltrative skin tumours.
Mohs surgery for basal cell carcinoma (BCC) of the skin attempts to ensure complete tumour removal by histological examination of the entire excision margin and further excision of involved sites. Advocates recommend its use in recurrent or incompletely excised tumours, poorly defined, histologically aggressive or large primary tumours and BCCs situated at high risk or cosmetically important sites. The claimed advantages over other surgical therapies are that it provides a better chance of cure and since less normal tissue is removed the simpler surgical repair ensures a superior cosmetic result. This review examines the published evidence that supports the enthusiasm for the use of Mohs surgery in the treatment of BCC, contrasting cure rates and cosmetic outcome with results achieved by attempted single complete excision and examines the 2 principles upon which Mohs surgery is based, namely that BCCs spread by contiguous growth and that all tumour cells have to be destroyed to achieve a cure.
BACKGROUND: Anecdotal evidence from program directors and Mohs surgeons suggests that Mohs fellowships are becoming increasingly popular and competitive among dermatology trainees. OBJECTIVE: To assess the characteristics and investigate the motivating factors of those pursuing Mohs fellowships. METHODS: Anonymous surveys were distributed to recent dermatology residency graduates taking a board exam review course in years 1999-2002. RESULTS: In 2002, 2001, and 1999, the percentages of recently trained dermatologists pursuing Mohs fellowships were 9.4%, 8.5%, and 8.8%, respectively. There were no significant differences between Mohs fellows and the rest of the recently graduated dermatologists in terms of debt levels, marital status, parenting status, and spousal employment status. The Mohs fellows were slightly more likely to be male than their non-Mohs counterparts. The factor considered the most important by both groups when choosing a job was location. CONCLUSIONS: Further research is needed to discover potential factors that may be playing a role in the increased popularity of Mohs surgery. The number of Mohs surgeons is increasing and is likely to expand over time. It remains to be seen what effect the growth will have on the supply of Mohs surgery and whether it will outpace the increased demand for services.
OBJECTIVES: To estimate and compare the recurrence rates of basal cell carcinoma (BCC) after Mohs surgery in patients with chronic lymphocytic leukemia (CLL) and controls and to evaluate differences among histologic subtypes of BCC. DESIGN: Retrospective assessment of clinical histories, postoperative notes, and surgical photographs. SETTING: Tertiary-care institution (Mayo Clinic, Rochester, Minn). PATIENTS: Twenty-four patients with CLL who underwent Mohs surgery for 33 BCCs and 66 controls matched for sex, age, and surgical year who underwent Mohs surgery for BCC of the head and neck from May 1988 through September 1998. RESULTS: Among the 24 patients with CLL who underwent Mohs surgery for 33 BCCs, there were 4 recurrences. The cumulative incidence of recurrence on a per-tumor basis was 3% at 1 year, 12% at 3 years, and 22% at 5 years. Basal cell carcinoma was 14 times more likely to recur in patients with CLL than in controls (P =.02). Overall, there were no significant differences between patients with CLL and controls in preoperative tumor size (median, 1.6 cm vs 1.4 cm; P =.18) and proportion of aggressive histologic subtypes of BCC (58% vs 41%; P =.12). CONCLUSIONS: Recurrence rates of BCC are significantly higher after Mohs surgery in patients with CLL. Overall, patients with CLL do not appear to have significantly larger BCCs or more aggressive histologic subtypes of BCC. In patients with CLL, close surveillance is warranted for recurrence of BCC and a decreased threshold is indicated for subsequent biopsies.