Skin Cancer xxix, 2011 : Page 62

HEALTH showed that the two techniques were equally effective. And the newer technique had many advantages: 1. It eliminated the discomfort of the zinc chloride paste. 2. You could resolve a skin cancer case in one day instead of many days — in fact, you could finish many cases in one day. 3. You didn’t have to wait the 5-7 days for the eschar to separate before beginning wound repairs; you could begin repair and reconstruction the same day. 4. You eliminated the possibility of excessive bleeding when the eschar separated from the healing tissue underneath. 8 Since 1974, I have used only the fresh tissue technique. 8 In 1980, I published research on 2,900 cases of BCC treated with the fresh-tissue technique, reporting 98.2 percent cure rates for primary BCCs, and 96.6 percent cure rates for recurrent BCCs, significantly exceeding the rates found with standard excision. I also reported similarly improved rates for SCCs. In the years since, the vast majority of Mohs surgeons have used the fresh-tissue approach. 8 With the advent of the “fresh tissue” technique, the term “chemosurgery” kept evolving. At first, the two methods were called “chemosurgery fixed tissue technique” and “che-mosurgery fresh tissue technique,” but it ultimately seemed absurd to use “chemosurgery” as part of the title if you were no longer using the chemical fixative. Dr. Günter Burg in Munich published a paper calling it “histographic surgery.” Finally, in 1974, Dr. Daniel Jones coined the term “micrographic surgery” to highlight the technique’s use of the microscope and the drawing of tissue maps. At the 1985 annual meeting of the American College of Chemosurgery, the name of the procedure was officially changed to “Mohs micrographic surgery,” 5,6 but for brevity’s sake, many just call it Mohs surgery. CURRENT PRACTICE Today, there are over 900 members of the American College of Mohs Surgery (ACMS), all of whom have received post-residency fellowship 62 training in Mohs surgery, pathology and reconstructive surgery. 14 Currently, Mohs surgery is indi-cated for basal and squamous cell carcinomas (BCCs and SCCs) with the characteristics listed in Table 1, 15,16 and multiple studies have confirmed its superiority over standard excision — in fact, over any other treatment modality — for these purposes, with five-year recurrence rates as low as 1 percent for BCCs and 3-5 percent for SCCs. 1,17 Standard excision may be preferable for some small or less aggressive cancers, and for cancers on larger open expansive areas of the body. To sum up, Mohs surgeons are best equipped to treat skin cancers. They know diseases of the skin, they know dermatopathology, and they are trained to do excisions and repairs. With its unparalleled cure rates, Mohs micrographic surgery is the treatment of choice for select basal cell and squamous cell carcinomas, in addition to other less common skin cancers. References available on p.97. DR. ROBINS , Professor Emeritus of Dermatol-ogy at New York University Medical Center, was Chief of the Mohs Micrographic Surgery Unit there for more than 40 years. A pioneer in Mohs surgery, he has performed more than 47,000 of the procedures. An accomplished educator, Dr. Robins was the first to offer one-year fel-lowships in Mohs surgery and the first to teach Mohs techniques to dermatologists from other countries. He has trained more than 70 doctors from around the world who are now leaders in dermatologic and skin cancer care. He has lectured in 34 countries in four languages. Founder and President of The Skin Cancer Foundation, he is also Founder/President of the International Society of Dermatologic Surgery, Founder/former President of the American College of Mohs Micrographic Surgery, and former President of the American Society of Dermatologic Surgery. Dr. Robins has published over 60 articles in leading medical journals and authored five books for the general public. He is the founder of the Journal of Dermatologic Surgery and Oncology and the Journal of Drugs in Dermatology . The American Academy of Dermatology has made Dr. Robins an honorary fellow for outstanding contributions in derma-tology; he has received its Award for Excellence in Education, 14 Gold Triangle Awards for Excellence in Community Education, and a Presidential Citation. He has been honored as a distinguished member of both the American College of Mohs Micrographic Surgery and the American Society of Dermatologic Surgery, and was awarded a Presidential Citation by the International Society of Dermatologic Surgery. DR. HALE is a Clinical Associate Professor of Dermatology at the New York University Lan-gone Medical Center. She is a Mohs surgeon and a member of the American College of Mohs Surgery. Dr. Hale practices dermatology at the Laser & Skin Surgery Center of NY, and lectures extensively on the prevention and treatment of skin cancer. DR. EBEDE is the Mohs Micrographic Sur-gery/Procedural Dermatology Fellow at NYU-Langone Medical Center and Memorial Sloan-Kettering Cancer Center, New York City. S K I N CA N C E R F O UND A T I O N J O URN A L By avoiding overly aggressive surgery, Mohs produces a much better cosmetic result. Mohs surgery can also be used to treat other skin cancers, including dermatofibrosarcoma, extramammary Paget’s Disease, Merkel cell carcinoma, sebaceous carcinomas, and microcys-tic adnexal carcinomas. 4,18 OF MOHS AND MELANOMA The use of Mohs micrographic surgery to treat melanoma, still relatively new, continues to evolve. For many years, melanoma was not treated with Mohs, because atypical melanocytes (the pigment cells where melanomas can develop) were difficult to assess using frozen sections. More recently, however, special stains called immu-nostains allow the Mohs surgeon to see possible residual tumor that may not be clearly visible with regular stain-ing. 19 For example, pathologists and select Mohs surgeons have begun us-ing the MART-1 (Melanoma-associated Antigen Recognized by T cells) stain to evaluate margins on Mohs frozen sections to diagnose and treat mela-noma; MART-1 is especially sensitive and specific for melanocytes. 20

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