Skin Cancer xxix, 2011 : Page 60

HEALTH Surgical repair of the wound could then be performed. 2,3,5 The technique had many advan-tages over standard excisional surgery, where the physician simply removes the tumor and a wide extra swath of presumably normal skin around it as a safety margin. 6 First and foremost, chemosurgery allowed 100 percent of the cancer to be removed while sparing the most possible tissue. By avoiding overly aggressive surgery and the removal of too much healthy tissue, it produced a much better cosmetic result. EARLY STRUGGLES When Dr. Mohs first spoke of che-mosurgery at a conference of plastic surgeons, he was greeted with nearly universal dismay and skepticism. When I began to practice the technique in 1965, only one out of every five dermatologists and possibly one of out every 20 physicians were aware that this technique for treating skin cancers even existed. 7 In the fall of 1965, I visited Dr. Mohs in Madison, WI, where he was using chemosurgery daily. After 5 weeks of training, I purchased a “how-to” kit, a jar of zinc chloride paste and Dr. Mohs’ textbook, which I took back to New York. I began to put what he had taught me into practice, but I was initially met with the same kind of resistance he faced. Many of my colleagues con-sidered chemotherapy “black magic,” and pointed out how uncomfortable the zinc chloride was to patients. They believed that dermatologists should THEN: In 1936, Dr. Mohs began performing the procedure, originally dubbed “chemosurgery” (“chemo” referring to the zinc chloride paste fixing method), on human patients. It was a scrupulous process that could take days. not also be surgeons. Some attempts were even made to have me removed from the NYU faculty and expelled from the American Academy of Der-matology (AAD). 8 Nonetheless, the potential value of the technique was all too clear to me, and I was convinced that with some additional training, dermatologists could become experts in excising skin cancers with the procedure. After all, we were the physicians best trained to recognize skin cancers, so we should also be the best at removing them. And chemosurgery seemed to guarantee the most success. Table 1. NMSC Indications for Mohs Micrographic Surgery Recurrent Tumors Tumors >0.6 cm on the face or >2.0 cm on the body and extremities High-risk anatomic locations (eyelids, nose, ears, lips, genitalia, fingers) Tumors with indistinct clinical margins or incompletely excised margins (positive margin after surgical resection) Tumors occurring in sites of previous radiation therapy or in chronic scars Tumors with aggressive patterns (micronodular, infiltrative and morpheaform BCC, basosquamous carcinoma, and poorly differentiated or deeply invasive squamous cell carcinomas) Tumors in immunosuppressed patients 60 Fortunately, a few other physicians agreed with me. At an international meeting, five other Mohs surgeons and I had a founders meeting, at a dinner hosted by Dr. Mohs in Munich, Germany. We agreed to form a chemo-surgery society and to hold our first meeting at the next annual meeting of the American Academy of Dermatology (AAD), in Chicago. In December of 1965, we indeed held our first meeting in the Palmer House’s “number 10 Wabash Room,” where we continued to meet for years. Only 20 of us attended that first meeting — we were essentially the only physicians practicing the technique in the country. 8 In my first year using chemosurgery, I treated 70 patients, and each year that number increased slowly. I found that the technique could also work well in other locations besides the head and face. For example, a few patients were referred to me with skin cancers on their fingers that were scheduled for amputation, and I was able to save the digit. Some also were referred to me with cancers on the penis, and we were able to save them from amputa-tion as well. 8 S K I N CA N C E R F O UND A T I O N J O URN A L

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