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Return to Doctors See Mohs Surgery as Viable in Treating Common Skin Cancers Overview

More on Doctors See Mohs Surgery as Viable in Treating Common Skin Cancers

Doctors See Mohs Surgery as Viable in Treating Common Skin Cancers

New York (Aug 2, 2011)

Dr. Hillary D. Johnson at microscope
Dr. Hillary D. Johnson at a
microscope used for Mohs surgery.

Many people rightly fear the most deadly form of skin cancer, melanoma, which caused about 8,700 U.S. deaths in 2010. Melanoma is serious since it tends to metastasize and it does require aggressive treatment, including a combination of surgery and radiation and/or chemotherapy. But, it is also less common than other types of skin cancer and accounts for fewer than 5% of skin cancer cases.

Far more common are basal cell and, to a lesser degree, squamous cell skin cancers, which are rarely lethal, but which occur in more than two million Americans each year, according to American Cancer Society estimates. Those cancers still require treatment, and most patients can benefit from a skin-sparing surgical procedure known as Mohs surgery.

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Mohs surgery, named for its inventor Frederic E. Mohs back in the 1930s, is a surgical technique for localized tumors in which cancer-containing skin is removed layer by layer until the margins are clear and only cancer-free tissue remains. The surgery is performed on biopsy-proven skin cancers so that the surgeon knows in advance both the type and location of the cancer. In the early days, Mohs surgeons would smear the tumor area with a "fixing paste" made of a toxic zinc chloride compound that would cause the cancer cells to blacken and form a crust. This painful procedure was time consuming, inexact (doctors had to guess where to spread the compound), and often left patients with some disfigurement, but it was effective at removing the cancer so its use continued.

Desiree Ratner, M.D.
Désirée Ratner, M.D.

The technique made a radical advance in the 1980s with the advent of freezing technology. That allowed surgeons to remove a disc of tissue, freeze and section it and examine it under a microscope – all while the patient waits. The excision and examination are continued until the surgeon is satisfied that the margins are clear and the cancer has been completely removed. "I am the surgeon, the pathologist and often the reconstructive surgeon as well," says Désirée Ratner, M.D., the Director of Dermatologic Surgery at NewYork-Presbyterian/Columbia University Medical Center. Dr. Ratner performs some 600-700 of these operations a year. She continues, "With Mohs, we get a real-time look at how much we need to remove and can be very precise, sparing the surrounding healthy tissue. That is very important, since most of the tumors I see are on the head, neck and face, and fully one third are on the nose."

Hillary D. Johnson, M.D., Ph.D.
Hillary D. Johnson, M.D.,
Ph.D.

Mohs surgery is especially useful for large or aggressive skin cancers and for cancers with hard to define borders, where precise mapping can minimize the amount of unnecessary tissue removal. The procedure is ideal for tumors located in areas where it is important to preserve as much healthy tissue as possible, such as the eyes, ears, nose, mouth, hairline, hands, feet and genitals. It is also used for cancers with a high risk of recurrence or for those that have recurred after previous treatment. The procedure boasts a high cure rate – greater than 98% for a previously untreated basal cell carcinoma, and only slightly less for squamous cell cancers or recurrent cancers.

Hillary D. Johnson, M.D., Ph.D., studied under Dr. Ratner and is the new Director of Mohs Micrographic and Dermatologic Surgery at NewYork-Presbyterian/Weill Cornell Medical Center. "Coventional tumor tissue processing may be referred to as 'breadloafing,' where a portion of the tissue is sliced vertically, similar to cutting slices through a loaf of bread," says Dr. Johnson. "With Mohs surgery, the tissue is sliced horizontally. Using the microscope, we can see around all of the skin edges and underneath the tumor to show that the skin cancer is fully removed." Mohs surgery is generally not used for treating melanoma, although it can be used in some cases of melanoma in situ, if the cancer cells have not spread. As with any surgical procedure, Mohs surgery carries the risks of bleeding; pain, tenderness or itching around the surgical site; and infection.

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While Mohs is considered the standard of care for many skin cancers, it is not the only treatment. Cryosurgery, which involves using liquid nitrogen to freeze and destroy the lesion, topical chemotherapy, and specially-formulated creams offer an alternative to surgery but are generally used only for actinic keratoses, or pre-cancerous lesions. Some of these boast cure rates of 80-85%, but may also have a 25-30% rate of recurrence. They may also be FDA-approved for use on superficial basal cell carcinomas, but not approved for use on the face. Dr. Johnson maintains a cautious approach to using these creams in higher risk locations. "The risk with creams is that they can improve the surface of the skin while the cancer is spreading underneath. Not only are you not really curing the cancer but you're allowing it extra time to grow," she says.

Skin cancer is the most common type of cancer, affecting millions of Americans every year. Current statistics claim that about 1 in 5 Americans will develop skin cancer during their lifetimes. Mohs surgery is usually done on an outpatient basis using a local anesthetic, and takes about half a day.

Contributing faculty for this article:

Désirée Ratner, M.D. is the Director of Dermatologic Surgery at NewYork-Presbyterian/Columbia University Medical Center and a Clinical Professor of Dermatology at Columbia University College of Physicians and Surgeons.

Hillary D. Johnson, M.D., Ph.D. is the Director of Mohs Micrographic and Dermatologic Surgery at NewYork-Presbyterian/Weill Cornell Medical Center and an Assistant Professor of Dermatology at Weill Cornell Medical College.

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