The history and evolution of Mohs micrographic surgery

Top 100 Most Cited Articles in Mohs Micrographic Surgery: A Bibliometric Analysis

BACKGROUND

Bibliometric analysis is a scientific method that can derive insights into major publications' trends within a field. Currently, no bibliometric study has been conducted for Mohs micrographic surgery (MMS).

OBJECTIVE

To characterize the most frequently cited articles in MMS.

METHODS

Web of Science was used to identify the 100 most cited publications on MMS between 1970 and 2022. Articles were analyzed by title, authorship, institution, journal, year, citation frequency, originating country, funding, citation index, Altmetric score, impact factor, Eigenfactor score, and article influence score.

RESULTS

Since January 2023, the top 100 articles had 9,096 total citations, ranging from 47 to 304. The top cited publication was "Mohs surgery is the treatment of choice for recurrent (previously treated) basal-cell carcinoma" in 1989. The top contributing organization was Harvard University (17%) and top contributing authors were Brodland, DJ (12%) and Zitelli, JA (11%). The year 2005 accounted for most of the articles (12%). Most articles were from the Journal of the American Academy of Dermatology (32%) and Dermatologic Surgery (27%). The United States contributed to 76% of the top articles.

CONCLUSION

This bibliometric analysis offers researchers a detailed overview of important MMS publications and provides useful data into current findings steering MMS research and practice.

Wound Care Adherence in Mohs Micrographic Surgery: A Prospective Cohort Study

BACKGROUND

Patients undergoing Mohs micrographic surgery (MMS) are given detailed wound care instructions to prevent postoperative complications. Previous studies have revealed low treatment adherence in general dermatology, but adherence to postoperative wound care and its potential association with poor surgical outcomes remain largely unstudied.

OBJECTIVE

To determine the frequency and causes of wound care nonadherence in patients who underwent MMS.

MATERIALS AND METHODS

A questionnaire containing a modified Eight-Item Morisky Medication Adherence Measure Scale was administered to Mohs patients at their 1 to 2 weeks postoperative visit.

RESULTS

Sixty-three patients were solicited and consented to completing the questionnaire. The average modified Eight-Item Morisky Medication Adherence Measure Scale score was 7.4 of 8, indicating high adherence. Old age and wound care assistance were associated with increased adherence. Factors contributing to nonadherence included feeling well, being too busy, wound care causing discomfort, and being with friends or family. One patient (1.6%) with high adherence developed an epidermal inclusion cyst within the scar. No other complications were observed.

CONCLUSION

Most MMS patients demonstrated high adherence to wound care instructions, and nonadherence was not associated with postoperative complications.

A new 3D printed applicator with radioactive gel for conformal brachytherapy of superficial skin tumors

Surface brachytherapy is an effective method in the treatment of skin cancer. Current skin brachytherapy techniques are based on the placement of a source of gamma or X-ray photons in a close distance from the skin to irradiate the lesion. Due to the nature of photons, radiation dose in these methods may affect healthy tissue as well as sensitive structures around the target. In order to minimize unwarranted and incidental exposure, we propose a new skin brachytherapy applicator based upon beta particles which have penetration ranges of a few millimeters in tissue. The proposed concept is radioactive gel housed within a pre-designed tumor-specific applicator matching the topology of the skin lesion. The particles mixed with the gel showed a uniform distribution pattern, which is an essential prerequisite in having a uniform dose profile on the skin surface. Based on the dose calculation data from the proposed concept, the dose delivered to the depth of 4500 μm in skin tissue is 10% of the dose delivered to the surface of the tumor, making it suitable is treating thin skin tumors especially when located on top of the bone. Through the innovative combination of radioactive gel and tumor-specific applicator, the radiation entering the skin surface can be personalized while minimizing the adverse effects of undesired exposure to the surrounding healthy tissue.

A challenging and rewarding time: The early days of graduate medical education in dermatology

Specialized residency training was still in its infancy in mid-20th century America. While specialty boards in various fields such as ophthalmology and otolaryngology had been established in the 1920s and 1930s, the details of training programs were still being fine-tuned and formal curricula were lacking. In dermatology, three prominent physicians including Harry L. Arnold Jr., J. Lamar Callaway and Walter B. Shelley trained during these experimental days of medical education. Each of them captured personal reflections of their own training experiences in brief memoirs published in scientific journals. A closer examination of these texts provides unique insights into how dermatology subspecialty training in particular and medical education more broadly evolved during this period.

Mohs micrographic surgery for cutaneous malignancies: A focus review of its indications in pediatric age groups

Mohs micrographic surgery (MMS) is a highly specialized technique that has been successful in the treatment of a variety of skin tumors. The technique can be performed as an outpatient procedure and encompasses surgical excision and intraoperative assessment of tumor margins in one setting by the same physician. The process ensures precise margin control with maximal preservation of healthy tissues. Mohs micrographic surgery has been practiced worldwide, including in the United States, Europe (United Kingdom, Germany, Spain, Netherlands, Switzerland), and Australia. Although it is commonly performed in adults with greater success, it has been discussed less frequently in children. In this article, we describe several cutaneous tumors in children and the role of Mohs micrographic surgery in their management. A PubMed search was conducted to review the most common cutaneous tumors in children treated using Mohs micrographic surgery. In this review, we discuss indications for Mohs micrographic surgery and pertinent studies examining success rates in children. Mohs micrographic surgery has been used to treat several tumors in children and offers the advantage of high cure rates and tissue conservation. This report emphasizes the benefits of Mohs micrographic surgery in children and highlights several cutaneous tumors for which it has been used to treat successfully.

How Mohs Surgery Transformed Into a First-Line Treatment of Skin Cancer

Mohs surgery is considered ideal treatment for many types of skin cancers. Developed by Dr Frederic Edward Mohs (1910-2002), Mohs surgery allows all surgical margins to be viewed microscopically, ensuring no cancer cells go unremoved, yet it failed to achieve immediate acceptance when first introduced in the 1940s. A catalyst to the widespread acceptance of Mohs surgery occurred with the work of dermatologic colleagues who reported excellent results without using the paste. It suggested the real innovation of Mohs surgery lay in its microscopic control and not the paste, the discontinuation of which removed all the problems associated with its use.

Three dimensional (3D) histology in daily routine: practical implementation and its evaluation

BACKGROUND

The continuous evaluation of the edges of a tumor by means of three-dimensional (3D) histology often appears complicated and require the surgeon and dermatopathologist to work together closely. We present clear rules that allow communication between all parties involved and then verify their application in daily routine.

METHODS

Tissue processing, interpretation of results, as well as communication between the surgeon and the dermatopathologist are based on an algorithm with the aid of exact times and embedding cassettes, which allow precise topographic orientation. We evaluated the use of this method in daily clinic practice, taking into account 947 operated basal cell carcinomas in regard to the development of recurrent tumors.

RESULTS

At a median follow-up of 47 months, 10 of the 947 operated basal cell carcinomas (1.1 %) recurred. Sclerodermiform basal cell carcinomas and basal cell carcinomas which could not be curatively resected (R0 resection) during the initial surgery showed a significantly higher recurrence rate (p < 0.05 and p < 0.001).

CONCLUSIONS

Standardized rules for dealing with excised tissue allow an effective application of 3D histology in daily clinical practice. 3D histology results in low recurrence rates. Sclerodermiform basal cell carcinomas which could not be curatively resected (R0 resection) were identified as a risk group for the development of recurrent tumors.

Mohs micrographic surgery for the management of nonmelanoma skin cancers

Many treatment modalities have been described to address the growing epidemic of nonmelanoma skin cancer (NMSC). Mohs micrographic surgery (MMS) is a surgical technique that allows complete and precise microscopic margin analysis by using horizontal frozen sections. The purpose of MMS is twofold: to ensure definitive excision and to minimize loss of normal surrounding tissue. MMS offers the advantages of superior cure rates and, because tissue removal is minimized, excellent cosmetic outcomes. Therefore, MMS has become the treatment of choice for many high-risk tumors. Because this technique is labor intensive, MMS is not indicated in certain situations. Understanding the indications, advantages, and disadvantages of MMS remains paramount for facial plastic surgeons managing NMSC.

Management of cutaneous tumors with mohs micrographic surgery

Since the inception of Mohs micrographic surgery in the 1930s, this technique has proved its utility in the treatment of cutaneous tumors. This review describes the technique of Mohs micrographic surgery and the various indications for which it is used. We discuss the use of Mohs micrographic surgery for the following cutaneous tumors: basal cell carcinoma, squamous cell carcinoma, melanoma in situ, dermatofibrosarcoma protuberans, Merkel cell carcinoma, microcystic adnexal carcinoma, atypical fibroxanthoma, and sebaceous carcinoma. Mohs micrographic surgery is cost effective in the U.S. health care system because billing for the surgeon-pathologist and laboratory processing is bundled together. However, Mohs micrographic surgery may be more expensive in European systems because the Mohs technique surgeon, pathologist, and laboratory fees may be billed separately.

[Mohs micrographic surgery: aplication of this technique to penile neoplasms]

Mohs micrographic surgery is a surgical technique that allows the excision in successive layers of cutaneous malignancies with the higher cure rates. At the same time, this surgical technique offers the maximal preservation of normal tissue. That is possible because Mohs surgery provides the advantage of microscopically controlled tumor-free borders in each stage guiding the surgeon in the tumor persistence until the complete surgical excision. Mohs micrographic surgery is a precise treatment for penile neoplasms and its utility is justified because the removal of a substantial surgical margin of normal tissue is obviated. MoHs micrographic surgery is indicated in the treatment of penile verrucous carcinoma due to the significant risk of loco-regional recurrence after conventional surgery. Although infrequent, other penile neoplasms that can benefit from Mohs micrographic surgery are: basal cell carcinoma, extrammamary Paget's disease, in situ melanoma and granular cell tumor.

A confusing world: what to call histology of three-dimensional tumour margins?

Complete three-dimensional histology of excised skin tumour margins has a long tradition and, unfortunately, a multitude of names as well. Mohs, who introduced it, called it 'microscopically controlled surgery'. Others have described it as 'micrographic surgery', 'Mohs' micrographic surgery', or simply 'Mohs' surgery'. Semantic confusion became truly rampant when variant forms, each useful in its own way for detecting subclinical outgrowths of malignant skin tumours, were later introduced under such names as histographic surgery, systematic histologic control of the tumour bed, histological control of excised tissue margins, the square procedure, the perimeter technique, etc. All of these methods are basically identical in concept. All involve complete, three-dimensional histological visualization and evaluation of excision margins. Their common goal is to detect unseen tumour outgrowths. For greater clarity, the authors of this paper recommend general adoption of '3D histology' as a collective designation for all the above methods. As an added advantage, 3D histology can also be used in other medical disciplines to confirm true R0 resection of, for example, breast cancer or intestinal cancer.

Topical protease therapy as a novel method of epidermal ablation: preliminary report

BACKGROUND

For more than 50 years, proteolytic enzymes have been extensively used in laboratory settings for the purposes of in vitro epidermal separation and keratinocyte isolation. However, the topical, in vivo pharmacologic properties of these enzymes are virtually unknown. Previous therapeutic applications for topically applied proteases have been limited to wound debridement.

OBJECTIVE

To characterize the clinical and histologic effects of topically applied proteases as a method of therapeutic epidermal ablation.

MATERIALS AND METHODS

SKH-1 hairless mouse and human skin samples were exposed both in vitro and in vivo to varying concentrations of the proteases subtilisin, trypsin, and dispase for different exposure durations. The effects of protease exposure were then assessed by both clinical and histologic examination.

RESULTS

Exposure of both human and mouse skin samples to topical protease solutions resulted in reproducible, differential patterns of epidermal ablation: subcorneal, intraepidermal, and subepidermal. In a limited study, topical application of trypsin solution resulted in the scar-free ablation of lesions of seborrheic keratosis located on the lower extremity.

CONCLUSION

Topically applied proteases represent an alternative method of epidermal ablation with several potential advantages over existing techniques. Further studies are needed to delineate ideal enzyme formulations, vehicles, and applications.

Optimizing the cut in Mohs' micrographic surgery in regard to skin sparing and microscopic view: is a round incision cut necessary?

Saucer incision is the common cut in Mohs' micrographic surgery. To date no proof as to the superiority of this cut over other patterns has been presented. In this work we examine the round pattern aspect of the saucer incision and answer two questions: does the round cut provide the best skin-sparing pattern? And, does it provide the best microscopic view? A two-dimensional geometric analysis is used to determine whether a round incision is optimal from the standpoint of skin sparing and microscopic view. Mohs' micrographic surgery views are used to back up the geometric hypothesis. The result is that the round incision pattern is skin-wasteful compared to an incision that follows the cancerous lesion. In the lesion presented here the two cuts have a ratio of 1.5 between the two excised skin areas, indicating a waste of healthy skin of 50%. It is also shown that specimens with a pointed edge provide better layer projection. The conclusion is that a tailored cut following the lesion pattern is the optimal Mohs' incision. Therefore in the first stage of Mohs' micrographic surgery the skin cut should replicate the lesion pattern instead of a round saucer cut. Though many Mohs' surgeons already implement this philosophy, in the literature the saucer incision recommended by Dr. Frederic Mohs' remains the norm.

A primer of Mohs micrographic surgery: common indications

Mohs micrographic surgery is a highly effective technique for the removal of some skin cancers. The technique is founded on the idea of excision with minimal margins (sparing normal tissue) and immediate histologic examination of horizontal frozen sections of the specimen while the patient waits. By doing this, a Mohs surgeon is able to examine the margins. If residual tumor is present, subsequent excisions are performed until it is completely removed. In cases of aggressive tumors, recurrent tumors, or in which the lesions are present in high-risk anatomic locations (H-zone of the face) or functionally important areas (e.g., digits, genitals), the preferred treatment is Mohs micrographic surgery.

Basal cell and squamous cell carcinoma

OBJECTIVES

To describe the clinical and histologic subtypes, pathophysiology, recognition, and treatment options for basal cell and squamous cell carcinoma, and the molecular biology of sunlight-induced carcinogenesis.

DATA SOURCES

Journal and review articles, research studies, textbooks, and clinical practice.

CONCLUSIONS

Basal cell and squamous cell carcinoma will occur in more than one million cases annually in the United States, and are highly curable when detected and treated early. During the last decade, significant progress has been made in elucidating the molecular basis of skin carcinogenesis and in identifying newer approaches for the management and treatment of these keratinocyte cancers.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can play crucial roles in decreasing the morbidity and mortality from the skin cancer epidemic by identifying and referring patients with lesions suspicious for basal cell and squamous cell carcinomas.

Micrographic surgery of basal cell carcinomas of the head

Basal cell carcinoma (BCC) is a locally invasive malignant cutaneous tumour with a rising incidence. This tumour can be treated successfully by a variety of techniques, including local excision, radiation, cryotherapy, curettage, electrodessication and laser obliteration. Micrographic surgery is a specialised type of minimal marginal surgery that offers higher cure rates than do other options in the treatment of contiguous skin cancers in selected settings. The horizontal frozen histological sections of the excised tumour permit complete microscopic examination of the surgical margin. Maximum sparing of tumour-free adjacent tissue is achieved with histological mapping of the tumour boundaries, and subsequent wound reconstruction is optimised. Data on topographical distribution, histopathological subtype, subclinical tumour extension, therapeutic procedures required for complete eradication, and recurrence rates were recorded in 3065 BCC of the head. Micrographic surgery is the treatment of choice for large or invasive primary BCC with uncertain clinical boundaries, especially in difficult anatomical regions, for recurrent or re-recurrent BCC, and for tumours with an aggressive histopathological pattern.

Imaging of Merkel cell carcinoma

Merkel cell carcinoma (MCC) is a rare, highly malignant cutaneous tumor, primarily of the head and neck, that requires timely diagnosis, adequate staging, and aggressive therapy. MCC tends to be overlooked in the early stage, has a high propensity for invading local and regional nodal basins, and exhibits a high postoperative recurrence rate, with distant thoracic, abdominal, and central nervous system metastases. Conventional radiography and cross-sectional imaging show lesions similar to those originating from other small cell carcinomas. Nuclear medicine procedures such as sentinel node scintigraphy, somatostatin receptor scintigraphy, and positron emission tomography may be used to supplement judicious cross-sectional imaging evaluation, thereby adding diagnostic value in staging and providing therapeutic guidance. Ultimately, however, the diagnosis relies exclusively on pathologic findings at immunohistochemical staining and electron microscopy. The rarity of MCC and the resulting insufficient awareness of this neoplasm often delay correct identification and treatment, which essentially consists of wide-margin surgical excision of the primary tumor and local and regional radiation therapy. To date, clinical information is still insufficient to fully appreciate the role of imaging in MCC management. A better imaging algorithm is expected with increased awareness and improved clinical understanding of this uncommon skin neoplasm.