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Get to Know Mohs (Surgery)

Written by  Lynette Mutter

A treatment for skin cancer developed by Dr. Frederick Mohs in the 1930s has become widely accepted in recent years as having the highest cure rate for most types of skin cancer. It has been refined over the years into the most advanced, precise and effective treatment for skin cancer, according to the American College of Mohs Surgery.  

Mohs surgery is most commonly used for basal cell carcinoma, widely used for squamous cell skin cancers, and is also used for some superficial, stage zero cases of melanoma, according to Mariana Phillips, MD, Section Chief of Dermatology and Mohs Surgery at Carilion Clinic. Mohs provides the highest chance for a cure and the lowest chance for recurrence, even when other treatments have failed.

Why is it so effective?

During Mohs surgery, frozen layers of the cancerous tumor or lesion are taken, one at a time, and examined on-site under a microscope until 100 percent of the skin cancer has been removed and the tissue surrounding the margins is cancer-free.

“As little healthy tissue as possible is removed to clear the tumor, keeping surgical defects as small as possible, which simplifies reconstruction and results in better cosmetic outcomes,” says Dr. Phillips. “Checking the tumor margins during surgery guarantees that all cancerous tissue is removed and virtually eliminates the need for a second procedure, which would lead to more scarring.

“Another advantage of Mohs surgery is that it is performed in a physician’s office under local anesthesia, minimizing surgical ‘down time’ for the patient, as well as recovery time,” Dr. Phillips notes. “It is also less expensive than surgical procedures performed in hospital settings where more sedation is required.”

Who knows Mohs more?

Mohs surgeons are board-certified dermatologists who have completed an extra year of training after residency and a procedural dermatology fellowship from one of 30 training centers in the country, according to Dr. Phillips, who is currently the only Mohs surgeon at Carilion Clinic. Another Mohs surgeon will be joining her practice in August.

Post-residency Mohs training programs are intensive with a highly selective fellowship application and selection process, according to the American College of Mohs Surgery. Mohs surgeons are required to be both reconstructive specialists and surgical pathologists with the ability to accurately interpret tissue samples.

According to Phillips, “With Mohs surgery, about 90 percent of the reconstruction necessary is performed at the same time of the procedure. In rare cases, patients might be referred to reconstructive (or plastic) surgeons if they have large tumors or request full anesthesia, which must be done in a hospital or surgery center.

“Depending on the location of the skin cancer, other reconstructive surgeons might be consulted, such as an oculoplastic (eye) surgeon or otolaryngologist (ear, nose and throat doctor, also known as an ENT),”says Dr. Phillips. “In some cases, a lymph node biopsy and radiation might also be recommended, along with Mohs surgery.”

Know your skin and cover it up

As with most medical conditions, prevention of skin cancer is the key. Sun exposure is the most important factor contributing to skin cancer. This is especially the case for people who have fair skin, red hair, who burn easily or may be genetically predisposed to develop skin cancer.

“Avoid the sun between 11 am and 4 pm, seek shade and wear sunscreen, hats and long sleeves,” advises Dr. Phillips.

People tend to develop skin cancer when chronic exposure to ultraviolet light (either outdoors or in tanning booths) damages the DNA of skin cells, causing them to grow out of control, rather than die. When caught early, 99 percent of skin cancer can be cured, according to the American College of Mohs Surgery.

“It’s important to look for patterns and pay special attention to what we call ‘outliers or ugly ducklings,’ any spot which differs from others on your body,” explains Dr. Phillips, who also advises being checked for skin cancer right away if you have a “pimple” that doesn’t go away in a month.

Other warning signs include lesions that bleed, itch, continue to grow or don’t heal. If suspicious changes to moles, freckles, spots or scars are found, schedule a visit with your primary care physician or dermatologist for a thorough skin screening as soon as possible.

Stay in check

Monthly self-exams and annual skin screenings by your primary care physician or dermatologist can help catch skin cancer in the early stages and greatly improve your chance of being cured.

“If you have experienced sun damage or you or a family member has a history of skin cancer, you should be checked by your PCP or a dermatologist every six months to a year, depending on your risk level,” Dr. Phillips suggests.

Be prepared to tell your doctor when the spot was noticed, symptoms you may have and your history of sun exposure. Skin cancer is diagnosed through a biopsy of all or part of a suspected lesion. If your primary care provider does not do them, a referral to a dermatologist will be made.

Skin cancer signs and symptoms

According to the American College of Mohs Surgery, basal cell is the most common type of skin cancer and tends to appear on areas most exposed to the sun – head, face, ears, neck, upper back, hands and arms. During your self-exam, look for:

  • small, pearly, translucent bumps
  • thickened scar tissue
  • red, scaly patches
  • areas that crust over, bleed or do not heal completely

The second most common skin cancer is squamous cell, with the greatest risk among people with light hair and eyes who have had chronic exposure to the sun. This type of skin cancer can spread into lymph nodes and internal organs, and is most commonly found on the scalp, face, ears, lips, hands and lower legs. It can appear as a red, scaly patch or bump.

Melanoma is the most dangerous form of skin cancer with only one-third arising from existing moles, according to the American College of Mohs Surgery. It may be found anywhere on the body, but is more prevalent on the chest, abdomen or back. It is most commonly found on the lower legs of women and the backs of men.

According to Dr. Phillips, “Not all moles will become cancerous, but if a mole meets even one of the ABCDE melanoma criteria, have it checked out.

“While not all skin cancer needs to be treated with Mohs surgery, it can be the ideal procedure in some cases, especially the most aggressive,” Dr. Phillips states. “If you are diagnosed with skin cancer, it is certainly worth discussing the possibility of Mohs surgery with your healthcare provider.”

“Mohs surgery provides the highest chance for a cure and the lowest chance for recurrence, even when other treatments have failed.”
-- Dr. Mariana Phillips, Section Chief, Dermatology and Mohs Surgery at Carilion Clinic.

Mohs surgery is especially appropriate for:

  • Large tumors or tumors with ill-defined edges
  • Skin cancer lesions which have grown rapidly
  • Areas where cosmetic appearance and function are important
  • Tumors that are recurring (or at risk of recurrence)
  • Areas located in scar tissue

Source: American College of Mohs Surgery


Know Your ABCDE Characteristics

During self-exams, remember the “ABCDE” characteristics used by dermatologists to classify melanomas. Look for spots that are:

  • A - Asymmetrical Shape: Melanoma lesions are often irregular, or not symmetrical, in shape. Benign moles are usually symmetrical.
  • B - Border: Typically, non-cancerous moles have smooth, even borders. Melanoma lesions usually have irregular borders that are difficult to define.
  • C - Color: The presence of more than one color (blue, black, brown, tan, etc.) or the uneven distribution of color can sometimes be a warning sign of melanoma. Benign moles are usually a single shade of brown or tan.
  • D - Diameter: Melanoma lesions are often greater than 6 millimeters in diameter (approximately the size of a pencil eraser).
  • E - Evolution: The evolution of your mole(s) has become the most important factor to consider when it comes to diagnosing a melanoma. Knowing “your normal” could save your life. If a mole has gone through recent changes in color and/or size, bring it to the attention of a dermatologist immediately.

Source: Melanoma Research Foundation

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Expert Contributor:
~ Mariana Phillips, MD, Section Chief of Dermatology and Mohs Surgery at Carilion Clinic.

 


 

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