There are many methods of skin-cancer removal including "scraping and burning," liquid nitrogen freezing, radiation therapy, interferon injection, laser destruction, regular or routine "cutting-out" with scalpel and Mohs Surgery. Each method has its own list of advantages and disadvantages, along with its own cure and failure rate statistics. Different patients with differing situations require different treatments.

No treatment will cure 100% of skin cancers; however, only Mohs surgery gets the closest to that number consistently. When appropriately chosen and carried out, however, some of the treatments mentioned in the first paragraph may provide cures of up to 90%, and sometimes more, for the appropriate cancers. Special properties may tell which cancers will resist certain treatments. Mohs Surgery is a useful tool for treating many new and resistant skin cancers. When properly performed, Mohs Micrographic Surgery gives the highest rate of cure for basal- and squamous-cell cancer while disturbing or removing the least amount of normal skin. Frederic E. Mohs developed Mohs Surgery at the University of Wisconsin. Although Dr. Mohs first began using what was called chemosurgery (presently Mohs Surgery) some 50 years ago, the technique was relatively unheard of among the general public until the 1990's for many reasons including political ones. Now virtually every major university medical center in the United States and many around the world are staffed with members of the American COLLEGE of Mohs Surgery the OFFICIAL certifying body for this treatment (note the difference between American College and American SOCIETY of Mohs Surgery which are two different things). The true performance of Mohs Surgery is time-consuming and requires highly specialized training, mechanical and quality standards and special office personnel.

Mohs Surgery is the removal of skin cancer by taking special horizontal sections (see figure). It differs from the routine/regular "cutting-out" which involves vertical sections (see figure). Remember, Mohs Surgery has the highest cure rates for the most treatment-resistant types of cancers while disturbing the least amount of normal tissue. In other words, Mohs Surgery leaves the smallest tumor-free surgical defect. Fortunately, the smaller defect may be sewn (closed) to result in a smaller scar. Unfortunately, Mohs Surgery takes a bit longer to perform and costs more money in the short-term than many of the other methods. However, for many skin cancers, Mohs is worth the wait and cost. Take for example, President Ronald Reagan while he was president, had successful Mohs Surgery (by a member of the American COLLEGE of Mohs Surgery!) for a skin cancer that Board Certified Plastic Surgeons had previously failed to cure during their standard (non-Mohs) vertical-section-surgery attempt. President Bush Sr. had a skin cancer not long after President Reagan and went directly to an American COLLEGE of Mohs Surgery Member for his surgery as well.

Most Mohs Surgeon's or a staff member will usually be happy to discuss thoroughly the Mohs procedure on the day of surgery or even before setting a surgery date. On the morning of surgery, patients usually may eat, drink and take all of their normal medicines unless otherwise directed. Any remaining questions will be answered. The area around the skin cancer is cleansed and a local anesthetic (numbing) injection is given for three seconds using a very tiny needle. The Website author prefers a special mixture (his own combination) of short- and long-acting local anesthetics. After letting the numbing medicine "percolate" and take effect for the appropriate amount of time, the surgeon takes a section of cancer (Mohs stage) from the patient. Removing a stage or section only takes one to two minutes. The surgeon or sometimes an assistant stops any bleeding by several mean and a temporary bandage is applied.

The tissue stage is specially processed in the lab. The tissue is horizontally sectioned and precisely stained for cancer. The processing usually takes 10 to 20 minutes depending on how many cases are being handled at once. The Website author, with appropriate precautions, runs the only lab in the world where the patients may, upon special request, watch the processing and read their own slides under the microscope, comparing what they see with pictures in a textbook. If the patient does not wish to observe the processing, then he/she may go to the waiting room to read a book, listen to music, watch television, speak with a friend or sit and relax, while enjoying a selection of teas, soups or coffees.

 

If the microscopic reading of the processed first stage of Mohs tissue slides reveals no cancer, the "hole" (defect) is delicately sewn together. See Stitching. The patient may then leave for home. But if cancer is still present on the slides, then the patient is returned to the procedure room. The long-lasting part of the local anesthetic is still in effect, so more local anesthetic mix may be injected painlessly into the already numb area. Since the Mohs technique determines exactly where the cancer remains, another Mohs section is taken only from the location of the remaining cancer; the process repeats itself until the slides show no remaining cancer. The cancer-free defect is delicately sewn together with plastic surgery and patient may go home.

Regis Philbin of television fame "Live with Regis and Kathie Lee", had Mohs Surgery on two separate cancers. His story is excerpted and told in the Web-site subsection Mohs Surgery Day - Preparations.

 

Mohs Surgery (microscopically controlled excision, formerly called chemosurgery) is a highly specialized procedure for the total removal of skin cancers.

......The ORIGINAL - A METHOD THAT IS RARELY USED NOW - procedure, as described/invented by Dr. Mohs, consisted of three steps:

THE CURRENT - MODERN WAY OF PERFORMING MOHS SURGERY

Over the years, the technique has been modified and improved. The painful chemical fixative is no longer necessary. However, much of the rest of the procedure, including marking with dyes and examination under the microscope, remains the same. Before the tissue is examined microscopically, it is cut into smaller sections and marked with colored dyes to distinguish right from left. The author has developed methods to improve the speed and quality of processing Mohs tissue samples. Each specimen is then cut into very thin horizontal sections to allow all of the deep and peripheral margins to be examined under a microscope. This method of cutting the specimen is far superior to standard pathology techniques (that cut the specimen vertically). Unfortunately, the standard techniques examine only small areas, usually less than 0.1% of the actual surgical margin. By using the Mohs cutting technique, rather than the standard technique, one can pinpoint the exact location of any remaining tumor during the microscopic examination. If more cancer is detected, the entire procedure is repeated, but only in the area of the remaining cancer.

Only by careful, systematic micro-scopic examination of the skin removed by Mohs Surgery, can one be as certain as possible that no cancer remains. The modern Mohs surgeon, if a member of the American COLLEGE of Mohs Micrographic Surgery and Cutaneous Oncology (please do not be confused with the "amazingly similar" name used by members American SOCIETY of Mohs Surgery), is specially trained to perform all phases of the operation including removal of the tissue, microscopic examination of the removed tissue and closure of the wound, when appropriate. Medicare of Florida has reaffirmed this definition in its new policy. Occasionally a Mohs surgeon may work with another specialist TO REPAIR THE FINAL MOHS DEFECT when dealing with unusually complicated tumors. In this unusual type of case, continuity of care is of prime importance.

As was mentioned previously, Regis Philbin of television's Live with Regis and Kathie Lee had Mohs Surgery on two separate skin cancers. Here are some of Regis' thoughts: "I lived in California for years and loved getting a tan. . . . When I used sunscreen, I never put it on my hands. . . . My first cancer, a squamous-cell cancer, was on my hand. . . . The treatment was done in the doctor's (American COLLEGE of Mohs Surgery Member) office and took about two hours. The carcinoma was taken off with . . . Mohs . . . in which every layer of the skin is studied under the microscope to see if it contains cancer cells. The surgery continues until it gets to a layer that is completely free of cancer. When the Mohs surgeon said the cancer was all out and would not come back, I was perfectly relieved. In fact, I didn't give a second thought to the possibility of future trouble. . . . My second cancer was on my face. This one was so big . . . that the doctor had to do a skin flap. A tremendous number of stitches was needed. . . . I was certainly happy to be back on the show four days after the treatment, looking pretty much the way I always do. That's how good the surgery was. It took a while for the scar to disappear completely, though I was able to hide it in the meantime with make-up. It's clean as a whistle now; you can't see a trace of it."

Note that all three: President Reagan, President Bush Sr., and Regis all went to American COLLEGE of Mohs Surgery Members for their surgery and avoided surgeons who were not members of that organization.

© 1997-2003, Paul J. Weber, M.D., P.A., All Rights Reserved