Talk:Mohs surgery
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Smeet NW et al "Surgical excision vs Mohs' micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial." [1] showed MOHS to be more expensive and of no statistical benefit in the treatment of BCC. The links supplied by 69.14.27.163 do not reference to RCT's, but rather to advertorials.
MOHS is an option in the treatment of BCC however it is slower, more expensive, and no better at cure rates than surgical excision so why do it?
The reliability of diagnosis of melanoma in situ is dubious. Based on a series of 104 patients with melanoma in situ 30 (29%) had invasive melanoma based on immunohistochemical testing. 1 metastatic death and 1 tumor recurrence was reported. [2]. As a consequence melanoma in situ has to be treated in the same way as melanoma. There has been no RCT published comparing standard surgical excision of melanoma with MOHS by J A Zitelli or anyone else. Until this has been done any MOHS treatment of melanoma or melanoma in situ is a procedure of unproven benefit.
I would rather be reported to Wikipedia for editing out advertorial puffery than have a posse of trial lawyers after me for inadequate treatment of a melanoma. —Preceding unsigned comment added by Nickcoop (talk • contribs) 01:34, 9 April 2008 (UTC)
Dear Dr. Nickcoop,
I respect your contribution. The study was well done by Smeet, and well within the accepted cure rate of Mohs surgery. I actually was the one that edited the claim that Mohs achieved a 99% cure rate, to that of 97 to 99%. In the hand of a competent plastic surgeon or physician (ie. who knows the limitation of bread loafing histology), one can achieve very good cure rate with standard excision - close to that of Mohs surgery.
However, in real life, physicians often take too narrow of surgical margins on facial excisions, and the weak link in the "cure" rate is the pathology lab. I think you are essentially throwing the baby out with the bath water. Remember that Smeet said that Mohs surgery in his trial achieved a 98% cure rate, vs. a 97% cure rate with excision. Follow through with current guideline on surgical margin, a 97% cure rate with standard excision is very achievable. However, I would not want it done on a nasal tip, nasal ala, or at an eyelid margin.
Thank you for your contribution. But please, leave it in the discussion, or add it as an addendum. You extrapolated Smeet's study beyond its original intent. —Preceding unsigned comment added by 24.192.18.224 (talk) 03:06, 13 April 2008 (UTC)
The comment about melanoma-in-situ is mainly to point out that for tumor of contigous nature, it might be effective. However, as you have stated, some "melanoma-in-situ" are actually invasive. This is the limitation of small incisional biopsy or punch biopsy techniques. However, to spare a patient of unnecessary 1 cm wide surgical margin on small melanoma in situ of the face, ignoring the use of double bladed scalpel or Mohs surgery might not be doing your patients a favor. Again, I am not advocating Mohs surgery for melanoma-in-situ, as it is too time consuming for H&E staining. The double bladed scalpel technique is superior, in my opinion. But we should mention Mohs surgery mainly for discussion purpose.
Please contribute. I've read Smeet's study before. It really points to the fact that Mohs surgery is not as good as many Mohs surgeon's claim. It is not as refined as we think, and is subjected to physician error. Especially when only TWO histologic sections are examined. I truly believe that to be accurate, multiple sections must be examined. This might really explain why true cure rate for Mohs might drop as low as 97%, and not the 99% frequently quoted.
Northerncedar Whatever Smeet's intention was, the study showed no statistical difference in outcome between SE and MOHS in the treatment of BCC. I have extrapolated nothing. His cure rates were not 98% vs 97% for MOHS vs SE but rather 98% +/- the statistical margin of error vs 97% +/- the statistical margin of error, i.e. there was no difference in outcome for the two techniques.
Whatever technique is used for removing a suspicious skin lesion the point of the study by Megahed M et Al was that until the excised lesion was analysed with immunohistochemical markers the diagnosis of Melanoma wasn't made. Doing simple H&E staining of frozen sections is inadequate treatment of melanoma in situ. —Preceding unsigned comment added by Nickcoop (talk • contribs) 21:13, 13 April 2008 (UTC)
Nick, No problems with Smeet's intention. Following current surgical guideline for free-margin, one can achieve cure rate of 80%, 85%, 90%, 95%, or 99% if standard bread loafing (with its inherent false negative rates) and wider and wider surgical margin. This gradual decrease in cure rate has nothing to do with the skill of the surgeon, it is the inadequacy of standard bread loafing, and the managed care decrease in reimbursement for pathology lab that do serial breadloafing, or margin controlled pathology (approximating the Mohs method).
Smeet should define his pathology lab's methodology - so the reader realize that 3 or 4 breadloafed slices done in managed lab's cost cutting measure - is not the same as his. Also, he needs to define his criteria for surgical margins. I find that if a dermatologist can master the art of dermatoscopy, his surgical margins will be much better. Whereas, one who uses his naked eye - it is much lower.
There is a skill to improve standard excision, there is guidelines for making cure rate with standard excisions high, and there has ALWAYs been pathology cutting techniques to improve the false negative rate of bread loafing to approximate 2% or less - but in real life - these methods are not applied, and not used.
As someone who has done many Mohs on recurrences of basal cell tumor from standard excisions - I find that the plastic surgeons who favor cosmetic over cure rate (i.e. very small surgical margin, much below what is currently recommended) get the highest recurrent rate. I regularly do Mohs on recurrences of one particular local dermatologist who does not realize his recurrence rate is so high from standard excision.
It is not that Mohs is God's answer to cancer treatment. It is not. But it saves the headache of finding a pathologist who will cooperate with you, Dr. Nickcoop, and assure that you have good margin control. It is the pathologist who defines the false negative rate, not the surgeon.
On the melanoma part, read my edit of a very erronous note below that I edited months ago. Someone noted that Mohs surgery was the best cure for melanoma! It was outrageous, and I deleted it. Mohs does not offer any improvement in cure of melanoma. Not at all. Not even for melanoma-in-situ. All it offers is the equivalent way to the double bladed scalpel technique with the cumberson H& E stain to mimimize tissue destruction and assure good margin control or better margin control than bread loafing. It isn't rocket science, Nick, it is simply mounting the edges to get 100% surgical control rather randomly selecting the edges with breadloafing, and examining less than 10% of the edges EVEN with through the block bread loafing. Remember that through the block bread loafing still discard about 80-90% of the wax slices, so the pathologist doesn't have to look at hundreds of section. I think Mohs surgery would be a total waste of time for melanoma in situ, as why waste time checking the bottom margin, when bread loafing of the center is adequate??
But I can tell you after a recent case where a plastic surgeon has done about 7 excision of a melanoma in situ on a woman's face over 10 years. She was absolutely shocked when I outlined how the tumor has covered nearly 1/3 of her face and eyelid. She was sent to U of Michigan for the double scalpel technique. This case clearly demonstrate the weakness of the bread loafing technique for margin control of ill defined melanoma in situ.
It is nice to have this discussion with you.
Northerncedar.
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[edit] Message for Nickcoop =
Mohs surgery has been used very successfully for melanoma-in-situ. Do a medline search and you'll see several articles on the matter. Look up Zitelli, primary author. It is similar to the "double bladed" scalpel technique use at U of michigan. Before you simply delete informations, please do your homework. —Preceding unsigned comment added by 69.14.27.163 (talk) 15:16, 8 April 2008 (UTC)
Also don't spread misinformation by deleting all references about cure rate on Mohs surgery and how "bad" it is. It is also very rude to delete all references to Mohs surgery on the options in treating basal cell carcinoma.
I've reported you to Wikipedia, and I hope that you will participate in discussions with references instead of blindly deleting referenced information. —Preceding unsigned comment added by 69.14.27.163 (talk) 15:18, 8 April 2008 (UTC)
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I have started this page with basic information about Mohs surgery. Philiphughesmd 16:07, 31 March 2006 (UTC)
- I have had two Mohs surgeres, one on nose, one of ear. I added "See also: and "External link" Some of the information in this article appears in the external link I have added. Phil talk 23:00, 23 July 2006 (UTC)
- As a Mohs surgeon, I agree that the two articles about Mohs surgery and Mohs cancer surgery should be merged under the heading Mohs Surgery. The information about using topical imiquimod cream (Aldara) is misleading - nearly all Mohs surgeons I know (> 20) do not use imiquimod cream and there is no reason why imiquimod cream is used over any other cream such as fluorouracil (Efudex or Carac) - I am concerned about this being a commercial endorsement.
- Topical imiquimod work quite differently than Efudex and Carac. The inflammatory response is much more brisk and "explosive". I personally believe that it is more effective than Efudex especially for invasive squamous and basal cell carcinoma. I am not endorsing either Aldara, Efudex, or Carac. Just want us to realize, it is another tool in our bag of tricks, and certainly better than maiming someone with Mohs surgery for large in-situ carcinoma.
- I believe that they should be merged because they are pretty much the same. --City-state 20:21, 18 October 2006 (UTC)
[edit] yes merge, and get rid of Aldara
Clearly, these are the same. Also, discusion of Aldara should be under skin cancer if at all.
I agree.
But, I disagree.
[edit] Aldara, Efudex, and Radiation therapy should be included
All 3 are standard of care. Both Aldara and Efudex have FDA approval for the treatment of in-situ basal cell cancer. The combined experience of many physicians have noted dramatic success in the treament of even invasive and extensive squamous cell carcinoma (in elderly and terminal patients). The end result of Mohs surgery on large in-situ carcinoma has result in significant morbidity and facial deformities in patients who were mis-informed of the viable option for such cancer. Radiation and topicals must be discussed as viable and acceptable treament for in-situ carcinoma.
I personally treated an extensive recurring squamous cell carcinoma of the scalp in an elderly patient that has had multiple Mohs excision to the point where his skull is exposed due to the excessive stretching of his scalp. The patient responded dramatically well to Aldara cream. The success rate of Mohs surgery is comparable to radiation therapy in squamous cell carcinoma, and one should also discuss this before approaching high-risk squamous cell cancers of the ear or lips. Combining these modalities should be considered to increase the cure rate in selective cases, and should also be discussed.
[edit] Best surgery for melanoma??
Someone added this:
"Although some consider Mohs surgery not to be the standard of care in the treatment of melanoma, Mohs surgery provides the best cure rate. "
While it might be true for melanoma-in-situ, assuming the same surgical margin, one might argue. But this statement is too broad, too vague, and can not be left as is. Mohs surgery might be very effective in melanoma-in-situ, the only class of melanoma we should consider. But to say that it is more effective than the double blade, margin controlled section, or other methods of margin control in the treatment of melanoma-in-situ is misleading. Not to define the melanoma type in the sentence if misleading to the average person.... As thus, can not be left as is. —The preceding unsigned comment was added by Northerncedar 69.47.205.61 (talk) 02:46, August 22, 2007 (UTC)
Some one inserted "melanoma", next to mohs surgery has been used to treat "melanoma-in-situ". I don't know of anyone who would be cavalier enough to recommend Mohs surgery for the treatment of melanoma more than the in situ varient. I deleted it, and wish that such person would not reinsert such claim unless you have references. As far as references for melanoma in situ, do a medline search on Zitelli, Mohs surgery, and melanoma, and you would get several articles. —Preceding unsigned comment added by 69.14.27.163 (talk) 17:27, 4 October 2007 (UTC)
