L.F.F. Kopke (*)

Coordinator of the Department of Micrographic Surgery of the Brazilian Society of Dermatology,

President of the Brazilian Society of Dermatologic Surgery, Florianopolis,

Santa Catarina, Brazil

e-mail: luiskopke@uol.com.br

G.N. Galimberti

Department of Dermatology,

School of Medicine Italian Hospital,

Buenos Aires, Argentina

Summary: The Brazilian Perspective

•Not only the original technique of Mohs surgery is performed in Brazil, but also some variations that are more known and used in Europe, mainly in Germany: the Munich method and the Tübingen Torte. The Brazilian Society of Dermatology recently has created a department of micrographic surgery, which put all techniques together, in a way to coordinate the growth of micrographic surgery in the country.

40.1The Brazilian Perspective

The history of the micrographic surgery in Brazil is quite new. At the beginning, individual but important contributions were essential to bring up the development that we have made over the years. Dr. Sebastião Sampaio, who was one the most important dermatologist in Brazil, should not be forgotten. Under his leadership in 1988 the Brazilian Society of Dermatologic Surgery (SBCD) was founded and since then the role of the surgical dermatology in Brazil has expanded enormously. The first Mohs surgery in Brazil was made in São Paulo in 1985 and in 1989 the first unit of Mohs micrographic surgery was created in the Clinical Hospital of the São Paulo University (HCUSP) [1]. Although at that time, this unit began to train some dermatologists in the field, with a 1 year duration fellowship, many of the new dermatologic surgeons in Brazil preferred to study about Mohs surgery abroad. The USA was the logical destination where the Brazilians went to and it still continues to be the main center today. In 1991, a Brazilian decided to take an alternative way to know about Mohs surgery: Germany. But he realized that what they called Mohs surgery over there was technically very different from the original method, so he proposed a new name for the procedure: The Munich method of micrographic surgery, which was used and called by Dr. Gunter Burg as histographic surgery, that means, to control microscopically the surgical margins without using the Mohs surgery [2, 3]. In the same context, Breuninger mentioned the Tübinger Torte just only in German literature, and many papers that he had published in English literature was interpreted as he had performed Mohs surgery, although it was not the real Mohs method [4]. Regarding this situation, only Rapini wrote clearly about it [5]. This is very important to understand how the micrographic surgery has grown in Brazil.

Despite the creation of the SBCD, the number of Mohs surgeons remained small for a big country like Brazil. The unit of HCUSP had formed only five surgeons, and since its creation fewer dermatologists have dedicated to micrographic surgery. Maybe the reasons lie in the current trend of cosmetic surgeries just at that time when the number of the Mohs surgeons was increasing. Our Public health care management also contributes with this. The procedure is not supported by the government or private health insurance groups.

In order to change this situation, a small group of Mohs surgeons created the Brazilian Group of Mohs Surgery (GBMOHS), but again, the effects were still shy. Although the Mohs surgery is by large the mainly performed micrographic surgery in Brazil, other methods like The Munich and Tübingen methods are still used in the country. Therefore, it was recently created in the Brazilian Society of Dermatology (SBD), a department of micrographic surgery, which brought all kinds of microscopically controlled surgery together. The great step of this initiative was giving an official concern about the subject, nothing more as individual contributions, but as a goal of a dermatological society that recognizes the importance of microscopically controlled surgery in the field of cutaneous oncology. In Brazil, only few specialists besides the dermatologists know about Mohs surgery, and it would be important for the whole health system to spread out a concept that it can control better the threat of skin cancer. In its first year, the department has begun to discuss the basic formation of the Mohs surgeons, where and how they could be trained. With easier opportunities to travel abroad, we could already identify that many people are getting some knowledge in the field, but not in a trustworthy way. Therefore, in a recent survey we found out that in Brazil there are 29 surgeons that have some good experience with Mohs surgery or with another method, and maybe twice as much of dermatological surgeons that do not call themselves Mohs surgeons, although they have a good knowledge of the technique through the many trips to different centers in USA.

Today, there are only three dermatological residences services, where Mohs surgery can be done: Clinical Hospital of São Paulo University (HCUSP), Dermatologic Clinic of the ABC University, and Hospital Municipal de São Paulo (a Hospital of the City of São Paulo). Although other centers like Curitiba, Belo Horizonte and Rio de Janeiro are going to do the same soon, fellowship in Mohs surgery is only possible in São Paulo nowadays. The objective of the SBDs Department of micrographic surgery is to create conditions to increase the number of universities where Mohs Surgery or any other method of micrographic surgery could be learned and to standardize the way to teach this in our country. After that, maybe, other specialties could absorb the importance of micrographic surgery in cutaneous oncology. The seeds of Frederic Mohs are still alive in Brazil, and certainly it will improve.

Summary: The Argentinean Perspective

•Not only dermatologists do Mohs surgery in Argentine, but also some Head and Neck Surgeons, although most patients are treated by dermatologists. The insurance Companies pay the procedure, helping raising the number of patients that can be treated with the technique.

40.2The Argentinean Perspective

The beginnings of Mohs micrographic surgery in Argentina are not linked to Dermatology.

Dr. Abel Gonzalez, Head and Neck Surgeon completed a period of time at Madison Wisconsin with Frederic Mohs and his chairman’s Drs. Steve Snow and Paul Larson. In June, 1990 he introduced this technique at the Angel Roffo Oncology Hospital.

Dr. Gaston Galimberti has initiated his studies in skin cancer and Mohs micrographic surgery at Sagrat Cor, Barcelona Spain, where Dr. Pablo Umbert has been his mentor. He continued his research at Mount Sinai School of Medicine, Dermatology department (head of the Dermatology Department Dr. Mark Lebwohl) under the tutelage of Dr. James Spencer. In October, 2003 at Dermatology Department Hospital Italiano (head of the department Prof Ricardo Galimberti) Dr. Gaston Galimberti performed his first Mohs micrographic surgery.

There are a small numbers of private centers in Buenos Aires and other states that perform this technique.

Mohs micrographic surgery is linked directly to Dermatology; it is part of dermatology programs and residence. Nowadays there is only one dermatology residence where Mohs surgery can be performed: Hospital Italiano Buenos Aires, with more than 700 Mohs micrographic surgeries yearly it is a referral center to treat skin cancer. There is also an annual scholarship on Dermatology surgery and Mohs micrographic surgery whose chairman is Gaston Galimberti. The objective is to increase the number of Dermatology Surgeons that perform this important technique for the treatment of skin cancer.

The private insurance groups generally pay for this procedure and the social security does the same at Angel Roffo Oncology Hospital, free of charge.

In Argentina the incidence of skin cancer is growing up as well as other parts of the world. Lack of concern about the risk of sun exposure, in addition to skin phototype, genetics, and climatic changes, are the main factors.

The idea of treating skin cancer with this particular technique is not only good for our patients but also for Dermatology which will be more developed in the near future in Argentina.

Summary: Conclusion

•Mohs surgery practice in South America includes the original technique, as well as variations performed in Europe, especially in Germany.

40.3Conclusion

In South America not only the original technique of Mohs surgery is performed, but also some variations that are more known and used in Europe, mainly in Germany: the Munich method and the Tübingen Torte.

References

1. Cernea SS. Experiência do grupo de cirurgia micrográfica de Mohs do HCFMUSP: dezembro/1989 a abril de 1993. An Bras Dermatol. 1994;69(5):365–73.

2. Kopke LFF, Konz B. Mikrographische chirurgie: eine methodische bestandsaufnahme. Hautarzt. 1995;46:607–14.

3. Burg G, Hirsch RD, Konz B, Braun-Falco O. Histographic surgery: accuracy of visual assessment of the margins of basal-cell epithelioma. J Dermatol Surg Oncol. 1975; 1:21–4.

4. Breuninger H, Dietz K. Prediction of subclinical tumor infiltration in basal cell carcinoma. J Dermatol Surg Oncol. 1991;17:574–8.

5.Rapini RP. On the definition of Mohs surgery and how it determines appropriate surgical margins. Arch Dermatol. 1992;128:673–8.

Mohs micrographic surgery (MMS) represents a paradigm shift in skin cancer excision technique. MMS is the brain child of Dr Frederic Mohs, who treated his first patient by the technique which now bears his name, in 1936 at Wisconsin General Hospital, Madison. The historical development of Mohs surgery is well documented [1], and progress in MMS has been hand in glove with the development of dermatologic surgery and skin surgical oncology. The legacy has been manifold and includes the establishment of a body of dermatologists who are specialists in skin cancer diagnosis and treatment and distinguished by the core skill of the Mohs micrographic excisional technique. MMS represents the gold standard in the treatment of skin cancers of the head and neck and those with a higher risk of local recurrence by non-Mohs techniques.

Mohs surgery has found wide acceptance by North American health care providers and patients. The American College of Mohs Surgery (ACMS) has a large membership with well-formed structures acting as advocates for the large well-trained body of ACMS Mohs surgeons practicing in North America. The ACMS has high standards of fellowship training and a strong annual scientific meeting focusing on new developments, research, and teaching components, as well as a parallel meeting of Mohs histotechnologists. Both the ACMS and the Mohs histotechnologists meetings attract an international audience, albeit a small fraction of the North American audience.

The ACMS website gives a geographical listing for members of the ACMS (www.mohscollege.org). The listing for the USA is by state and the total USA membership exceeds 600. The country outside the USA with most members listed is Australia with 22 and then Canada with 17. The only European countries listed are the UK with seven and Ireland with one. There are five ACMS members listed in Israel.

The history of MMS in Europe has been previously described [2]. Progress of MMS in Europe, by contrast with the USA, has generally been slow. MMS development has typically relied on the interest, insight, and energy of individuals to find training in MMS and develop a MMS service to a local population. The absence of a regional or national framework for MMS services or a critical mass of MMS practitioners forming a strong professional body with a common understanding and aim acting as the advocate for MMS training standards, practice standards, audit, and research has led to the slow and uncharted progress of MMS in Europe.

Mohs surgeons in Europe have acquired their training in a number of ways, including ACMS fellowships, visits to the Mohs centers in the USA, training in European countries which varies from within residency training (e.g., Holland), clinical attachments of up to 3 months duration (e.g., Portugal) and 1 year Mohs fellowship training programs (e.g., UK). It can be seen that training across Europe is diverse in

nature and even within countries Mohs practitioners training may have been from any of the sources described, vis-a-vis in residency, clinical attachment or fellowship.

Colleagues in Germany have developed a number of alternative margin control techniques which include the Munchner method, Tubinger tort, Muffin technique, La Galette method, and Wallgraben technique [3].

There are a number of well-established MMS services in Holland, Spain, Portugal, Sweden, UK, and Ireland. However a number of countries, including Denmark and Norway have no access to MMS.

Authors from European MMS units have made some important contributions to the literature, particularly in taking a critical approach to Mohs surgery where there exists a dearth of randomized controlled

Fig. 41.5 Mohs section (H&E stain) of basal cell carcinoma nose showing mixed histological pattern of basal cell carcinoma and adjacent nasal cartilage

studies. Both extant prospective controlled studies are from European centers, one comparing Mohs surgery with standard excision [4] and one assessing the tis- sue-sparing outcome for small nodular basal cell carcinomas [5].

The European Society for Mohs Surgery (ESMS) was established several years ago (www.esme-mohs.eu) but has faced the challenges resulting from the diversity of Mohs across Europe. Unlike the USA where there is evidence of a well-attended body of MMS experts with a unified vision and direction, a coordinated approach is lacking within many European countries and maybe not surprisingly at European level.

Fig. 41.7 Mohs defect squamous cell carcinoma lower lip after 1 stage and 4 blocks

The available evidence suggests an increasing incidence of skin cancer across Europe [6, 7] which is likely to continue to rise for several decades [8]. Along with changes in incidence of skin cancer there exist societal changes and an explosion in the availability of high quality information. The public at large is thus becoming an ever more sophisticated “consumer” of health services in general, and skin cancer treatment in particular. The demand for high-quality skin cancer treatment, and therefore MMS, is likely to continue to rise. Patients are increasingly consumers of healthcare rather than recipients, and are better placed than ever to understand the range of treatments available including MMS.

There is likely to be change in the direction of MMS, from large, neglected or recurrent tumors, toward the treatment of smaller tumors with resultant small Mohs wounds and the prospect of repair in a seamless manner.

In England and Wales, the National Health Service (NHS) 2006 Improving Outcomes Guidance [9], for skin cancer laid out a set of guidelines with recommendations for Mohs surgery as a desirable treatment outcome for defined indications, including basal cell carcinoma (BCC) greater than 2 cm diameter, BCC located in high-risk facial zones, recurrent BCC, and BCC with aggressive histological growth pattern. This has led to an increasing demand for Mohs surgeons in the UK.

The UK has a number of MMS units with good operating rooms and Mohs laboratory facilities, based mainly in teaching hospitals with annual MMS caseloads greater than 500 (including St John’s Hospital, London, Cardiff, Manchester, Nottingham, and Newcastle upon Tyne). Recent years have seen the establishment of Mohs surgery fellowships in the UK, including those at St John’s Hospital, London, Cardiff, Nottingham, and Newcastle upon Tyne.

The British Society for Dermatological Surgery (BSDS) has recently developed a dermatologic surgery fellowship curriculum (MMS training being central to this) as well as national guidelines (“MMS setting standards document”) for MMS. The BSDS lists the MMS fellowships currently available in the UK on its website (www.bsds.org.uk) and in its newsletter. In recent years, the BSDS has seen an increasing number of MMS-related abstract submissions to the BSDS annual scientific meeting [10–12].

The development of a “British College of Mohs Surgery” has been a subject of discussion at various times in recent years.

Important agenda areas for MMS in Europe include, the development of information systems to record