Summary: An Introduction to Mohs Micrographic Surgery

•Mohs was only a medical student when he began to develop his new surgical technique during the 1930s.

•In 1941, Mohs reported his findings using fixed tissue chemosurgery in the Archives of Surgery.

Dr. Michael Guyer, Professor of Zoology at the University of Wisconsin. Initially, Mohs injected platinum into implanted tumors of rats and subsequently made horizontal sections to be viewed under the microscope.

At the turn of the twentieth century, Cancquin in Paris and Bougard in Brussels began investigating zinc chloride as a treatment for all types of cancer. Zinc chloride had been known to exist for at least

lid. In order to speed the surgery for the video, he did not use the zinc chloride fixative. Instead, he used fresh frozen tissue to generate the horizontal sections.

•During 1956, Mohs published his first book entitled Chemosurgery in Cancer, Gangrene and Infections.

•In 1967, the first meeting of the American College of Chemosurgery occurred at the Palmer House in Chicago with 23 members.

•During the 1970s, the fresh tissue technique became the main form of Mohs surgery practiced, reducing the time required for the technique, the pain experienced by the patient, and improving the cosmetic results.

•In 1983, the first 1-year fellowship program formally approved by the American College of Mohs Micrographic Surgery and Cutaneous Oncology (ACMMSCO).

•In 1985, the American College of Chemosurgery changed its name to the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

•Mohs micrographic surgery is spreading across the world, and we have dedicated a section of this book to document its travel.

1.1Introduction

The founding father of Mohs micrographic surgery, Frederic E. Mohs, was born in Wisconsin in 1910. While he was a young child, his father died, and his family moved to Madison, Wisconsin. Mohs was only a medical student when he began to develop his new surgical technique during the 1930s [1, 2]. At that time he was working under the supervision of

zinc chloride could be used to “fix” a tumor so that the histologic architecture could be viewed under a microscope.

In 1936, Mohs translated his research method into use for cutaneous tumors in humans. He began injecting zinc chloride into human skin cancers and taking horizontal frozen sections in thin layers to observe whether any tumors had cells extending beyond the margins of the section. It was at this time that chemosurgery, the precursor to modern day Mohs micrographic surgery, was born.

In 1941, Mohs reported his findings using fixed tissue chemosurgery in the Archives of Surgery in 440 consecutive patients involving primary cutaneous malignancies [3]. Out of those 440 patients, 409 or 93% did not experience any recurrences [3]. Dr. Mohs reported that a number of the cases that did recur were advanced in their initial presentation. Later in 1946, he reported more results at the American Academy of Dermatology in Chicago. In 1947, he described his technique and work using chemosurgery for the face [4].

After these initial reports, Dr. Mohs’ clinic at the University of Wisconsin became flooded with patients who had skin cancer. In addition to skin cancer, he treated gangrene as well as cutaneous infections.

Despite the early success of Mohs’ technique, there were some drawbacks to fixed tissue chemosurgery. It was labor intensive, time-consuming, and painful for the patient. The zinc chloride paste had to be left overnight in order to fix the tissue. Patients complained of great pain during the process as zinc chloride is known to be a chemical irritant. In addition, the zinc chloride paste required several weeks to be removed from the tissue so that reconstruction could be undertaken.

In 1953, Mohs was creating a video illustrating the chemosurgery technique for the eyelid. In order to speed the surgery for the video, he did not use the zinc

Today, Mohs micrographic surgery is becoming more advanced; now using immunohistochemistry in combination with fresh frozen tissue to more closely delineate tumor margins. It is considered the most effective procedure for certain types of skin cancer today.

References

1.Swanson NA, Taylor WB. Plantar verrucous carcinoma. Literature review and treatment by the Mohs’ chemosurgery technique. Arch Dermatol. 1980;116(7):794–7.

2. Shriner DL, McCoy DK, Goldberg DJ, Wagner RF. Mohs micrographic surgery. J Am Acad Dermatol. 1998;39(1): 79–97.

3.Mohs FE, Chemosurgery A. Microscopically controlled method of cancer excision. Arch Surg. 1941;42(2):279–95.

4. Mohs FE. Chemosurgical treatment of cancer of the face; a microscopically controlled method of excision. Arch Derm Syphilol. 1947;56(2):143–56.

5.Tromovitch TA, Stegman SJ. Microscopically controlled excision of skin tumors. Arch Dermatol. 1974;110:231–2.

6. Hanke CW, Temofeew RK, Miyamoto RT, Lingeman RE. Basal cell carcinoma involving the external auditory canal: treatment with Mohs micrographic surgery. J Dermatol Surg Oncol. 1985;11:1189–94.

M.P. McLeod • S. Choudhary

Department of Dermatology and Cutaneous Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA

Y.A. Alqubaisy

Department of Dermatology and Cutaneous Surgery,

University of Miami Hospital, Miami, FL, USA

K. Nouri (*)

Department of Dermatology and Cutaneous Surgery,

University of Miami Leonard M. Miller School of Medicine,

Miami, FL, USA

Sylvester Comprehensive Cancer Center, University of Miami Hospital and Clinics, Miami, FL, USA

e-mail: knouri@med.miami.edu

Summary: Introduction

•General indications for Mohs micrographic surgery require that the cutaneous tumor be continuously growing.

•MMS is considered well suited for tumors:

–That exhibit perineural invasion

–Tumors in high-risk anatomical areas

–Tumors that have been incompletely excised

–Tumors with poorly defined clinical margins