Talk:Mohs surgery/Archive 1

CAN WE JUST LEAVE THE POLITICS OF MOHS SURGERY ALONE??
Dr. Mohs never intended to limit Mohs surgery to be practiced in the USA by ACMS fellows alone. He encouraged ALL doctors to learn and apply Mohs surgery.

Why do we still have to shove the AMERICAN viewpoint onto the English world, and the whole world by trying to pretend that Dr. Mohs was a dermatologist (HE IS NOT). And that only dermatologist can legally remove skin cancer using Dr. Mohs method?

Anonymous Mohs doctor 74.173.120.44 from Atlanta keeps on wanting to say that dermatologists invented dermatopathology, and only dermatologists should be doing Mohs surgery. Very sad indeed when political agendas are being pushed onto Wikipedia.

We have heard this all before: Only plastic surgeons should do reconstruction, only plastics can do nosejobs and facelifts, surgeries can only be done in the hospitals, etc....  The same garbage that dermatologists have been trying to fight, is being brought upon the profession by the selfishness of a few ACMS fellows.

Controversial article by Smeet NW
Smeet NW et al "Surgical excision vs Mohs' micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial." 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. . 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.

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)

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)

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.

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.

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 Special:Contributions/ (talk)

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)

Please cite sources
Please cite sources, else material will be challenged and removed. kilbad (talk) 02:19, 27 November 2008 (UTC)

How does the history fit into this?
I see that I've stumbled onto a controversial topic. Speaking as a layperson, the "escharitic agent" mentioned in the section on History seems to have nothing to do with the procedure as it is currently practiced. Whatever the controversy is, could someone please clarify whether or not this agent is still used, why the term "chemosurgery" applies to the current procedure, and also why the current procedure is known as "Mohs surgery"?

--W.F.Galway (talk) 17:23, 21 January 2009 (UTC)

1. Escharitic agent has nothing to do with what is currently practiced. Apparently the paste has 2 effect: a. Anesthetic - which is good for surgery. b. Escharitic - which is bad for wound healing. There is no benefit for using an escharitic agent in surgery - so that is why injectable anesthetic like lidocaine is currently used - it causes no tissue destruction.

2. The term "chemosurgery" is a carry over and is occasionally seen in medical billing. It must have started in the day when Mohs surgery was being performed with the paste, and when it switched over to fresh frozen tissue, the term sticks. Chemosurgery has nothing to do with the way how Mohs surgery is being used today. But we can't change what we can't change.

Northerncedar —Preceding unsigned comment added by Northerncedar (talk • contribs) 21:13, 2 February 2009 (UTC)

How to Read Mohs Micrographic Slides
This whole section seems out of place on WP. This is an encyclopedia, not a tutorial for pathology review. A much shorter version, describing Mohs path reading, might be appropriate, but in its current form (content and tone) it seems inappropriate. --Scray (talk) 17:15, 14 February 2009 (UTC)

I agree with you with the style is out of place. This site has been under continous attack by Nickcoop, and such discussion was place so that he will leave the site alone or participate in its discussion. However, he has continued to chose to vandalize this article and references to Mohs surgery.--Northerncedar (talk) 19:58, 14 February 2009 (UTC)

Controversial content
This restoration: seems appropriate to me, having looked at the article, the content in question, and the referenced literature. The controversial material, which has been subject of multiple reverts in the past 24 hours, should be retained. Overall, as I commented in the section above, there are portions of this article that could be improved for readability, but the citations support the content. --Scray (talk) 12:16, 15 February 2009 (UTC)

Nickcoop's single article discussion
This single article, Smeets et al, and its hot link is discussed in the main body of the article. It is also discussed here last year on the talk page. Multiple articles were cited in support of the current content. Nickcoop also deleted any discussion about the use of Mohs surgery for melanoma in situ. In fact, we have included several references for both low (70%) and high (90% plus) to support this use.

It is possible to include many more references to support the current cure rate quoted here -- and we can do that, but it would be a little redundance - it probably will not stop Dr. Nickcoop from using his own personal experience ("I've removed hundreds of basal cell cancer with excision", and his singular article - Smeets, et al - in his quest to delete any references to Mohs surgery in the treatment of basal cell cancer (see his history), and his current and past vandalism of the Mohs surgery article.  Northerncedar.  —Preceding unsigned comment added by 24.56.205.138 (talk) 12:53, 15 February 2009 (UTC)

Nickcoop's proposal for "randomized controlled trial" and Mohs surgery
"Mohs surgery Hi Cyclonenim,

the article on Mohs surgery is not neutral.

There has only ever been one randomized control trial done on this technique and that shows no benefit over standard surgical excision. (Lancet 2004 Nov 13-19;364(9447):1732). There isn't much else to say about the technique and yet the entry in Wikipedia is huge.

I talked this through with Northerncedar last year. Northernceder was unable to produce any randomized control trial that showed any advantage to Mohs surgery. The editing that I had done last year was deleted by Northernceder and others. I haven't had a chance to review what had been done to the entry until now.

I know that the Mohs surgeons who have written this page believe that what they do is great but the evidence is that is no better than traditional standard surgical excision, and much more expensive.

This fact is crucial and needs to be prominent in the Wikipedia entry.

What concerns me most is that this entry is going to be used for some shroud waving by Northernceder. People with skin cancer need to know what are the most effective treatments, and then of those which is the most cost effective.

Nicholas Cooper FRNZCGP Auckland New Zealand —Preceding unsigned comment added by Nickcoop (talk • contribs) 04:04, 15 February 2009 (UTC)"

'''While commendable, it might not be doable, unless you run a dictatorship. Why?'''

Mohs surgery is not a unique method. It simply is one of many methods of "margin controlled" histology processing. Its origin was rooted in an archaic eschar causing chemical, but otherwise, it is simply a method for cutting tissue. If offered two methods for processing tumors:

1. Standard breadloafing where you are guaranteed false negative errors.

2. Margin controlled histology processing where you are guaranteed very little false negative erros (unless introduced by the histotechnicians themselves).

Who would want standard breadloafing?

It is almost laughable that someone would want to have such a study as published by Smeets et al, where no mentioning of the method of tissue processing was done in the "standard surgical excision".

No mention of surgical margin vs. tumor size, if frozen section was utilized, and if "through the block processing" or margin controlled technique used.

Ask any pathologists who were trained in traditional tissue processing method, and is aware of the many different margin controlled techniques to comment on this area; and he would tell you - there is nothing unique about Mohs surgery. It is just a simple method for margin controlled.

Nothing magical, nothing miraculous, nothing amazing - as some of the ACMS Mohs fellows would claim. It is a simple to do, simple to understand method of achieving high cure rate through something pathologists have always known - 100% margin control equals high cure rate.

--Northerncedar (talk) 18:11, 15 February 2009 (UTC)

Randomized study in support of Mohs surgery for recurrent basal cell carcinomas of the face
Lancet Oncol. 2008 Dec;9(12):1149-56. Epub 2008 Nov 17. Links

Comment in: Lancet Oncol. 2008 Dec;9(12):1119-20. Lancet Oncol. 2009 Jan;10(1):9-10; author reply 10. Surgical excision versus Mohs' micrographic surgery for primary and recurrent basal-cell carcinoma of the face: a prospective randomised controlled trial with 5-years' follow-up.Mosterd K, Krekels GA, Nieman FH, Ostertag JU, Essers BA, Dirksen CD, Steijlen PM, Vermeulen A, Neumann H, Kelleners-Smeets NW. Department of Dermatology, Maastricht University Medical Centre, Maastricht, Netherlands.

BACKGROUND: Basal-cell carcinoma (BCC) is the most common form of skin cancer and its incidence is still rising worldwide. Surgery is the most frequently used treatment for BCC, but large randomised controlled trials with 5-year follow-up to compare treatment modalities are rare. We did a prospective randomised controlled trial to compare the effectiveness of surgical excision with Mohs' micrographic surgery (MMS) for the treatment of primary and recurrent facial BCC. METHODS: Between Oct 5, 1999, and Feb 27, 2002, 408 primary BCCs (pBCCs) and 204 recurrent BCCs (rBCCs) in patients from seven hospitals in the Netherlands were randomly assigned to surgical excision or MMS. Randomisation and allocation was done separately for both groups by a computer-generated allocation scheme. Tumours had a follow-up of 5 years. Analyses were done on an intention-to-treat basis. The primary outcome was recurrence of carcinoma, diagnosed clinically by visual inspection with histological confirmation. Secondary outcomes were determinants of failure and cost-effectiveness. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN65009900. FINDINGS: Of the 397 pBCCs that were treated, 127 pBCCs in 113 patients were lost to follow-up. Of the 11 recurrences that occurred in patients with pBCC, seven (4.1%) occurred in patients treated with surgical excision and four (2.5%) occurred in patients treated with MMS (log-rank test chi(2) 0.718, p=0.397). Of the 202 rBCCs that were treated, 56 BCCs in 52 patients were lost to follow-up. Two BCCs (2.4%) in two patients treated with MMS recurred, versus ten BCCs (12.1%) in ten patients treated with surgical excision (log-rank test chi(2) 5.958, p=0.015). The difference in the number of recurrences between treatments was not significant for pBCC, but significantly favoured MMS in rBCC. In pBCC, Cox-regression analysis showed no significant effects from risk factors measured in the study. In rBCC, aggressive histological subtype was a significant risk factor for recurrence in the Cox-regression analysis. For pBCC, total treatment costs were euro1248 for MMS and euro990 for surgical excision, whereas for rBCC, treatment costs were euro1284 and euro1043, respectively. Dividing the difference in costs between MMS and surgical excision by their difference in effectiveness leads to an incremental cost-effectiveness ratio of euro23 454 for pBCC and euro3171 for rBCC. INTERPRETATION: MMS is preferred over surgical excision for the treatment of facial rBCC, on the basis of significantly fewer recurrences after MMS than after surgical excision. However, because there was no significant difference in recurrence of pBCC between treatment groups, treatment with surgical excision is probably sufficient in most cases of pBCC.

Randomized study not supporting surgery
One of Dr. Smeets article as quoted by Dr. Nick Coop above.

Is there a need for randomized study??
Yes, says Dr. Coop, and this study:

Sei JF, Chaussade V, Zimmermann U, Tchakerian A, Clerici T, Franc B, Saiag P. Service de Dermatologie, Hôpital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, CHU Paris-Ile de France Ouest, Université de Versailles-Saint Quentin en Yvelines, Boulogne.

OBJECTIVES: To systematically review the literature for studies reporting on the role of Mohs' micrographic (MMS) surgery in the treatment of skin tumors. To show how it is performed in France. DESIGN: We reviewed with a quality grid all studies indexed in MEDLINE before 2003/01/01 and published in English or French. Data were extracted by two independent reviewers. MAIN OUTCOME MEASURES: Quality of clinical studies, recurrence rates, number of patients lost to follow-up. RESULTS: No randomized study was found among the 493 references found. Studies of lower quality, on procedures similar to MMS, or previous systematic reviews were therefore selected. In tumors such as basal (BCC) or spinous (SCC) cell carcinoma, microcystic adnexal carcinoma, dermatofibrosarcoma protuberans, and Merkel cell carcinoma, MMS commonly induced lower recurrence rates than figures reported for conventional treatments and/or reduced surgical margins. Studies on melanoma were of low quality. CONCLUSIONS: Although no evidence-based guidelines could be developed, MMS should be used mainly for larger, morphea, micronodular or infiltrative-type, or recurrent BCCs located in danger zones, but also (sometimes with a slightly modified procedure) in microcystic adnexal carcinomas, dermatofibrosarcoma protuberans, Merkel cell carcinoma, and in aggressive forms of SCC. Randomized, controlled studies should be performed. --Northerncedar (talk) 20:08, 15 February 2009 (UTC)

Would you allowed yourself to be enrolled in such a study?
For me, no. If I had a choice between margin controlled (Mohs method or not) vs. standard breadloafing - I would be the most stupid man on earth to allow myself to be enrolled in such a study.

It would be cruel and unusual punishment to force someone to make such a choice. Do you want a car with seat belts and air bags, or do you want a car with out? Or, in the early days of medicine, would you want to have assist in a vaginal delivery with washed hands or unwashed hands - as in the case when in history, doctors did not believe in hand washing? How can you subject individuals to such grave errors in thinking? Let us say the death rate for occupants of cars with seat belts and air bags is 4 death per 1000 accidents, and the death rate of those who don't wear seatbelts and not having airbags is 20 per 1000 accidents. Is it then right to demand a randomized controlled trial to show that one car is better than another? Especially, like Smeet's study - where the numbers are low, and the methodology is not clear (margin size not noted, method of processing not noted.) It is not an issue about Mohs surgery and its "exorbitant claims". It is simply a statistical method of examining margin and correcting for false negative and false positive errors. The answer is obvious to me... But cruel to subject individuals to such a study.--Northerncedar (talk) 20:07, 15 February 2009 (UTC)