Leonardo Marini M'D' Aleksandar Krunic M'D'

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Micrographic Surgery and non-melanoma skin cancer
Cancer, Cell Death and Differentiation
XXIII IATMO Conference - TRIESTE 19-21 October,
2007

• Leonardo Marini M.D. Aleksandar Krunic M.D.
• SDC The Skin Doctors Center Trieste, Italy
• Aviano AB Pordenone, Italy

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MOHS MICROGRAPHIC SURGERY AN OLD STORY (I)

• 1930 FIRST CONCEPTS
• Frederic E. Mohs research assistant at Dept of
  Zoology of the University of Winsconsin, USA
• 1941 FIRST PUBLICATION
• Mohs FE, Guyer MF Pre-excisional fixation of
  tissues in the treatment of cancer in rats Cancer
  Res 149-51, 1941
• 1941 OFFICIAL PRESENTATION
• Mohs FE Chemosurgery a microscopically
  controlled method of cancer excision. Arch Surg
  42279-295, 1941
• 1948 TECHNICAL DEVELOPMENTS
• Mohs FE The preparation of frozen sections for
  use in the chemosurgical technique for
  microscopically controlled excision of cancer. J
  Lab Clinic Med, 33392, 1948
• 1974 FRESH TISSUE TECHIQUE
• Tromovitch TA, Stegman SJ Microscopically
  controlled excision of skin tumors Chemosurgery
  (Mohs) fresh tissue technique. Arch Dermatol
  110231-232, 1974

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MOHS MICROGRAPHIC SURGERY AN OLD STORY (II)

• 1977 EVOLVING INDICATIONS
• Mohs FE Chemosurgery for melanoma. Arch
  Dermatol 113285-291, 1977
• 1986 EVOLVING INDICATIONS
• Ratz JL, Luu-Duong S, Kulwin DR Sebaceous
  carcinoma of the eyelid treated with Mohs
  surgery, Arch Dermatol 14668-73, 1986
• 1988 EVOLVING INDICATIONS
• Hobbs ER, Wheeland RG, Bailin PL. Treatment of
  dermatofibrosarcoma protruberans with Mohs
  micrographic surgery Ann Surg 207102-107, 1988
• 1989 EVOLVING INDICATIONS
• Brown MD, Swanson NA Treatment of malignant
  fibrous histiocytoma and atypical fibrous xantoma
  with micrographic surgery. J Dermatol Surg Oncol
  15 1287-1292, 1989
• 1997 EVOLVING INDICATIONS
• OConnor WJ, Roenigk RK, Brodland DG Merkel
  cell carcinoma Comparison of Mohs micrographic
  surgery and wide excision in eighty-six patients
  J Dermatol Surg Oncol 23 929-933, 1997

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MOHS MICROGRAPHIC SURGERY AN OLD STORY (III)

• 1977 NEW DEVELOPMENTS
• Krunic AL, Garrod DR, Viehman GE, Madani
  S,Buchanan MD, Clark RE The use of
  antidermoglein stain in Mohs micrographic
  surgery. J Dermatol Surg Oncol 23 463-468, 1977
• 2000 NEW DEVELOPMENTS
• Zalla MJ, Lim KK, DiCaudo DJ Cagnot M Mohs
  micrographic excision of melanoma using
  immunostains. Dermatol Surg 26(8) 771-784, 2000

MOHS MICROGRAPHIC SURGERY PRESENT

• IMMUNOMARKERS IN MOHS SURGERY
• NON INVASIVE PRE-SURGICAL CANCER EXTENSION
  ASSESSMENT
• Confocal microscopy - CM
• Fluorescence diagnosis FD or Photodynamic
  Diagnosis PDD
• Positron emission tomography (PET)
• MOHS SURGERY ADVANCED TRAINING AND EDUCATION

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MOHS MICROGRAPHIC SURGERY THE EUROPEAN STORY (I)

• 1972 GERMANY FIRST STEPS
• Gunter Burg, Robins P Chemochirurgie, chirurgis
  entfernung chemisch fixierten tumorgewebes mit
  mikroskopischer kontrolle. Der Hautarttz, 1972
• 1977 GERMANY FIRST DEVELOPMENTS
• Birger Konz introduced the fresh tissue technique
  in Munich
• 1980 PORTUGAL THE SECOND COLONISATION
• Antonio Picoto started to perform Mohs surgery in
  Lisbon
• 1981 SPAIN THE THIRD COLONISATION
• Francisco Camacho, Alejandro Camps Fresneda,
  Julian Sancez Conejo Mir started Mohs surgery in
  Granada, Barcelona and Seville
• 1984-1986 THE FOURTH COLONISATION
• Richard Mothey, Neil Walker, Christopher Zachary
  started their micrographic surgery practice in
  Cardiff and London
• 1988 GERMANY INNOVATIVE TECHNIQUE
• Helmut Breuninger developed the Tubingen Torte
  technique

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MOHS MICROGRAPHIC SURGERY THE EUROPEAN STORY (II)
6-7 APRIL 1990 Estoril, PORTUGAL The European
Society for Mohs Micrographic Surgery ( ESLD )
was established thanks to the contribution of the
following founding members Helmut Breuninger,
Gunter Burg, Birger Konz GERMANY Francisco
Camacho, Alejandro Camps-Fresneda SPAIN Galvao
Costa and Marai Celeste Brito, Josè Manuel
Labareda, A.F. Ribas dos Santos, Paulo Santos,
Antonio Picoto PORTUGAL Patrick Dierick,
Arlette de Coninck, Diane Roseeuw
BELGIUM Alejandro Ginzburg ISRAEL Martino
Neumann THE NETHERLANDS Olle Larko, Bo
Stenquist SWEDEN Neil Walker UNITED KINGDOM
Giorgio Landi, Leonardo Marini - ITALY
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NON MELANOMA SKIN CANCER BCC - SCC
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MOHS MICROGRAPHIC SURGERY indications (I)

• BCC
• Morphea-like
• Nodular-Ulcerated long lasting
• Ill defined borders
• Recurrent
• Anatomical regions at high risk for recurrence
• Immune depression
• Previous radiotherapy
• Large dimensions

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MOHS MICROGRAPHIC SURGERY indications (II)

• SCC
• LED-associated
• Chronic osteomyelitis-associated
• Lichen sclerosus and atrophicus-associated
• Chronic ulcers-associated
• Ill defined borders
• Recurrent
• Anatomical regions at high risk for recurrence
• Immune depression
• Previous radiotherapy
• Large dimensions

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MOHS MICROGRAPHIC SURGERY indications (III)

• OTHER INDICATIONS
• Melanoma (SSM)
• Keratoachantoma recurrent (SCC)
• DFSP
• Malignant fibrohystiocytoma
• Verrucous carcinoma
• Extramammary Paget disease
• Queirat erythroplasia
• Microcystic adnexal carcinoma
• Merkel carcinoma
• Sebaceous carcinoma

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MOHS MICROGRAPHIC SURGERY the whole sequence

• Patient referral
• Patient evaluation
• Lesion clinical evaluation
• Lesion BX Dermatopathology
• Mohs Surgery - operative sequence
• Photographic documentation
• Operative charts
• Laboratory
• Surgical repair
• Immediate and long-term F/U

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MOHS MICROGRAPHIC SURGERY Surgical Specimen
Cutting Methods
THE MOHS METHOD
TUBINGEN TORTE METHOD
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MOHS MICROGRAPHIC SURGERY OP SEQUENCE
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MOHS MICROGRAPHIC SURGERY EQUIPMENT
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MOHS MICROGRAPHIC SURGERY BCC
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MOHS MICROGRAPHIC SURGERY BCC
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MOHS MICROGRAPHIC SURGERY BCC
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MOHS MICROGRAPHIC SURGERY BCC
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MOHS MICROGRAPHIC SURGERY BCC
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MOHS MICROGRAPHIC SURGERY BCC
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MOHS MICROGRAPHIC SURGERY BCC
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MOHS MICROGRAPHIC SURGERY Training
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• MOHS SURGERY IN EUROPE IS STILL CONSIDERED BY THE
  MAJORITY OF PHYSICIANS
• DIFFICULT TO PERFORM
• OURAGEOUSLY EXPENSIVE
• SOMEWHAT UNNECESSARY
• EXCESSIVELY METICULOUS
• ESOTERIC
• AS A LAST RESORT AFTER FAILURE OF OTHER
  TECHNIQUES

UNIVERSITY RESIDENCY PROGRAMS ARE NOT UNIFORMELY
STRUCTURED IN EUROPE THEREFORE MOHS SURGERY
KNOWLEDGE AND TRAINING ARE NOT ALWAYS AVAILABLE
PATIENTS ARE NOT SUFFICIENTLY INFORMED ABOUT THE
POTENTIAL RISKS OF LOCAL RECURRENCES AFTER NON
MELANOMA SKIN CANCERS ORIGINATING FROM
COSMETICALLY AND FUNCTIONALLY IMPORTANT
ANATOMICAL AREAS
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THERE ARE SOME POTENTIALLY INEVITABLE
CONSEQUENCES TO BE CONSIDERED BECAUSE OF THESE
LIMITATIONS
MORE SUBTLE PROFESSIONAL RISKS ARE INVOLVED IN
PERFORMING MOHS SURGERY IN EUROPE THAN IN THE US
OR AUSTRALIA

• Patients could be reluctant to accept Mohs
  Micrographic surgery since they never heard of
  such a technique
• Patients could be discouraged by other
  physicians (family physicians or other
  specialists) to undergo Mohs Surgery for a
  simple non melanoma skin cancer
• Patients could start a medico-legal litigation,
  supported by inappropriate information provided
  by not up-to-date colleagues after paying the fee
  for a Micrographic surgery procedure
• Patients could doubt about the real need of the
  proposed surgical procedure after consulting with
  less informed colleagues, exposing Mohs surgeons
  to unjustified criticism with potential damage to
  their professional integrity and overall
  reputation

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IN CONCLUSION
MOHS MICROGRAPHIC SURGERY, THANKS TO THE 3D
HISTOLOGIC ASSESSMENT OF CLINICALLY IDENTIFIED
SKIN CANCER MARGINS
ALLOWS
DERMATOLOGIC SURGEONS TO AVOID TO USE THEIR
SCALPELS BLINDLY EXCISIONS WILL BE MADE ONLY TO
ELIMINATE HYSTOLOGICALLY POSITIVE TISSUE
PRESERVING UNAFFECTED SKIN WITHOUT LIMITING THE
EFFECTIVENESS OF FINAL ONCHOLOGIC RESULT
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THANK YOU FOR YOUR ATTENTION
LEONARDO MARINI, M.D. ALEKSANDAR KRUNIC,
M.D. SDC - TRIESTE, ITALY