Mohs surgery, developed in 1938 by general surgeon Frederic E. Mohs, is microscopically controlled surgery used to treat both common and rare types of skin cancer. During the surgery, after each removal of tissue and while the patient waits, the tissue is examined for cancer cells. That examination dictates the decision for additional tissue removal. Mohs surgery is the gold standard method for obtaining complete margin control during removal of a skin cancer (complete circumferential peripheral and deep margin assessment using frozen section histology). This method allows for the removal of skin cancer with a very narrow surgical margin and a high cure rate. The cure rate with Mohs surgery cited by most studies is between 97% and 99.8% for primary basal-cell carcinoma, the most common type of skin cancer. Mohs procedure is also used for squamous cell carcinoma, but with a lower cure rate. Recurrent basal-cell cancer has a lower cure rate with Mohs surgery, more in the range of 94%. It has been used in the removal of melanoma-in-situ (cure rate 77% to 98% depending on surgeon), and certain types of melanoma (cure rate 52%). Other indications for Mohs surgery include dermatofibrosarcoma protuberans, keratoacanthoma, spindle cell tumors, sebaceous carcinomas, microcystic adnexal carcinoma, merkel cell carcinoma, Paget's disease of the breast, atypical fibroxanthoma, and leiomyosarcoma. Because the Mohs procedure is micrographically controlled, it provides precise removal of the cancerous tissue, while healthy tissue is spared. Mohs surgery can also be more cost-effective than other surgical methods, when considering the cost of surgical removal and separate histopathological analysis. However, Mohs surgery should be reserved for the treatment of skin cancers in anatomic areas where tissue preservation is of utmost importance (face, neck, hands, lower legs, feet, genitals).
Uses
Skin cancer can be categorized into two groups: melanoma, which is considered more severe, and nonmelanoma skin cancer, which includes basal cell carcinoma and cutaneous squamous cell carcinoma. Mohs micrographic surgery is used for high-risk nonmelanoma skin cancers located in cosmetically critical or sensitive areas like the face, ears, scalp, neck, genitalia, hands, and feet, where tissue conservation is of utmost importance. It is also indicated when the tumor is recurrent, aggressive, large, or painful, which tells us there is invasion of the nerve or vasculature.
Some cases of melanoma, such as early, surface-level melanoma (lentigo maligna) or thin invasive melanoma, can be treated with Mohs surgery. This is especially considered in areas where tissue sparing is essential. In these cases, special immunohistochemical staining is used to visualize the melanoma cells, evaluate the margins, and ensure the cancer has been completely removed. More evidence today is linking Mohs surgery with lower recurrence rates of melanoma in these cases. This approach is also used in treating rare skin cancers. For example, dermatofibrosarcoma protuberans, a slow-growing cancer that begins in the deeper layers of the skin, as well as cancers arising from hair follicles, oil glands, or sweat glands, would benefit from Mohs surgery as these are cases where margin clearance is essential. In summary, the Mohs micrographic surgery criteria are as follows:
Recurrent or high-risk basal cell and cutaneous squamous cell carcinomas in anatomically or cosmetically sensitive areas. Specific cases of early-stage or surface-level melanoma (melanoma in situ or lentigo maligna), and thin invasive melanoma in similarly sensitive sites. Other rare skin cancers where all the margins need to be visualized.
Contraindications Mohs surgery is generally contraindicated when the criteria summarized in the “Uses” section above are not met. For example, the tumor is small, low-risk, has well-defined margins, and is in a non-critical area. The standard protocol for Mohs surgery requires the surgeon to both remove the tissue and interpret the pathology. The procedure is not considered Mohs surgery if the removed tissue is sent and read by a pathologist instead of the surgeon performing the procedure. In this case, it is considered a standard excision and should be documented as such. Another doctor interpreting histopathology is incompatible with Mohs surgery. Relative contraindications include instances where the risks of surgery outweigh the benefits such as in patients with co-morbidities, in cases where the defect caused by surgery would need complex reconstruction beyond the scope of the surgery, or when patient factors such as severe bleeding predispositions or being unable to tolerate local anesthesia would affect the prognosis. Increased postoperative complications are associated with immunosuppressed patients (e.g. solid organ transplant recipients) and elderly patients. These are not absolute contraindications, but the risks of this procedure should be weighed against the benefits for each individual patient.
Risks and complications The overall risk of Mohs micrographic surgery complications is very low. Reported adverse event rates are between 0.7% and 2.6% according to large multi-center prospective studies. Infection of the surgical site, hematoma formation, bleeding, and suboptimal wound repair with dehiscence or ischemic necrosis are the most reported adverse events. Complication rates leading to permanent damage or requiring hospitalization are below 0.1% and no deaths have resulted from this procedure. Certain patient factors may make complications more likely. These include immunosuppression (after an organ transplant) and use of anticoagulants or anti-platelets (“blood thinners”). Increased risk is not independently associated with older age. There are surgical characteristics which also may increase the risk of complications including cancer location (extremities vs. forehead), large tumors with depth, and tumors requiring advanced flap or graft repairs.
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