Mohs Surgery Means Minimal Scarring for Skin Cancer Patients

MD Anderson Cancer Center
Date: 07/18/2011

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Lisa Garvin: Welcome to Cancer Newsline, a weekly podcast series from The University of Texas M.D. Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention, providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin. Today, our guest is Dr. Deborah McFarlane. She is the director of our Mohs unit here at M.D. Anderson and we're going to be talking Mohs surgery today. Dr. McFarlane, let's start with a primer. What is Mohs surgery exactly?

Dr. Deborah McFarlane: So Mohs surgery is a technique invented by Frederic Mohs in the 1930s. It's used primarily today to remove non-melanoma skin cancers by that I mean basal and squamous cell skin cancers that are located on the head and neck, primarily. We can also use it to treat cancers that are located on the trunk and the extremities, but principally, we're wanting to conserve tissue when we use the Mohs surgery technique, we're wanting to maximize the amount of skin cancer that we remove and minimize the amount of normal skin that we're taking out. So it's a technique that's been around for many years and it's now actually used all around the world.

Lisa Garvin: Now, I guess what happens is that in the old days, first of all, a lot of skin cancers on the head and neck were often disfiguring to remove because you had to take such a wide margin of healthy tissue. Now, Mohs, I guess--are you taking frozen sections or how exactly are you determining the margins of the tumor with Mohs?

Dr. Deborah McFarlane: Well, it might help best if I tell you exactly what happens in the unit with a classic patient. So the Mohs surgery technique is done under local anesthetic. You're not put to sleep. You come into the Mohs unit and we locate the tumor. We inject the area with local anesthetic, you're wide awake, and then we take that piece of tissue with a minimal margin which we have decided upon by looking at the tissue. That's a visual idea as to the extent of the margin that we take that tissue to the lab which we have in the Mohs unit, and the tissue is processed by the histotechs. There they cut it and stain it, and then approximately an hour to an hour and a half later after we've given them the tissue, we look at the slides which they've prepared for us and then we can actually determine whether the tissue has cancer or not. We have a map that we're using at the same time and we mark out any areas where there's tumor onto that map and we take that back to the patient who is waiting in the room. And then if there's more tumor to be taken, we numb them up again, take that tumor and we repeat this process until the area is negative. Once we have a negative defect as we call it, then we can close the area surgically ourselves or if it's a very large defect then we work in liaison with other areas at M.D. Anderson, head and neck or plastic surgery, sometimes ocuplastic surgery, too.

Lisa Garvin: Because I guess depending on the size of the tumor, there may have to be some reconstructive surgery done afterwards. Is that correct?

Dr. Deborah McFarlane: Um-hmm, that's correct. And we often determine that at a consultation visit, new patients because we have patients coming from out of state sometimes and they've had to travel a long distance. So often, if there are larger tumors, we'll see them in particular at consultation and if they have to have--if we have to have plastic surgery or head and neck, or indeed any other facility involved--faculty involved, then that can be decided at consultation.

Lisa Garvin: Are we seeing an increase in the number of patients that are eligible for Mohs? I mean are a lot more skin cancers being treated with Mohs as opposed to 10 years ago, or?

Dr. Deborah McFarlane: Well, it's a bit of a tricky question to answer. We are seeing an increase in skin cancers. We're seeing an increase in skin cancers in younger patients. That's true and we're also tending to use the Mohs surgery more widely. I think as patients become aware of it, they're often wanting to have Mohs surgery because they know that they're going to have a minimal disruption and minimal removal of normal tissue, so I think it's something that's gaining popularity out there.

Lisa Garvin: Are there limitations to Mohs? I mean can you only treat a certain-sized tumor in certain locations?

Dr. Deborah McFarlane: Limitations to Mohs, I think sometimes the limitations can be due to the patient, actually. If we're dealing with a patient who is confused, we often don't want to have to put them through the rigors of having to have a cancer removed under local anesthetic. If it's a particularly large tumor, it can be very painful for the patient so that's another reason why we wouldn't want to do Mohs, so not all large tumors actually. I think those are indications for where we wouldn't want to do Mohs surgery so not all comers actually are approved for Mohs surgery.

Lisa Garvin: As far as multidisciplinary and/or supportive care, you'd mention before our interview that there are lots of Mohs clinics out there but some of them are just stand-alone single discipline. Is it important to have the multidisciplinary care that's may be offered at a larger center?

Dr. Deborah McFarlane: Um-hmm, I think often it is because sometimes patients who get skin cancers can be immunocompromised. For instance, they can have a CLL, they can have leukemias, lymphomas, and at an institution like this you've got the benefit of being able to interface with the other disciplines so that the patient's care is, you know--I can't say guaranteed, but that certainly everyone is going to do the very best that they can and we're in very good communication with each other.

Lisa Garvin: Skin cancer is one of those cancers that even if you've been successfully treated, followup is extremely critical. A lot of patients don't do that though. How important is it to follow up--to have followup?

Dr. Deborah McFarlane: Incredibly important Lisa. We can tell patients that if they've had a skin cancer, they've got a 50 percent chance of getting another skin cancer, so we really want to emphasize such things as UV protection. We want to have patients wearing UV protective hats and by that, we don't just mean the old straw hat or the baseball cap. We want them to actually be wearing hats that are made of UV protective fabric that doesn't absorb the sun's rays. We want them to be using sunscreen and to be minimizing their time out in the sun, so ideally before 10 in the morning and after 4 o'clock in the afternoon. So followup is absolutely vital because it's so much nicer if you're a Mohs surgeon to get a skin cancer when it's early in the game rather than to have the patient present with something large. Unfortunately, skin cancers don't tend to hurt so patients may have skin cancers and not really be aware of them so that's why we also like to advise everybody else who hasn't had a skin cancer to have once yearly skin checks head to toe with their dermatologists.

Lisa Garvin: Where are the most common areas on the head and neck that you see skin cancers? I've heard that sometimes, it's on the left hand side because that's where you sit when you're driving. Do you tend to see certain areas, you know, like the forehead, the backs of the ears most commonly?

Dr. Deborah McFarlane: Well, they can really occur anywhere on the head and neck. It's true that depending which hemisphere you're working in that you will tend to get more skin cancers, for instance, in the northern hemisphere on the left hand side because, you know, of the side that we--of the road that we drive in. But by and large, skin cancers they can pretty much occur anywhere, and I mean that's another strong thing to remember. We can get them inside our ears. We can get them underneath our nails. We can get them in areas that haven't even been exposed to the sun.

Lisa Garvin: Thank you very much for being with us today. If you have questions about anything you've heard today on Cancer Newsline, contact askMDAnderson at 1-877-MDA-6789 or online at www.mdanderson.org/ask.

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