The Effectiveness Of Mohs Surgery Towards Curing Skin Cancer

The most common form of cancer globally is skin cancer. Although it is rarely fatal, the morbidity rate is substantial. One of the ways to combat skin cancer is through mohs micrographic surgery (MMS), a microscopically controlled surgery that accurately targets skin cancers.¹

Mohs surgery was first developed by Dr Frederic Mohs from the United States of America, but is now a gold standard technique widely practised worldwide to treat various skin cancers.¹ As a surgical method, MMS has been used to treat skin cancer for at least 80 years and has been described as “Better health with the best cosmetic result.”²

MMS’s history, process, indications, and recurrence rates will be discussed below to allow patients to understand the certain instances where they will best benefit from this procedure.¹

Let’s look at how mohs surgery works and its effectiveness in curing skin cancer.

What is mohs surgery?

Mohs micrographic surgery is a precise surgical approach for skin cancer treatment and is tissue sparing. It offers the highest treatment rates for a variety of skin cancers, including basal cell carcinomas (typically locally invasive in the majority of cases and less likely to spread to other areas) and squamous cell carcinomas (higher chance of spread to other areas).³

Because it originally involved the application of a chemical compound (zinc chloride) to the tumour, it was initially called “chemosurgery”. After 24 hours of in-situ fixation, the tumour was extracted and examined microscopically. It is then repeated until the tumour is completely taken out.³

Over time, mohs surgery discarded the use of zinc chloride in favour of fresh tissue processing that was frozen and placed in a cryostat microtome. This helped to improve processing times, with increased tissue preservation and lower patient discomfort.³

This surgery is recommended for skin cancers with a high chance of recurrence and when tissue conservation is crucial.³

The technique of Mohs surgery

1. The surgeon will first outline the tumour before injecting anaesthetic.³

2. Before removal, the tissue layer is marked by placing surface marks with a scalpel around the tissue layer and the respective in-situ skin. Usually, the marks made would be located at 3 o’clock, 6 o’clock, 9 o’clock, and noon.³

3. A thin tissue margin is then excised around and deep into the tumour defect. It is removed with an angle of about 45 degrees, helping to facilitate tissue procession.³

4. The tissue layers are split into halves or quadrants and marked with coloured dyes to help with accurate tumour mapping. It is pressed flat to ensure that the edge of the outermost layer occupies the same tissue plane with the deep margin. The sloped edge of the acquired issue removal helps this flattening process.³

5. The tissue is cut and processed horizontally (ie en face) so that almost all of the peripheral and deep margin can be analysed on the same tissue section with the microscope. This is different from vertical tissue processing, which only allows examination of a small part of the tumour.³

6. Should residual tumour be detected with the microscope, then the Mohs map is marked and the respective in-situ tissue is removed from the patient in the portion the tumour was found.³

7. This process is repeated until the tumour is completely gone, thus ensuring total tumour removal, while conserving as much healthy tissue as possible.³

8. Once the tumour is extracted, various methods are then used to close your wound appropriately, such as primary closure, locoregional flaps, skin grafts and secondary intention healing.³

The maximum effectiveness is dependent on the presence of contiguous tumour growth. Fortunately, it is highly dependable because this trait is present in most non-melanoma skin cancers.

How effective is mohs surgery?

Mohs surgery is said to have a high chance of clinical success.³ Reports have revealed that there are excellent 5-year cure rates for non-melanoma skin cancers (NMSC). In particular, it is the gold standard treatment for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).³

Some examples include a 99% success rate for primary BCC, 94.4% for recurrent BCC, 92-99% for primary SCC and 90% for recurrent SCC.³This is a superior cure rate when compared to standard wide local excisions.

Moreover, it can be used to treat rarer tumours, such as:

Dermatofibrosarcoma protuberans: a very rare type of skin cancer that starts from the connective tissue cells in the skin’s middle layer.
Microcystic adnexal carcinoma: skin tumour that is mainly found around the head and neck region, especially in the middle of the face.
Extramammary Paget disease: a rare cancer associated with Paget’s breast disease but is usually seen around the anus and genitals.
Merkel cell carcinoma: a rare, aggressive skin cancer that causes painless, flesh-coloured or a bluish-red nodule to develop on your skin. Usually found on the face, head or neck.
Sebaceous carcinoma: a type of cancer that starts from an oil gland in the skin. Mostly, it affects the eyelid and may cause a lump or thickening of the skin.

Recently, with reliable immunohistochemical stains, it also effectively treats some forms of malignant melanoma. Examples include:

Lentigo maligna: An early form of melanoma in which the malignant cells are kept to the outer skin layer, caused by photodamaged skin.
Lentigo maligna melanoma: An invasive skin cancer that develops from lentigo maligna.
Thin melanomas: The first stage of the most serious type of skin cancer that can spread to other parts of your body.

Like all other surgeries, there can be potential complications. For example, the surgery could leave scarring or bleeding, and hematoma may occur, especially if local flaps and grafts have to be used to close the wound. However, the surgeon would likely have methods on hand to minimise complications.

Conclusion

Mohs micrographic surgery has existed for decades as a way to treat tumours that grow on skin. Over the years, the process has been refined to become the precise technique that we are now using.

Before deciding if this surgery is suitable for you, it’s recommended that you visit a dermatologist who specialises in skin cancer management for a consultation.

Aside from mohs micrographic surgery, Angeline Yong Dermatology also offers full body mole checks (including digital mole mapping) and skin cancer screening for a better analysis of your condition and will be able to recommend the best personal treatment plan that can treat pre-cancerous skin lesions to malignant skin cancers.

Not only is Dr Yong an expert dermatologist and Mohs Micrographic Surgeon who specialises in skin cancers, she has also earned various professional dermatology memberships worldwide and is an international member of the American College of Mohs Surgery. Should you notice unusual symptoms on your skin, contact us at AYD for a consultation today.

References

Finley E. M. (2003). The principles of mohs micrographic surgery for cutaneous neoplasia. The Ochsner journal, 5(2), 22–33.

Alcalay J. (2012). The value of mohs surgery for the treatment of nonmelanoma skin cancers. Journal of cutaneous and aesthetic surgery, 5(1), 1–2. https://doi.org/10.4103/0974-2077.94322

Prickett, K. A., Ramsey, M. L. (2022). Mohs Micrographic Surgery. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK441833/

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The Effectiveness Of Mohs Surgery Towards Curing Skin Cancer