MOHS SURGERY FOR NMSC IS IT REALLY NESESSARY???

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1 MOHS SURGERY FOR NMSC IS IT REALLY NESESSARY??? Mariana Zamir, MD MOHS and Dermatosurgery Unit Department of Dermatology Hadassah - Hebrew University Medical Center Jerusalem

2 Why talking about Mohs surgery???

3 NMSC incidence is confnuously rasing The total number of registered NMSCs in the US popula>on in 2006 was 3,507,693 and the total number of persons in the United States treated for NMSC about 2,152,500. The expected incidence is thought to be about 4,000,000 new NMSC cases every year. Rogers HW1, Weinstock MA, Arch Dermatol Mar;146(3):283-7.

4 Skin cancer treatment costs are rapidly increasing From 1996 to 2008, the total number of skin cancer treatment procedures [excision, destruc>on, and Mohs micrographic surgery (MMS)] increased by 53% increase The uflizafon of MMS increased drama>cally by 400% between the years , one out of four NMSC are treated by MMS Howard W. Rodgers, Brea M. Coldiron, Dermatol Surg 2013;39: Asgari M.M., Olson J.M., Alam M. Dermatol Clin 2012; 30:

5 MOHS surgery (ab)use became a hot issue

6 Na>onal report - - Mohs surgeons are experiencing a dras>c reduc>on in reimbursement due to a change in Medicare policy. The gap can be 23 percent or more, depending on how many procedures are performed on the same day.

7 Dermatol Surg 2012;38:

8 Mohs micrographic surgery is facing scru>ny due to increased u>liza>on. The use of Mohs surgery is increasing more rapidly than is the incidence of skin cancer, and this is an area of concern for payers. The value of Mohs surgery in trea>ng skin cancer, reimbursement for the procedure, and our con>nued ability to perform Mohs surgery are, in a manner of speaking, under the microscope.

9 SAN FRANCISCO Dermatologists and dermatologic surgeons risk a decreased reimbursement value for Mohs surgery if they don t review the published criteria on its appropriate use, according to Dr. Sumaira Aasi. "The reason is, at the end of the day, we might be killing the goose that laid the golden egg ourselves" if too many Mohs surgeries are done for inappropriate reasons, said Dr. Aasi of Stanford (Calif.) University. There are an estimated 4 million nonmelanoma skin cancers in the United States each year, and the use of Mohs surgery increased by 400% from 1995 to 2009, Dr. Aasi said (Dermatol. Clin. 2012;30:167-75).

10 Dr. Brea Coldiron removes suspected cancerous skin cells from a pa>ent during Mohs surgery at The Skin Cancer Center in Cincinna>, Ohio. CreditLuke Sharrea for The New York Times

11 J Am Acad Dermatol 2012;67: & Dermatol Surg 2012;38:1581

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14 How is it working???

15 MOHS micrographic surgery Principles developed in the early 1930 s by Dr. Frederic E. Mohs at the Wisconsin University Basic concepts: Ver%cally cut sec%ons of excised cancerous >ssue will never give a complete microscopic marginal control Horizontal complete layers of >ssue from the tumor bed can obtain such a control

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18 MOHS micrographic surgery - advantages l Intra- opera>ve pathological examina>on of the whole tumor bed =>complete microscopic margin control is achieved l Result - > local recurrence rates are significantly lower, especially for certain histological subtypes & loca>ons of high risk van Loo E, Mosterd K, Krekels GAM, et al. Eur J Cancer 2014; 50:

19 Simple surgical excision disadvantages l Regular pathological secfoning & examinafon is based on sampling representafve cuts

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31 CERTAIN TUMORS ARE ASSOCIATED WITH HIGHER RECURRENCE RATE AND POORER PROGNOSIS PrognosFc factor Tumor size Tumor site DefiniFon of clinical margins Histological subtype Histological features of aggression Failure of previous treatment Immunosuppression Comment Tumor size (diameter greater than 2 cm) correlates with higher risk of recurrence and metastases Lesions on the central face, especially around the eyes, nose, lips and ears are at higher risk of recurrence Poorly defined lesions are at higher risk of recurrence Certain subtypes confer higher risk of recurrence and metastases Perineural and/or perivascular involvement confers higher risk of recurrence PaFents who had BCC have 10 Fmes higher risk of developing subsequent BCC compared to general populafon Recurrent lesions are at a higher risk of further recurrence and metastases Confers increased risk of recurrence and metastases (e.g. recipients of solid- organ transplants) Telfer NR et al. Br J Dermatol 2008;159: Rubin AI et al. N Engl J Med 2005;353:

32 MOHS micrographic surgery - advantages l Only tumor and the whole tumor is taken out => No need for safety margins l Result - > maximal healthy /ssue sparring can be achieved, especially important for cosme%cally sensi%ve areas, fingers and genitalia Muller FM, Dawe RS, Moseley H, Fleming CJ. Dermatol Surg 2009; 35:

33 Simple surgical excision disadvantages l Ordinary tumor excision requires arbitrary safety margins

34 Guidelines for the management of BCC Small (<20mm) well defined BCC: 3mm healthy appearing skin margin (HASM) = 85% of lesions are clear 4-5mm HASM = 95% of lesions are clear 5% of tumors extend more then 4-5 mm beyond visual margin N.R. Telfer, G.B. Colver and C.A. Morton Br J Dermatol ,

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37 Guidelines for the management of BCC Primary morpheiform BCC lesions: 3mm HASM = 66% of lesions are clear 5mm HASM = 82% 13-15mm HASM = >95% N.R. Telfer, G.B. Colver and C.A. Morton Br J Dermatol , 35

38 0.3 Dermoscopically diagnosed Primary, superficial appearing, 3mm BCC Guidelines recommended safety margins make a 1.3cm excision

39 Single stage MOHS => complete clearance, excellent cosme>c result and a 100% clear margin by MOHS technique with only 1mm margin! Dermablade 1 st stage with 1mm margin from dermoscopic lesion edge

40 IndicaFons - summary NMSC tumors arer (mul>ple) local recurrence Primary NMSC tumors in high risk loca>ons, tumors of certain histologic subtypes with aggressive features, big lesions on esthe>cal/func>onal sensi>ve areas Other tumors - Len>go maligna - Dermatofibrosarcoma protuberans - Merkel cell carcinoma - Microcys>c adnexal carcinoma - Extramammary Paget s disease - Sebaceous carcinoma..

41 THANK YOU!!!

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