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MOHS MICROGRAPHIC SURGERY: A HISTORICAL PERSPECTIVE Patricia Ting, BSc, Anatoli Freiman, MD Division of Dermatology, McGill University Health Centre, Montreal, Canada – PowerPoint PPT presentation

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Title: MOHS MICROGRAPHIC SURGERY: A HISTORICAL PERSPECTIVE


1
MOHS MICROGRAPHIC SURGERY A HISTORICAL
PERSPECTIVE Patricia Ting, BSc, Anatoli Freiman,
MD Division of Dermatology, McGill University
Health Centre, Montreal, Canada
ABSTRACT In the early 1930s, as a medical student
at the University of Wisconsin, Fredric E. Mohs
pioneered the idea of microscopically-controlled
removal of cutaneous tumours. With its ability to
systematically examine 100 of lesion margins,
Mohs Micrographic Surgery (MMS) allows for
maximal sparing of normal tissues and provides
excellent cosmetic results. Whereas today, it is
considered one of the greatest contributions to
the field of dermatologic surgery, the widespread
acceptance of the technique took over 50 years.
We review the key historical events and people
involved in the development of MMS.
  • INK DYES
  • Mohs refined his technique by color-coding the
    specimen edges with
  • Red (merbromin)
  • Blue (laundry dye)
  • Black (India ink)
  • The addition of ink dyes provided a precise
    reference map of the tumour to be drawn and
    juxtaposed upon the corresponding surgical wound
    bed.

Dr. Fredric E. Mohs (1910-2000)
  • THE BEGINNINGS
  • In the early 1930s, as a young medical
    student at the University of Wisconsin, Frederic
    E. Mohs worked as an
  • assistant in a cancer research laboratory,
    investigating the effect of various irritants on
    implanted cancers in rats.
  • Mohs observed that injections of 20 zinc
    chloride effectively and accurately penetrated
    the tissues without
  • systemic toxicity. Furthermore, the chemical
    was also safe to handle, as it did not diffuse
    into the keratin layer of
  • the skin, unless a keratolytic, such as
    dichloroacetic acid, was previously applied.
    Most importantly, this zinc
  • preparation maintained the histologic
    architecture of tissues.
  • Mohs subsequently proposed the concept of
    chemical fixation followed by surgical excision
    of tumors with
  • microscopic examination of tumor margins.
    And thus, the concept of micrographic
    chemosurgery was born.
  • In 1936, after formal training as a general
    surgeon, Dr. Mohs began treating patients with
    cutaneous malignancies in
  • the dermatology clinic at the Wisconsin
    General Hospital. An elderly pharmacist at the
    drug store supplied him with
  • the ingredients required for the topical
    fixative paste containing stibinite (an antimony
    ore, which served as a
  • granular matrix) and sanguinaria canadenis
    (a binder for the saturated solution of zinc
    chloride).
  • FRESH TISSUE TECHNIQUE
  • In 1951, Dr. Ray Allington suggested that
    dichloroacetic acid could be used for hemostatis
    after the debulking
  • procedure. A monumental change in Mohs fixed
    tissue technique serendipitously occurred in 1953
    during the filming of
  • an instructional documentary demonstrating
    Dr. Allingtons suggestion on a multistage
    removal of an eyelid basal cell
  • carcinoma. Due to the time constraints of
    the filming session, Mohs injected the residual
    tumour area with local
  • anesthetic and omitted the second round of
    the zinc chloride fixation.
  • It was soon realized that the resolution of
    tumor margins was not significantly impeded
    without fixation. This
  • became known as the fresh-tissue technique,
    which was also illustrated in Mohs chapter in
    the 1st edition of
  • Epsteins Skin Surgery in 1956.
  • With this procedural modification, patients
    experienced significantly less pain and
    morbidity. Because of the
  • absence of tissue inflammation and
    sloughing, which were previously observed
    secondary to zinc chloride application,
  • more tissue could be conserved and
    reconstruction of the wound bed could now take
    place on the same day as the
  • excision.

1st Meeting of the American College of
Chemosurgery in 1967 (Chicago). Front row
center Dr. Fredric E. Mohs.
Source Brodland et al. 2000
  • MILESTONES IN THE DEVELOPMENT OF MOHS
    MICROGRAPHIC SURGERY
  • 1933 Fredric Mohs original concept of
    chemosurgery for cutaneous neoplasms.
  • 1936 Dr. Mohs begins using his technique at the
    Wisconsin General Hospital.
  • Dr. Mohs reports 440 patients successfully
    treated with chemosurgery.
  • 1946 Mohs technique caught the attention of
    dermatologists at the American Academy of
    Dermatology meeting in Chicago.
  • The fresh tissue technique used for the first
    time during the filming of an instructional
    documentary on Mohs technique for the removal of
    eyelid tumours.
  • 1956 Mohs technique appears in the 1st edition of
    Epsteins Skin Surgery.
  • Establishment of the first 1-year fellowship in
    Mohs surgery at NYU Medical Centre by Perry
    Robbins.
  • 1st American College of Chemosurgery meeting with
    23 attendees.
  • 1969 Dr. Mohs presents a 100 cure rate for
    eyelid tumours using the fresh tissue technique
    at the 3rd American College of Chemosurgery
    meeting.
  • 1970 Dr. Theodore Tromovitch reports successful
    results with the fresh tissue technique at the
    4th American College of Chemosurgery meeting.
  • Dr. Daniel Jones, a trainee of Dr. Mohs, coins
    the term micrographic surgery."
  • 1st issue of the Journal of Dermatologic Surgery
    and Oncology published.
  • Textbook of Chemosurgery Microscopically
    Controlled Surgery for Skin Cancer written by Dr.
    Mohs.
  • Minimum 1-year fellowships regulated by the
    American College of Chemosurgery.
  • American College of Chemosurgery renamed to
    American College of Mohs Micrographic Surgery and
    Cutaneous Oncology (ACMMSCO).
  • 1991 Establishment of the American Board of Mohs
    Micrographic Surgery and Cutaneous Oncology.
  • Adapted from Brodland et al. 2000

ORIGINAL PROCEDURE FOR MOHS CHEMOSURGERY FIXED
TISSUE TECHNIQUE (1936 1948) Step 1 Injection
of local anesthetic (Figure 1) . Step 2 Removal
and curettage of superficial tumour (Figure
2). Step 3 Application of dichloracetic acid
(Figure 3) and in-situ zinc
chloride fixative paste for 12 to 24 hours
(Figure 4 5). Step 4 Surgical excision of
tumour in saucer-like horizontal
sections (Figure 6). Step 5 Microscopic
examination of frozen sections.
Figure 6. Diagrammatic representation of
horizontal sections used in Mohs technique.
  • ACCEPTANCE OF MOHS MICROGRAPHIC TECHNIQUE
  • By the mid-1960s, Mohs technique gained wide
    acceptance, eventually leading to the
    establishment of American
  • College of Chemotherapy in 1967.
  • At the annual meeting in 1970, Dr. Theodore
    Tromovitch, who had been using the fresh tissue
    technique since the
  • 1960s, presented a case series of 75
    patients treated for cutaneous carcinomas and
    reported equally high cure
  • rates with this new technique, which also
    proved that the real reason for the success of
    the fresh-tissue Mohs
  • surgery was not the chemical fixation of the
    tissue, but the microscopic control.
  • In 1986, the American College of Chemosurgery
    was renamed the American College of Mohs
    Micrographic Surgery
  • and Cutaneous Oncology (ACMMSCO) and minimum
    one-year fellowships in Mohs Micrographic Surgery
    were
  • officially regulated via this organization.
  • The Mohs surgery fellowship requires
    specialized training in a composite of skills
    including dermatopathology and
  • reconstructive surgery.

Source Mohs, FE. Chemosurgery Microscopically
Controlled Surgery for Skin Cancer (1978).
  • CONCLUSIONS
  • Winning general acceptance takes much patience,
    said Dr. Fredric Mohs.
  • The development and widespread acceptance of
    Mohs micrographic surgery has taken over 50
    years.
  • Although the original concept of micrographic
    surgery began in the early 1930s, 12 years
    elapsed before the
  • development of the original fresh tissue
    technique (1936 to 1948), and its use for
    cutaneous carcinomas did not
  • begin until 17 years later (1953 to 1970).
  • With its ability to systematically examine
    100 of tumour margins, Mohs Micrographic Surgery
    allows for maximal
  • sparing of normal tissues and provides
    excellent cosmetic results.
  • Today, it is considered one of the greatest
    contributions to the field of dermatologic
    surgery.

INITIAL REJECTION OF MOHS FIXED TISSUE
TECHNIQUE Between the 1930 1950s, Mohs
pioneering surgical concept for the treatment of
cutaneous malignancies was not well accepted by
the medical community for several reasons
1. Patients complained of extreme pain due to the
caustic effects of zinc chloride fixative, which
induced edema and tissue necrosis 2. Local
inflammation made it difficult to interpret
tumour histopathology 3. Microscopic
examination of the margins and repeating process
for incompletely excised tumor was very labor
intensive 4. Increased infection rates due to
delayed surgical reconstruction and closure of
wound bed/defect 5. Belief that cutting
through the tumour would promote local seeding of
tumour cells and metastatic spread Therefore,
surgeons at the time preferred to use
conventional wide surgical margins.
  • For residual neoplastic tissue, the process
    of fixation, surgical
  • excision and microscopic examination were
    repeated until the margins
  • cleared.
  • The defect was allowed to heal by secondary
    intention as the
  • fixative sloughed over the course of 7 to
    10 days (Figure 7 8).
  • If required, skin grafts were performed
    after this time period.
  • Mohs technique allowed for histological
    examination of entire base and
  • margins of the defect,

ACKNOWLEDGEMENTS Special thanks to Dr. Lawrence
Warshawski, Dr. Dan Issen Dr. David Zloty
(Vancouver, BC) for the clinical photos and to
Dr. Channy Y. Muhn (Burlington, Ontario) for the
inspiration.
Source Mohs, FE. Chemosurgery Microscopically
Controlled Surgery for Skin Cancer (1978).
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