SAN DIEGO – It would be somewhat of an understatement to say that Mohs surgery was not particularly welcomed at hospitals where Dr. Rainer Sachse used to practice.
As a plastic and reconstructive surgeon, he had hoped to utilize the technique to treat extensive, high-stage tumors in high-risk patients within a hospital setting, believing that the literature convincingly suggested that Mohs offered the best hope for cancer control in such patients.
Nurses, he recalled, considered Mohs a "slow, mutilating, expensive" procedure. Surgeons felt it was unnecessary. Pathologists thought their traditional methods "worked perfectly well."
Dermatologists seemed preoccupied by turf battles between the American Society for Mohs Surgery (ASMS) and the American College of Mohs Surgery. Dermatology residents had no time, and plastic surgery residents were uninterested, Dr. Sachse said at the meeting sponsored by the ASMS.
He pressed on, though, inspired by cases in which conventional excisions and standard therapy mutilated patients or led to their untimely deaths from tumors with continuous growth patterns.
He observed colleagues and sought out preceptorships, pored over the literature, and took a Mohs surgery course before beginning to try small cases with a pathologist who had received dermatopathology training. Finally, he began to change minds and take on more challenging cases.
Seeing the results, "a pathologist who was initially very skeptical eventually became a strong supporter," said Dr. Sachse, who is in private practice in Fort Lauderdale, Fla.
Hospital-based Mohs surgery has a role in the treatment of "psychologically problematic" patients, including those with severe anxiety and/or dementia; patients with high-risk medical conditions, including ischemic heart disease, severe arrhythmias, significant pulmonary insufficiencies, or coagulopathies; the physical handicapped; and the morbidly obese, he said.
Additionally, some hospitalized patients require urgent care, what Dr. Sachse terms "emergency Mohs surgery." He offered, as an example, a leukemia patient with skin necrosis of the scalp that was doubling in size every 24 hours. A biopsy revealed that the patient had a zygomycete fungal infection.
Mohs micrographic surgery was followed by topical and oral antifungal therapy and, after a delay, a skin graft, for a clinically and aesthetically acceptable result, he said.
With unusual and complex cases, it is important to build teamwork within the hospital since a multispecialty approach is necessary for cases that invade multiple structures of the head and neck, said Dr. Sachse.
In such cases, the concept of complete margin control must be emphasized, since many colleagues in otolaryngology, plastic surgery, and pathology will be unfamiliar with the basic tenets of the approach and the precision required to achieving those goals, he noted.
He learned to counter perceptions of Mohs surgery as tedious and slow by using careful planning and documentation of results in patients who might have been previously considered inoperable.
Education helps, as does realistic scheduling of operating rooms for the time required for extensive debridement, meticulous staging, excision, and repair.
Presenting Mohs cases to a hospital tumor board can be illuminating to the uninitiated, and the cases themselves are "very rewarding," he said.
Dr. Sachse cautioned that surgeons taking on highly complex cases should "be prepared to meet a patient you may not be able to cure." That said, "Mohs is a surgical tool which can and should be used for very extensive tumors. The complexity of the margins may increase exponentially, but you can always cut quicker than any tumor can grow."
Dr. Sachse said that he had no relevant disclosures.