Letters COMMENT & RESPONSE
3. Rowe DE, Carroll RJ, Day CL Jr. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol. 1989;15(3):315-328.
Mohs Needs a Better Look To the Editor In the thoughtful study by Schell et al,1 the authors predicate their conclusions on the assumption that all surgeons view the initial lesion with equal ability. This is not the case. In their article, the lighting and magnification for determining the initial size of the lesion is not described. When superior lighting and loop magnification are used at the time of surgery, the true extent of the cancer can be better visualized, making one question many findings in this study, including the conclusion that “traditional” surgical excision would incompletely excise 14.2% to 27.6% of lesions. Furthermore, I am disappointed that the authors included in their article “before and after” pictures of defects that do not support their findings and further the misconception that facial nonmelanoma skin carcinomas are difficult and best treated by Mohs micrographic surgery. This distinction has broad implications about what constitutes the standard of care or gold standard for skin cancer excisions and, consequently, what access will be available for patients with skin carcinoma. The American Academy of Dermatology seized upon this article and reported that “Mohs is the only recommended treatment for certain facial skin cancers.”2 This is not a valid conclusion based on this study, but a historical pattern that proponents of Mohs micrographic surgery have repeated. The most important of these is the claim that the Mohs technique has superior cure rates comparable with those of standard surgery. These claims come from articles that compare Mohs cure rates to those in a heterogeneous surgical population treated with unknown surgical techniques.3 When intraoperative frozen sections and loop magnification are used, however, randomized control and retrospective trials demonstrate equal cure rates to the Mohs technique.4,5 Because cure rates are similar between these 2 techniques, Mohs should not be the gold standard for excision of nonmelanoma skin carcinoma, because Mohs surgical times are lengthy, and not all wounds created by Mohs can be closed by the dermatologist. The standard of care should be excision and repair utilizing intraoperative frozen sections and loop magnification by a facial plastic surgeon. Michael Alexiou, MD
4. Smeets NWJ, Krekels GAM, Ostertag JU, et al. Surgical excision vs Mohs’ micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial. Lancet. 2004;364(9447):1766-1772. 5. Bentkover SH, Grande DM, Soto H, Kozlicak BA, Guillaume D, Girouard S. Excision of head and neck basal cell carcinoma with a rapid, cross-sectional, frozen-section technique. Arch Facial Plast Surg. 2002;4(2):114-119.
In reply It is nice to see the correspondence and interest of Michael Alexiou, MD. He brings up several excellent points, and it is a pleasure to respond. First, the point of our study1 is to recognize that when Mohs surgery is not performed, perhaps a slightly larger margin should be obtained during primary gross excision. It does not claim that Mohs surgery is always indicated. Dr Alexiou’s letter challenges Mohs surgery as the gold standard for skin cancer excision. To that end, I will attempt to address his points. There is no question that all surgeons are not the same in ability. Having said that, however, one must assume that we all have the patient’s best interest in mind and would like nothing more than to have the cancer completely excised at first go-round. Good lighting and loupe magnification certainly make sense, but I hope he is not insinuating that they compare with the microscope in terms of identifying tumor margins. Mohs surgeons remove skin cancer, all day, every day, for a career, and yet they still occasionally underestimate clinical tumor extent. One cannot compare the 2 techniques (Mohs surgery vs frozen section control) in terms of percentage of specimen margin that is analyzed histopathologically. Furthermore, excellent cure rates are not the only advantage of Mohs surgery. An aggressive surgical margin on all nodular basal cell carcinomas would likely diminish the recurrence rate to well less than 1%. Mohs surgery achieves high cure rates while maximizing tissue preservation, a paramount consideration on the face. With regards to time, I am not sure a routine visit to the Mohs surgeon is much longer than an operative visit in which frozen sections are being obtained, as Dr Alexiou suggests. The fact that a Mohs surgeon cannot close all cutaneous defects is not a reason to avoid them; it leads to interdisciplinary patient care. Collaboration between the primary dermatologist, Mohs surgeon, plastic surgeon, oculoplastic surgeon, and facial plastic surgeon should be the “gold standard.”
Author Affiliation: Otolaryngology–Head and Neck Surgery, Alexiou Hearing and Sinus Center, Harrisonburg, Virginia.
Stephen S. Park, MD
Corresponding Author: Michael Alexiou, MD, Alexiou Hearing and Sinus Center, 2062 Pro Pointe Ln, Harrisonburg, VA 22801 ([email protected]).
Author Affiliation: Department of Otolaryngology–Head and Neck Surgery, University of Virginia, Charlottesville.
Conflict of Interest Disclosures: None reported.
Corresponding Author: Stephen S. Park, MD, Department of Otolaryngology–Head and Neck Surgery, University of Virginia, PO Box 800713, Charlottesville, VA 22908 ([email protected]).
1. Schell AE, Russell MA, Park SS. Suggested excisional margins for cutaneous malignant lesions based on Mohs micrographic surgery [online publication June 6, 2013]. JAMA Facial Plast Surg. doi:10.1001/jamafacial.2013.1011. 2. American Academy of Dermatology. Mohs best bet for high-risk cancers on face. Schaumburg, IL: MedPage Today. June 7, 2013. http://www.medpagetoday .com/Dermatology/SkinCancer/39692. Accessed September 24, 2013. jamafacialplasticsurgery.com
Conflict of Interest Disclosures: None reported. 1. Schell AE, Russell MA, Park SS. Suggested excisional margins for cutaneous malignant lesions based on Mohs micrographic surgery [online publication June 6, 2013]. JAMA Facial Plast Surg. doi:10.1001/jamafacial.2013.1011.
JAMA Facial Plastic Surgery November/December 2013 Volume 15, Number 6
Copyright 2013 American Medical Association. All rights reserved.
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3. Rowe DE, Carroll RJ, Day CL Jr. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol. 1989;15(3):315-328.
Mohs Needs a Better Look To the Editor In the thoughtful study by Schell et al,1 the authors predicate their conclusions on the assumption that all surgeons view the initial lesion with equal ability. This is not the case. In their article, the lighting and magnification for determining the initial size of the lesion is not described. When superior lighting and loop magnification are used at the time of surgery, the true extent of the cancer can be better visualized, making one question many findings in this study, including the conclusion that “traditional” surgical excision would incompletely excise 14.2% to 27.6% of lesions. Furthermore, I am disappointed that the authors included in their article “before and after” pictures of defects that do not support their findings and further the misconception that facial nonmelanoma skin carcinomas are difficult and best treated by Mohs micrographic surgery. This distinction has broad implications about what constitutes the standard of care or gold standard for skin cancer excisions and, consequently, what access will be available for patients with skin carcinoma. The American Academy of Dermatology seized upon this article and reported that “Mohs is the only recommended treatment for certain facial skin cancers.”2 This is not a valid conclusion based on this study, but a historical pattern that proponents of Mohs micrographic surgery have repeated. The most important of these is the claim that the Mohs technique has superior cure rates comparable with those of standard surgery. These claims come from articles that compare Mohs cure rates to those in a heterogeneous surgical population treated with unknown surgical techniques.3 When intraoperative frozen sections and loop magnification are used, however, randomized control and retrospective trials demonstrate equal cure rates to the Mohs technique.4,5 Because cure rates are similar between these 2 techniques, Mohs should not be the gold standard for excision of nonmelanoma skin carcinoma, because Mohs surgical times are lengthy, and not all wounds created by Mohs can be closed by the dermatologist. The standard of care should be excision and repair utilizing intraoperative frozen sections and loop magnification by a facial plastic surgeon. Michael Alexiou, MD
4. Smeets NWJ, Krekels GAM, Ostertag JU, et al. Surgical excision vs Mohs’ micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial. Lancet. 2004;364(9447):1766-1772. 5. Bentkover SH, Grande DM, Soto H, Kozlicak BA, Guillaume D, Girouard S. Excision of head and neck basal cell carcinoma with a rapid, cross-sectional, frozen-section technique. Arch Facial Plast Surg. 2002;4(2):114-119.
In reply It is nice to see the correspondence and interest of Michael Alexiou, MD. He brings up several excellent points, and it is a pleasure to respond. First, the point of our study1 is to recognize that when Mohs surgery is not performed, perhaps a slightly larger margin should be obtained during primary gross excision. It does not claim that Mohs surgery is always indicated. Dr Alexiou’s letter challenges Mohs surgery as the gold standard for skin cancer excision. To that end, I will attempt to address his points. There is no question that all surgeons are not the same in ability. Having said that, however, one must assume that we all have the patient’s best interest in mind and would like nothing more than to have the cancer completely excised at first go-round. Good lighting and loupe magnification certainly make sense, but I hope he is not insinuating that they compare with the microscope in terms of identifying tumor margins. Mohs surgeons remove skin cancer, all day, every day, for a career, and yet they still occasionally underestimate clinical tumor extent. One cannot compare the 2 techniques (Mohs surgery vs frozen section control) in terms of percentage of specimen margin that is analyzed histopathologically. Furthermore, excellent cure rates are not the only advantage of Mohs surgery. An aggressive surgical margin on all nodular basal cell carcinomas would likely diminish the recurrence rate to well less than 1%. Mohs surgery achieves high cure rates while maximizing tissue preservation, a paramount consideration on the face. With regards to time, I am not sure a routine visit to the Mohs surgeon is much longer than an operative visit in which frozen sections are being obtained, as Dr Alexiou suggests. The fact that a Mohs surgeon cannot close all cutaneous defects is not a reason to avoid them; it leads to interdisciplinary patient care. Collaboration between the primary dermatologist, Mohs surgeon, plastic surgeon, oculoplastic surgeon, and facial plastic surgeon should be the “gold standard.”
Author Affiliation: Otolaryngology–Head and Neck Surgery, Alexiou Hearing and Sinus Center, Harrisonburg, Virginia.
Stephen S. Park, MD
Corresponding Author: Michael Alexiou, MD, Alexiou Hearing and Sinus Center, 2062 Pro Pointe Ln, Harrisonburg, VA 22801 ([email protected]).
Author Affiliation: Department of Otolaryngology–Head and Neck Surgery, University of Virginia, Charlottesville.
Conflict of Interest Disclosures: None reported.
Corresponding Author: Stephen S. Park, MD, Department of Otolaryngology–Head and Neck Surgery, University of Virginia, PO Box 800713, Charlottesville, VA 22908 ([email protected]).
1. Schell AE, Russell MA, Park SS. Suggested excisional margins for cutaneous malignant lesions based on Mohs micrographic surgery [online publication June 6, 2013]. JAMA Facial Plast Surg. doi:10.1001/jamafacial.2013.1011. 2. American Academy of Dermatology. Mohs best bet for high-risk cancers on face. Schaumburg, IL: MedPage Today. June 7, 2013. http://www.medpagetoday .com/Dermatology/SkinCancer/39692. Accessed September 24, 2013. jamafacialplasticsurgery.com
Conflict of Interest Disclosures: None reported. 1. Schell AE, Russell MA, Park SS. Suggested excisional margins for cutaneous malignant lesions based on Mohs micrographic surgery [online publication June 6, 2013]. JAMA Facial Plast Surg. doi:10.1001/jamafacial.2013.1011.
JAMA Facial Plastic Surgery November/December 2013 Volume 15, Number 6
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a University of Texas at Austin User on 06/06/2015
461
