PÁGINA DEL RESIDENTE

What should the treatment be?

¿Cuál sería su manejo terapéutico?

A 58-year-old male patient was seen in our department for a chronic skin ulcer on the left cheek measuring approximately 1 cm in diameter and located at the site of a previous scar. The patient had previously undergone surgery for the condition three times, the first time 5 years ago and the last time 4 months ago. No pathology report was available for any of the interventions. The patient’s personal history included an operation for duodenal ulcer and he was being treated with ranitidine.

The physical examination revealed a scar on the left cheek extending from the labial commissure to the lower eyelid region. The scar was associated with a skin ulcer and a satellite nodule on the upper lip.

Two biopsies were made. A genial biopsy was reported as a solid and infiltrative basal-cell carcinoma of microductal nature. The other biopsy, from the upper lip, was reported as well differentiated squamous-cell carcinoma. Contrast computed tomography (CT) of the neck and thorax ruled out the presence of metastatic disease. There was no pulmonary parenchymal or cervical lymph node involvement. Facial CT disclosed radiologic signs suggestive of bone involvement.

Mohs’ surgery

Cirugía de Mohs

A. Castro¹, G. Schoendorff², J. Giner², N. Montesdeoca³

1 Médico Residente.
2 Médico Adjunto.
3 Jefe de Servicio.
Servicio de Cirugía Oral y Maxilofacial. Clínica Universitaria de Navarra. Pamplona, España.

Correspondence

The patient underwent surgery with general anesthesia to remove the facial lesion using Mohs’ technique (Figs. 1 and 2).

The surgical piece measured 7 x 2.8 x 1.5 cm and included skin, subcutaneous tissue, and muscle. Thirteen margins were identified and consecutively designated with the letters «A» to «LL.» The basal-cell epithelioma affected two of the resection margins next to the labial commissure. The other lateral and deep margins of resection were tumor-free. Fortyeight hours after the first intervention, margins were enlarged to obtain tumor-free margins. The area was reconstructed with a rotated left deltopectoral flap (Figs. 3 and 4).

No recurrence was found at 6 months of the intervention (Fig. 5).

Discussion

Skin tumors usually are treated by local excision, but many techniques have been used for their control, like irradiation, cryotherapy, laser ablation or chemotherapy. Mohs’ surgery is a refinement of these techniques that is used in certain situations depending on factors like type of lesion, location, or degree of infiltration.¹

Mohs’ micrographic surgery, described by Dr. Frederic E. Mohs, is a therapeutic alternative to conventional skin tumor management that includes histologic control of the surgical margins of resection before reconstructing the defect. Two surgical techniques with microscopic control exist. The original technique included fixation in situ of the margins of the piece with zinc chloride. The modified technique uses fresh tissue and is the modality most often used now. This surgery has several denominations in the literature, such as «microscopically controlled tumor excision,» «micrographic surgery,» and «microscopically guided histographic surgery.» The term that has lasted and is used for the modified fresh tissue technique is Mohs’ micrographic surgery.²

The technique begins by geometrically marking the area of the tumor on the skin in sections of approximately 1 cm (Fig. 1). A graphic record of the piece before excision is made to serve as an element of reference for communication between the pathologist and surgeon. The lesion is excised using the usual surgical technique, serially enlarging the margin of tumor resection in depth. All margins should be included, divided and marked with stitches or other reference material to correctly orient the tissue obtained (Fig. 2). In large tumors, it is preferable to draw a grid on the fragments, marking vertical sections with red ink and horizontal sections with black ink. In the laboratory, fragments were cold-fixed in a liquid nitrogen cryostat. The tissue is shown as it is received in the microtome. Microtome sections are stained with hematoxylin-eosin and examined under the microscope. Zones with tumor cells are marked on the map of the defect. If there is an infiltrated margin, the technique is repeated on the infiltrated margin as many times as needed until the margin is left tumor-free. Finally, reconstruction is performed using grafts or flaps, as appropriate. ¹

Mohs’ micrographic surgery has limited indications and it is not a technique that is used routinely for maxillofacial interventions. Several factors should be considered, such as tumor size, histology, invasiveness, concomitant disease, and previous recurrence.⁵

Mohs’ surgery may be considered in large, locally aggressive tumors with poorly defined margins because these tumors have a greater incidence of recurrence when treated with the usual techniques. It also is suitable for tumors with predominantly perineural involvement and a tendency to spread at a distance. Studies demonstrate a greater rate of recurrence with conventional resection techniques. It also is appropriate for tumors with a high risk of metastasis, in immunodepressed patients, in recurrent tumors because the anatomic disturbances produced by fibrosis or irradiation can alter growth patterns, in locations with a high risk of recurrence (nasolabial region, medial and lateral orbital canthus, and periauricular area), and in anatomic locations where it is important to preserve as much tissue as possible, such as the facial area.

The indications for Mohs’ micrographic surgery also depend on the histologic type. Generally, the tumor is a basal-cell carcinoma, although other types of histology are reported in the literature, for example, squamous- cell carcinoma, melanoma, angiosarcoma, leiomyoma, keratoacanthoma, apocrine carcinoma, Bowen’s disease, dermatofibrosarcoma, etc.^2-4

There are certain drawbacks to performing Mohs’ surgery, such as the delayed reconstructive procedure due to the need for histologic study of the margins. The patient must be willing to cooperate. Inflammatory infiltration of the piece may be confused with malignant cells and other histopathologic errors may be a common cause of tumor recurrence in Mohs’ surgery. By comparison with local excision, this procedure is more expensive due to the need for histologic study, several surgical times, and longer hospital stay. However, the intrinsic value of the costeffectiveness of this procedure compared with the usual surgical technique must be considered.⁶

Correspondence:
Alfredo Castro
Servicio de Cirugía Oral y Maxilofacial. Clínica Universitaria de Navarra
Av. Pío XII, nº 36
31008 Pamplona, España
Email: acastro@unav.es

References

1. David L. Shriner, MPH, Danny K. McCoy, David J. Goldberg, JD, and Richard F. Wagner, Jr, JD Newark, New Jersey, Galveston, Texas, and New York, New York. Mohs micrographic surgery. J Am Acad Dermatol. July 1998.        [ Links ]

2. Aliseda D, Vázquez J, Idoate M. Clínica Universitaria de Navarra. España. Servicio de Oftalmología. Servicio de Dermatología. Servicio de Anatomía Patológica. Cirugía micrográfica de Mohs en tumores periorbitarios. Studium Volumen XVI-Nº 3 1997.        [ Links ]

3. Martinelli PT, Cohen PR, Schulze KE, Tschen JA, Nelson BR, Nelson BR. Mohs micrographic surgery for tubular apocrine adenoma. Int J Dermatol 2006;45:1377.        [ Links ]

4. Alice N. Do Do, Kyle Goleno Pa-C, John K. Geisse Md. Mohs Micrographic Surgery and partial amputation preserving funtion and aesthetic in digits: case reports of invasive melanoma and digital dermatofibrosarcoma protuberans. Dermatol Surge2006;32:1516.        [ Links ]

5. Satoru Aoyagi Md, Keyvan Nouri Md. Difference between pigmented and nonpigmented basal cell carcinoma treated with mohs micrographic Surgery. Dermatol Surg 2006;32:1375.        [ Links ]

6. Brigitte Essers AB, Dirksen CD, Martino Neuman H. Cost-effectiveness of mohs micrographic surgery vs surgical excision for basal cell carcinoma of the face. Dermatol 2006;142:1235-6.        [ Links ]