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Simultaneous Intraoperative Mohs Clearance and Reconstruction for Advanced Cutaneous Malignancies

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Simultaneous Intraoperative Mohs Clearance and Reconstruction for Advanced Cutaneous Malignancies ORIGINAL ARTICLE Simultaneous Intraoperative Mohs Clearance and Reconstruction for Advanced Cutaneous Malignancies Rahul Seth, MD; Peter C. Revenaugh, MD; Allison T. Vidimos, MD; Joseph Scharpf, MD; Ally-Khan Somani, MD; Michael A. Fritz, MD Background: Improved control of cutaneous malig- Results: Twenty-six patients underwent large cutane- nancies using Mohs micrographic pathologic clearance ous tumor resection using intraoperative Mohs micro- has been well established. However, surgical margin con- graphic surgery. Most lesions were basal (48%) or squa- trol of advanced and complex cutaneous tumors of the mous (34%) cell carcinoma. A mean (SD) of 2.1 (0.98) head and neck is commonly performed by far less reli- resection layers were required before negative margins able frozen section margin analysis. were achieved. Objective: To describe a routine and ideal collaboration between dermatologic surgery and facial plastic surgery/ Conclusions: We demonstrate the intraoperative tech- head and neck surgery in which the Mohs micrographic nique and utility of Mohs micrographic analysis via an method is used intraoperatively to achieve marginal clear- efficient collaborative effort. Well established for accu- ance during resection and reconstruction. racy greater than intraoperative frozen section margin analysis, intraoperative Mohs micrographic surgery pro- Methods: A single-institution retrospective analysis was vides an optimal method of intraoperative margin as- performed of patients who underwent intraoperative Mohs sessment of cutaneous malignancies. micrographic surgery. Intraoperative margins (periph- eral and deep) of tissue specimens were analyzed by the Mohs surgeon. Arch Facial Plast Surg. 2011;13(6):404-410 KIN CANCER IS THE MOST COM- the operating suite using general anesthe- mon malignancy in the sia along with extensive reconstructive United States. Most of these measures. In these cases, conventional ex- are nonmelanoma skin can- cision is typically performed using gross cer, with basal cell carci- margin assessment and intraoperative fro- noma (BCC) accounting for 75% and squa- zen section analysis.5,6 In these situa- S 1 mous cell carcinoma composing 20%. tions, MMS is not commonly used de- After appropriate diagnosis, treatment of spite established increased accuracy in these lesions is typically performed by sur- margin assessment and superior tumor gical excision. Mohs micrographic sur- control.3,4,7 Given the limitations of con- gery (MMS) and conventional excision ventional margin clearance, definitive re- with margin assessment by postoperative construction of defects is often withheld permanent or intraoperative frozen sec- to observe for recurrence, resulting in ad- tion histopathologic analysis are the most ditional patient morbidity and psychoso- commonly performed excision tech- cial detriment. niques.2 Mohs micrographic surgery has Compared with permanent pathologic demonstrated advantages over other meth- analysis, frozen section analysis of the same ods of resection by providing improved tissue sample has an accuracy of 72% for margin control. Typically, MMS is used in assessing BCC.7 Accuracy is further lim- the outpatient setting for small- and me- ited by surgeon and pathologist selection Author Affiliations: Head and dium-sized tumors of the head and neck error if a complete circumferential resec- Neck Institute (Drs Seth, (Ͻ5 cm).3,4 tion margin cannot be assessed. An esti- Revenaugh, Scharpf, and Fritz) Ͼ and Dermatologic Institute Large or so-called giant tumors ( 5 mated less than 1% of the specimen’s (Drs Vidimos and Somani), cm), aggressive pathologic features, and sections are typically assessed by a patholo- Cleveland Clinic, Cleveland, involvement of multiple aesthetic units or gist.3,4 The MMS technique, in contrast, al- Ohio. critical structures may warrant excision in lows for assessment of 100% of the ex- ARCH FACIAL PLAST SURG/ VOL 13 (NO. 6), NOV/DEC 2011 WWW.ARCHFACIAL.COM 404 ©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 A Surgical excision with Only selected en face frozen frozen sections sections of peripheral and deep margin examined (sampling error leads to missed tumor) Permanent sections True Negative A B False Negative C True Positive D False Negative E True Positive <2% of specimen examined in standard vertical sections Identified tumor tracked and removed using IMMS until all margins clear Mohs micrographic sections 100% of peripheral and deep B margin examined and mapped Surgical excision with using frozen horizontal sections Mohs sections © Dr. A-K. Somani Figure 1. The Mohs technique compared with frozen section method. A, Margin assessment by permanent and frozen section analysis assesses a small fraction of the tumor margins, leading to significant sampling error, resulting in potentially incomplete tumor resection and a lack of confidence when assessed margins are deemed to be negative. B, Frozen Mohs section analysis can assess the entire peripheral and deep surgical margin, leading to greater certainty of complete tumor resection. IMMS indicates intraoperative Mohs micrographic surgery. cised tumor margin. Thus, MMS leads to more complete vant therapies, recurrence, survival, and follow-up data were tumor clearance and improved cure rates. Established collected and assessed. Continuous variables are presented as 5-year cure rates are shown to be up to 98.9% for primary mean (SD). and recurrent BCC and squamous cell carcinoma.8-11 As a result, MMS has been established as the crite- OPERATIVE PROCEDURE rion standard for excision of higher-risk cutaneous ma- AND TISSUE ANALYSIS lignancies.12-14 These malignancies include tumors that are recurrent, are located in areas typically at high risk General anesthesia was used in all cases, and initial tumor re- for recurrence (midface, ears, lips, and embryonic fu- section margins were jointly planned by the surgical teams. Un- sion planes), are larger than 2 cm, have ill-defined bound- like the traditional MMS technique, resection was performed aries, or have aggressive pathologic findings.2 with the intent of aggressive peripheral and deep margin clear- To achieve margin clearance greater than that pro- ance (ie, “wide-margin Mohs” that is not tissue sparing). This vided by conventional resection techniques in the man- method ideally provides margin clearance in the first 1 or 2 re- section layers. Tumor mapping was performed by the Mohs mi- agement of large, complex cutaneous malignancies, we crographic surgeon, while the ablative surgeon performed the used a novel collaborative approach of intraoperative MMS initial resection. Once complete, the specimen was taken to the (IMMS) involving multiple subspecialties at Cleveland Mohs histology laboratory, where complete margin analysis was Clinic, Cleveland, Ohio (Figure 1). This method al- performed using the MMS technique by a dedicated Mohs team lows for optimal oncologic resection and immediate consisting of several technicians and Mohs surgeons. Because aesthetic and functional reconstruction of complex the Cleveland Clinic Mohs team has made resource and time defects. accommodations to enable rapid readings, large specimen reads were performed within 1 to 3 hours. Margins of particular con- cern were identified and read as a high priority to expedite fi- METHODS nal clearance. Tissues that were assessed by the Mohs tech- nique included skin and deep tissues, muscle, fat, mucosa, A retrospective analysis was performed of patients between Sep- cartilage, and periosteum. Major nerve margins (eg, facial nerve) tember 1, 2007, and June 1, 2010, who underwent resection were assessed using frozen section by the surgical pathologist. of cutaneous head and neck malignancy using IMMS by the col- During margin analysis, additional required extirpative proce- laborative effort of Mohs dermatologic, head and neck, and fa- dures, such as maxillectomy, neck dissection, and parotidec- cial plastic surgeons. The Cleveland Clinic institutional re- tomy, were performed by the head and neck surgeon. Recon- view board approved this study. Demographic details, tumor structive efforts, including the raising of local, regional, or free abnormalities and characteristics, surgical procedures, adju- tissue flaps and acquisition of cartilage or bone grafts, were also ARCH FACIAL PLAST SURG/ VOL 13 (NO. 6), NOV/DEC 2011 WWW.ARCHFACIAL.COM 405 ©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 A B C D E F Figure 2. Case 1. Wide resection margins are demarcated by the ablative surgeons (A), with intraoperative tumor mapping performed by the Mohs surgeon (B). C, Subtotal rhinectomy, left medial maxillectomy, and left infraorbital nerve excision were performed. D, The harvested anterolateral thigh fascia was used to re-create the nasal lining, and the fat component was used to reconstitute the cheek contour. E, Cervicofacial, paramedian, and nasolabial flaps were used to provide defect skin coverage. F, The patient is without recurrence 2 years after surgery and maintains an optimized cosmetic and functional reconstruction. Adapted from Dermatol Clin. 2011;29(2):319-324. commenced during this period if they were not dependent on Case 2 the final margins. Specific areas of positive margins were marked on the mi- A 53-year-old woman presented with a large recurrent BCC in- crographic map, and the Mohs surgeon returned to the oper- volving the right side of the midface,
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