[Why Mohs micrographic surgery?].
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Biomedical subjects
J-F Sei
Publications and source records attributed to J-F Sei.
[The cost of Mohs micrographic surgery for basal cell carcinoma. The Ambroise Paré hospital's experience (Boulogne, France)].
OBJECTIVE: Mohs'micrographic surgery is generally considered as the best procedure for the treatment of difficult basal cell carcinomas. It is supposed to be costly, but an economic evaluation, with a cost-outcome analysis, is necessary to estimate the actual contribution of this procedure in skin cancer treatment, in comparison with the reference procedure, i.e. traditional surgical excision. Our aim was to evaluate the actual cost of Mohs'surgery applied on basal cell carcinoma treatment in France. METHODS: The charts of 97 patients treated by Mohs'surgery between january 1997 and july 2001 in a teaching hospital near Paris (Ambroise Paré hospital, Boulogne), where Mohs'surgery is exclusively performed in France, were reviewed. Direct costs were derived from resource utilization of staff and material required for Mohs'surgery, estimated by a micro-costing method. Indirect costs and total costs were then calculated. RESULTS: When adding surgery and pathology facility costs, mean direct and total costs per basal cell carcinoma were 776.0 (range: 538.4-1273.9), and 1014.6 Euros (range: 777-1512.4), respectively. When including costs of diagnosis, the average total cost per procedure was 1084.3 Euros. DISCUSSION: These costs appear higher than those obtained with other methods of valuation of hospital costs used in France, but they are slightly lower than those found in the literature. The next stage will be to estimate, in the same way, the cost of traditional surgical excision for the same type of lesions, and to calculate the incremental cost-effectiveness ratio between the two procedures, with rate of recurrence at five years as the effectiveness outcome.
Adult↗
[Treatment of dermatofibroma protuberans with fixed Mohs' micrographic surgery].
INTRODUCTION: Dermatofibrosarcoma protuberans is a tumor of intermediate malignancy characterized by its aggressive local growth due to pseudopodium-like outgrowths and marked propensity to recur after surgical excision. To achieve complete cure with conventional surgery, surgical margins up to 5 cm are required, leading to wide scars. Mohs' micrographic surgery is used for the removal of certain malignant tumors, both ensuring complete excision by examination of all margins as well as minimizing normal tissue loss. However, differentiating minimal residual tumor from normal skin can be difficult on the frozen sections used in Mohs' micrographic surgery. Our aim was to develop a procedure of Mohs' micrographic surgery in conjunction with rush formalin-fixed, paraffin-embedded tangential sections. PATIENTS AND METHODS: Ten consecutive cases have been prospectively treated since 1998. Under local anesthesia, the tumor was first excised including lateral margin of 1 cm and a deep margin including the underlying muscle aponevrosis. A 2 to 3 mm thick horizontal section of the surgical bed was then removed, rush formalin-fixed, paraffin-embedded, tangentially sectioned, hematin-eosin stained, and eventually stained with an anti-CD34 monoclonal antibody. While waiting for pathology results, the surgical bed was not definitively closed. If excision was incomplete, an oriented complementary excision was performed. RESULTS: Excision was complete after the first stage in 7 patients and incomplete only deeply in 3. Lateral surgical margins were reduced to 1.3 cm in all patients, facilitating wound closure: direct suture (5 patients), controlled wound healing (3 patients) or flap coverage (2 patients). No recurrence has been observed after a mean follow-up of 26 months. DISCUSSION: The use of Mohs' micrographic surgery in conjunction with rush formalin-fixed, paraffin-embedded tangential sections reduce surgical margins in dermatofibrosarcoma protuberans. This procedure would be interesting in difficult sites, such as the genitalia, the breast, or the periarticular regions. Other cases, and longer follow-up are however necessary to validate this promising technique.
Adult↗
[Mohs' micrographic surgery: history, principles, critical analysis of its efficacy and indications].
OBJECTIVES: To systematically review the literature for studies reporting on the role of Mohs' micrographic (MMS) surgery in the treatment of skin tumors. To show how it is performed in France. DESIGN: We reviewed with a quality grid all studies indexed in MEDLINE before 2003/01/01 and published in English or French. Data were extracted by two independent reviewers. MAIN OUTCOME MEASURES: Quality of clinical studies, recurrence rates, number of patients lost to follow-up. RESULTS: No randomized study was found among the 493 references found. Studies of lower quality, on procedures similar to MMS, or previous systematic reviews were therefore selected. In tumors such as basal (BCC) or spinous (SCC) cell carcinoma, microcystic adnexal carcinoma, dermatofibrosarcoma protuberans, and Merkel cell carcinoma, MMS commonly induced lower recurrence rates than figures reported for conventional treatments and/or reduced surgical margins. Studies on melanoma were of low quality. CONCLUSIONS: Although no evidence-based guidelines could be developed, MMS should be used mainly for larger, morphea, micronodular or infiltrative-type, or recurrent BCCs located in danger zones, but also (sometimes with a slightly modified procedure) in microcystic adnexal carcinomas, dermatofibrosarcoma protuberans, Merkel cell carcinoma, and in aggressive forms of SCC. Randomized, controlled studies should be performed.
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