Why not Mohs?

[MOHS_01]

That’s terrifying...remind me to avoid those, what’s the zip, lol

Each of those pics were taken this year and each of them had been ED&C by a BCD within the year prior to presentation - that’s why the photo was taken - to send back to the referring with the surgical report. Each of the original biopsies was read out as non-aggressive. I’ve learned to not trust partial sampling of larger lesions.

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[sore eye asses]

This makes me feel good that I rarely edc, and only as a last resort, for the very reasons you mention. For some folks that aren’t good surgical candidates edc is a decent option.

 

[username456789]

This makes me feel good that I rarely edc, and only as a last resort, for the very reasons you mention. For some folks that aren’t good surgical candidates edc is a decent option.

I think it can sometimes depend on the clinical impression pre-bx as well as your understanding of how you did the biopsy. If it’s a sub-1cm BCC that looks pretty “pearly papule with telangiectasias”-like, and your biopsy was a shave of the bulk of the lesion, the absence of morpheaform features can probably be relied upon fairly well, no?

Then again maybe this hubris is what gets us into trouble in the first place.

I very rarely excise on the face. We have a Mohs surgeon in house and most patients have come to expect it anyway. With some exceptions (patient advanced age, dementia, other morbidity), Mohs is probably the best option here.

I send shins/hands/fingers/toes/genitals for Mohs usually as well. But almost everything else I excise (or ED&C).

 

[sore eye asses]

I think it can sometimes depend on the clinical impression pre-bx as well as your understanding of how you did the biopsy. If it’s a sub-1cm BCC that looks pretty “pearly papule with telangiectasias”-like, and your biopsy was a shave of the bulk of the lesion, the absence of morpheaform features can probably be relied upon fairly well, no?

Then again maybe this hubris is what gets us into trouble in the first place.

I very rarely excise on the face. We have a Mohs surgeon in house and most patients have come to expect it anyway. With some exceptions (patient advanced age, dementia, other morbidity), Mohs is probably the best option here.

I send shins/hands/fingers/toes/genitals for Mohs usually as well. But almost everything else I excise (or ED&C).

I practice much the same way. If that Jaad article is generalizable then 9% of bx fail to show other morphology or deeper component. So yeah, more excisions than edc here.

 

[doctalaughs]

This makes me feel good that I rarely edc, and only as a last resort, for the very reasons you mention. For some folks that aren’t good surgical candidates edc is a decent option.

We have in-house mohs (which I profit from) so I have nothing against mohs at all.

Everyone has a perspective/story but I practice in a high incidence skin cancer area (estimate I find 10 bcc/scc a day x x 5 days week) and probably 10% go to mohs. Majority of rest are EDC, topical and a few excused.

Of course I’m sending the midface lesions and the other high risk ones to mohs. But of the ones I find -90% are superficial, small nodular or small well-diff SCC. Why would any Derm not scoop out the whole lesion in these cases to not miss mixed path?

I know everyone likes their own anecdotes but I think I do about 1500 ed&c a year (most already with clear margins on saucerization but ed&c directly after) and have maybe 10 recurrences since I select the lesions carefully. The recurrences go directly to mohs.

Maybe I don’t see my own recurrences (doubt it - very closed patient population seeing me for 15 years I know them super well). Maybe there are hordes of dermatologists who don’t saucerize small lesions like I do?

All I know is that I would instantly ED&C a sub 1cm BCC on my mom’s back and not even have a second thought about mentioning mohs as an option (as it’s a dumb option . - again my opinion only! - maybe I’m too much of an old-timer)

 

[doctalaughs]

Also for what it’s worth I’ve never (in 15 years) seen one of my own excisions recur for sure (talking bcc/scc, not melanocytic). I know what some of the literature claims - but I have no idea why. Obviously I’ve seen plenty of excisions on poorly-selected tumors that recur horribly or metastasize... but in my opinion for a low risk well-demarcated lesion if you do it with proper technique and margins, the recurrence rate is close to if not equal to zero. Most of the time there isn’t any tumor there anyway after my saucerization

 

[MOHS_01]

My experience is that people rarely see their own long term complications or recurrences -- they go elsewhere. I cannot count the number of recurrences that I see; it's not half but it's a good 1/4 of my referrals, nice little recurrences in an excision line or at the margin of an atrophic hypopigmented scar from a local destruction. Better yet, the number of referrals that I get for a recurrent BCC with multiple providers and multiple path reports on the same lesion. It's not uncommon, and given the number of skin cancers we see it should not come as a surprise to anyone that even a 5% recurrence rate results in a **** ton of recurrences.

Low risk, well demarcated is one thing -- as long as it's not in the mid face, ears, digits, or immunosuppressed -- then all bets are off. Mid face, ears,fingers, and the immunossuppressed will humble you quickly.

 

[doctalaughs]

Low risk, well demarcated is one thing -- as long as it's not in the mid face, ears, digits, or immunosuppressed -- then all bets are off. Mid face, ears,fingers, and the immunossuppressed will humble you quickly.

Agree on that last statement and those all go to our mohs guy (except superficial tumors which I would argue are frequently not good for mohs d/t multi focal nature/ skip areas). Also fingers agree on around the nail unit but dorsal mid digit I ED&c all day long.

Maybe my practice is unusual but those higher risk ones are 10 percent. When you are the mohs guy it’s 100%.

I have so many patients that have 4 small low risk tumors every time they come in q 3 months. No way they are going to mohs for all (or even 50%) of them.

 

[doctalaughs]

Also for the immunosuppressed patients I think a lot of derms don’t push the transplant docs /rheumatologist hard enough to change or lower agents. If a high burden of skin cancer is apparent, they have a very high risk of dying no matter if you send them to mohs a thousand times or not.

Often I see these with so many tumors that you can’t realistically use mohs, because they all run into each other. The answer to that isn’t mohs q 2 weeks with no real chance at margin control anyway, waiting for a met - it’s to change agents, add niacinamide+/-acetretin and chip away with ED&C 5-10 at a time q4 weeks (if all small/well diff) with mohs and/or xrt thrown in occasionally if a particular high risk one is found. Their whole body won’t be skin cancer after 6-12 months. That medical strategy matters way more than how each tumor is managed.

 

[Solodyn]

I have never seen this forum light up like this before! Usually, the derm forum is a snooze.

Solodyn, you offer mohs to all of your patients for truncal BCC? If so, I suspect that would put you in the very small minority of fellowship trained mohs surgeons who make a similar recommendation.

Yes, I do offer all treatment options to patients. They make the informed decision on the treatments they choose.

Since we are all bunch of 15 years-out old-timers, let me get straight to the point. First of all, I am a society guy. I will never misrepresent myself as I believe my opinion is as valid as anyone else's. I got my own 15 years and 20000 cases of experience. My point of view is not unique to the society mohs surgeon. I know there are fellowship trained mohs who shared my view. To your question, I do not do Mohs on all my patients with truncal BCC. However, I present ALL treatment options to everyone, (Mohs, wide excision, SRT, Aldara, Cryosurgery). If you withhold options, the patients cannot make informed consent; even if you think the option is stupid it is your job to educate and not to omit. You can offer your opinion, but the patients have to be the ones making the decision. If you disagree, you can refuse to treat the patients and refer them to another dermatologist. But I believe by not at least mention all options, you run the same risk of the patients coming back saying why didn't you tell me about this superior treatment for truncal BCC that will give me 99% cure rate? Why is my mother getting ED&C with lower cure rate and with no pathology analyzed? Why is my father not getting the best treatment cure rate with the smallest scar?

We live in a world of third party payers. Where I am at, almost no one pay for their Mohs. If everyone pays for all their own surgery, this AUC/"why do you do Mohs on this and that hypothetical trucal BCC" will not even be a discussion. If the patients want Mohs or ED&C, they will pay for what they can afford. However, when Medicare or Private Insurance is paying for the procedures, everyone wants the best treatment and will question your integrity when you don't give it to them. Thus if the 1cm Trunal BCC is on my mother, I will want her to have the Mohs surgery. I would even pay for you to do it or do it myself. If your mother shows up at my office and you call me saying I want me to ED&C or excise it, I will do my very best to honor yours and her wish. Before you accuse me of the profit motive, I will say that I don't need to convert unwilling patients to Mohs to make a buck. There are plenty of patients who done their research and already come in wanting nothing else but Mohs no matter what I tell them... my mother included.

I don't believe in being the arbiter of health care resources and dollars; it is not my place. I believe in appropriate treatment with respect to patient's decision. I have good number of patients not wanting Mohs because they don't want to have to wait all day. They rather ED&C or Excision on the nose or scalp. I would inform them of the risk and if that is still their choice, I will document it and do it. I am not the one to block people from getting Mohs because I act as the "death panel" (per Sarah Palin) for Medicare in my office. The patient needs to know if the insurance do not authorize due to AUC, or refuse to pay, they are on the hook and I have they sign for it.

As I stated in previous post, Doing Mohs vs Excision cost the system roughly $250 more. It is not a wasteful proposition given the better visualization of the margins. For my profit margin, it is break-even whether I do one or the other since it cost me more staff and consumable to do Mohs. To inappropriately undertreat a skin cancer with ED&C will cost the system more in the long run. Therefore, I know I am not bankrupting the healthcare system as long as the patients are appropriately treated within the confines of their wishes.

The whole Society vs College/Who should get Mohs controversy will not get resolved soon. The disagreements have been going on since we are residents. We certainly are not going to find the consensus in this small forum. But allow me to say, it is still a pleasure to have a lively discussion and to hear different point of views.

 

[MOHS_01]

Agree on that last statement and those all go to our mohs guy (except superficial tumors which I would argue are frequently not good for mohs d/t multi focal nature/ skip areas). Also fingers agree on around the nail unit but dorsal mid digit I ED&c all day long.

Maybe my practice is unusual but those higher risk ones are 10 percent. When you are the mohs guy it’s 100%.

I have so many patients that have 4 small low risk tumors every time they come in q 3 months. No way they are going to mohs for all (or even 50%) of them.

Where did you ever get that small tumors are multifocal? They’re not - until someone does a destruction on them.... NMSCs don’t start as small, multifocal lesions and congeal into confluence as a rule...

 

[MOHS_01]

Also for the immunosuppressed patients I think a lot of derms don’t push the transplant docs /rheumatologist hard enough to change or lower agents. If a high burden of skin cancer is apparent, they have a very high risk of dying no matter if you send them to mohs a thousand times or not.

Often I see these with so many tumors that you can’t realistically use mohs, because they all run into each other. The answer to that isn’t mohs q 2 weeks with no real chance at margin control anyway, waiting for a met - it’s to change agents, add niacinamide+/-acetretin and chip away with ED&C 5-10 at a time q4 weeks (if all small/well diff) with mohs and/or xrt thrown in occasionally if a particular high risk one is found. Their whole body won’t be skin cancer after 6-12 months. That medical strategy matters way more than how each tumor is managed.

...and I do not doubt that the aggressive nightmarish BS are the only ones thrown my way - and that they’re the minority. Idk about 10% minority, but I feel pretty confident that a lot of the **** dropped on my doorstep would not have anything approaching a 95% cure rate with 3mm margins. Why the confidence? Glad you asked - because >5% of my cases require a second stage to clear... and 3mm is a pretty damn narrow margin, even for most non-alar/eyelid margin cases!

 

[MOHS_01]

Also for the immunosuppressed patients I think a lot of derms don’t push the transplant docs /rheumatologist hard enough to change or lower agents. If a high burden of skin cancer is apparent, they have a very high risk of dying no matter if you send them to mohs a thousand times or not.

Often I see these with so many tumors that you can’t realistically use mohs, because they all run into each other. The answer to that isn’t mohs q 2 weeks with no real chance at margin control anyway, waiting for a met - it’s to change agents, add niacinamide+/-acetretin and chip away with ED&C 5-10 at a time q4 weeks (if all small/well diff) with mohs and/or xrt thrown in occasionally if a particular high risk one is found. Their whole body won’t be skin cancer after 6-12 months. That medical strategy matters way more than how each tumor is managed.

Agreed on the need to communicate with the transplant team - but I also understand the desire to not rock the boat in an otherwise risky rejection / scarce organ world. It’s tough.

 

[zanzizic]

Interesting perspectives, everyone.

My experience after 18 years in practice (fellowship trained) is that I’m getting easier cases referred than ever before. When I first hung my shingle there were a lot of older male dermatologists that were more surgically aggressive and doing their own excisions but especially tons of curettage. Mostly they did a good job although I got plenty of people pissed by ugly scars. I also saw lots of recurrences. So my average Mohs case was a recurrence or difficult locations only nose/eyelids/etc.

As time has gone on, several of these old guys have retired or gone on to the VA to work. My referral sources include way more women and mid-levels who are not as surgically confident or aggressive. Frankly, lots of these female providers like the medical or cosmetic side of derm better than skin cancer so I think they’re happy to punt these people out. So I’m still seeing the difficult cases but there’s a greater volume of more straightforward cases such as forearms and back BCCs and well-diff SCCs (especially in the female patient population...the old guys are still getting curetted).

At this point, I excise and process them as a Mohs layer and close but bill for excision with frozen section and get paid less. So the patient gets the high cure rate and insurance pays less. Oh well.

 

[zanzizic]

Agreed on the need to communicate with the transplant team - but I also understand the desire to not rock the boat in an otherwise risky rejection / scarce organ world. It’s tough.

Aside from transplant patients, there’s lots of autoimmune disease patients that are on serious immunosuppressive medications. I had a red-headed lady with Crohns on azathioprine coming to me q3 mo getting 2-3 SCCs excised. After a couple of visits I called her GI and he switched her to another agent and she came once a year a couple of times for an SCC and now has been cancer free for several years. Sometimes their prescribing doc needs to take the risk of cutaneous SCC seriously because there are usually medical alternatives to the more profoudly immunosuppressive agents (especially now that biologics are here).

 

[MOHS_01]

Interesting perspectives, everyone.

My experience after 18 years in practice (fellowship trained) is that I’m getting easier cases referred than ever before. When I first hung my shingle there were a lot of older male dermatologists that were more surgically aggressive and doing their own excisions but especially tons of curettage. Mostly they did a good job although I got plenty of people pissed by ugly scars. I also saw lots of recurrences. So my average Mohs case was a recurrence or difficult locations only nose/eyelids/etc.

As time has gone on, several of these old guys have retired or gone on to the VA to work. My referral sources include way more women and mid-levels who are not as surgically confident or aggressive. Frankly, lots of these female providers like the medical or cosmetic side of derm better than skin cancer so I think they’re happy to punt these people out. So I’m still seeing the difficult cases but there’s a greater volume of more straightforward cases such as forearms and back BCCs and well-diff SCCs (especially in the female patient population...the old guys are still getting curetted).

At this point, I excise and process them as a Mohs layer and close but bill for excision with frozen section and get paid less. So the patient gets the high cure rate and insurance pays less. Oh well.

That’s sounds horrible! You should definitely encourage your referring providers to relocate - I’ll find a more suitable location for them!

 

[zanzizic]

Yeah I can’t complain about that. Those are chip shots.

Sometimes I will see the patient who had a shave biopsy that said “margins were clear in the sections”. And we have a big discussion with the patient and go back and do Mohs. Can’t tell you how many times I’ve seen residual basal cell on those cases.

I’m not sure why the general dermatologists think that a Vertical cut through a shave biopsy can be used to make any clinical decisions on clear margins.

 

[MOHS_01]

Yeah I can’t complain about that. Those are chip shots.

Sometimes I will see the patient who had a shave biopsy that said “margins were clear in the sections”. And we have a big discussion with the patient and go back and do Mohs. Can’t tell you how many times I’ve seen residual basal cell on those cases.

I’m not sure why the general dermatologists think that a Vertical cut through a shave biopsy can be used to make any clinical decisions on clear margins.

It's practically every day here from one particular referring group who politically has to use the local hospital general path; not opening the can of worms about people needing to stay in their lane, but damn, at least recognize that lanes exist! I feel bad for them, one of these days they will get burned as a result.

 

[sore eye asses]

I have never seen this forum light up like this before! Usually, the derm forum is a snooze.



Yes, I do offer all treatment options to patients. They make the informed decision on the treatments they choose.

Since we are all bunch of 15 years-out old-timers, let me get straight to the point. First of all, I am a society guy. I will never misrepresent myself as I believe my opinion is as valid as anyone else's. I got my own 15 years and 20000 cases of experience. My point of view is not unique to the society mohs surgeon. I know there are fellowship trained mohs who shared my view. To your question, I do not do Mohs on all my patients with truncal BCC. However, I present ALL treatment options to everyone, (Mohs, wide excision, SRT, Aldara, Cryosurgery). If you withhold options, the patients cannot make informed consent; even if you think the option is stupid it is your job to educate and not to omit. You can offer your opinion, but the patients have to be the ones making the decision. If you disagree, you can refuse to treat the patients and refer them to another dermatologist. But I believe by not at least mention all options, you run the same risk of the patients coming back saying why didn't you tell me about this superior treatment for truncal BCC that will give me 99% cure rate? Why is my mother getting ED&C with lower cure rate and with no pathology analyzed? Why is my father not getting the best treatment cure rate with the smallest scar?

We live in a world of third party payers. Where I am at, almost no one pay for their Mohs. If everyone pays for all their own surgery, this AUC/"why do you do Mohs on this and that hypothetical trucal BCC" will not even be a discussion. If the patients want Mohs or ED&C, they will pay for what they can afford. However, when Medicare or Private Insurance is paying for the procedures, everyone wants the best treatment and will question your integrity when you don't give it to them. Thus if the 1cm Trunal BCC is on my mother, I will want her to have the Mohs surgery. I would even pay for you to do it or do it myself. If your mother shows up at my office and you call me saying I want me to ED&C or excise it, I will do my very best to honor yours and her wish. Before you accuse me of the profit motive, I will say that I don't need to convert unwilling patients to Mohs to make a buck. There are plenty of patients who done their research and already come in wanting nothing else but Mohs no matter what I tell them... my mother included.

I don't believe in being the arbiter of health care resources and dollars; it is not my place. I believe in appropriate treatment with respect to patient's decision. I have good number of patients not wanting Mohs because they don't want to have to wait all day. They rather ED&C or Excision on the nose or scalp. I would inform them of the risk and if that is still their choice, I will document it and do it. I am not the one to block people from getting Mohs because I act as the "death panel" (per Sarah Palin) for Medicare in my office. The patient needs to know if the insurance do not authorize due to AUC, or refuse to pay, they are on the hook and I have they sign for it.

As I stated in previous post, Doing Mohs vs Excision cost the system roughly $250 more. It is not a wasteful proposition given the better visualization of the margins. For my profit margin, it is break-even whether I do one or the other since it cost me more staff and consumable to do Mohs. To inappropriately undertreat a skin cancer with ED&C will cost the system more in the long run. Therefore, I know I am not bankrupting the healthcare system as long as the patients are appropriately treated within the confines of their wishes.

The whole Society vs College/Who should get Mohs controversy will not get resolved soon. The disagreements have been going on since we are residents. We certainly are not going to find the consensus in this small forum. But allow me to say, it is still a pleasure to have a lively discussion and to hear different point of views.

For every patient, for every biopsy, you personally (or have a HIGHLY skilled and trained MA/nurse) explain the nuances of XRT as a viable treatment option for NMSC? Why would you offer mohs on a lesion where it’s not the standard of care? I would think you’d have just as hard a time justifying why you did mohs on a 4 mm truncal nod BCC than not offering it or mentioning it only cursorily as an option that might give 1-2% extra percentage point of cure in a low risk tumor at a low risk site, and that it will be 25-30% more expensive (regardless of who pays for it). If your verbiage covers these points, then kudos to you. It does not seem practical or pragmatic.

 

[doctalaughs]

For every patient, for every biopsy, you personally (or have a HIGHLY skilled and trained MA/nurse) explain the nuances of XRT as a viable treatment option for NMSC? Why would you offer mohs on a lesion where it’s not the standard of care? I would think you’d have just as hard a time justifying why you did mohs on a 4 mm truncal nod BCC than not offering it or mentioning it only cursorily as an option that might give 1-2% extra percentage point of cure in a low risk tumor at a low risk site, and that it will be 25-30% more expensive (regardless of who pays for it). If your verbiage covers these points, then kudos to you. It does not seem practical or pragmatic.

This. And also, show me the study that compared mohs to ed&c head-to head on small truncal nodular BCC (hint- it doesn’t exist). The varying cute rates for ed&c in the studies are I’m 100% convinced because of not saucerizing to see full representative path (or done with residents who don’t know how to edc).

On the other hand I can show you studies that show a 98-99% cure rate for ED&C on these types of low risk lesions.

So no, I don’t discuss mohs (or xrt or injecting interferon or crazy stuff like that). on these types lesions.

 

[MOHS_01]

People may want to familiarize themselves with the NCCN guidelines.

 

[doctalaughs]

I’m

People may want to familiarize themselves with the NCCN guidelines.

I’m a big fan of NCCN. Residents graduating recently seem to think you can’t ED&c small well-diff SCC... yet look at the guidelines.

 

[Slack3r]

Recent Blue journal article discussing your exact point...I think it was roughly 9% of biopsies failed to capture more invasive tumor.

I think it’s closer to 25%.

 

[sore eye asses]

I think it’s closer to 25%.

No, I don’t think the numbers were that high in the study. Unless I’m misremembering it. Or are you just giving your own personal estimate?

 

[MOHS_01]

No, I don’t think the numbers were that high in the study. Unless I’m misremembering it. Or are you just giving your own personal estimate?

Not sure which study you actually referenced, but there was one from about 5 years ago that showed biopsies were inconsistent with subtype identified upon MMS in over half of the cases and failed to identify the aggressive features about 25% of the time. Murad Alam may have been the author? That sounds right, but don't hold me to it.

 

[MOHS_01]

30 seconds on theGoogle(TM) finds that this has been looked at several times over the years and all reach the same conclusion: biopsies under identify aggressive subtype quite frequently.

 

[doctalaughs]

30 seconds on theGoogle(TM) finds that this has been looked at several times over the years and all reach the same conclusion: biopsies under identify aggressive subtype quite frequently.

Meh- I don’t know of any study that shows this for saucerization with intent to remove. Sure - we all know about the limits of breadloafing but if it’s infiltrative this should be apparent in one of the sections if you got the vast majority of the lesion captured in the block.

My philosophy for NMSC is the same as melanocytic- take the whole lesion that you can see clinically unless you have already decided it’s going to mohs (or full excision).

People argue it will result in bad cosmetic outcomes but with demoscopy you should already know that it’s NMSC anyway, so it’s not a scar for nothing.

If you decide to do a small surface shave then in my mind, you’ve already committed to mohs or a more complete margin eval technique.

 

[MOHS_01]

Meh- I don’t know of any study that shows this for saucerization with intent to remove. Sure - we all know about the limits of breadloafing but if it’s infiltrative this should be apparent in one of the sections if you got the vast majority of the lesion captured in the block.

My philosophy for NMSC is the same as melanocytic- take the whole lesion that you can see clinically unless you have already decided it’s going to mohs (or full excision).

People argue it will result in bad cosmetic outcomes but with demoscopy you should already know that it’s NMSC anyway, so it’s not a scar for nothing.

If you decide to do a small surface shave then in my mind, you’ve already committed to mohs or a more complete margin eval technique.

Okay.... possibly that's because no one really does that? A half measure excision with intent of removal, I mean... and the "scar for nothing" is little more than a post hoc rationalization for a predictable adverse outcome -- especially on the head and neck.

...and even your saucerizations are processed via breadloafing.

I really don't see this as a hill worth dying on, but you do you. I've already said that it was not wrong always and everywhere to do a local destruction or standard excision, but for some areas and some tumors it is more wrong than right....

...and yes, most people prefer to diagnose ---> treat, as that is the most appropriate, least bridge burning manner to operate.

 

[doctalaughs]

Okay.... possibly that's because no one really does that? A half measure excision with intent of removal, I mean... and the "scar for nothing" is little more than a post hoc rationalization for a predictable adverse outcome -- especially on the head and neck.

...and even your saucerizations are processed via breadloafing.

I really don't see this as a hill worth dying on, but you do you. I've already said that it was not wrong always and everywhere to do a local destruction or standard excision, but for some areas and some tumors it is more wrong than right....

...and yes, most people prefer to diagnose ---> treat, as that is the most appropriate, least bridge burning manner to operate.

No prob, you are right everyone will practice the way they please.

I just think that doing mohs for small nodular bccs on the trunk or majority of superficial lesions is like prescribing dupixent for every mild atopic dermatitis patient. Sure, you can do it and even claim it’s more effective- but eventually someone is going to realize it’s not wise, appropriate or benefiting patients from a global perspective.

Regarding the superficial lesions here are a few articles showing the skip areas for primary lesions (which is why I view topical or modified PDT as first line for these):

8. Mina MA, Picariello A, Fewkes JL. Superficial basal cell carcinomas of the head and neck. Dermatol Surg. 2013;39(7):1003-8, 10.1111/dsu.12178

The importance of superficial basal cell carcinoma in a retrospective study of 139 patients who underwent Mohs micrographic surgery in a Brazilian university hospital

OBJECTIVE: Mohs micrographic surgery is a specialized surgical procedure used to treat skin...

www.scielo.br

Regarding diagnosis-> treat... that is what I do. My diagnosis is the dermoscopy and clinical presentation that it’s a low risk NMSC. My treatment is the saucerization followed by ed&c. If path disagrees (which is Pretty rare) then yes, my mohs partner gets it... just like he gets the indistinct 3mm papule with an ice-pick dell on the nose that I can tell will be morpheaform and I didn’t even attempt to treat because I know it will be going to mohs anyway.

But I don’t think we are actually disagreeing much- sounds like you do pretty aggressive tumors anyway which is appropriate for mohs (1 tool in the toolbox, not the only tool as some would have us believe).

 

[MOHS_01]

No prob, you are right everyone will practice the way they please.

I just think that doing mohs for small nodular bccs on the trunk or majority of superficial lesions is like prescribing dupixent for every mild atopic dermatitis patient. Sure, you can do it and even claim it’s more effective- but eventually someone is going to realize it’s not wise from a global perspective.

Regarding the superficial lesions here are a few articles showing the skip areas for primary lesions (which is why I view topical or modified PDT as first line for these):

8. Mina MA, Picariello A, Fewkes JL. Superficial basal cell carcinomas of the head and neck. Dermatol Surg. 2013;39(7):1003-8, 10.1111/dsu.12178

The importance of superficial basal cell carcinoma in a retrospective study of 139 patients who underwent Mohs micrographic surgery in a Brazilian university hospital

OBJECTIVE: Mohs micrographic surgery is a specialized surgical procedure used to treat skin...

www.scielo.br

Regarding diagnosis-> treat... that is what I do. My diagnosis is the dermoscopy and clinical presentation that it’s a low risk NMSC. My treatment is the saucerization followed by ed&c. If path disagrees (which is Pretty rare) then yes, my mohs partner gets it... just like he gets the indistinct 3mm papule with an ice-pick dell on the nose that I can tell will be morpheaform and I didn’t even attempt to treat because I know it will be going to mohs anyway.

But I don’t think we are actually disagreeing much- sounds like you do pretty aggressive tumors anyway which is appropriate for mohs (1 tool in the toolbox, not the only tool as some would have us believe).

Yeah, sounds like we are in agreement for the most part and, I will say, that I am not a fan of excisional surgery of any sort for sBCC if it can be avoided. With all due respect to the authors of the 2013 article, I believe their assignment of causation for the recurrence is a faulty presumption -- that the proximate causation for recurrence was skip areas for any given tumor -- and and underweighting of what is likely going on -- field effect cancerization. This is not the "distinction without difference" scenario that it may appear; there is a very real difference between multiple primary tumors in an irradiated field and a singular tumor with skip areas.

FWIW, if something is clinically a sBCC, path (read out by a dermpath that I know or trust) shows sBCC, and the biopsy obtained was truly representative, I recommend imiquimod prior to considering surgery -- I don't care if it is an ala. Controversial among my peers, maybe, but defensible.

As for the person doing MMS for a small sBCC on the trunk -- one would hope that the medical necessity police catch up with them at some point.

 

[Skindoc83]

I think it’s higher than 95% actually

And mohs is a (great) thing for certain tumors, you know which I mean.

Not even close. If that were true, why do I treat so many recurrences from plastics? The problem with recurrence is several fold. First of all, how do you define a recurrence? What if it’s several millimeters out of a scar? 1cm? There was a convoluted article in derm surgery within the last year just trying to figure out a mathematical equation to figure out how to quantify something as recurrent. Furthermore, a lot of those papers showing stellar cure rates with wide local, or sometimes even “narrow excision” are based upon bread loafing the excised specimen which we all know only examines less than 1 percent of the true margin. But studies that look at taking narrow margins with mohs, giving the true margin, show a high rate of positive margins. Want to increase your average number of stages? Take 3mm margins around the clinical lesion.

 

[sore eye asses]

Not even close. If that were true, why do I treat so many recurrences from plastics? The problem with recurrence is several fold. First of all, how do you define a recurrence? What if it’s several millimeters out of a scar? 1cm? There was a convoluted article in derm surgery within the last year just trying to figure out a mathematical equation to figure out how to quantify something as recurrent. Furthermore, a lot of those papers showing stellar cure rates with wide local, or sometimes even “narrow excision” are based upon bread loafing the excised specimen which we all know only examines less than 1 percent of the true margin. But studies that look at taking narrow margins with mohs, giving the true margin, show a high rate of positive margins. Want to increase your average number of stages? Take 3mm margins around the clinical lesion.

What margins do you take for your first mohs layer? Is there a standard?

Your anecdata does not match mine.

My recurrence rate on NMSC excision (with 3-6 mm margin depending on site and tumor) is definitely below 5%. This mirrors or is superior to previously published rates.

But our experience colors our view, so I can understand why you hold your view looking at recurrences all the time. In my clinic they’re unicorns, I probably see more EB.

 

[reno911]

Meh- I don’t know of any study that shows this for saucerization with intent to remove. Sure - we all know about the limits of breadloafing but if it’s infiltrative this should be apparent in one of the sections if you got the vast majority of the lesion captured in the block.

Out of curiosity, how do you code your saucerizations?

 

[sore eye asses]

Not sure which study you actually referenced, but there was one from about 5 years ago that showed biopsies were inconsistent with subtype identified upon MMS in over half of the cases and failed to identify the aggressive features about 25% of the time. Murad Alam may have been the author? That sounds right, but don't hold me to it.

I misremembered the percentage, but I was close, it was 10.3%
Histopathologic upgrading of nonmelanoma skin cancer at the time of Mohs micrographic surgery: A prospective review.

 

[doctalaughs]

Out of curiosity, how do you code your saucerizations?

Tangential biopsies (in the new 2019 codes). Not coding as shady excisions or anything like that. Also I could up my revenue significantly by bringing them back for the ed&c but I don’t - as it takes 25 seconds and it’s better care when I know it’s a small nodular or superficial BCC or well diff scc cured within 90 seconds of diagnosis.

Also, I have no proof but I suspect ED&C immediately after the saucerization biopsy is infinitely more effective than a superficial shave then digging at it a few weeks later after granulating over cancer cells down there (again- no proof or expectation that I will convince anyone -but anecdotally my recurrence rate over more than 20,000 low risk tumors seems- to me - to be far less than 1%, which I wonder if it is partially because of that). If I were more academic-minded I would do a study but I’m too busy clinically to bother...



I do have my billers go back and pull the path to change tangential codes to malignant destruction which reimburses slightly more, as that’s what was done.

 

[MOHS_01]

I misremembered the percentage, but I was close, it was 10.3%
Histopathologic upgrading of nonmelanoma skin cancer at the time of Mohs micrographic surgery: A prospective review.

Yeah, I knew which one you were referring to, it’s the most recent one that I recall as well. There were multiple articles on this in the past twenty years, but congrats on remembering the one with the lowest percentage! Ha!

 

[sore eye asses]

I remembered it because it’s what I read most recently, not because of the percentage, which I recalled incorrectly anyway. Lol

 

[reno911]

Tangential biopsies (in the new 2019 codes). Not coding as shady excisions or anything like that. Also I could up my revenue significantly by bringing them back for the ed&c but I don’t - as it takes 25 seconds and it’s better care when I know it’s a small nodular or superficial BCC or well diff scc cured within 90 seconds of diagnosis.

Also, I have no proof but I suspect ED&C immediately after the saucerization biopsy is infinitely more effective than a superficial shave then digging at it a few weeks later after granulating over cancer cells down there (again- no proof or expectation that I will convince anyone -but anecdotally my recurrence rate over more than 20,000 low risk tumors seems- to me - to be far less than 1%, which I wonder if it is partially because of that). If I were more academic-minded I would do a study but I’m too busy clinically to bother...

I do have my billers go back and pull the path to change tangential codes to malignant destruction which reimburses slightly more, as that’s what was done.

If you "know it’s a small nodular or superficial BCC or well diff scc cured within 90 seconds of diagnosis." Then why not just bill as malignant destruction right off the bat. If you're wrong (which really shouldn't happen, given that you already "know" what it is) you can just ask your billers to change to tangential bx code. Seems like there would be a lot less changing that way.

I still don't understand what benefit you think you're getting over Mohs aside from cost and patient waiting time.

Imagine if your saucerization specimen was processed en face while the patient waited. If it's negative, then you can save the patient an unnecessary ED&C. If it's positive you can just clear it with another very thin layer (which should be possible given how easily you can clear it with ED&C) and allow it to granulate just like an ED&C wound. And if it's something more aggressive you can deal with that appropriately.

What I'm not clear on is if you think ED&C is better for reasons other than cost and speed? It sounds like you think there are, but I'm not sure what they would be.

 

[doctalaughs]

If you "know it’s a small nodular or superficial BCC or well diff scc cured within 90 seconds of diagnosis." Then why not just bill as malignant destruction right off the bat. If you're wrong (which really shouldn't happen, given that you already "know" what it is) you can just ask your billers to change to tangential bx code. Seems like there would be a lot less changing that way.

I still don't understand what benefit you think you're getting over Mohs aside from cost and patient waiting time.

Imagine if your saucerization specimen was processed en face while the patient waited. If it's negative, then you can save the patient an unnecessary ED&C. If it's positive you can just clear it with another very thin layer (which should be possible given how easily you can clear it with ED&C) and allow it to granulate just like an ED&C wound. And if it's something more aggressive you can deal with that appropriately.

What I'm not clear on is if you think ED&C is better for reasons other than cost and speed? It sounds like you think there are, but I'm not sure what they would be.

Because if I’m wrong even 1 in 500 times then it’s billing fraud if they submit it. And I’m not going to risk that. Better my billers forget to change a few tangentials to malig destruction. Obviously, I don’t do this for every single biopsy as no one is 100% sure of everything and I’d be an idiot to put a huge divot that will become a hypertropic scar into a 27 year-old woman’s chest.... but after 15 years I know which ones I can do that way or not.... and it’s a large majority of cancers day to day that get cured this way....

Regarding is it “better” than mohs for very low risk tumors- speed, patient cost (in time and dollars) and cost to our society are not nothing. Like I said, you could treat every mild atopic with dupixent with equal if not better control.... but most would not advocate for that or even give patients the option.

 

[MOHS_01]

Because if I’m wrong even 1 in 500 times then it’s billing fraud if they submit it. And I’m not going to risk that. Better my billers forget to change a few tangentials to malig destruction. Obviously, I don’t do this for every single biopsy as no one is 100% sure of everything and I’d be an idiot to put a huge divot that will become a hypertropic scar into a 27 year-old woman’s chest.... but after 15 years I know which ones I can do that way or not.... and it’s a large majority of cancers day to day that get cured this way....

Regarding is it “better” than mohs for very low risk tumors- speed, patient cost (in time and dollars) and cost to our society are not nothing. Like I said, you could treat every mild atopic with dupixent with equal if not better control.... but most would not advocate for that or even give patients the option.

I’m not sure that I’d be too damn comfortable with holding billing for pathology - I’ve head people argue out of both sides of their mouth re: the intent at the time of treatment being the determining factor. I know that this is commonly done - and how it was done where I trained - but it’s not the cleanest way of doing things by any stretch. If you’re wrong - and it was, say, an AK or ISK or BLK — well, you just performed one helluva benign or local destruction (and I’m pretty sure there exists a significant subset of the population who would be fairly pissy about the unnecessarily aggressive treatment). The convenience argument only carries so much water... and I’d personally rather inconvenience someone a little and have a defensible position than the counter.

...and God forbid when that 1 in 100000 ulcerated amelanotic melanoma darkens your door (had one in a 46yo just last month - ugh!)

 

[reno911]

Because if I’m wrong even 1 in 500 times then it’s billing fraud if they submit it. And I’m not going to risk that.

I'm not a lawyer, but that's not fraud. If you mistakenly bill something incorrectly, that's different. Of course, if the issue comes up it will be on you to show that your standard is to change when the path comes back as benign, and one of them just slipped through the cracks. Nevertheless, I can understand you not wanting to deal with that. But it's clearly not fraud, although I suppose an over-zealous DOJ prosecutor might be able to wrongly convince 12 laypeople that it is.

Regarding is it “better” than mohs for very low risk tumors- speed, patient cost (in time and dollars) and cost to our society are not nothing. Like I said, you could treat every mild atopic with dupixent with equal if not better control.... but most would not advocate for that or even give patients the option.

I never said that speed and cost were "nothing". Not sure where you got that from. I just wanted to make sure that you weren't claiming benefits other than those two things. So, it's just a question of speed and cost? Nothing else?

 

[reno911]

If you’re wrong - and it was, say, an AK or ISK or BLK — well, you just performed one helluva benign or local destruction (and I’m pretty sure there exists a significant subset of the population who would be fairly pissy about the unnecessarily aggressive treatment). The convenience argument only carries so much water... and I’d personally rather inconvenience someone a little and have a defensible position than the counter.

Agree with this.

There are way too many of bolded in my patient population, to do routine saucerizations (assuming I'm understanding that correctly -- everyone does it a little differently I suppose) let alone routine ED&C.

 

[doctalaughs]

I’m not sure that I’d be too damn comfortable with holding billing for pathology - I’ve head people argue out of both sides of their mouth re: the intent at the time of treatment being the determining factor. I know that this is commonly done - and how it was done where I trained - but it’s not the cleanest way of doing things by any stretch. If you’re wrong - and it was, say, an AK or ISK or BLK — well, you just performed one helluva benign or local destruction (and I’m pretty sure there exists a significant subset of the population who would be fairly pissy about the unnecessarily aggressive treatment). The convenience argument only carries so much water... and I’d personally rather inconvenience someone a little and have a defensible position than the counter.

...and God forbid when that 1 in 100000 ulcerated amelanotic melanoma darkens your door (had one in a 46yo just last month - ugh!)

Our Dermpath is pretty quick so holding it for 2-3 days isn’t a big deal.

I can’t remember the last time I biopsied an AK or BLK... the benign ones I biopsy usually are weird benign stuff like desmoplastic trichoeps. And again, I don’t saucerize 100% of lesions- only when my confidence is approaching 100%. Then again, I’m a big dermoscopy fanatic and for BCC/SCC I’m a firm believer that you can get close to 100% sensitivity/specificity with this alone (not subtyping of course).

Not sure what patient populations we each have but mine is probably 50% old men... then when you account for cancer distributions the NMSC ends up being 60% old men (35% old women and <5% younger pts). Maybe socioeconomics plays a role too but I don’t have too many pissy patients thank god.

Regarding amelanotic melanoma -hopefully it would be one that I would not mistake for NMSC due to the dermoscopy features.... but then again if you saucerized, curetted and went back after path for WLE etc ....it would be bad form but I don’t know of any literature to suggest it would be harmful.

 

[sore eye asses]

I don’t practice the way that Doctalaughs does, partially because I don’t have a nimble billing team, partially because I’m not an expert demoscopist, but his approach sounds reasonable to me in the hands of a highly skilled dermoscopist.

His message seems to focus on system-wide cost containment, and patient time. Like Reno, I agree that these are nontrivial issues.

 

[doctalaughs]

I don’t practice the way that Doctalaughs does, partially because I don’t have a nimble billing team, partially because I’m not an expert demoscopist, but his approach sounds reasonable to me in the hands of a highly skilled dermoscopist.

His message seems to focus on system-wide cost containment, and patient time. Like Reno, I agree that these are nontrivial issues.

Don’t get me wrong I think mohs is an essential part of our practice and I’m grateful that my partner does the nasty cases. I just think part of our value as dermatologists (what we can add over the PCPs and midlevels) is distinguishing between those aggressive cancers and not with accuracy and not over-treat.

A year or two ago I heard a Mohs Surgeon (a fairly famous one) at a conference talk and she literally said that every -EVERY- scc should always go to mohs, no exceptions. I almost choked.

One other pet peeve I have is that no one seems to give super-old/sick patients the option of doing nothing for their skin cancers. If they are 90 with a bunch of co-morbid conditions Most of them time I tell them only to come back if something bothers them and after a reasonable first discussion 99% of of them don’t even want biopsies for the dozen apparent cancers on their body anyway.... sure, treatment is safe in this population but if it’s not going to kill them, doesn’t bother them, and they have an average life expectancy of 2 years most don’t want anything at all....

 

[avidrapper]

Pretty cool discussion here. Almost plays out like a quintessential ethics question.

What matters most: saving system-wide costs? Providing 99% vs 95% cure? Presenting patients with ALL options? Saving patient’s time or minimizing scarring?

They’re important questions to answer since it seems like there’s a significant amount of variability in the area between clear fraud/overuse and inadequate treatment.

 

[MOHS_01]

Don’t get me wrong I think mohs is an essential part of our practice and I’m grateful that my partner does the nasty cases. I just think part of our value as dermatologists (what we can add over the PCPs and midlevels) is distinguishing between those aggressive cancers and not with accuracy and not over-treat.

A year or two ago I heard a Mohs Surgeon (a fairly famous one) at a conference talk and she literally said that every -EVERY- scc should always go to mohs, no exceptions. I almost choked.

One other pet peeve I have is that no one seems to give super-old/sick patients the option of doing nothing for their skin cancers. If they are 90 with a bunch of co-morbid conditions Most of them time I tell them only to come back if something bothers them and after a reasonable first discussion 99% of of them don’t even want biopsies for the dozen apparent cancers on their body anyway.... sure, treatment is safe in this population but if it’s not going to kill them, doesn’t bother them, and they have an average life expectancy of 2 years most don’t want anything at all....

Yeah... but when they become symptomatic the window for easy treatment has often closed as the cause of the symptomatology is more advanced, severe disease. Been there, done that, and it's a situation best avoided. Patients' families often don't remember that they were the ones who wanted to wait, chose to ignore, etc -- you're the doctor, you should have known and told them! (despite the fact that you did). Documentation does not save you from the trouble and expense of dealing with the problem, either.

So no, I do not agree that nonchalant "you're probably going to die in a few anyway" is either good medicine or defensible reasoning, and people will line up around the corner to throw rocks at you. I've done it with several family members and patients that almost view me as family, but as a general practice or approach, f' that.

 

[doctalaughs]

Yeah... but when they become symptomatic the window for easy treatment has often closed as the cause of the symptomatology is more advanced, severe disease. Been there, done that, and it's a situation best avoided. Patients' families often don't remember that they were the ones who wanted to wait, chose to ignore, etc -- you're the doctor, you should have known and told them! (despite the fact that you did). Documentation does not save you from the trouble and expense of dealing with the problem, either.

So no, I do not agree that nonchalant "you're probably going to die in a few anyway" is either good medicine or defensible reasoning, and people will line up around the corner to throw rocks at you. I've done it with several family members and patients that almost view me as family, but as a general practice or approach, f' that.

Not sure it so black or white as you say and “you’re probably going to die anyway” is not quite how I would say the conversation quite goes.

Obviously I always offer treatment and let the patient/family decide— but as you also well know, the nuance with how you phrase things makes a huge difference. And I disagree that documentation doesn’t matter- if you tell them the risks of observation and document it, the family/patient might not remember or be mad later (which I find to be exceedingly rare) but it’s 100% defensible.

I think it’s equally unreasonable to say to a 92 yo with severe CHF, afib and wheelchair bound that his dozen small BCCs are “cancer that absolutely should have surgery and if you wait it will be too late to do anything!” Of course his family will then consent to dragging him across town for multiple surgical sessions. Also not cool.

 

[MOHS_01]

Not sure it so black or white as you say and “you’re probably going to die anyway” is not quite how I would say the conversation quite goes.

Obviously I always offer treatment and let the patient/family decide— but as you also well know, the nuance with how you phrase things makes a huge difference. And I disagree that documentation doesn’t matter- if you tell them the risks of observation and document it, the family/patient might not remember or be mad later (which I find to be exceedingly rare) but it’s 100% defensible.

I think it’s equally unreasonable to say to a 92 yo with severe CHF, afib and wheelchair bound that his dozen small BCCs are “cancer that absolutely should have surgery and if you wait it will be too late to do anything!” Of course his family will then consent to dragging him across town for multiple surgical sessions. Also not cool.

I’m not meaning to be overly argumentative, it’s just that I have recurring burns from “less aggressive” docs weekly. I’m not saying that they’re bad docs, but damn.... don’t spend your week creating problems that someone else has to fix (and then believe that person should be grateful for the referral!).

Yes, there is a big difference between the 5mm SCC or nBCC that you clear and cure with the biopsy and the same ulceration fixed to bone on the scalp or mental crease - but I really shouldn’t be seeing something like the latter weekly, either, as “the rarity that slipped through”. Then, to add insult to injury, the white horse riding daughter (always from out of state) flies in with 100 angry questions about “Dr So and So always just scrapes them off and that’s it, I don’t know why you had to cut clear to bone. That’s ridiculous.” Well, dear, if that earlier **** had worked I wouldn’t be dealing with it now, would I. Want to know why we went to bone? Because the cancer did. If I had been looped in while the cancer was in the dermis, it would have ended there. Want to know what happens if we don’t? Radiation. Likely failure.

 

[MOHS_01]

Not sure it so black or white as you say and “you’re probably going to die anyway” is not quite how I would say the conversation quite goes.

Obviously I always offer treatment and let the patient/family decide— but as you also well know, the nuance with how you phrase things makes a huge difference. And I disagree that documentation doesn’t matter- if you tell them the risks of observation and document it, the family/patient might not remember or be mad later (which I find to be exceedingly rare) but it’s 100% defensible.

I think it’s equally unreasonable to say to a 92 yo with severe CHF, afib and wheelchair bound that his dozen small BCCs are “cancer that absolutely should have surgery and if you wait it will be too late to do anything!” Of course his family will then consent to dragging him across town for multiple surgical sessions. Also not cool.

Oh, not saying that the documentation does not aid or come in handy, I’m saying that it does not mitigate or forego you the cost of having to defend. The costs will still he imposed, and, ironically, the written record has taken on less credence with the advent of EHRs - go figure.