Preface

The primary goal of this book is to explain what cutaneous margin control surgery (MCS) is and how you can apply it to your skin cancer surgery or pathology practice. We’ll explain why it is needed, what options exist for how to perform it, and the scenarios it can be applied in. Hopefully, those already doing MCS will learn some new concepts, techniques, and applications. We set ourselves the lofty goal of writing a text which can be read with ease from cover to cover while hopefully still being interesting and accurate. To avoid going off on unnecessary tangents and to limit repetition, we’ve aimed for cohesion by being involved in all the chapters while still benefiting from the expertise of the invited contributing authors.

We’ve used acronyms in the text. Though these can be distracting, we ultimately decided to mimic most contemporary texts by using those that are widely known for the sake of consistency. We’ve limited them to those we think are essential and encourage the reader to familiarize themselves with these.

In the recommendations put out by the National Comprehensive Cancer Network® (NCCN), MCS is included as a treatment option for a variety of skin cancers. For one set of tumors, MCS is suggested as an alternative to a standard surgical excision with the recommended measured surgical margins (e.g., high-risk squamous cell carcinoma [SCC] and basal cell carcinoma [BCC]). For another set of tumors, MCS is recommended as the only surgical option (e.g., dermatofibrosarcoma protuberans), while for a different set of tumors, MCS is recommended but for specific scenarios (e.g., melanoma in situ or minimally invasive melanoma on cosmetically sensitive skin).

Mohs micrographic surgery (MMS) or continuous complete peripheral and deep margin assessment (CCPDMA; also called peripheral and deep en face margin assessment [PDEMA]) is practically equivalent therapies in the NCCN. There are numerous textbooks, training programs, societies, and annual conferences for MMS. But what is CCPDMA? Is it the same thing done by a different type of specialist? Is it something new?

CCPDMA involves the examination of the entire peripheral and deep margin without any gaps. In the NCCN definition, a surgical procedure can be described as CCPDMA if all the following criteria are met:

• The entire marginal surface is microscopically examined.

• The surgical specimen is orientated so that a positive margin can be mapped.

• The surgical margin is re-excised and once more the entire margin is visualized until a clear margin is assured.

• The steps are rapid enough to ensure no significant change in the size of the wound.

CCPDMA can be achieved with histopathologic examination using intraoperative frozen section processing or with formalin-fixed paraffin processing. There are a variety of laboratory methods available to achieve this goal. Just as there are no studies to compare variations of the MMS techniques, there is no evidence to suggest that the different forms of MCS (MMS or CCPDMA) have different cure rates. Common sense would agree with the NCCN in considering the MCS options as equivalent procedures.

There are many mentions in the literature of the superior cure rates of MCS when compared with a “wide local excision.” But any comparison depends entirely on how the specimen has been processed in the laboratory and the consequent thoroughness of the margin assessment.

A whole range of medical professionals excises skin cancers. Plastic and reconstructive surgeons, dermatologists, head and neck surgeons, general surgeons, and general practitioners do so in their daily practice. Rather than engaging in some form of surgical paragone or debate as to which type of doctor is best equipped to achieve negative surgical margins, we hope this text interests all types of surgeons as they strive for the best surgical results for their patients.

To cater to this wider audience, we’ve focused mainly on common tumors and scenarios. However, we’ve also attempted to show that some of the techniques can be applied to the treatment of more advanced or uncommon malignancies usually dealt with by oncologic surgeons rather than dermatologists or primary care doctors with an interest in skin cancer.

Pathologists and laboratory staff are usually charged with the task of assessing the margins of skin excisions. They may be well-versed in some techniques but less familiar with some of the other options or perhaps uncomfortable with their use for certain tumors. We hope this book clears up some of these concerns.

An understanding of the histopathology of skin tumors helps in formulating a surgical strategy. Throughout the book, we’ve integrated the relevant pathology and some of the key issues that need to be considered for the various tumors. We hope this will be of interest to surgeons as well as pathologists. One reason why MMS has proved so successful is that the operating surgeon understands and usually interprets the pathology. This understanding is, however, not beyond the scope of other surgeons, especially those who work closely with their colleagues in pathology.

Where possible, histopathologic photos of frozen section slides are used to illustrate features. While this means the images are not as clear as those from paraffin-embedded tissue, we believe these more accurately reflect what is seen in routine practice.

Finally, we’ve tried to create a text which encourages a sense of collegiality. An integrated collegial approach in which specialties learn from each other serves the patient well and is to be encouraged above other more mundane considerations. Collegiality is equally important in all geographic locations, regardless of the access that patients have to different specialist providers.