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MOHS SURGERY AND HISTOPATHOLOGY: BEYOND THE FUNDAMENTALS MOHS SURGERY is a highly effective technique for the surgical removal of most types of cutaneous and oral pharyngeal cancers. The procedure allows for the precise and complete removal of cancers while maximizing the preservation of surrounding normal tissue. Through the presentation and orientation of the specimens’ complete surgical margin on pathology slides, the location of tumor foci and other relevant findings can be correlated with their locations on the surgical wound. The ability to create perfect slides for histological examination lies at the core of effective Mohs surgery. This procedure has the highest cure rate among alternative cancer treatment modalities for the cancers for which it is utilized. This book describes the methods the Mohs surgeon-pathologist and Mohs technician use to optimize the Mohs technique and produce the highest-quality slides and highest cure rates possible, and it breaks new ground in describing techniques that the Mohs technician uses in the lab. Ken Gross, MD, is non-salaried Clinical Professor in the Division of Dermatology at the University of California, San Diego School of Medicine, San Diego, and is also in private practice limited to the treatment of skin cancer in San Diego, California. Howard K. Steinman, MD, is Director of Dermatologic and Skin Cancer Surgery and Associate Professor of Dermatology at the Texas A&M University Health Sciences Center College of Medicine, Scott and White Medical Center, Temple, Texas. MOHS SURGERY AND HISTOPATHOLOGY: BEYOND THE FUNDAMENTALS Edited by Ken Gross University of California, San Diego School of Medicine San Diego, California Howard K. Steinman Texas A&M University Health Sciences Center College of Medicine Temple, Texas CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo, Delhi, Dubai, Tokyo Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521888042 © Cambridge University Press 2009 This publication is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published in print format 2009 ISBN-13 978-0-511-58091-8 eBook (NetLibrary) ISBN-13 978-0-521-88804-2 Hardback Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Every effort has been made in preparing this book to provide accurate and up-todate information that is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors, and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. I hope this book will eventually find its way to the bookshelf equivalent of the “dustbin of history,” as targeted immunotherapy and other evolving cancer treatments replace the surgical model employed today. Even a procedure as elegant as Mohs surgery will find its rightful place alongside other outdated surgical techniques. I hope the transformation happens in my lifetime. To Ruth Gross and Edith Chepin: two peas in a pod enjoying their tenth decade of life. KGG To Barry Goldsmith, for patiently and thoughtfully teaching me Mohs surgery. To the many Mohs surgery course participants for showing me how to better practice and teach our craft. And most assuredly to Robert and Madeline, now gone, and Diedre and our sons, Adam and Steven, sine qua nons, for their boundless love, encouragement, support, and humor, which gives foundation, perspective, joy, and contentment to my life. HKS Our dear friend and colleague, Terry O’Grady, who died during the preparation of this book, will be greatly missed. KGG and HKS Contents C ONTRIBUTORS Chap. 7. LAB PEARLS: STAINING, INKING, AND COVERSLIPPING 57 Alex Lutz ix PART I MICROSCOPY AND TISSUE PREPARATION 1 Chap. 8. LAB PEARLS: TROUBLESHOOTING SLIDE QUALITY 62 Alex Lutz Chap. 1. INTRODUCTION 3 Ken Gross and Howard K. Steinman Chap. 2. HOW TO EXCISE TISSUE FOR OPTIMAL SECTIONING 5 Ken Gross Chap. 9. MOHS SLIDES ORGANIZATION AND STANDARDIZATION FOR EFFECTIVE INTERPRETATION 67 Ken Gross Chap. 3. OPTIMIZING THE MOHS MICROSCOPE 15 Ken Gross Chap. 10. MOHS MAPPING Howard K. Steinman Chap. 4. TISSUE PREPARATION AND CHROMACODING 21 Howard K. Steinman PART III MICROANATOMY AND NEOPLASTIC DISEASE 83 Chap. 5. EMBEDDING TECHNIQUES Edward H. Yob 27 Chap. 11. NORMAL MICROANATOMY: VERTICAL AND HORIZONTAL 85 John B. Campbell PART II INTRODUCTION TO LABORATORY TECHNIQUES 35 Alex Lutz Chap. 12. BASAL CELL CARCINOMA: VERTICAL AND HORIZONTAL 96 A. Neil Crowson and Carlos Garcia Chap. 13. SQUAMOUS CELL CARCINOMA: VERTICAL AND HORIZONTAL 109 A. Neil Crowson and Edward H. Yob Chap. 6. LAB PEARLS: MAKING GREAT SLIDES 37 Alex Lutz PREPARING SLIDES WITH CARTILAGE Michael Shelton 78 Chap. 14. UNUSUAL TUMORS: VERTICAL AND HORIZONTAL 118 Terence O’Grady 52 vii viii C ONTENTS Chap. 15. MOHS FOR MELANOMA 129 Adam J. Mamelak and Arash Kimyai-Asadi Chap. 16. TAKING STAGES BEYOND STAGE I 138 Tri H. Nguyen Chap. 17. PERINEURAL TUMORS 142 Alexander Miller Chap. 19. TOLUIDINE BLUE STAIN FOR MOHS MICROGRAPHIC SURGERY 155 Ofer Arnon, Adam J. Mamelak, and Leonard H. Goldberg Chap. 20. FORMS AND TEMPLATES FOR MOHS SURGERY 161 Ken Gross and Howard K. Steinman I NDEX PART IV SPECIAL TECHNIQUES AND STAINS 149 Chap. 18. FIXED-TISSUE MOHS 151 Laura T. Cepeda, Daniel M. Siegel, and Norman A. Brooks 177 Contributors Ofer Arnon, MD Department of Plastic and Reconstructive Surgery Soroka University Medical Center Beer-Sheva, Israel Division of Dermatology Department of Medicine University of California, San Diego School of Medicine San Diego, California Norman A. Brooks, MD Skin Cancer Medical Center Encino, California Arash Kimyai-Asadi, MD DermSurgery Associates Houston, Texas John B. Campbell, MD Pacific Pathology San Diego, California Alex Lutz Travel Tech Mohs Services, Inc. Torrance, California Laura T. Cepeda, MD Long Island Skin Cancer & Dermatologic Surgery Smithtown, New York Adam J. Mamelak, MD Department of Dermatology The Methodist Hospital Houston, Texas A. Neil Crowson, MD Departments of Dermatology, Pathology, and Surgery University of Oklahoma and Regional Medical Laboratories St. John Medical Center Tulsa, Oklahoma Alexander Miller, MD Department of Dermatology University of California, Irvine Irvine, California Private Practice, Dermatology Yorba Linda, California Carlos Garcia, MD Department of Dermatology University of Oklahoma Oklahoma City, Oklahoma Tri H. Nguyen, MD Departments of Dermatology and Otorhinolaryngology The University of Texas MD Anderson Cancer Center Houston, Texas Terence O’Grady, MD† Division of Dermatology Department of Medicine University of California San Diego School of Medicine San Diego, California Leonard H. Goldberg, MD DermSurgery Associates Houston, Texas Ken Gross, MD Private Practice, Dermatologic Surgery San Diego, California † ix deceased