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South Texas Veterans Health Care System (STVHCS)

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Beating cancer with Mohs.

A woman holds a slide up to the light to check its quality.

South Texas VA Histotech Debbie Theis-Pruett holds a slide sample to the light to check on the quality of the image. Theis-Pruett has been working in Mohs surgery for 30 years.

By Steven Goetsch
Monday, March 7, 2016

Meryl Streep inadvertently summed up the utility of Mohs surgery when asked about the secrets to parenting. “There’s no road map on how to raise a family; it’s always an enormous negotiation.”

A Mohs surgery is much like that, meticulously using information gleaned from many samples, making adaptations as each layer eliminates a bit of uncertainty, negotiating you might say, through the cancer.

Mohs surgery initially started with its developer, Fred Mohs, using zinc chloride paste to mark particular areas of the skin. In the early years, you were sent home after application, and then the next day the area was excised without anesthesia because the tissue was dead.

Mohs developed later developed techniques to achieve a better cure rate for cancer. He looked at ways to “map” the tissue. This results in conservation of as much healthy tissue as possible.

That early procedure led to the transition of the “fresh technique” developed in the 70’s, which is still used today. Samples of tissue are taken, frozen, and cut with a cryostat by a histotech. A cryostat is an apparatus that can slice very thin pieces of tissue under cold temperatures. The margins are then reviewed by a certified Mohs surgeon.

South Texas VA patients are fortunate to have this valuable health care asset, one of only a handful in the entire system. Patients are taking full advantage as the Dermatology Clinic completes about 550 cases every year. 

A graphic representation of a Moh's procedure with several illustrations of the process

A Mohs surgeon samples the entire margin, whereas oncological surgeons might only sample one percent. The surgeon makes progressive beveled cuts that are immediately viewed to provide the surgeon a map of the tumor or cancer.

Removing that uncertainty is the beauty of Mohs, says Dr. Richard Keller, Chief of Dermatology at the South Texas Veterans Health care System (STVHCS) who has been performing these surgeries at Audie L. Murphy Veterans Memorial Hospital since 2008. “Standard pathology typically reviews about one percent of a margin,” Keller said. “They don’t actually do a review of the entire margin, just a small portion.”

The extra steps involved in Mohs surgery are well worth the results that Keller and his team deliver for their dermatology patients. “I have had approximately 17 reccurrences of cancer in almost 18 years of doing Mohs,” Keller said. Those rates are far better than standard excision. 

South Texas Histotech Debbie Pruett-Theis said the recurrence rates are nearly perfect at 99.95 percent. She has seen the improvements over her time in the field which includes 30 years of Mohs surgery. Besides accuracy, she says sending patients home with a complete treatment is a big plus.

According to Dr. Debra Baruch-Bienen, Chief of the South Texas Medical Service, every 500 Mohs surgeries completed saves the VA roughly one million dollars. 

Even prior to Mohs surgery, the dermatology clinic also offers risk management to Veterans. Many patients with chronic conditions are more susceptible to skin cancers such as squamous cell and melanomas because they are on immune-suppressing medication.  “One of the things that can prevent you from getting skin cancer is your body’s immunity,” Keller explained. “Things that we do to people to prevent some diseases actually cause them to get skin cancer. Like people who get organ transplants. We give them medications that allow them to keep their solid organs, or their bone marrow, and that reduces their immunity and sets them up down the road for getting skin cancer.”

A closeup photo of a dermatological histotech taking samples and building slides as part of the Moh's process

South Texas VA Histotech, Debbie Theis-Pruett, takes the sample and applies it to a slide. The finished product is used by the surgeon to make subsequent excisions, preserving as much healthy tissue as possible.

Keller and the VA manage this risk by providing skin assessments prior to any type of transplant. “The whole idea is to see what kind of burden they have in their skin with pre-existing skin cancers,” Keller added.

If a patient is determined a good candidate for Mohs, the process begins by making multiple progressive beveled cuts. The extra steps are worth the effort. “It takes me an average of 15 minutes per section to process the tissue,” Pruett-Theis said. She added that beats having a patient come in daily for radiation treatments. The problem can be exacerbated if the patient has transportation issues, or is not ambulatory, making a process like Mohs a big convenience for Veterans.

Keller also said the Veteran’s benefit of getting a report back the same day is because the entire process is self-contained. The Mohs surgeon is trained in multiple disciplines during their Mohs fellowship. “That’s the whole beauty of Mohs because the surgeon knows the orientation and location of tumors,” Keller said. Mohs surgeons function as surgical oncologists, pathologists and reconstructive surgeons.  

Keller gave a couple of recommendations that could potentially keep you off of his surgical table. “80 percent of skin cancers are on the head and neck, “Keller said, noting that this is due mainly to sun or UV exposure. He said even people who use sunscreens are using them improperly. “They don’t realize that you need about a tablespoon to cover one arm, and you should reapply in a couple of hours.” He added that a standard tube should last a week, and not the entire summer.

He also recommended wearing long-sleeve shirts, whenever possible, and a full, 3-inch brimmed hat instead of a baseball cap that only protects the nose.



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