More Than Just Microscopes and Scalpels: The Critical Role of Pathology in Mohs Surgery

Accurate pathology analysis is the crucial foundation of the Mohs technique for skin cancer removal

Mohs pathology is a way to examine skin tissue from Mohs surgery under a microscope. It helps make sure all the skin cancer cells are removed during the surgery.

Mohs surgery may sound like just another surgical procedure, but there’s something unique happening behind the scenes. While the surgeons excise tissue layer by layer, an entire team of pathologists work tirelessly preparing specimens and peering through microscopes hunting for clues. 

Pathology is what makes Mohs surgery so precise. 

By thoroughly examining the surgical margins down to a microscopic level, pathology provides a detailed cancer map that guides the surgeon to clear margins. This process of staged resection combined with real-time pathological analysis allows maximal preservation of healthy tissue and optimization of outcomes. 

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A Closer Look at Mohs Surgery

Mohs micrographic surgery is a technique for removing certain types of skin cancer one layer at a time. After each tissue layer is taken out, it is frozen, stained, meticulously mapped, and examined under a microscope by a pathologist. 

Any areas of cancer found are precisely marked on a diagram. This provides the surgeon with a detailed “cancer map” to direct removal of additional tissue layers until only cancer-free tissue remains.

By analyzing 100% of surgical margins and preserving orientation, Mohs provides unparalleled precision compared to standard biopsies. This allows complete cancer removal while maximally preserving surrounding healthy tissue.

What are the Responsibilities of a Mohs Pathologist?

The main job of the pathologist in Mohs surgery is to thoroughly examine removed tissue samples under a microscope. Their analysis guides the surgeon in determining where additional cancerous tissue may be present.

Once the surgeon removes a tissue layer, the sample is color-coded, mapped, and brought to the pathologist. The pathologist prepares the specimen and views it under the microscope. They carefully scan the margins of the sample, looking for any remaining cancer cells.

If cancer cells are identified, the pathologist marks their location on a map. This allows the surgeon to return to the precise area of involved tissue and continue removing additional layers. The cycle is repeated until the specimens come back completely clear of cancer.

Tissue Preparation and Microscopic Analysis

1. To prepare the tissue for microscopic examination, the sample first undergoes a freezing process. This allows thin slices to be cut from the specimen for optimal viewing under the microscope.
2. The pathologist then methodically analyzes these frozen sections, looking for any sign of remaining cancer. Skin cancers often have characteristic appearances under the microscope that allow them to be distinguished from normal tissue.
3. The pathologist stains the tissue slices using special dyes to highlight cancer cells. Abnormal cellular features like pleomorphism, hyperchromasia, and increased mitotic figures can help identify malignant cells.
4. If any concerning areas are identified, the pathologist notes the specific location so the surgeon can return to that spot and remove additional tissue. This mapping technique is unique to Mohs surgery.

The Importance of Proper Specimen Handling 

Meticulous specimen preparation and handling is imperative for accurate microscopic analysis during Mohs surgery. Careful tissue removal, precise color-coding and mapping, proper freezing, and expert sectioning are critical.

Mishandling of samples can lead to errors in margin interpretation, causing either too much or too little tissue removal. Attention to detail prevents miscommunication between the pathologist and surgeon.

Additionally, chemical fixatives are avoided to prevent artifacts that could obscure cell details important for cancer detection. Delicate handling preserves tissue architecture vital to locating the remaining tumor.

Why a Pathology Report is Necessary After Mohs

A pathology report is an essential documentation of the Mohs procedure and your diagnosis. This permanent record includes key details about the size, depth, and margins of the removed cancer.

The report will identify the specific type of skin cancer, which informs recommendations for follow-up care and surveillance. It also indicates if the cancer was fully excised.

For insurance and medico-legal purposes, the pathology report provides proof of your diagnosis and the extent of treatment completed. It also substantiates the medical necessity of the Mohs procedure.

Save copies of your pathology report. For future skin exams and procedures, this information allows comparison to any new areas of concern.

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Unique Aspects of Mohs Histology

The pathology technique used in Mohs surgery has important differences from standard biopsy analysis:

Unique Aspect	Mohs Histology	Standard Biopsy
Complete Margin Evaluation	Evaluates 100% of both vertical and peripheral margins of excised tissue.	Analyzes only a small, random sample of tissue.
On-site Rapid Analysis	Allows for immediate assessment of the entire surgical edge before closing the wound.	Relies on remote laboratories for analysis, leading to potential delays in results.
Detailed Mapping	Involves meticulous mapping of excised tissue to document locations of residual cancer for targeted removal.	Provides only a positive or negative result without detailed localization.
Color-Coding for Orientation	Uses color-coding to maintain orientation between samples for accurate assessment.	Does not require precise tracking of samples.
Specialized Stains and Preparation	Employs specialized staining techniques and preparation methods to enhance detection of cancerous cells.	Routine processing may miss subtle malignancies due to standard staining techniques.
High Accuracy	Contributes to high accuracy in ensuring complete removal of skin cancers, eliminating guesswork.	May not guarantee complete cancer removal due to limited margin evaluation.

These unique attributes make Mohs pathology highly accurate for ensuring complete removal of skin cancers. No guesswork is involved.

Complementary Expertise: How the Surgeon and Pathologist Work Together

Mohs surgery depends on seamless teamwork between the surgeon and pathologist, with each playing a specialized role.

• The surgeon methodically removes tissue layers and brings samples to the pathology lab. 
• The pathologist examines the specimens under a microscope, analyzing for any remaining cancer cells.

The surgeon carefully extracts thin tissue layers using scalpels, forceps, and other instruments. They take precautions to maintain proper orientation and accurately map removal sites. The samples then undergo delicate handling to prepare microscope slides.

The pathologist meticulously analyzes these frozen sections, scanning for subtle signs of remaining cancer using specialized stains and examination techniques. They must discern benign from malignant patterns based on visual evidence.

When abnormal cells are identified, the pathologist precisely marks their location on diagrammed maps of the wound. These maps guide the surgeon to areas needing further removal.

Some Mohs surgeons receive additional pathology training to analyze their own specimens. More often, a dedicated pathology team works with the surgeon. Their complementary expertise produces comprehensive and accurate analysis.

Seamless coordination between the surgery and pathology staff is vital for success. Each performs their specialized role with precision, allowing the staged excision and microscopic analysis that makes Mohs surgery so effective. The pathologist’s findings guide the surgeon to clear margins while maximally preserving healthy tissue.

Dermatology & Skin Health’s coordinated surgical and pathology expertise provides precisely targeted removal of skin cancers. Schedule your consultation with our experts

Conclusion

Pathology forms the foundation of Mohs micrographic surgery. Meticulous tissue preparation, specialized staining, and expert microscopic analysis allow precise mapping of any remaining cancer cells. This guides the surgeon during the staged excision process to clear margins.

By thoroughly evaluating the surgical margins down to a cellular level, quality pathology is essential for accurately removing skin cancers while preserving healthy tissue. Successful outcomes depend on the collaborative effort between the surgical and pathology team. 

Pathology is what makes Mohs surgery the "gold standard" technique for certain common skin cancers.

[For optimal outcomes in skin cancer removal, partner with the experts at Dermatology & Skin Health.]