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Are dermatologists qualified to read pathology if they are MOHS surgeons?

Forums General Melanoma Community Are dermatologists qualified to read pathology if they are MOHS surgeons?

  • Post
    mlbjab
    Participant

      Curious.  Shopping around for new derm.  Found one I like but she reads her own pathology, and sends out for stains if necessary.  Thought that was odd.  Is that ok?  She is a teaching Derm with research part of her practice that has med students – but not associated with any major hospital that  I know of?

      Curious.  Shopping around for new derm.  Found one I like but she reads her own pathology, and sends out for stains if necessary.  Thought that was odd.  Is that ok?  She is a teaching Derm with research part of her practice that has med students – but not associated with any major hospital that  I know of?

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    • Replies
        Janner
        Participant

          Since reading melanocytes best requires staining, I'm not sure.  I want all my biopsied stained.  Certainly there are derms who are trained in dermatopathology.  I'd ask if she has certification as such.  Just because they read their own slides doesn't meaned they have extra training to do so.  I think you need to ask more questions or do more research.

            mlbjab
            Participant

              The derm is a MOHS surgeon, which is why she said she was trained to do pathology.

              Janner
              Participant

                Now your question makes more sense to me.  Mohs surgeons primarily remove basal and squamous cell cancers.  Melanoma isn't typically done via Mohs because melanocytes don't show up well on "frozen section" techniques which is how Mohs processes tissue samples for analysis.  Melanocytes show up best when stained.  So I would be fine having this derm look at any basal/squamous cell lesions, but I would want anything pigmented stained.  My cutaneous onc is also a Mohs surgeon, but he doesn't do his own pathology on biopsies suspicious for melanoma.  If it's removed via Mohs, then we know basal/squamous and Mohs is appropriate and he does his own pathology.  But anything suspicious of melanoma is not removed via Mohs and it goes to dermatopathologists for staining.

                Janner

                chalknpens
                Participant

                  Hi Janner,

                  My melanoma sites were removed by what my surgeon calls "Slow Mohs", and each cutting is sent out for stains and I'm called with the results and return the next day for either sutures or another cutting. The squamous site was done the same way, and the basal sites are closed the same day. Does this agree with what you said above, "If it's removed via Mohs, then we know basal/squamous and Mohs is appropriate and he does his own pathology.  But anything suspicious of melanoma is not removed via Mohs and it goes to dermatopathologists for staining." ?

                  chalknpens
                  Participant

                    Hi Janner,

                    My melanoma sites were removed by what my surgeon calls "Slow Mohs", and each cutting is sent out for stains and I'm called with the results and return the next day for either sutures or another cutting. The squamous site was done the same way, and the basal sites are closed the same day. Does this agree with what you said above, "If it's removed via Mohs, then we know basal/squamous and Mohs is appropriate and he does his own pathology.  But anything suspicious of melanoma is not removed via Mohs and it goes to dermatopathologists for staining." ?

                    chalknpens
                    Participant

                      Hi Janner,

                      My melanoma sites were removed by what my surgeon calls "Slow Mohs", and each cutting is sent out for stains and I'm called with the results and return the next day for either sutures or another cutting. The squamous site was done the same way, and the basal sites are closed the same day. Does this agree with what you said above, "If it's removed via Mohs, then we know basal/squamous and Mohs is appropriate and he does his own pathology.  But anything suspicious of melanoma is not removed via Mohs and it goes to dermatopathologists for staining." ?

                      Janner
                      Participant

                        I've never understood your slow Mohs.  It's not how most melanoma is removed except possibly in the case of Lentigo Maligna Melanoma.  If this were on your face, then tissue saving is of great concern.  That is typically what Mohs was designed for – SCC/BCC on the face.  Lentigo Maligna Melanoma is also in sun exposed areas and has a high local recurrence rate, so some doctors will use Mohs for it.  Since I don't believe yours was on your face, having a wide excision span days seems overkill to me.  Most everyone else here has their melanoma removed with extra margins.  Mohs is designed to remove only the affected tissue and leave normal tissue behind.  Truthfully, while they probably analyze more tissue with Mohs, the extra margins a WLE gives me a measure of comfort.  Just to be clear – Mohs was not designed for melanoma, it was designed for basal cell carcinoma and squamous cell carcinoma which are EASILY seen via frozen section.  Doing Mohs on these cancers allows them to be removed completely at one setting with a much smaller chance of local recurrence and minimizes tissue removal.  Doing Mohs for melanoma is something that has come along later.  My cutaneous oncologist (Mohs surgeon) would not use it on me for melanoma – he does a WLE.  He does use it for Lentigo Maligna Melanoma on the face AFTER using Aldara first.  Aldara (topical chemo) tends to significantly shrink a LMM lesion and the the Mohs surgery can remove the rest.  As for your question, it your lesion is being stained, then that's important.  What still eludes me is if your surgeon only removes the melanoma or if he takes extra margins. 

                        chalknpens
                        Participant

                          Hi Janner, re: Slow Moh surgery

                          I went back to the dermpath lab reports to look for the term lentigo. Closest I found was in the site on my inner forearm (see below.) The 'slow Mohs' surgery takes place over a period of days. The surgeon takes the first excision (following the dermatologist's biopsy) and sends it to the path lab for analysis. It usually comes back the next day (barring a weekend) and, in my case, indicates that the margins are not yet clear. On my back, they were not clear at all 'clock face points' (12 – 3, 3 – 6 etc.) So I return the next day and the surgeon cuts again, wider. The wound is not closed with sutures until the path lab says all margins clear, which on my back took three separate cuttings over a week's time. Between cuttings the wound is covered with a generous dollop of aquaphor (like baby vaseline) and an aquaphor-permeated skin-like covering, and then a tefla pad and tape.

                          Neither of these sites had a mole; my back had a light red coloring about the size of a softball, and my arm had a variegated brown coloring the size of a quarter. My back was diagnosed with a biopsy report that read "superficial spreading lentiginous variant", and took three separate cuttings. the first cutting path report referred to residual malignant melanoma in situ with appendageal involvement present at margin broadly throughout. The second cutting's path lab read "focal atypical melanocytic hyperplasia, consistent with edge of malignant melanoma in situ, present at margin in center of  specimen,"  and the third cutting's path lab read "margin free of atypical melanocytes." These three surgeries extended over six days, resulting in a wound the size of a softball, eventually sutured in the shape of a Z about 7" x 4" in size.

                          My arm's melanoma site required two surgeries: the biopsy's path report read " severely atypical lentinous junctiional melanocytic proliferation consistent with early malignant melanomain situ, extending to the tissue edges;  the first surgery's path report read "present at margin broadly throughout from 12-3 and 3-6." The other half of the site was 'margin clear. '  I returned for a second cutting a day later, and the path report read 'margins free of malignant melanoma in situ,"and resulted in my returning the next day for sutures closing a wound about the size of a silver dollar. The suture line was again a Z shape, measuring 4" x 1" in size.

                          I think his first excisions were conservative, but they grew cutting by cutting. The passage of time with open wounds caused me some anxiety, particularly when the back was still open the early morning I was taken and admitted to the hospital due to a syncopal seizure (fainting and rigidity while unconscious) caused by a severe back spasm. I had had the third cut on a Friday, and the eventual sutures that Monday, after spending Sat/Sunday in our local hospital.

                          I'm due to go next month (already!) for my three month check. I pray they find nothing more.

                          Janner
                          Participant

                            I think your lesions sound much more consistent with Lentigo Maligna Melanoma which is something my doc will do via Mohs.  Even if it isn't specified as such, it's obviously being treated just like LMM.  Most have a discreet mole, not an area of involved skin.  LMM has a higher local recurrence rate because it is difficult to get clear margins.  It often spreads further under the skin than is seen on top.  My doc is involved in a clinical study where they apply Aldara first for several weeks before doing the excision.  They say that the lesion may be as much as 2/3rds smaller after the Aldara so the excision doesn't need to be so large  However, most people here do not have the same type of melanoma you do and Mohs (slow or not) is probably not the best choice for those.  I've had 3 superficial spreading melanoma lesions.  Superficial Spreading accounts for about 70% of all melanomas and by far is the most prevalent type on this board. 

                            Janner
                            Participant

                              I think your lesions sound much more consistent with Lentigo Maligna Melanoma which is something my doc will do via Mohs.  Even if it isn't specified as such, it's obviously being treated just like LMM.  Most have a discreet mole, not an area of involved skin.  LMM has a higher local recurrence rate because it is difficult to get clear margins.  It often spreads further under the skin than is seen on top.  My doc is involved in a clinical study where they apply Aldara first for several weeks before doing the excision.  They say that the lesion may be as much as 2/3rds smaller after the Aldara so the excision doesn't need to be so large  However, most people here do not have the same type of melanoma you do and Mohs (slow or not) is probably not the best choice for those.  I've had 3 superficial spreading melanoma lesions.  Superficial Spreading accounts for about 70% of all melanomas and by far is the most prevalent type on this board. 

                              Janner
                              Participant

                                I think your lesions sound much more consistent with Lentigo Maligna Melanoma which is something my doc will do via Mohs.  Even if it isn't specified as such, it's obviously being treated just like LMM.  Most have a discreet mole, not an area of involved skin.  LMM has a higher local recurrence rate because it is difficult to get clear margins.  It often spreads further under the skin than is seen on top.  My doc is involved in a clinical study where they apply Aldara first for several weeks before doing the excision.  They say that the lesion may be as much as 2/3rds smaller after the Aldara so the excision doesn't need to be so large  However, most people here do not have the same type of melanoma you do and Mohs (slow or not) is probably not the best choice for those.  I've had 3 superficial spreading melanoma lesions.  Superficial Spreading accounts for about 70% of all melanomas and by far is the most prevalent type on this board. 

                                chalknpens
                                Participant

                                  Hi Janner, re: Slow Moh surgery

                                  I went back to the dermpath lab reports to look for the term lentigo. Closest I found was in the site on my inner forearm (see below.) The 'slow Mohs' surgery takes place over a period of days. The surgeon takes the first excision (following the dermatologist's biopsy) and sends it to the path lab for analysis. It usually comes back the next day (barring a weekend) and, in my case, indicates that the margins are not yet clear. On my back, they were not clear at all 'clock face points' (12 – 3, 3 – 6 etc.) So I return the next day and the surgeon cuts again, wider. The wound is not closed with sutures until the path lab says all margins clear, which on my back took three separate cuttings over a week's time. Between cuttings the wound is covered with a generous dollop of aquaphor (like baby vaseline) and an aquaphor-permeated skin-like covering, and then a tefla pad and tape.

                                  Neither of these sites had a mole; my back had a light red coloring about the size of a softball, and my arm had a variegated brown coloring the size of a quarter. My back was diagnosed with a biopsy report that read "superficial spreading lentiginous variant", and took three separate cuttings. the first cutting path report referred to residual malignant melanoma in situ with appendageal involvement present at margin broadly throughout. The second cutting's path lab read "focal atypical melanocytic hyperplasia, consistent with edge of malignant melanoma in situ, present at margin in center of  specimen,"  and the third cutting's path lab read "margin free of atypical melanocytes." These three surgeries extended over six days, resulting in a wound the size of a softball, eventually sutured in the shape of a Z about 7" x 4" in size.

                                  My arm's melanoma site required two surgeries: the biopsy's path report read " severely atypical lentinous junctiional melanocytic proliferation consistent with early malignant melanomain situ, extending to the tissue edges;  the first surgery's path report read "present at margin broadly throughout from 12-3 and 3-6." The other half of the site was 'margin clear. '  I returned for a second cutting a day later, and the path report read 'margins free of malignant melanoma in situ,"and resulted in my returning the next day for sutures closing a wound about the size of a silver dollar. The suture line was again a Z shape, measuring 4" x 1" in size.

                                  I think his first excisions were conservative, but they grew cutting by cutting. The passage of time with open wounds caused me some anxiety, particularly when the back was still open the early morning I was taken and admitted to the hospital due to a syncopal seizure (fainting and rigidity while unconscious) caused by a severe back spasm. I had had the third cut on a Friday, and the eventual sutures that Monday, after spending Sat/Sunday in our local hospital.

                                  I'm due to go next month (already!) for my three month check. I pray they find nothing more.

                                  chalknpens
                                  Participant

                                    Hi Janner, re: Slow Moh surgery

                                    I went back to the dermpath lab reports to look for the term lentigo. Closest I found was in the site on my inner forearm (see below.) The 'slow Mohs' surgery takes place over a period of days. The surgeon takes the first excision (following the dermatologist's biopsy) and sends it to the path lab for analysis. It usually comes back the next day (barring a weekend) and, in my case, indicates that the margins are not yet clear. On my back, they were not clear at all 'clock face points' (12 – 3, 3 – 6 etc.) So I return the next day and the surgeon cuts again, wider. The wound is not closed with sutures until the path lab says all margins clear, which on my back took three separate cuttings over a week's time. Between cuttings the wound is covered with a generous dollop of aquaphor (like baby vaseline) and an aquaphor-permeated skin-like covering, and then a tefla pad and tape.

                                    Neither of these sites had a mole; my back had a light red coloring about the size of a softball, and my arm had a variegated brown coloring the size of a quarter. My back was diagnosed with a biopsy report that read "superficial spreading lentiginous variant", and took three separate cuttings. the first cutting path report referred to residual malignant melanoma in situ with appendageal involvement present at margin broadly throughout. The second cutting's path lab read "focal atypical melanocytic hyperplasia, consistent with edge of malignant melanoma in situ, present at margin in center of  specimen,"  and the third cutting's path lab read "margin free of atypical melanocytes." These three surgeries extended over six days, resulting in a wound the size of a softball, eventually sutured in the shape of a Z about 7" x 4" in size.

                                    My arm's melanoma site required two surgeries: the biopsy's path report read " severely atypical lentinous junctiional melanocytic proliferation consistent with early malignant melanomain situ, extending to the tissue edges;  the first surgery's path report read "present at margin broadly throughout from 12-3 and 3-6." The other half of the site was 'margin clear. '  I returned for a second cutting a day later, and the path report read 'margins free of malignant melanoma in situ,"and resulted in my returning the next day for sutures closing a wound about the size of a silver dollar. The suture line was again a Z shape, measuring 4" x 1" in size.

                                    I think his first excisions were conservative, but they grew cutting by cutting. The passage of time with open wounds caused me some anxiety, particularly when the back was still open the early morning I was taken and admitted to the hospital due to a syncopal seizure (fainting and rigidity while unconscious) caused by a severe back spasm. I had had the third cut on a Friday, and the eventual sutures that Monday, after spending Sat/Sunday in our local hospital.

                                    I'm due to go next month (already!) for my three month check. I pray they find nothing more.

                                    Janner
                                    Participant

                                      I've never understood your slow Mohs.  It's not how most melanoma is removed except possibly in the case of Lentigo Maligna Melanoma.  If this were on your face, then tissue saving is of great concern.  That is typically what Mohs was designed for – SCC/BCC on the face.  Lentigo Maligna Melanoma is also in sun exposed areas and has a high local recurrence rate, so some doctors will use Mohs for it.  Since I don't believe yours was on your face, having a wide excision span days seems overkill to me.  Most everyone else here has their melanoma removed with extra margins.  Mohs is designed to remove only the affected tissue and leave normal tissue behind.  Truthfully, while they probably analyze more tissue with Mohs, the extra margins a WLE gives me a measure of comfort.  Just to be clear – Mohs was not designed for melanoma, it was designed for basal cell carcinoma and squamous cell carcinoma which are EASILY seen via frozen section.  Doing Mohs on these cancers allows them to be removed completely at one setting with a much smaller chance of local recurrence and minimizes tissue removal.  Doing Mohs for melanoma is something that has come along later.  My cutaneous oncologist (Mohs surgeon) would not use it on me for melanoma – he does a WLE.  He does use it for Lentigo Maligna Melanoma on the face AFTER using Aldara first.  Aldara (topical chemo) tends to significantly shrink a LMM lesion and the the Mohs surgery can remove the rest.  As for your question, it your lesion is being stained, then that's important.  What still eludes me is if your surgeon only removes the melanoma or if he takes extra margins. 

                                      Janner
                                      Participant

                                        I've never understood your slow Mohs.  It's not how most melanoma is removed except possibly in the case of Lentigo Maligna Melanoma.  If this were on your face, then tissue saving is of great concern.  That is typically what Mohs was designed for – SCC/BCC on the face.  Lentigo Maligna Melanoma is also in sun exposed areas and has a high local recurrence rate, so some doctors will use Mohs for it.  Since I don't believe yours was on your face, having a wide excision span days seems overkill to me.  Most everyone else here has their melanoma removed with extra margins.  Mohs is designed to remove only the affected tissue and leave normal tissue behind.  Truthfully, while they probably analyze more tissue with Mohs, the extra margins a WLE gives me a measure of comfort.  Just to be clear – Mohs was not designed for melanoma, it was designed for basal cell carcinoma and squamous cell carcinoma which are EASILY seen via frozen section.  Doing Mohs on these cancers allows them to be removed completely at one setting with a much smaller chance of local recurrence and minimizes tissue removal.  Doing Mohs for melanoma is something that has come along later.  My cutaneous oncologist (Mohs surgeon) would not use it on me for melanoma – he does a WLE.  He does use it for Lentigo Maligna Melanoma on the face AFTER using Aldara first.  Aldara (topical chemo) tends to significantly shrink a LMM lesion and the the Mohs surgery can remove the rest.  As for your question, it your lesion is being stained, then that's important.  What still eludes me is if your surgeon only removes the melanoma or if he takes extra margins. 

                                        Janner
                                        Participant

                                          Now your question makes more sense to me.  Mohs surgeons primarily remove basal and squamous cell cancers.  Melanoma isn't typically done via Mohs because melanocytes don't show up well on "frozen section" techniques which is how Mohs processes tissue samples for analysis.  Melanocytes show up best when stained.  So I would be fine having this derm look at any basal/squamous cell lesions, but I would want anything pigmented stained.  My cutaneous onc is also a Mohs surgeon, but he doesn't do his own pathology on biopsies suspicious for melanoma.  If it's removed via Mohs, then we know basal/squamous and Mohs is appropriate and he does his own pathology.  But anything suspicious of melanoma is not removed via Mohs and it goes to dermatopathologists for staining.

                                          Janner

                                          Janner
                                          Participant

                                            Now your question makes more sense to me.  Mohs surgeons primarily remove basal and squamous cell cancers.  Melanoma isn't typically done via Mohs because melanocytes don't show up well on "frozen section" techniques which is how Mohs processes tissue samples for analysis.  Melanocytes show up best when stained.  So I would be fine having this derm look at any basal/squamous cell lesions, but I would want anything pigmented stained.  My cutaneous onc is also a Mohs surgeon, but he doesn't do his own pathology on biopsies suspicious for melanoma.  If it's removed via Mohs, then we know basal/squamous and Mohs is appropriate and he does his own pathology.  But anything suspicious of melanoma is not removed via Mohs and it goes to dermatopathologists for staining.

                                            Janner

                                            mlbjab
                                            Participant

                                              The derm is a MOHS surgeon, which is why she said she was trained to do pathology.

                                              mlbjab
                                              Participant

                                                The derm is a MOHS surgeon, which is why she said she was trained to do pathology.

                                              Janner
                                              Participant

                                                Since reading melanocytes best requires staining, I'm not sure.  I want all my biopsied stained.  Certainly there are derms who are trained in dermatopathology.  I'd ask if she has certification as such.  Just because they read their own slides doesn't meaned they have extra training to do so.  I think you need to ask more questions or do more research.

                                                Janner
                                                Participant

                                                  Since reading melanocytes best requires staining, I'm not sure.  I want all my biopsied stained.  Certainly there are derms who are trained in dermatopathology.  I'd ask if she has certification as such.  Just because they read their own slides doesn't meaned they have extra training to do so.  I think you need to ask more questions or do more research.

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