17847 A critical appraisal of the history of Mohs micrographic surgery and its evolution in the management of primary mucinous adenocarcinoma

Abstract

Primary mucinous carcinoma (PMC) of the skin is a rare head and neck malignancy. It is resistant to chemotherapy and radiation; therefore, standard treatment includes surgical excision with 1–2-cm margins. Mohs micrographic surgery (MMS) is fast becoming the criterion standard for management of cutaneous carcinomas, offering maximal tissue conservation and high cure rates. We present a brief review of the evolution of MMS, highlight changing practice patterns and introduce a new therapeutic option for PMC. MMS was developed in the 1930s by Frederic E. Mohs. Initially referred to as “chemosurgery,” Dr. Mohs implemented fixed tissue techniques using a chemical cauterant, zinc chloride (ZnCl). He discovered that tissue injected with ZnCl remained histologically preserved. He microscopically examined horizontal sections of fixed tissue from various tumors thereby developing the basic premise of MMS. In 1936, he successfully treated the first squamous cell carcinoma of the lower lip using MMS. The technique has since evolved and is currently applied to various cutaneous malignancies. Our extensive PubMed literature review revealed that the majority of PMC cases are treated with traditional surgical excision (85.5%) and only few with MMS (9.4%). The first case of PMC treated with MMS was published in 1988 with only 20 cases reported in total. Published data reveals lower recurrence rates of PMC treated with MMS (0%-7%) versus excision (30%-40%). In conclusion, MMS appears to be superior to standard excision for PMC and should be considered as first line therapy for primary and recurrent lesions especially in cosmetically sensitive areas.