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Slow-Mohs versus regular Mohs

Posted By: JT on 2008-01-22
In Reply to: More info in Mohs procedure. - nm

I am a patient, not a doctor, but my understanding is this:

A regular Mohs procedure takes many hours but is finished the same day you start the procedure. The doctor cuts out the visible tumor, then makes either vertical or horizontal slices from what she has removed. Those slices are made into frozen slides (not literally frozen) and analyzed by the doctor while the patient waits in the office. This allows the doctor to "map" the tumor. If a part of a slide doesn't show a clear (tumor-free) margin, the patient is called back in to a little more tissue removed. Again, that tissue is made into frozen slides and the doctor looks for clear margins. The patient will keep being called back in to have more removed until all the slides show clear margins. This can take many hours, but once the margins are clear, the wound is closed and that is the end of it.

Slow-Mohs is when the wound is left open for a day or two (and up to a week) while the slides are analyzed. That is why it is called "slow" (the time you spend in the office on the first day of surgery should be about the same as if you had regular Mohs). The reason it takes so much longer to analyze the slow-Mohs slides is because the doctor uses paraffin-embedded slides instead of frozen slides. Paraffin-embedded slides are of much higher quality than frozen (my doctor said it's the difference between a huge HD TV and an old black and white TV with bunny-ear antennas).

For most of the malignant tumors treated by Mohs, frozen slides (and thus regular Mohs) is sufficient. But there are some types of tumors that have long, finger-like extensions (like roots) that are hard to see on frozen slides. If they are removed with regular Mohs than these roots could be missed and lead to a recurrance of the tumor. So that is when Slow-Mohs is usually used.

Sometimes Slow-Mohs is called Modified Mohs, but I have also heard Modified Mohs refer to a regular Mohs procedure with other variations. So if a doctor says they are going to do Modified Mohs, ask them exactly what they mean by that.

You should also ask if your doctor will be using vertical (bread-loafing) slices, or horizontal slices. I think vertical is the norm, but horizontal is better for tumors with irregular boarders.

Also, sometimes after doing regular Mohs with frozen slides, the doctor will take a final slice for paraffin-embedded slides to be analyzed just in case. This final paraffin-embedded slide isn't the same as Slow-Mohs. In the rare instance that the final slide comes back with a positive margin, the patient will be brought back in for another Mohs procedure, but usually regular Mohs is a one-day affair.

Overall, Mohs and Slow-Mohs are a great alternative to a wide surgical excision that could result in greater (and unnessesary) tissue loss. I think it is widely accepted for skin cancers, but more controvertial in other cancers like sarcomas.

I have a very rare sarcoma called Dermatofibrosarcoma protuberans (DFSP) and while most of the literature I read says Mohs is at least equal to or better than wide excision (but with less tissue loss), I have seen 2 sarcoma specialists that are strongly opposed to Mohs for DFSP. However, their reasons are that vertical slices and frozen slides are inadequate for DFSP. However, it doesn't seem like they are aware of the horizontal slicing options and the ability to do paraffin-embedded slides in Slow-Mohs (and doctors don't respond well to any implication that there is something they don't know). So I am trying to arm myself with as much knowledge as possible...and I suggest you do the same if you have one of the more controversial tumors.

Here is a good (technical) article about Mohs and DFSP that describes the different types of Mohs:
"Modified Mohs Micrographic Surgery in the Therapy of
Dermatofibrosarcoma Protuberans: Analysis of 22 Patients" http://www.annalssurgicaloncology.org/cgi/reprint/11/4/438


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Slow. Laid back or high maintenance?
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