Tiefenbrunn - American Society for Mohs Surgery

Sharon F. Tiefenbrunn, M.D.
Private Practice
Clinical Instructor, Washington University, St. Louis,
Missouri
Disclosure of Relevant Relationships with Industry:
• Improve the quality of Mohs
Surgery
• Monitor our success as a
teaching organization
• Provide one of the two
episodes of peer review
required by CLIA
• An ASMS Member picks his most
presentable case from the previous
year.
• Two or three stages
• Minimal number of slides
• Must have tumor on stage I
• Must be clear on the final stage
• Non controversial histology
• Must use standard Mohs Technique
St. Petersberg, June 30 2006, Sunset 11:15 PM
Where you worked until almost midnight and it took ten
stages to clear, and the patient had to have a free flap to
repair the defect, and you were ready to tear your hair
out and swear off Mohs forever.

St I
St II
1. Positive stage I
2. Clear Stage II
3. Stage II adequate
to encompass
tumor on stage I
allowing for the
inherent
inaccuracy of
Mohs surgery.
This is a good case to send for peer review.
4. Can be reviewed
by looking a two
selected sections.
5. No controversial
histology.
6. No complicated
maps to follow.
Keep
It
Simple
Stupid
Atypical Fibroxanthoma Stage I,
Inflammation stage II--? Residual
tumor
This was the tumor
on stage I, called a
microcystic adnexal
carcinoma.
The eStructure
These structures remained on
stage III that was called clear.
Six dermatopathologists could
not agree if they were foreign
body giant cells, sweat duct
tumors or regenerating sweat
ducts in scar tissue.
We felt these were
fibrofollicuomas and
therefore the case
did meet the criteria
for peer review.
Similar structure

•Cases using nonstandard
technique
should not be selected.
Don’t let it
show that
your tech is
struggling to
get a section
of the slide
at all.
Tumor mapped but not taken
As for the
secret
handshake–
Nobody
seems to
know what
it is. There
are three
or four
basic
styles out
there.
The selected case should conform
to

I
• Complete skin edge (90%)
• Complete Deep Margin
• Intact tissue
• Structural details are visible
• Adequate stain
• Visible ink
• For orientation
• To insure complete exam on
sectioned wafers.
What is meant by skin edge?
Horny layer.

II
• If skin edge is missing in stage I, it will be
taken in stage II.
• Stage II must include the tumor in stage I
• The section as seen on the slide does not
accurately reflect tumor left in the patient.
• Overlap in all directions from edge of tumor
• Connect to previous layer and confirm with
inked margins.
• Bevel all edges.

I
Missing skin edge in
stage I must be
examined in stage II
II
Note map not marked
• Traditionally Mohs surgeons have
asssumed that the location of the tumor
on the slide is exactly the same as it is in
the patient.
t
• The ideas about to be presented
contradict this theory and have
implications for the planning of stage II.
• It is in the planning and execution of stage
II that many errors in Mohs Surgery occur.
• A finite amount of tissue is sectioned
away from the specimen before the first
section is placed on a slide.
• Assuming 20 turns of the cryostat before
a section is obtained, at 6 microns with
“sawdust effect” to equal 10 microns,
200 microns are lost.
• 200 microns = .2 mm, a space in which
tumor can travel undetected.

Observed margin
True margin/defect in patient
• We take 20 turns of the cryostat before
putting a section on the slide =.2mm
• We want to examine 95% of possible angles
of extension (180 degrees x.05=9 degrees)
• (9/2 =4.5), tan 4.5=.078
• .2/.078=2.564

• .
Defect Size 1 cm 2cm 3cm 4cm
St II overlap, each
side 1.4mm 2mm 2.4mm 2.8mm
Angle from center,
each side 16 deg 11 deg 9 deg 8 deg

• 1mm of skin edge will give
you 5 sections that
contain skin edge if you
select every 20 th section—
if you save sections more
frequently, it will give
more.
• A long narrow strip of
skin edge attached to a
wide area of dermis and
fat bounded by ink is
ideal.
• Reviewers are your colleagues who are
just as busy as you.
• We want to whip through these cases and
just circle satisfactory and go home.
• So we need for your to fill out your
presenter form completely and accurately.
• This is a job for the physician. It should
not be assigned to anyone else.
Submission date:
Physican Name:
Address:
City State Zip:
Phone:
Fax:
Two forms will be sent.
The Case Submission Form
will have a number on it
that is assigned by ASMS.
ASMS Case Identification Form
Physician Case Number: ____________________
Surgery date:______________________________
ASMS Case Number: __07001___(assigned by ASMS staff)
The Case Identification Form
will link the case with its
presenter and the number it
holds in his office. This Case
ID form will not be seen by the
reviewers, only by the
administrative staff. It will be
destroyed after 6 mo.
2/15/2007
1
2
Don’t forget to
label the sections,
matching the
labels on the
slides.
Don’t forget to
map the tumor!!!!!!
Date Submitted—
Not the date
done.
Site (Location)
Tumor Type
Recurrent?
Stain
Diagram of site
Number of stages
Number of
sections in stage
I. The number of
pieces into which
you cut the
tissue, not the
number of pieces
of tissue on the
slides.
Number of
section in stage
II.
Ink legend -OK to
use colored ink
on form.

I-A-R1
I-1 I-2
Map the location of the
tumor.
II
III
And there
are many
more like
these in
the files!!!
Black
dots, red
dots, red
circles,
red x’s,
black x’s.
Just do it!

B2
•Ideally B2 should be inked as a
mirror image to B1, or even
better as with a third color ink.
Note the dotted line represents
the defect in the patient and the
solid line is stage II in
relationship to that defect.
B2
This case is
nontraditional
in
that is has a
central
vertical
section taken
from stage I.
This results
in tissue loss
from stage I.
No
relationships
are shown.
A legend of dotted,
solid, dashed and
squiggly lines is
acceptable, as is
the use of colored
pens or pencils.
This case was inked on the skin edge. Even
that ink is not very visible.
Right!
WRONG!!!!
• This is probably the number one
problem with the presentation
of cases.
The defect in the
patent is represented
with the dotted line.
The second stage is
shown by the solid
line. Ink should be
placed on the
surface exposed at
the end of the
previous stage

Solid line was used to
represent stage I and
dotted to represent
stage II; explanation
that it was a deep only
with no expected skin
edge indicated which
line was which.
Solid line is
the tissue
taken on
stage II.
Straight lines drawn through defects imply
straight down cuts with undermining brought
up to it. More rounded stage II lines suggest
beveled specimens were taken.
We need to know if you put sections on slides from bottom to top or top
to bottom. If you put two rows on a slide we need to know exactly how
you do it. For example: 1 2
Do you flip sections?
3 4
5 6
7 8
Missing skin edge should be
indicated. It helps and you and us
know if stage II took the skin edge
that stage I missed.
This case excludes itself
from being satisfactory
based on the map alone.
If stage I is missing skin
edge, stage II needs to
examine the skin edge in
that area.
• Do you know what
this means?

The section is
then teased
from underneath
onto the knife
and picked up
with the slide.
It is flipped
vertically from
its normal
orientation.
Stage I taken
from file
folder, lying
just below
defect,
epidermis up.
Section
on chuck
dermal
side
toward
blade.
Section
on x-ray
film
transfer
media,
epidermis
up
Section
on
blade,
dermal
side
up.
Tissue picked
up by slide now
has epidermal
side up, dermal
side against
slide.
Map seen through
microsope Slide rotated 180
As seen through hth
the
microscope.
Rotated to match
the orientation in
the patient.

• Follicular
abnormalities
• Areas of
Inflammation
• AKs
• Nevi
• SKs

• Circle the relevant
sections--
YOURSELF.
• This makes it easy
for the reviewers to
quickly focus on
the essentials.
• Also, sometimes a
a case with a flaw
can get past.
• Mark outside
the skin edge
• This is most
appropriate for
superficial
tumors
• Do not mark
over sections.
Has the mounting
medium
deteriorated?
• Draw what you see
• Rotate
• Don’t flip and turn
microscopic images
in your head.

•Label the case with the case
number assigned by ASMS
•Use Roman Numerals for
Stage I,II,III
•Use Arabic numerals for
sections
•Use R-Arabic numerals for
recuts - R1, R2, R3,
I-1 2
O6001 O6001 O6001 O6001 O6001 O6001
I-1-R0 1-1-R1 I-2-R0 I-2-R1 II-R0 II-R1
II
• To the ASMS staff
• To reviewers
• To the presenter

It will be classified into one of the
following categories:
1. Satisfactory
2. Comments only
3. Unreviewable
Case No.__________________
Reviewer Form
____Case Not Reviewable –please submit another case or correct the
presentation of this one.
Map issues-ink legend, Tumor not marked on map Relationship not shown
Sections not labeled Confusing slide labeling Non-standard Mohs technique
Bubbles Too complex a case – over 3 Stages. No Identifiable Tumor Stage I
Other (Specify)
____Case Reviewed _____Satisfactory _____Comments
Mark “U” where unsatisfactory
General gross appearance of slides
Stage I-A
Pertains to all Stages
Skin Edge Adequate (90% with
exceptions)
Deep Margin (90% with exceptions)
Structure Details (thick sections, etc.)
Stain
Ink for orientation
Ink to ascertain completeness
ess
Tumor identified and accurately mapped
Normal structures ID’d as tumor
Pertains to Stage II
Missing Skin Edge Stage I taken in
Stage II
Missing Deep Tissue I taken in Stage II
Tumor from Stage I taken in stage II
Adequate Overlap
Adequate connection- Visible ink on
non-epidermal edge and adequate ink
visualized.
Clear Final Stage
Comments:
• Satisfactory cases are
beautiful cases with
obvious tumor on stage
I and absence of tumor
on stage II

Comments
Not enough overlap to determine clear margin.
This case can be reviewed
and gets comments:
Stain is too dark
Tumor is near epidermis in
stage II and therefore
stage III needs to have
skin edge, which it doesn’t
• The slides will be scanned, and
possibly photographed.
• The map will be scanned.
• A critique of the case, including the
first reviewers comments will be
created and sent to the presenter.
• The case may become a teaching
case.
• Satisfactory means pass
• Comments means fail
• Loss of ASMS Fellowship is no longer
associated with lack of satisfactory
completion of peer review.
• Participation is not only required for the
first four years.
However, if you get Comments, hide the
case and meet your CLIA requirements by
cross-reading with another lab.
• One cause is lack of information.

• But until we
get a map, we
are not going
to agonize
over it.
• It’s
unreviewable.
• Are these follicular
structure or tumor?
• The peer review
committee split 6 to
6.
• Map issues-ink legend,
• Tumor not marked on map
• Relationship not shown
• Sections not labeled
• Confusing slide labeling
• Non-standard Mohs technique
• Bubbles
• Too complex a case – over 3 Stages.
• No Identifiable Tumor Stage I
• Other (Specify)
• Fix the case and send it back—map
the tumor, draw the relationships.
• Sometimes this can be done by fax.
• If it is unreviewable because of an
unsolvable controversy, a new case
must be picked and submitted. The
first case does not count toward the
limit of two free tries per year.
• A Satisfactory outcome can be used as
one of the two peer review episodes
required by CLIA.
• Comments are meant to steer the
presenter into improving his Mohs.
• Unreviewable is used when there is no
map, or the map is not marked, or when
the panel cannot agree if a structure is
tumor or not. A second case should be
sent for review.
• Select your case carefully
y
y
• Present it well
• OR THIS COULD HAPPEN TO YOU