LITERATURE UPDATE


Mohs micrographic surgery: the face of dermatopathology cooperation


Frozen section support is a vital aspect of Mohs micrographic surgery (MMS) practice. Once focused on the head and neck, MMS is extending its cutaneous reach to other areas of the body. Here, Pathology in Practice Science Editor Brian Nation selects a sample of relevant research in the current literature.


Incomplete Staining Artifact: A Confounding Frozen Section Pathology Artifact Encountered During Mohs Micrographic Surgery Flint N, Friedman P, Frigerio A, Tinklepaugh A. J Drugs Dermatol. 2022 May 1;21(5):544. doi: 10.36849/JDD.542.


The intent of this brief communication is to describe a unique incomplete staining frozen section pathology artefact encountered during Mohs micrographic surgery (MMS).


At the authors’ institution, an amorphous, eosinophilic artefact that obscured cellular architecture was observed multiple times during histological interpretation. It was determined that incomplete tissue staining was likely caused by weak staining, possibly related to an interaction between haematoxylin dye solution and acetone. They adjusted their SLS stain line protocol by adding a 15 second water rinse between the acetone and haematoxylin pots and then compared the old fixation protocol with our new fixation protocol. This artefact, which was regularly found intraoperatively at five separate MMS laboratories has sustainably resolved. Mohs micrographic surgery is a


dermatologic procedure that includes tumour extirpation, tissue grossing, slide preparation, and microscopic histologic interpretation. Tissue grossing and slide preparation are vital components of the MMS procedure. There are many steps throughout tissue processing that can result in frozen section pathology artefacts. Frequently encountered frozen section pathology artefacts include vacuolation of cytoplasm or freeze artefacts; overstaining and understaining with haematoxylin and eosin, incomplete dehydration, and splaying of collagen in the dermis.


Frozen Section Mohs: A Hybrid Technique and One Plastic Surgeon’s Experience with 1714 Consecutive Skin Cancer Removals. Chang ML, Chang SL, Gerges F, Delancy MM, Yang AC, Chang LD. Ann Plast Surg. 2025 Apr 1;94(4S Suppl 2):S121-S125. doi: 10.1097/ SAP.0000000000004254.


While US non-melanoma skin cancer (NMSC) mortality rate has decreased in the past decade, its incidence is rising. Traditional surgical treatments include wide local excision, intraoperative frozen section analysis (IFSA), and Mohs micrographic surgery (MMS). IFSA and MMS are techniques that provide intraoperative analysis allowing the surgeon to confirm margins clear of


malignancy and minimise tissue damage, especially in cosmetically sensitive subunits. Mohs micrographic surgery, with cure rates of 99%-100%, is considered the gold standard but is limited geographically and financially because of specialised training. Here, the authors report a hybrid


surgical technique that effectively excises cutaneous malignancy but can be utilised by plastic surgeons. This hybrid technique is called frozen section Mohs (FSM), which combines both techniques utilised in IFSA and MMS. FSM is similar to IFSA in that the middle breadloaf visualises the central deep margin but is similar to MMS in that the entire periphery is also analysed. This paper is a retrospective review of all patients who have undergone the FSM procedure


In the 1930s, Dr Frederic Mohs was instrumental in revolutionising the field of dermatology with the development of Mohs micrographic surgery to remove skin cancer.


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