He skin cancer It is one of the most frequent worldwide. In Spain, according to the Spanish Association Against Cancer, in 2023, 20,392 new skin cancers were diagnosed in total, which represents just over 8% of the total cancers diagnosed this year. Non-melanoma carcinomas are the most frequent with 14,430 new cases, compared to the 5,962 melanoma diagnoses made in our country in 2023.
Treatments can be different depending on the type of tumor, frequently being surgical in the earliest phases, although other therapies can also be used such as: radiotherapy, chemotherapy, targeted treatments and immunotherapy… Depending on the tumor types and phase of the disease in that is found.
Oncological dermatology is currently expanding with the development of new techniques, treatments and approaches to skin cancer. Proof of this is the Mohs surgerya surgical technique that allows for the precise removal of cancer cells while preserving as much healthy tissue as possible.
Some of the most prominent leading experts in this specialized technique met on May 10 at the Ramón Areces Foundation, in an international conference organized by the International Dermatological Clinic (CDI), the Ruber International Hospital and the Foundation, to share and discuss the latest developments and discoveries in this fundamental field of dermatology.
Management of skin cancer
The doctor. Ricardo Ruiz Rodríguez, medical director of Dermatology at Clínica Dermatológica Internacional (CDI) and head of the Dermatology Service at Hospital Ruber Internacional, summarized the enormous evolution that the management of skin cancer has experienced in recent years, in which Mohs surgery is the protagonist . «Currently we have the “magic bullets” (immunotherapy), which are based on using drugs that, instead of destroying tumor cells, stimulate our immune system to act against cancer. We also have the liquid biopsy or Gene Expression Profile Test, which consists of performing a blood test on a patient and looking for genetic material from the tumor in said analysis. And, of course, we have Mohs surgery, a technique with which we remove skin cancer using microscopic control, achieving the best oncological and aesthetic results by respecting healthy tissue as much as possible.
He Dr. Pedro Rodrígueza dermatologist specializing in Oncology and Dermatological Surgery at the Ruber International Hospital and International Dermatological Clinic, defined in which specific cases it is possible to perform Mohs surgery: «This type of surgery has many indications, although in the vast majority of times we use it to treat most common type of skin cancer, which is Basal cell carcinoma».
Objectives of Mohs surgery
The two fundamental objectives of Mohs surgery, as explained by Dr. Rodríguez, are «completely remove a tumor and preserve maximum healthy tissue. “Always looking secondarily, but no less importantly, for the best functional result and the best aesthetic result.” It is indicated for high-risk tumors and/or in high-risk areas, especially the facial mask, but also for areas that may have special needs, such as hands, feet or genitals.
The doctor. Fernando Pinedohead of the Pathological Anatomy Unit of the Alcorcón Foundation University Hospital, insisted on the essential collaboration between the dermatologist, the dermopathologist and the specialist in pathological anatomy, given that the immediate pathological analysis of the tissues resected during the procedure ensures that all cancer has been removed.
Types of Mohs surgery
«We can distinguish two types of Mohs surgery: conventionalwhich we are going to do fundamentally in basal cell carcinoma and squamous cell carcinoma, and the Delayed Mohs or slow Mohs, or more recently micrographic surgery with controlled edges in paraffin. “This requires an experienced dermatologist, an experienced dermatopathologist and, of course, a pathological anatomy technician who knows how to process the samples correctly,” explained Dr. Pinedo.
Dr. spoke of another cutting-edge technology in the framework of Mohs surgery. Onofre Sanmartínhead of the Dermatology Service of the Valencian Institute of Oncology and coordinator of the Spanish Group of Dermatological Surgery and Oncology (GEDOC): «The ex vivo confocal microscopy», he noted, «it uses two types of laser: an infrared reflectance laser and a blue fluorescence laser. Both images are merged into one to study it. “It is a technology that offers very good resolution and represents a significant saving of time.”
The use of this advanced microscope does not exempt, however, from the essential presence of the pathologist in the procedure: «All negativities are confirmed in pathological anatomy, because the sensitivity of this technique is very high, but the specificity is not 100%. . “That is why we prefer, when the margin is positive, to continue cutting in the patient, and when we see that it is negative, we confirm with pathological anatomy to avoid leaving tumor in the patient.”
The presentation of Dr. Javier Cañuetohead of the Dermatology Service, High Risk Skin Cancer Unit of the Salamanca University Care Complex, focused on the application of this surgical technique in the treatment of cutaneous squamous cell carcinoma.
«It is a clinically very heterogeneous tumor, which can cause patient death in a number that is not insignificant. “Surgery is the standard of treatment,” said Dr. Cañueto. “In these carcinomas, Mohs surgery allows a high cure rate, since it completely examines the margins of the tumor” and adds: “There are studies in which it has been observed that Mohs surgery is associated with almost half the risk of death and almost half the risk of relapse compared to conventional surgery”, even in high and very high risk cases.
Risk areas for the Mohs surgeon
The Mohs surgeon must have a thorough knowledge of the areas of special risk and apply extreme caution during each intervention, as explained by Dr. Yolanda Delgadohead of the Dermatology Service of the Mohs Surgery Unit of the La Princesa University Hospital (Madrid).
«In oncological surgery, a very important balance of benefit and risk must be made. The aim is always to achieve two objectives: on the one hand, the complete removal of the tumor, but we have to take the greatest possible care to minimize collateral damage. To do this, it is essential to have a deep knowledge of the anatomy of the area that we are going to treat and know how to recognize, identify and correctly treat the areas of maximum danger, where extreme care must be taken,” Dr. Delgado insisted.
Common errors in Mohs surgery
In his presentation, Dr. Tomas Toledo, dermatologist specializing in Mohs Surgery and skin cancer oncological surgery at Hopital Quirónsalud Infanta Luisa (Seville), explained some of the common errors in Mohs surgery. “We have to be constantly creative to deal with the problems we encounter,” said Dr. Toledo. Which implies that the reconstruction restores functional and aesthetic normality to the patient: “Where before there was an injury to which no one had given importance most of the time, we subject them to a procedure that is tedious, long and uncomfortable for the patient.” , which creates anxiety for both the patient and their families. And our role should be, from my point of view, to recover normality,” explained Dr. Toledo.
«Many times we can resolve the entire surgical defect with skin from the anatomical unit where the said defect was. “We take our time and mobilize each of the interested anatomical subunits so that they converge on the surgical defect, and in that convergence a new union of the anatomical subunits is formed.” This means that the surgeries, although longer, bleed less, have better results and there is less distortion of the tissues, according to Dr. Toledo.
Patient expectations
Dr. emphasized the key importance of the pre-surgical consultation. Javier Vicente, head of the Comprehensive Skin Cancer Unit at the International Dermatological Clinic: «We must try to explain the different possibilities of defects after removal and what the reconstructive options will be. And know what the patient’s expectations will be, because many times they believe that with Mohs surgery they will be left with a small defect and little scar, but this may vary depending on the final defect of the tumor, since sometimes it is greater than what we thought a priori,” concluded Dr. Vicente.