LETTERS AND COMMUNICATIONS
sectioning, and embedding, can also play a role. As discussed in the article, expert consensus is that wearing the same gloves to debulk the tumor before taking the first layer may predispose to the presence of floaters. According to the expert consensus of 26 surgeons, 38% always performed debulking, 50% sometimes, and 12% never. The mean rate of floaters was 1.8% per tumor treated and 0.70% per block. We feel that curettage with or without changing gloves before the first stage may predispose to floaters. Curettage and debulking procedures dislodge loose tumor pieces that are probably found throughout the surgical field and not just on the surgeons’ gloves. We would like to know if Dr. Alam has data regarding the rate of floaters for surgeons who always debulk versus those who do not. Curettage is meant to aid in delineating tumor margins and removing friable tissue, but previous articles show that it may not successfully delineate tumor margins or affect the number of stages needed for histologic clearance.2 Furthermore, there seemed to be little consensus as to what to do with the presence of a floater. We agree with the steps that Alam and colleagues outlined to try to determine the origin of the floater, such as correlating tumor histology and evaluating for gaps on the slide. This survey revealed that up to 43% of surgeons react by taking a new stage in the vicinity of the floater. In opposition, a recent study by Ingraffea and colleagues concluded that additional layers are not needed solely because floaters are detected.3 Further studies are needed to identify how to handle floaters appropriately, and we believe that clarifying the link between debulking and the rate of floaters is a good place to start.
References 1. Alam M, Shah AD, Ali S, Rauf M, et al. Floaters in Mohs micrographic surgery. Dermatol Surg 2013;39:1317– 22. 2. Jih MH, Friedman PM, Goldberg LH, Kimyai-Asadi A. Curettage prior to Mohs’ micrographic surgery for previously biopsied nonmelanoma skin cancers: what are we curetting? Retrospective, prospective, and comparative study. Dermatol Surg 2005;31:10–5. 3. Ingraffea AA, Bosley R, Godsey T, Gloster HM. The significance of floaters in the nicks of Mohs frozen sections. Dermatol Surg 2012;38:797–9.
KATHRYN J. RUSSELL, MD MICHAEL D. LEE, MD ELI R. SALEEBY, MD Skin Institute of South Florida Coral Springs, Florida EDUARDO T. WEISS, MD Hollywood Dermatology and Cosmetic Specialists Hollywood, Florida; Department of Dermatology and Dermatological Surgery Miller School of Medicine University of Miami Miami, Florida; and Department of Dermatology Florida International University Miami, Florida MARTIN N. ZAIAC, MD Department of Dermatology Florida International University Miami, Florida and Greater Miami Skin and Laser Center Miami, Florida
Commentary: Does Preoperative Curettage Predispose to Floaters? We read with great interest the thoughtful communication by Russell and colleagues. We believe that their suggestion that debulking via curettage
348
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may increase the production of floaters is a reasonable hypothesis that should be explored further. In accordance with their request, we have
LETTERS / COMMUNICATIONS
TABLE 1. Rate of Floaters per Surgery and per Tissue Block According to Debulking Frequency Frequency of debulking Always Sometimes Never
Institutions (n)
Floaters per surgery (%)
Floaters per tissue block (%)
10 13 3
1.8 2.5 1.0
0.7 1.1 0.4
extracted from our existing dataset1 more information on the association between preoperative curettage and subsequent floater production (Table 1). Our sample of surgeons and institutions was not large enough for a statistically valid subgroup analysis, so the data provided should be considered preliminary trend information. Also interesting is the fascinating and important study by Ingraffea and colleagues2 that suggests that taking another stage at the site of a floater may not be necessary because there does not appear to be more occult tumor at this margin. More data from additional sites may confirm this result. It may also be worthwhile to consider the possibility of detecting floater-associated tumor by taking an additional stage circumferentially around the entire wound defect and then step sectioning through parts of the specimen not adjacent to the floater. Perhaps the floater comes from somewhere
far displaced from where it is located on the block or slide. We would like to thank Russell and colleagues for initiating this fruitful discussion and Ingraffea and colleagues2 for advancing the science in this area. Their work illustrates how Mohs surgeons continue to work consistently to minimize even the most minute sources of error in the processing of tissue and margin assessment.
References 1. Alam M, Shah AD, Ali S, Rauf M, et al. Mohs Consensus Conference. Floaters in mohs micrographic surgery. Dermatol Surg 2013;39(9):1317–22. 2. Ingraffea AA, Bosley R, Godsey T, Gloster HM Jr. The significance of floaters in the nicks of Mohs frozen sections. Dermatol Surg 2012;38(5):797–9.
MURAD ALAM, MD, MSCI Departments of Dermatology, OtolaryngologyHead and Neck Surgery and Surgery Northwestern University Chicago, Illinois Address correspondence and reprint requests to: Murad Alam, MD, MSCI, Department of Dermatology, 676 N. St. Clair Street, Suite 1600, Chicago, Illinois 60611, or e-mail: [email protected]
The author has indicated no significant interest with commercial supporters.
Use of Digital Photographic Maps for Mohs Micrographic Surgery
Mohs micrographic surgery relies upon the ability of the surgeon to reproduce the position and orientation of an excised specimen on a freehand image or a printed schematic wound map. The artistic ability of the surgeon, patient and tumor variation, and the ability to represent tumors in complex three-dimensional locations and to precisely reflect
changes in anatomy in multistage excisions limit the accuracy of the reproduction. Instant1 and digital2,3 photography have been used as alternative techniques for creating maps. In 2003, only 1.3% of Mohs surgeons used digital photographic maps, and 0.6% used instant photographs.4 Digital photography has progressed rapidly in the last decade,
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349
sectioning, and embedding, can also play a role. As discussed in the article, expert consensus is that wearing the same gloves to debulk the tumor before taking the first layer may predispose to the presence of floaters. According to the expert consensus of 26 surgeons, 38% always performed debulking, 50% sometimes, and 12% never. The mean rate of floaters was 1.8% per tumor treated and 0.70% per block. We feel that curettage with or without changing gloves before the first stage may predispose to floaters. Curettage and debulking procedures dislodge loose tumor pieces that are probably found throughout the surgical field and not just on the surgeons’ gloves. We would like to know if Dr. Alam has data regarding the rate of floaters for surgeons who always debulk versus those who do not. Curettage is meant to aid in delineating tumor margins and removing friable tissue, but previous articles show that it may not successfully delineate tumor margins or affect the number of stages needed for histologic clearance.2 Furthermore, there seemed to be little consensus as to what to do with the presence of a floater. We agree with the steps that Alam and colleagues outlined to try to determine the origin of the floater, such as correlating tumor histology and evaluating for gaps on the slide. This survey revealed that up to 43% of surgeons react by taking a new stage in the vicinity of the floater. In opposition, a recent study by Ingraffea and colleagues concluded that additional layers are not needed solely because floaters are detected.3 Further studies are needed to identify how to handle floaters appropriately, and we believe that clarifying the link between debulking and the rate of floaters is a good place to start.
References 1. Alam M, Shah AD, Ali S, Rauf M, et al. Floaters in Mohs micrographic surgery. Dermatol Surg 2013;39:1317– 22. 2. Jih MH, Friedman PM, Goldberg LH, Kimyai-Asadi A. Curettage prior to Mohs’ micrographic surgery for previously biopsied nonmelanoma skin cancers: what are we curetting? Retrospective, prospective, and comparative study. Dermatol Surg 2005;31:10–5. 3. Ingraffea AA, Bosley R, Godsey T, Gloster HM. The significance of floaters in the nicks of Mohs frozen sections. Dermatol Surg 2012;38:797–9.
KATHRYN J. RUSSELL, MD MICHAEL D. LEE, MD ELI R. SALEEBY, MD Skin Institute of South Florida Coral Springs, Florida EDUARDO T. WEISS, MD Hollywood Dermatology and Cosmetic Specialists Hollywood, Florida; Department of Dermatology and Dermatological Surgery Miller School of Medicine University of Miami Miami, Florida; and Department of Dermatology Florida International University Miami, Florida MARTIN N. ZAIAC, MD Department of Dermatology Florida International University Miami, Florida and Greater Miami Skin and Laser Center Miami, Florida
Commentary: Does Preoperative Curettage Predispose to Floaters? We read with great interest the thoughtful communication by Russell and colleagues. We believe that their suggestion that debulking via curettage
348
DERMATOLOGIC SURGERY
may increase the production of floaters is a reasonable hypothesis that should be explored further. In accordance with their request, we have
LETTERS / COMMUNICATIONS
TABLE 1. Rate of Floaters per Surgery and per Tissue Block According to Debulking Frequency Frequency of debulking Always Sometimes Never
Institutions (n)
Floaters per surgery (%)
Floaters per tissue block (%)
10 13 3
1.8 2.5 1.0
0.7 1.1 0.4
extracted from our existing dataset1 more information on the association between preoperative curettage and subsequent floater production (Table 1). Our sample of surgeons and institutions was not large enough for a statistically valid subgroup analysis, so the data provided should be considered preliminary trend information. Also interesting is the fascinating and important study by Ingraffea and colleagues2 that suggests that taking another stage at the site of a floater may not be necessary because there does not appear to be more occult tumor at this margin. More data from additional sites may confirm this result. It may also be worthwhile to consider the possibility of detecting floater-associated tumor by taking an additional stage circumferentially around the entire wound defect and then step sectioning through parts of the specimen not adjacent to the floater. Perhaps the floater comes from somewhere
far displaced from where it is located on the block or slide. We would like to thank Russell and colleagues for initiating this fruitful discussion and Ingraffea and colleagues2 for advancing the science in this area. Their work illustrates how Mohs surgeons continue to work consistently to minimize even the most minute sources of error in the processing of tissue and margin assessment.
References 1. Alam M, Shah AD, Ali S, Rauf M, et al. Mohs Consensus Conference. Floaters in mohs micrographic surgery. Dermatol Surg 2013;39(9):1317–22. 2. Ingraffea AA, Bosley R, Godsey T, Gloster HM Jr. The significance of floaters in the nicks of Mohs frozen sections. Dermatol Surg 2012;38(5):797–9.
MURAD ALAM, MD, MSCI Departments of Dermatology, OtolaryngologyHead and Neck Surgery and Surgery Northwestern University Chicago, Illinois Address correspondence and reprint requests to: Murad Alam, MD, MSCI, Department of Dermatology, 676 N. St. Clair Street, Suite 1600, Chicago, Illinois 60611, or e-mail: [email protected]
The author has indicated no significant interest with commercial supporters.
Use of Digital Photographic Maps for Mohs Micrographic Surgery
Mohs micrographic surgery relies upon the ability of the surgeon to reproduce the position and orientation of an excised specimen on a freehand image or a printed schematic wound map. The artistic ability of the surgeon, patient and tumor variation, and the ability to represent tumors in complex three-dimensional locations and to precisely reflect
changes in anatomy in multistage excisions limit the accuracy of the reproduction. Instant1 and digital2,3 photography have been used as alternative techniques for creating maps. In 2003, only 1.3% of Mohs surgeons used digital photographic maps, and 0.6% used instant photographs.4 Digital photography has progressed rapidly in the last decade,
40:3:MARCH 2014
349
