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04/27/2021 Bryan C. Markinson, DPM
Treatment for ungual melanoma in situ (Leonard A. Levy, DPM, MPH)
I am not sure if Dr. Levy's intention on paraphrasing the article on Mohs surgery was informational only or if he was recommending that podiatrists employ it. Clearly, Dr. Wolf interpreted it as the latter and asks how one could "get the training and qualification" to do it. I am also confused about his point on leaving the nail plate in place, but that point is moot when it comes to excising a melanoma for which surely a preliminary biopsy has been performed, and total excision is now the reason for further surgery. Moh surgery is not at all new.
The short answer to Dr. Wolf's question involves multiple steps towards getting the training and qualification to perform this surgery. Step one: Graduate from an accredited MD/DO program Step two: Complete a ACGME-approved dermatology, surgery, or plastic surgery residency. Step three: Complete a certified dermatopathology fellowship since Mohs surgery requires real time pathologic diagnosis of slices of excised tissue. (There are some operators not dermpath trained that have a dermatopathologist in attendance at the procedure. )
The real learning point about melanoma of the nail unit is as follows: It has been shown that amputation to any level does NOT increase long term survival, thus the increased interest in digit sparing surgery over the past ten years. In fact, margin rules of resection for many cancers have been shown only to affect local recurrence only. Cold steel en bloc resection of the nail unit with grafting is one way to achieve this. The other way is MohS, and sometimes, depending on the defect left with MohS, a graft is still required.
Referral to a qualified Mohs surgeon therefore has been an emerging resource for podiatrists who have diagnosed nail unit melanoma. As an aside, this very short discourse is miles away from the fund of knowledge and experience required to thoroughly grasp the nuances of this subject. I have always maintained and still maintain that the management of malignancy should be hospital/university based as considerations way beyond the scope of local diagnosis may require the evaluation and attention by various specialists BEFORE definitive treatment is planned and commenced.
Bryan C. Markinson, DPM, NY, NY
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04/30/2021 Bryan C. Markinson, DPM
Treatment for ungual melanoma in situ (Leonard A. Levy, DPM, MPH)
Dr. Levy’s persistence on the issue of podiatrists performing Mohs surgery on the foot is perplexing. He is supporting his opinion based on advances podiatry as a profession has made over decades regarding residency training and practice act changes. Dr. Levy asks "Are or are we not physicians?" Personal feelings aside, including mine, the fact is that this question is still a raging debate closer to question than consensus, and has nothing to do with performing Mohs surgery.
He states "We should not be denied training to perform any kind of surgery on the foot and ankle." Really? Sorry Dr. Levy, when it comes to many kinds of surgery involving the foot, others may be more endowed with the requisite knowledge, training and experience. Would Dr. Levy support removal of a malignant nerve sheath tumor by a DPM that demands the attention of a neurosurgeon with extensive training in both the biology of these cancers, including the way they metastasize, and the extensive microsurgical techniques required to remove them safely? Does Dr. Levy support the surgical treatment by a DPM of an osteogenic sarcoma of the calcaneus that demands the expertise of an orthopedic oncologist trained in the biology, work up and surgical management of the disease and who do it on a daily basis? Dr. Levy actually proposes that dexterity with a scalpel and Henry Schein providing the supplies puts the DPM on the stage to perform Mohs surgery. Because of that I am not sure if he is aware that when a Mohs surgeon is operating, he is resecting a tumor slice by slice WHILE performing histologic sectioning AND interpretation of the prepared slides in real time. Where in Dr. Levy’s experience is any DPM able to do that? Where is anyone who is not an MD/DO certified in dermatopathology or pathology able to do this? Nowhere.
I write from more than a casual point of reference. I write this being a DPM who actually did a formal dermatopathology fellowship program between 1993 and 1995, at a major academic medical center, side by side with dermatology trained physicians who were becoming certified in dermatopathology. One of them, the chief fellow, was my direct mentor who was going on to a MOHS surgery fellowship after completing the one we were in. At the beginning of the program I had to acknowledge and sign that because of my DPM license, and non MD/DO education, and limited scope of practice, I could not in any way put forth that I was formally trained in or practice dermatopathology, which I gladly agreed to. I received a certificate in Podiatric Pathology which is not really a subset specialty of pathology, but it is signed by the Chairs of dermatology and dermatopathology and was handed to me at a graduation ceremony by the dean of the medical school.
My purpose was to increase my knowledge of skin biology and disease, and the fact that it paved my way in podiatry is undeniable. But those with whom I shared this space had a fund of knowledge from medical school and their dermatology residencies that was way superior to mine, and they were going to use their fellowship training in the daily analysis of sections of human tissue with ongoing study of cancer biology. My mentor then went on to study in fellowship with a Mohs surgeon. Therefore when Dr. Levy asserts that DPMs "should not be denied the opportunity to acquire the knowledge, skills, and training to perform Mohs surgery," he is doing nothing more than cheerleading, and honesty, it would embarrass me for a Mohs surgeon to see it. The simple truth is that no podiatrist is denied the opportunity to perform Mohs surgery, he or she just has to go to medical school, get trained in dermatology/dermatologic surgery, fellowship in dermatopathology, than fellowship in Mohs surgery. Simply put, Mohs surgery on the foot is not podiatric medicine and surgery.
Bryan C. Markinson, DPM, NY, NY
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