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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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