What are the appropriate use criteria for Mohs micrographic surgery (MMS) in the treatment of basal cell carcinoma (BCC)?

Updated: Mar 02, 2020
  • Author: Robert S Bader, MD; Chief Editor: William D James, MD  more...
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Answer

In 2012, the American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery, and the American Society for Mohs Surgery published appropriate use criteria (AUC) for Mohs micrographic surgery (MMS). The recommendations were based on the expert opinion and consensus of a rating panel of 17 Mohs surgeons and non-Mohs dermatologists. [77]

The report deemed MMS appropriate for all basal cell carcinomas—regardless of location, size, and histologic subtype—in the following:

  • Previously irradiated skin
  • Traumatic scars
  • Areas of osteomyelitis
  • Areas of chronic inflammation or ulceration
  • Patients with genetic conditions such as xeroderma pigmentosum, basal cell nevus syndrome, or other syndromes that increase risk for skin cancer

MMS was also considered appropriate for all primary and recurrent BCCs in Area H (central face, eyelids [including inner/outer canthi], eyebrows, nose, lips [cutaneous/mucosal/vermilion], chin, ear and periauricular skin /sulci, temple, genitalia [including perineal and perianal], hands, feet, nail units, ankles, and nipples/areola).

MMS was endorsed for the following BCCs in Area M (cheeks, forehead, scalp, neck, jawline, pretibial surface):

  • All recurrent basal cell tumors
  • Primary histologically aggressive and nodular tumors
  • Primary superficial tumors in non-immunocompromised individuals with lesions ≥0.6 cm in diameter

MMS was also deemed appropriate for the following BCCs in Area L (trunk and extremities, excluding pretibial surface, hands, feet, nail units and ankles):

  • Recurrent histologically aggressive and nodular basal cell cancers
  • Primary, histologically aggressive tumors ≥0.6 cm
  • Primary nodular tumors >2 cm
  • Prmary nodular tumors ≥1.1 cm in immunocompromised patients

Use of MMS was considered inappropriate solely in Area L for the following [77] :

  • Recurrent superficial BCCs
  • Primary nodular tumors ≤1 cm
  • Primary nodular tumors ≤0.5 cm in immunocompromised patients
  • Superficial BCCs in healthy individuals
  • Superficial tumors ≤1 cm in immunocompromised patients

The NCCN prefers MMS for high-risk tumors and as adjuvant therapy if margins are positive after excision. [7]


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