Using stains with Mohs surgery

As dermatologists and dermatopathologists gain greater insight into the evolving role of immunohistochemical stains as an adjunct to Mohs surgery, Robert Clark, M.D., Ph.D., of the Cary Skin Center, Cary, N.C., discusses the cost effectiveness of utilizing these stains in practice.

Effective but expensive

"These monoclonal antibodies and assay kits are very expensive, the antibodies themselves can run anywhere from $75 to $200 per antibody. In addition, the kits themselves are priced at about $365, and one needs to take into consideration the time required to perform the reaction, which is a minimum of an hour plus personnel time to prepare solutions and then the relatively high expense of performing the reaction. In terms of reimbursement, you are not adequately compensated for your time, your effort or even your supplies.

"So you can see once again, you may end up paying 10 times the amount of your reimbursement just to do a stain that you may only do in less than 1 percent of your surgery cases. So it is not cost effective to use it. Instead, when I do need it on those rare occasions, I arrange to have the stains done at a reference laboratory," Dr. Clark says.

Added benefit

The added benefit of using these stains depends on the particular surgical situation. Dr. Clark notes two situations where utilizing immunostains would provide insight into the type of tumor and extent of tumor progression.

"There are cases when you are removing a tumor that is difficult to evaluate with the standard H & E staining. In those cases, you would want to see or discriminate the tumor from the surrounding tissue and this is where an immunohistochemical stain can come in to play.

"The immunostains allow you to tag the tumor cells so that they light up a particular color that allows you to now see where the margins of the tumor are located, whereas if you did not use that stain you may not be able to see where the margins of the tumor exists within the tissue. So, consequently, you could end up getting a false negative or false positive evaluation and would not be adequately removing the tumor," Dr. Clark says.

"In other situations there can be a lot of inflammatory reaction in the tissue. As a result, you may not be able to discern the tumor present. By using an immunohistochemical stain you can discriminate between the inflammatory reaction and the tumor. These are examples of two different scenarios where one would consider using an immunohistochemical stain in conjunction with Mohs micrographic surgery to allow you to do a better job for the patient," Dr. Clark says.

Practicing dermatologists

Overall, despite cost constraints, Dr. Clark suggests that immunostains following Mohs surgery can be an effective method to use in select situations.