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Name
: John de Leeuw
Age
: 39 years (10th march 1975)
Stichting PATHAN
Residence : `s Gravendeel
Laboratory for pathology
Rotterdam
Education :
Residence
(`s Gravendeel)
1997 Æ 1998
Work placement
Laboratory school
Histology & cytology
'KU-GH/HHXZ
Analyst Practitioner / Mohs specialist
Stichting PAMM , Eindhoven
The Netherlands
MohsA
1998 Æ 2006
Histology analyst
Immunology analyst
Autopsy assistant
2006 Æ ….
Analyst Practitioner
Mohs Expert
Phoenix , Arizona USA
3rd of May 2014
Sponsored by: Stichting PAMM Mohs klinieken Eindhoven
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MohsA Venray
Stichting PAMM
Laboratory for pathology and
medical microbiology
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It will be a small journey from Phoenix to the Netherlands with information
about Mohs in the Neterlands
Land information
7KH1HWKHUODQGV
Typical Dutch
Europe :Germany(east), Belgium(south)
,QGH[
Surface
: 37.354km2 ( 14422mi2 )
coastline
: 451km ( 280mi )
Land border : 1027km ( 638mi )
Small information about the country
Distance :
8726 km
( 5422mi )
History : Mohs in The Netherlands
Climate: moderate sea climate
( mild winters and cool summers)
Organization around the Mohs
In the Netherlands
Stichting PAMM
In the Mohs clinic
Resident: 16.805.037 (2013)
Typical Mohs day (mohs process)
Language: Dutch
Process: slow mohs
Flag: red – white – blue stripes
Windmill , wooden shoe , cheese
market , tulip (flower bulbs)
Innovation / improvement / future
Phoenix , Arizona US
3rd of May 2014
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Phoenix , Arizona US
3rd of May 2014
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Sint Lambertus Ziekenhuis
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1982 Prof. H.A.M. Neumann
Helmond
1st Dermatologist
in training
Dr. M. Verhaegh
Education
in the USA
The Netherlands
to
Protugal (Lissabon)
Training requirements :
Only a few mohs operations a year
- 100 mohs operations under guidance
- extensive documentation
1992
Prof. H.A.M. Neumann
Maastricht UMC+
(GXFDWLRQ
Phoenix , Arizona US
3rd of May 2014
- able:
surgical , pathological , plastic surgical
First dermatologist
in training
Dr. M. Verhaegh
Working by:
Mohs Klinieken
Eindhoven
Phoenix , Arizona US
3rd of May 2014
Dr. Picoto
1992 1st dermatologist
to be mohs surgeon
by
Prof. Neumann (NL)
Dr. Picoto (P)
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Venray
Mohs klinieken
Eindhoven
Phoenix , Arizona US
3rd of May 2014
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Place of birth ( Dongen )
St. Elisabeth hospital
Laboratory for pathology
Tilburg
Work experience :
+/- 16 years
Education
Laboratory school
(histology & cytology)
Breda
1992 Æ 1998
Education
Laboratory school
Histology & cytology
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1992
Mohs surgeon:
Prof. Dr. Neumann
Dr. Verhaegh
(XURSD
1XPEHUVRIPRKVVXUJHRQ
4 Sweden
1 Iceland
The Netherlands :
Mohs surgery are done in
Hospital
Netherlands
10 Germany
17 England
5 Belgium
9 Spain
6 Portugal
6 Italy
4 Switzerland
1 Poland
3 Greece
2 Romania
In 20 years more
dermatologists are
educated to mohs surgeon
2013
In the Netherlands:
Private clinic
Groningen
Hoorn
Private clinic with more places
(One organization)
Zwolle
Amsterdam
NEW in Hospital
Arnhem QHZ
Rotterdam
Dordrecht
Venray
Eindhoven
At this moment (2014)
There are more hospitals / pathology
labs to set up mohs surgery in the
Netherlands
Eindhoven
mohs surgeons
Maastricht
Phoenix , Arizona US
3rd of May 2014
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The Netherlands :
Phoenix , Arizona US
3rd of May 2014
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Mohs analyst is working for a pathology lab as
histology analyst (HT)
The most pathology labs are accredit by
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0edical
0icrobiology
autopsy
3DWKRORJ\
ODE
Unit of Dermatology (hospital) and private clinics
need a pathology laboratory
3Dthology
lab
Cytology and Immunology
Histology analysts are skilled in histology and
cytology
Histology analysts are skilled to mohs analysts
General Histology
education: about 6 months by mohs expert
Hist.analysts are member of
Phoenix , Arizona US
3rd of May 2014
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Phoenix , Arizona US
3rd of May 2014
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Managerial / Analyst
Analyst Practitioner
Analyst
Basis Analyst
Autopsy Assistant
Special tasks:
assisting by autopsy
Lab Assistant
Total of 23 persons
Phoenix , Arizona US
3rd of May 2014
Clinic :
Mohs Klinieken
Eindhoven
Activity :
registration patients material
assisting pathologist by macro
cutting out small material
making frozen section
embedding paraffin blocks
cutting paraffin blocks
HE staining
histochemical staining
archive blocks and coupes
frozen section by mohs
instructions / quality
ordering chemical and items
Making rosters of work and tasks
Mohs expert
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General histology
3DWKRORJ\ODE
Total of 5 mohs analysts
Mohs
support
to
Clinic :
MohsA
Venray
(john)
organization
contact between lab and clinics
frozen section mohs
Hospital:
Catharina hospital Eindhoven
Mohs analyst
DQDO\VWV
frozen section mohs
Total of 5 analysts
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Phoenix , Arizona US
3rd of May 2014
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People who are working in
the clinic:
Patient goes to recreation room
Dermatologist
Physician assistant
Operational manager (region)
Nurse
Doctor`s assistant
Desk officer
Administrative assistant
Operating room
Mohs operation
Mohs analyst
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Pathology lab
Team of mohs klinieken Eindhoven
Patients are coming to the clinic
Cutting and colors by mohs surgeon
Phoenix , Arizona US
3rd of May 2014
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Phoenix , Arizona US
3rd of May 2014
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Preparation :
Mohs form +
colored pieces
All chucks are numbered
before starting with
numbers like (1-1 , 1-2 ,
etc.)
All chucks are filled with
some tissue tech
compound
Mohs lab
Embedding
Mohs analyst:
Mohs analyst :
Checking name + birthday of the
patient at the mohs form and the
name sticker
We are using the
cryoembedder for
embedding our pieces
Registration of the information
Workspace for the
mohs analyst
Phoenix , Arizona US
3rd of May 2014
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Phoenix , Arizona US
3rd of May 2014
67,&+7,1*3$00
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Cutting
frozen
sections
0RKVSURFHVV
Every piece of two
slides
Level 1
Coloring the sections
Level 3
Automatic color machine
Level 4
Level 2
Color protocol (HE staining):
Mohs analyst:
Cutting all peaces at 4 levels
(from outside to inside –
cutting to the tumor)
Phoenix , Arizona US
3rd of May 2014
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Alc.70% fixation
1x Tapwater
Drying
Alc.70-96-100-100%
Hematoxylin (3x)
(dehydration)
3x Tapwater
Xylene (clearing)
Eosin (1x)
30sec. each bath = total of 7 minutes
Paste on slide
Quality of staining always the same
Efficient using the time
During color proces – cutting new
frozen sections
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Phoenix , Arizona US
3rd of May 2014
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Discussion microscope
Mohs proces:
Colored slides taping with
a coverslip by using Pertex
and glass covers
Examine the slides
by mohs surgeon
Slides can be stored 80 years now ( lifelong )
All negative slides will
be re-examine by a
pathologist
Colored slides
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Phoenix , Arizona US
3rd of May 2014
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Phoenix , Arizona US
3rd of May 2014
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Digital techniques
Mohs form
by using
+ or –
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DUHQHJDWLYH
3DWLHQWWXPRU
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Digital pictures can
directly use in the
operating room
%HIRUH
$IWHU
MKE is using both way of reporting
Reconstructive
Reporting Mohs results
Phoenix , Arizona US
3rd of May 2014
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By mohs surgeon or plastic surgeon
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Phoenix , Arizona US
3rd of May 2014
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By Basal Cell Carcinoma (BCC)
6ORZ0RKV«Using mohs technic on paraffin procedure
BCC grows in the years on one spot (metastasis – negative)
- Examine all cutting edges of an excision
Using frozen sections (mohs process – one day treatment)
6ORZ0RKV«
Excision is
colored by
dermatologist
By Squamous Cell Carcinoma (SCC / PCC)
SCC / PCC , metastasis – positive , by using lymphatic system
Upper side (skin)
tumor
Bottom side
yellow
blue
SCC / PCC located on lower lip , ear and the bigger SCC / PCC tumors
Using mohs technic on paraffin procedure
- Examine all cutting edges of an excision
black
green
red
Paraffin procedure (smohs – TWO day treatment)
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3rd of May 2014
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3rd of May 2014
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Slow Mohs (embedding)
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Report and cutting :
- measurement (3D , cm)
- texture skin
- place tumor on skin
- texture tumor
Cassette A
cutting edge 11h-1h (blue-yellow)
Cassette B
cutting edge 1h-4h (yellow-green)
Cassette C
cutting edge 4h-7h (green-red)
Cassette D
cutting edge 7h-11h (red-blue)
Cassette E
total bottom edge (black)
Upper side (skin)
Upper side (skin)
- cutting:
bottom (colored black)
&ORFN edge 11h-1h (blue-yellow)
ZLVH edge 1h-4h (yellow-green)
edge 4h-7h (green-red)
edge 7h-11h (red-blue)
Cass. A t/m E , all HE staining ,
“four” levels (same as mohs)
Cassette F Æ I
Central part 12h-6h , up to two
pieces per cassette
central part cutting 12h-6h
(perpendicular to the skin surface)
Phoenix , Arizona US
3rd of May 2014
Cass. F t/m I , all HE staining ,
“one” level
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By using a 'PLFURVFRSHand
using a staining protocol
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Tap water (H2O)
Acetic acid 10%
Tap water (H2O)
Toluidine blue 0,2%
Tap water (H2O)
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Phoenix , Arizona US
3rd of May 2014
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5HVXOWby using a 'PLFURVFRSH
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washing
30 sec
15 sec
30 sec
5 sec
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3rd of May 2014
epidermis
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+(SLFWXUH
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3rd of May 2014
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Dr. Matthias Moehrle
Universitäts-Hautklinik
Tuebingen - Germany
Colors of the Netherlands
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$UWLFOH ´Rapid Lump Examination (RLE) –
a new tool for Mohs surgery? ´
5/(
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German society of
dermatology
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3rd of May 2014
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