CONTACTS 

SUBJECTS
Schedule 080227 0830 Minor Outpatient  Srgery Remove Blemish Nose Ca

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1703 -    ..
1704 - Summary/Objective
1705 -
170501 - Follow up ref SDS 62 0000. ref SDS 61 0000.
170502 -
170503 -
170504 -
170506 -  ..
1706 -
1707 -
1708 - Progress
1709 -
170901 - Surgery Scheduled Remove Skin Cancer VA Sacramento 080227
170902 -
170903 - Follow up ref SDS 62 HS6G, ref SDS 61 HS6G.
170904 -
170905 - Received ref DRT 1 0001 letter dated 071214 responding to the letter,
170906 - ref DIP 7 0001, submitted on 071211 to Lisa, ref SDS 62 HS6G, with
170907 - link to the record on 071210. ref SDS 61 HS6G
170909 -  ..
170910 - Lisa says...
170911 -
170912 -    1.  This is a reminder of the following clinic appointment:
170913 -
170914 -        Wedensday February 27, 2008, 0830
170915 -        Sacramento Medical Dermatology Surgery Clinic, ref DRT 1 0001
170917 -         ..
170918 -    2.  To cancel or reschedule this appointment, please call the
170919 -        scheduling desk at 800 382 8387, Mnday through Friday, 0800 to
170920 -        1530, excluding holidays, so that another veteran may be
170921 -        provided care in your place.  This will assist us in conserving
170922 -        resources and improving the quality of care for our patients.
170923 -        ref DRT 1 GW6G
170925 -         ..
170926 -    3.  The VA Dermatology Clinic is located in Building 801, on the VA
170927 -        Campus. ref DRT 1 LJ6L
170929 -  ..
170930 - Is this the same or near to the location of prior work on 060330,
170931 - ref SDS 47 446F, and per driving instructions reported in the record
170932 - on 060125? ref SDS 40 EG36
170934 -  ..
170935 - Lisa's letter from the VA continues...
170936 -
170937 -    4.  Please check in 15 minutes prior to your appointment.  In order
170938 -        to keep our records current, please report any changes in your
170939 -        address, phone number or insurance to the clerk when you check
170940 -        in. ref DRT 1 LJ6P
170941 -
170942 -            [On 080227 0830 surgry to remove minor cancer on nose
170943 -            performed at VA in Sacramento. ref SDS 63 PQ8P
170945 -             ..
170946 -            [On 080229 changing the bandage worked well. ref SDS 64
170947 -            0001
170949 -             ..
170950 -            [On 080311 0830 follow up examination indicates surgery to
170951 -            remove minor cancer on the nose was successful. ref SDS 65
170952 -            HS6G
170953 -
170955 -  ..
170956 - Skin Cancers and MOHS Surgery
170957 -
170958 -    Telephone...
170959 -
170960 -        916 843 9068
170961 -        916 366 5300
170963 -     ..
170964 -    Cancers of the skin are the most common form of malignancy with
170965 -    over 500,000 new cases diagnosed each year in the United States.
170966 -    Cancers of the skin are abnormal growth of tissue that develop at
170967 -    an uncontrollable and unpredictable rate.
170969 -     ..
170970 -    A preceding history of radiation therapy or chronic overexposure
170971 -    of the skin to sunlight can be obtained from most patients.  While
170972 -    not limited to any group of individuals, the typical skin cancer
170973 -    patient has fair complexion (blue-eyed blonds or redheads),
170974 -    sunburns easily, and tans poorly.  The main forms fo skin cancer
170975 -    are the basal cell and the squamous cell carcinomas.  These names
170976 -    refer to the type of cells in the skin that have resutled in
170977 -    cancer.  While some forms of squamous cell carcinomas do have a
170978 -    potential to spread (metastasize) to distant parts of the body,
170979 -    generally both types of tumors enlarge locally at their point of
170980 -    origin.  However, if incompletely removed, both types of skin
170981 -    cancer will frequently invade deeply and destroy vital structures
170982 -    in the path of their growth.  Skin cancer, compared to other forms
170983 -    of cancer can be readily cured if diagnosed in the early stages of
170984 -    growth.
170986 -     ..
170987 -    Because some forms of skin cancer are prone to invade deeply or
170988 -    widely and will commonly recur after conventional treatment, Doctor
170989 -    Drederick E.  Mohs of the University of Wisconsin developed a
170990 -    method in 1936 to treat problematic skin cancers and still provide
170991 -    cure rates of 99% for previously untreated (primary) tumors and
170992 -    90-93% for previously treated (recurrent) tumors.  This method once
170993 -    known as chemosurgery is now more appropriately called Mohs
170994 -    surgery.  Since this technique may be very time consuming and
170995 -    requires additional training and highly specialized personnel,
170996 -    relatively few medical centers in the United States are equipped to
170997 -    offer such treatment.
170999 -     ..
171000 -    The American College of Chemosurgery, formed in 1967, was
171001 -    established to provide a forum for interaction and continuing
171002 -    education among the trained Mohs surgeons throughout the country.
171003 -    Additionall, it has established eduational requirements in order to
171004 -    maintain the high quality of Mohs surgeons and their training
171005 -    programs.  This summary will attempt to describe the procedure and
171006 -    answer some of the common questions regarding the Mohs surgical
171007 -    technique and its role in the treamtent of skin cancers.
171009 -     ..
171010 -    Mohs surgery is one of serveral methods for the treatment of skin
171011 -    cancer.  The main advantage of Mohs surgery over virtually all
171012 -    other forms of theraoy is that through microscopic examination of
171013 -    tissue, the skin cancer can be traced out completely to its depths
171014 -    while removing the least amount ot normal tissue possible and
171015 -    providing the highest chance of cure.  High cure rates are possible
171016 -    even for those tumors that have recurred after prior unsuccessful
171017 -    treatment; developed at any high risk location such as the central
171018 -    face, the nose, the ears, or about the eyes; are of large size,
171019 -    poorly demarcated or deeply invasive; or are composed of scar
171020 -    tissue adn basal cell carcinoma cells, the so-called morpheafoam
171021 -    basal cell casrcinoma; all of which are associated with a greater
171022 -    risk of recurrence after conventional treatment.
171024 -     ..
171025 -    The Mohs surgical procedure is generally performed in an outpatient
171026 -    setting under local anesthesia with the patient awake at all times,
171027 -    thereby avoiding the cost of hospitalization, operating room
171028 -    charges and risk and expense of general anesthesia.  If the cancer
171029 -    is large or present in an individual with multiple medical
171030 -    problems, the procedure is sometimes performed on an inpatient
171031 -    basis.  The Mohs surgeon may combine his skills with those of a
171032 -    plastic surgeon with the best functional and cosmetic result
171033 -    possible by utilizing the expertise of those specialists.
171035 -     ..
171036 -    The original "chemosurgical" technique employed the application of
171037 -    an external chemical, zinc chloride, to the cancer surface prior to
171038 -    surgical removal.  While effective, this method was painful,
171039 -    exceedingly slow, and required multiple daily visits in order to
171040 -    adequately treat many skin cancers.  After considerable refinement,
171041 -    the surgical technique most commonly employed today in Mohs surgery
171042 -    is the "fresh tissue" technique.  This modification of the original
171043 -    method no longer utilizes zinc chloride so that rapid microscopic
171044 -    examinatoin of multiple layers of tissue over a period of several
171045 -    hours can be performed.  The surgery can be safely completed in
171046 -    only one day in most cases.
171048 -     ..
171049 -    The technique differs from that conventionally used by non-Mohs
171050 -    surgeons in that thin horizontal layers of tissue are removed which
171051 -    permits complete microscopic control of cancer removal.  The first
171052 -    layer of tissue is removed so as to include all the cancer that is
171053 -    visible clinically (Figure 1A).  Electrocautery may be used to stop
171054 -    any minor bleeding.  A small pressue dressing is applied to the
171055 -    wound so that the patient may return to wait in the comfort of the
171056 -    waiting room while the tissue has been removed, a map or diagram is
171057 -    drawn that corresponds to the anatomic location of the body being
171058 -    treated (Figure 1B).  The specimen is divided into smaller segments
171059 -    and carefully color-coded using special colored dyes according to
171060 -    the diagram so that the exact location fo each portion of the
171061 -    speicmen can be pinpointed (Figure 1C).  The segments are cut into
171062 -    thin pieces in the lab (Figure 1D) and the Mohs surgeon carefully
171063 -    examines the slides using a microscope (Figure 1E) to determine the
171064 -    presence and location of any remaining cancer cells and whether any
171065 -    additional suergery must be performed in order to totally remove
171066 -    the skin cancer.  If additional cancer is present (Figure 1F) and
171067 -    subsequent layers of tissue are remvoed, the same procedure is
171068 -    repeated but only for those areas where residual cancer cells have
171069 -    been identified (Figure 1G).  This process is repeated layer by
171070 -    layer until all of the cancer has bene removed.
171072 -     ..
171073 -    While each stage of the surgical procedure takes only 15 to 20
171074 -    minutes, the time required for the tissue to be processed in the
171075 -    laboratory may be anywhere from 30 to 60 minutes.  Consequently,
171076 -    the length of the surgical procedure is dependent upon the number
171077 -    of stages necessary to remove all cancer cells.  In most cases,
171078 -    using the fresh tissue technique, the procedure can be completed
171079 -    in a single day.
171081 -     ..
171082 -    Once Mohs surgery has been completed, the wound may be allowed to
171083 -    heal on its own, known as secondary intention health, or it may be
171084 -    closed with sutures (stitches).  While a scar does result from the
171085 -    Mohs surgical procedures, the Mohs surgeon is able to provide the
171086 -    patient with the best chance for a cosmetically acceptable and
171087 -    functional result by minimizing the size of the scar through
171088 -    removal of only the the smallest amount of normal tissue possible,
171089 -    thus preserving adjacent vital structures and tissues to the
171090 -    greatest extent.  At the same time, the cure rate for the skin
171091 -    cancer remains the highest possible.
171093 -     ..
171094 -    In some cases where healing by secondary intention or simple
171095 -    closure of the wound with sutures may result in an unacceptable
171096 -    cosmetic or functional result, the defect may be immediately
171097 -    repaired with a skin flap or graft.  The skin flap employs use of
171098 -    the adjacent loose tissue which can be rotated or slid over the
171099 -    defect and sutured into the new position to cove the wound.
171100 -    Additionally, the wound may be closed using a skin graft.  This is
171101 -    a thin piece of skin taken from another area of the body and
171102 -    sutured over the skin cancer defect.  The donor area for the skin
171103 -    graft can be closed with sutures or allowed to heal by secondary
171104 -    intention depending upon the type of skin graft used and the
171105 -    location from where it was taken.
171107 -     ..
171108 -    Rarely, if the cancer has shown signs of aggressive growth by
171109 -    invading deeply or widely or recurring after several prior
171110 -    procedures, the defect may not be repaired immediately.  Instead,
171111 -    the wound may be covered with a thin skin graft or allowed to heal
171112 -    by secondary intention.  After close and careful observation and
171113 -    examination for a period of six to twelve months without sign of
171114 -    residual cancer, the defect may then be reconstructed to provide a
171115 -    better cosmetic or functional result.
171117 -     ..
171118 -    In summary, Mohs surgery has proven to be an extremely effectiv
171119 -    emethod to treat skin cancer.  In addition to the high cure rates
171120 -    obtained with this technique, it minimizes scarringsince only the
171121 -    smallest  amount of normal tissue is removed.  The American College
171122 -    of Chemosurgery acts as the governing body to ensure continued
171123 -    excellence in the practice of Mohs surgery by trained, certified
171124 -    Mohs surgeons.
171125 -
171126 -
1712 -

SUBJECTS
Confirm Schedule 080227 0830 Minor  Otpatient Surgery Remove Blemish

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3204 - 2335
320501 -  ..
320502 - Notify VA Surgery Scheduled February 2008
320503 -
320504 - Submitted ref DIT 1 0001 notifying Lisa received her letter, and have
320505 - planned for surgery...
320506 -
320507 -    1.  Thanks for your letter dated December 14th, received today.  I
320508 -        have penciled in the meeting with your team on 080227 for
320509 -        outpatient surgery. ref SDS 0 HS6G
320511 -         ..
320512 -    2.  Also, reviewed the material on Mohs; thanks for a thorough
320513 -        explanation. ref SDS 0 VJ8H
320515 -         ..
320516 -    3.  See you on Feb 27th.
320518 -         ..
320519 -    4.  Concerns about privacy, classified data, etc., pertaining to
320520 -        me, is reviewed in POIMS. ref OF 4 V8P1
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