Malignant / FungatingWounds A Clinical Perspective
F. Alex Khan, APRN ACNS-BC MSN
2018
Email: [email protected]
Malignant wounds are caused by the metastatic spread from a malignant tumor. Cancerous cells cause massive damage to the localized tissue, through a combination of proliferative growth, ischemia and ulceration. These Wounds are non-healable due to co-existing untreatable medical life limiting conditions.
2018
Malignant WoundsMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
2018
Malignant WoundsMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
Primary skin cancer such as a squamous or basal cell carcinoma and malignant melanoma can develop into a malignant fungating wound if left untreated. The most common malignant / fungating wound sites include breast 62%, head and face 24% and groin and genitals 3%.
2018
StatisticsMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
Malignant wounds are usually polymicrobic, containing both aerobic and anaerobic bacteria causing foul odor and purulent drainage from the tissue necrosis. Anaerobic bacteria emit putrescine and cadaverine, which results in foul odors and some aerobic bacteria such as Proteus and Klebsiella can also produce foul odors. Each wound is unique but pain, foul odor, bleeding, and tissue necrosis is common in malignant wounds .
2018
CharacteristicsMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
2018
Radiation TherapyMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
• As a result of radiation therapy (3) three types of skin problems are commonly seen:
• Erythema (Redness)
• Dry Desquamation
• Moist Desquamation
• Skin Ulcers
2018
Radiation TherapyMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
2018
Radiation TherapyMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
Primary Site Metastatic Cutaneous Sites
Lung and Breast Head, neck, anterior chest
Gastrointestinal Upper abdominal wall, suture lines
Genitourinary Lower abdominal wall and external genitals
Stomach Umbilicus, suture lines
Melanoma Extremities
Oral Cavity Face
2018
Malignant DegenerationMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
Chronic wounds may exhibit chronic inflammation that can undergo malignant transformation. A Marjolin ulcer may develop in an area of chronic inflammation.
2018
Marjolin UlcerMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
2018
Kennedy Terminal UlcerMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
•A pressure ulcer some people develop at end of life .Sudden onset•Associated with imminent death•Pear, butterfly, or horseshoe shaped•Often on coccyx or sacrum•Skin Failure: Occurs when skin and underlying tissue develops necrosis due to lack of tissue perfusion associated with severe dysfunction or failure of other organ systems.
2018
Management StrategiesMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
In some malignant/fungating wounds; treating oncologist can perform palliative radiotherapy, which can reduce drainage and bleeding. Further, Chemotherapy can be used to reduce the size of the tumor, reduce pain, and bleeding. Hormone therapy can be used to reduce the symptoms associated with hormone responsive tumors such as breast cancers. Surgical excision of the malignant tissue is also useful in reducing the size of the wound and allows better wound management options.
2018
Management StrategiesMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
• Managing malignant wounds is frequently based on expert opinion and the experiences of the clinicians.
• The assessment of a malignant wound requires clinician to gain insight into the patient’s perception of the wound and its consequent impact on his/her life.
• Nursing care requires counseling skills and knowing how to provide care that is based on an awareness of and insight into the patients’ experience
2018
Management StrategiesMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
• Treatment selections should include those that provide minimum side effects and maximum benefit to the client.
• Establish goal of care Healing vs Palliation• Wound bed preparation will vary based on the goal. If
palliation is the goal, tissue debridement and management of bacterial overload is required to minimize odor and decrease risk of infection.
2018
Management StrategiesMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
• The impact of a malignant/ fungating wound on a patient’s life cannot be underestimated. It can have a devastating effect on physical, psychological and social wellbeing as well as on the family and friends.
• Treatment plan shall include the management of; Pain, Comfort, Psychological factors, Aesthetics, odor, drainage, and quality of life.
2018
Management StrategiesMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
Pain ManagementAlthough many patients experience debilitating pain at the end of life, there are many options to improve analgesia and quality of life. Appropriate pain assessment with attention to patient needs and specific goals, helps tailor individual treatment plans. Medications: Morphine, Hydromorphone, Oxycodone, Methadone, Fentanyl
2018
Management StrategiesMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
Exudate / Drainage ManagementFor wounds with mild to moderate drainage; use of super absorbent pads is recommended. For copious drainage, Negative Pressure Wound Therapy is ideal; only if patient is able to tolerate it.
2018
Management StrategiesMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
Exudate / Drainage ManagementFor wounds with frequent bleeding issues can be managed with:- Hemostatic dressings- Surgifoam/Gelfoam to fill the cavity- Silver Nitrate sticks- Topical Tranexamic acid (TXA)
2018
Management StrategiesMalignant Wounds
MA
LIG
NA
NT
/ FU
NG
ATI
NG
W
OU
ND
S
Odor ManagementWound malodor causes serious physical and psychological effects on the client. Management may include:- Removal of necrotic tissue- Sharp Wound Debridement - Wound Culture – Antibiotics & Antifungals- Topical Antimicrobials / Antifungals: Dakin’s Solution, Gentian
violet, Methylene Blue, Polyhexanide solution, Cider, Baxedin. Vinegar,Metronidazole Powder, Nystatin Powder, Charcoal dsg.
- Malodor Concealers – Lavender Oil, Chamomile Oil
2018
References
• Bergstrom, K. Assessment and Management of Fungating Wounds. Source: Journal of Wound, Ostomy and Continence
Nursing. 38 (1): 31-37, 2011 Jan/Feb
• Bryant, R. (2000). Acute and Chronic Wounds: Nursing Management,
Second Edition (pp. 374-379). Mosby Inc.
• Barton, P., & Parslow, N, (1998) Caring for Oncology Wounds.
Management Guidelines
• Krasner, D, Rodeheaver G, Sibbald G. (2001) Chronic Wound Care Third Edition Chapter 10 (pp. 79-90)
• Kohr, Rosemary. Sawhney, Mona. Advanced practice nurses' role in the treatment of pain. [Review] [23 refs] Source: Canadian
Nurse. 101(3): 30-4, 2005. March
• Reddy, M., Kohr, R., Queen, D., Sibbald, R Gary. Practical treatment of wound pain and trauma: a patient-centered approach.
An overview. Ostomy Wound Management. 49(4 Suppl):2-15, 2003 Apr
• Sibblad, G., Woo, K. & Goodman, L. Update on Wound Bed Preparation 2011: A review of the principles of treating the
root cause of wounds, pain and wound healing, and local wound care. Wound Care Canada, vol. 10, number 10, pp18-22
• Woo, K. & Sibbald, G. (2010). Local Wound Care for Malignant and Palliative Wounds. ADV SKIN WOUND CARE 2010;23:417-
28; quiz 429-30
• www.woundcarenurses.org