O MANAGEMENT OF MALIGNANT FUNGATING WOUNDS IN ADVANCED ANCER

Seminars in Oncology Nursing, Vol 22, No 3 (August), 2006: pp 185–193 185

OBJECTIVE: MANAGEMENT OF
MALIGNANT
To review the pathophysiology FUNGATING
and assessment of malignant WOUNDS IN
wounds and management tech- ADVANCED
niques aimed at controlling pain, CANCER
odor, exudate, and local bleeding.

DATA SOURCES:

Current research and published
literature.

CONCLUSION:

Assessment of malignant wounds,
selection of appropriate dressings,
related symptom management,
and patient and family support
are vital aspects of cutaneous
wound management in advanced
cancer.

IMPLICATIONS FOR NURSING SUSIE SEAMAN
PRACTICE:
M ALIGNANT fungating wounds present both
A thorough understanding of the physical and emotional challenges to the pa-
care of malignant wounds will tient, family, and even the most experienced
assist oncology nurses achieving oncology nurse. These wounds may be associ-
palliative goals of care including ated with pain, odor, exudate, bleeding, and an
optimal symptom management, unsightly appearance. They may adversely affect self-esteem and
odor and drainage control, and body image, causing patients to isolate themselves at a time when
emotional support. social support is critically needed.1 An understanding of the pal-
liative goals in the care of these patients is essential in developing
Sharp Grossmont Hospital Wound Heal- a treatment plan aimed toward decreasing the effect that these
ing Center, La Mesa, CA. lesions have on the patient’s quality of life. These goals include
managing symptoms, controlling exudate, odor, and bleeding, pre-
Susie Seaman, MSN, FNP, CWOCN: Sharp venting infection, and optimizing the emotional well-being of the
Grossmont Hospital Wound Healing Center, patient and family.
La Mesa, CA.
EPIDEMIOLOGY
Address correspondence to Susie Sea-
man, MSN, FNP, CWOCN, Grossmont M alignant cutaneous lesions may occur in up to 5% of patients
Hospital Wound Healing Center, 5555 with cancer and 10% of patients with metastatic disease.
Grossmont Center Drive, La Mesa, CA Lookingbill et al2 retrospectively reviewed data accumulated over
91942; e-mail: [email protected] a 10-year period from the tumor registry at Hershey Medical
Center (Hershey, PA). Of 7,316 patients, 367 (5.0%) had cutane-
© 2006 Elsevier Inc. All rights reserved. ous malignancies. Of these, 38 patients had lesions as a result of
0749-2081/06/2203-$30.00/0 direct local invasion, 337 had metastatic lesions, and eight had
doi:10.1016/j.soncn.2006.04.006 both. A secondary analysis from the same registry found that 420
patients (10.4%) out of 4,020 with metastatic disease had cutane-

186 S. SEAMAN

ous involvement.3 In women, the most common As both locally invasive and metastatic lesions
origins of metastasis were breast carcinoma extend, changes in vascular and lymphatic flow
(70.7%) and melanoma (12.0%). In men, mela- lead to edema, exudate, and tissue necrosis.11,14,15
noma (32.3%), lung carcinoma (11.8%), and colo- The resulting lesion may be fungating, in which
rectal cancer (11.0%) accounted for the most the tumor mass extends above the skin surface
common primary tumors. Ambrogi et al4 retro- with a fungus or cauliflower-like appearance, or it
spectively reviewed the cases of 677 patients may be erosive and ulcerative.16 The wound bed
cared for over a 10-year period with lung cancer. may be pale to pink with very friable tissue, com-
Cutaneous metastasis was noted in 26 patients pletely necrotic, or a combination of both. The
(3.8%). A study of 77 patients with skin metastasis presence of necrotic tissue provides an ideal en-
cared for at a large Veteran’s Administration hos- vironment for the overgrowth of anaerobic
pital reported that the primary tumor site was microorganisms, which may result in significant
most commonly the lungs, skin (melanoma), and malodor.17,18 The surrounding skin may be ery-
gastrointestinal tract. 5 Although breast, lung, and thematous, fragile, and exceedingly tender to
gastrointestinal cancer and melanoma account for touch. The skin may also be macerated in the
the majority of skin involvement, it is important presence of excessive wound exudate. The degree
to note that metastatic cutaneous lesions may of pain experienced by the patient will depend on
arise from any other type of malignancy, including wound location, depth of tissue invasion and dam-
cancer of the ovary,6 head and neck,7 genitouri- age, nerve involvement, presence of viable tissue
nary system,8 or may be of unknown primary with exposed nerve endings, and the patient’s
origin.9 previous experience with pain and analgesia.16

PATHOPHYSIOLOGY AND CLINICAL ASSESSMENT

PRESENTATION Thorough evaluation of the patient and the
malignant wound is essential to formulate a
Cutaneous involvement of the skin may be patient-centered treatment plan.13,14,19 Wound lo-
secondary to local invasion of a primary tu- cation, size, appearance, exudate, odor, surround-
mor or metastasis from a nearby or distant ing skin, and any associated symptoms should be
site.10,11 Local invasion, which occurs as the result assessed to guide local therapy and the use of
of direct extension of a tumor to the surface of the analgesics. The potential for serious complica-
skin, may initially manifest as inflammation with tions such as hemorrhage, vessel compression/
induration, redness, heat, and/or tenderness. The obstruction, or airway obstruction should be
skin may have a peau d’orange appearance and noted so that the caregiver can be instructed in
can be fixed to underlying tissue. As the tumor palliative measures to maintain patient comfort.
spreads and more tissue destruction occurs, the Table 1 summarizes the key points in the assess-
skin eventually ulcerates. In metastatic disease, ment of the malignant wound and their ratio-
tumor cells detach from the primary site and nale.20
travel via blood and/or lymphatic vessels or tissue
planes to distant organs, including the skin.10,12,13 Haisfield-Wolfe and Baxendale-Cox21 have pro-
These lesions may initially present as well-demar- posed a staging system for malignant wounds.
cated nodules ranging in size from a few millime- Using the Hopkins Wound Assessment Tool and
ters to several centimeters. Their consistency may digital examination of photographs, they assessed
vary from firm to rubbery. There may be pigmen- malignant wounds in 13 patients. Four stages of
tation changes noted over the lesions, from deep wound progression were identified based on the
red to brown-black. In general, these nodules are parameters of wound color, hydration status, the
painless. Early on, they may be mistaken for epi- absence or presence of nodules, drainage, pain,
dermal cysts, lipomas, or other benign conditions. odor, and tunneling. Although further research is
Cutaneous metastasis may also present as ery- needed to validate this pilot study, use of this
thematous patches or plaques, violaceous papules standard set of descriptors can facilitate consis-
and vesicles, or areas of alopecia. Over time, met- tent documentation and communication among
astatic papules, nodules, and plaques may ulcer- nurses.
ate, drain, and become very painful.
Malignant wounds will likely change over time

MALIGNANT FUNGATING WOUNDS IN ADVANCED CANCER 187

TABLE 1.

Assessment of Malignant Wounds

Assessment Rationale
Wound location
Consider occupational therapy referral to facilitate activities of daily living
Is mobility impaired? Impacts dressing selection
Is the lesion easily covered from public view? Impacts dressing fixation
Located near wrinkled or flat skin?
Thick adhesive dressings such as foams or hydrocolloids may not conform and
Wound appearance adhere well to wrinkled skin. Use thinner adhesives, such as gentle tapes, or
Size: Length, width, depth, undermining, deep transparent films.
structure exposure
Fungating or ulcerative Impacts dressing selection; provides info re: deterioration or response to
Percentage of viable vs. necrotic tissue palliative treatment
Tissue friability and bleeding
Presence of odor Impacts dressing selection and fixation
Presence of fistula Need for cleansing/debridement
Exudate amount Need for nonadherent dressings and other measures to control bleeding
Wound colonized or clinically infected Need for odor-reducing strategies
Possible need for pouching
Surrounding skin Impacts dressing selection
Erythematous Need for local vs systemic care
Fragile or denuded
Infection or tumor extension
Nodular Impacts dressing type and fixation
Macerated
Radiation-related skin damage Avoid daily removal of adhesive tape from fragile skin.
Utilize alternative fixation:
Symptoms Apply flexible ostomy barriers to surrounding skin where tape will contact.
Deep pain: aching, stabbing, continuous
Superficial pain: burning, stinging, may be only Change barrier every 5-7 days.
associated with dressing changes Use netting, brassiere, tube tops, snug tank tops, panties, briefs
Pruritis Tumor extension/metastasis
Need for improved exudate management; may need liquid skin sealant applied to
Potential for serious complications
Lesion is near major blood vessels: Potential for surrounding skin to protect it.
hemorrhage Need for topical care of skin; impacts dressing fixation (same as fragile skin)

Lesion is near major blood vessels: Potential for Need to adjust systemic analgesia
vessel compression/obstruction Need for topical analgesia

Lesion is near airway: Potential for obstruction Related to dressings? If not, may need systemic anti-pruritic medications

Adapted and reprinted with permission.20 Need for education of patient/family re: palliative management of severe bleeding
Call hospice
Cover area with dark towels, apply local pressure if indicated
Elevate area of bleeding, if possible
Keep patient comfortable, administer rapid-acting sedative (eg., midazolam
2.5 – 5 mg IV or SQ), speak in calm tone

Need for education of patient/family re: palliative management of severe swelling
and pain

Use compression stockings or wraps if it will increase patient comfort
Need for education of patient/family re: palliative management of airway

obstruction
Call hospice
Administer narcotics and sedatives as indicated
Raise head of bed
Sit with patient; speak in comforting tones

based on the aggressiveness of the cancer and any sult in regression of the lesion, it can be expected
treatment, including surgery, radiation, or chemo- to eventually recur.22 It is crucial for the nurse to
therapy. While even palliative treatment may re- perform ongoing assessment so that the treatment

188 S. SEAMAN

plan can be tailored to the current needs of the however, their use should be weighed against the
patient and wound. potential negative effects of local irritation, wound
desiccation with subsequent pain and bleeding
MANAGEMENT OF MALIGNANT WOUNDS upon dressing removal, and unpleasant odor asso-
ciated with some solutions, which may be bother-
M uch has been published over the last three some to patients.
decades on chronic wound management.
However, evidence-based literature focusing on Necrotic tissue in malignant wounds is typi-
the palliative management of malignant wounds cally moist yellow slough. In the absence of
remains limited, reflecting the vital need for fur- exudate, there may be dry black eschar, but this
ther research to provide a framework for consis- is uncommon. Debridement is best performed
tent care. Many articles are based on expert opin- using autolytic and/or gentle mechanical meth-
ion and the personal experience of practitioners ods as opposed to wet-to-dry dressings, which
knowledgeable in palliative and hospice care. Al- are traumatic and can cause significant bleeding
though research-based treatment is the gold stan- upon removal. Autolytic debridement can be
dard of care, anecdotal reports on the successful achieved using dressings that support a moist
treatment of patients with these challenging wound environment,24 but this should be bal-
wounds is helpful to individual nurses striving to anced with the odor that may be increased
provide the best care. Literature on the treatment under occlusion. Local debridement can be per-
of malignant wounds focuses on controlling infec- formed by very gently scrubbing the necrotic
tion and odor, managing exudate and protecting areas with gauze saturated with saline or wound
surrounding skin, minimizing bleeding, reducing cleanser. Low-pressure irrigation with normal
pain, and optimizing the emotional welfare of the saline using a 35-cc syringe and a 19-gauge
patient and family.11,13,15,16,18,23 needle can be used to remove loose necrotic
tissue and decrease bacterial counts. Care
INFECTION AND ODOR CONTROL should be taken to avoid causing pain with ei-
ther procedure. In addition, sharp debridement
Infection and odor control is achieved by man- by clinicians trained in this procedure can be
aging local bacterial colonization with wound performed to remove loose necrotic tissue. Care
cleansing and debridement and the use of local should be taken to avoid penetrating viable tis-
antimicrobial agents. Wound cleansing reduces sue because bleeding may be difficult to control.
odor by removing necrotic debris and decreasing If necrotic tissue on the tumor is extensive,
bacterial counts. If the lesion is not friable and the surgical debridement may be indicated to allow
patient is able, the wound may be cleansed in the for infection prevention, odor control, and exu-
shower. This not only provides for local cleansing date management, if compatible with the pallia-
but also gives the added psychological benefit of tive goals of care for the patient.
helping the patient to feel clean. The patient
should be instructed to allow the shower water to Local colonization and odor can be reduced
hit the skin above the wound and run over it. If with the use of topical antimicrobial preparations.
there is friable tissue or the patient is unable to There is broad support for the use of topical met-
shower, the caregiver should gently irrigate the ronidazole, which has a wide range of activity
wound with normal saline or a commercial wound against anaerobic bacteria, to control wound
cleanser. Skin/incontinence cleansers, which con- odor.25–29 Topical therapy is available by crushing
tain mild soaps and antibacterial ingredients used metronidazole tablets in sterile water and creating
in bathing, may be very effective at controlling either a 0.5% solution (5 mg/cc) or a 1% solution
local colonization and odor. They may be sprayed (10 mg/cc).25–27 This can be used as a wound
directly on the wound as long as they do not cause irrigant, or gauze can be saturated with the solu-
burning. If pain occurs with use of skin cleansers tion and packed into wound cavities. Care must be
in the wound, they should be used only on the taken not to allow the gauze packing to desiccate
surrounding skin. Topical antimicrobials such as because dressing adherence may lead to bleeding
hydrogen peroxide, Dakin’s solution, and povi- and pain. Gomolin and Brandt25 reported the use
done iodine are recommended by some authors22; of a 1% metronidazole solution in the treatment of
four patients with malodorous pressure ulcers.
Odor was completely eradicated in three of the

MALIGNANT FUNGATING WOUNDS IN ADVANCED CANCER 189

patients within 3 to 7 days, and dramatically de- in the environment around the patient may also
creased in the fourth patient within 2 days. help to decrease odor.

An effective alternative to metronidazole solu- While local colonization is treated with topical
tion is MetroGel Topical Gel (metronidazole cleansing, debridement, and antibacterial agents,
0.75%, Galderma Laboratories, Montreal, Can- clinical infection, as evidenced by erythema, in-
ada), which is applied to the wound in a layer one duration, increased pain, and exudate, leukocyto-
eighth inch thick. Poteete28 evaluated the use of sis, and fever, should be treated with systemic
metronidazole 0.75% gel in the treatment of 13 antibiotics. Cultures should be used to identify
patients with malodorous wounds. The product infecting organisms once the patient is diagnosed
was applied to the wounds daily and covered with with an infection based on clinical signs; they
either saline-moistened or hydrogel-saturated should not be used routinely to diagnose infection.
gauze. At day 9, no odor was detected in any Because of the local inflammatory effects of the
wound when the dressings were removed. Finlay tumor, wounds may have many of the same signs
et al29 prospectively studied subjective odor and as infection, so the clinician must be discriminat-
pain, appearance, and bacteriological response in ing in differentiating between the two. A complete
47 patients with malodorous wounds treated with blood count assessing the white cell count and
daily application of metronidazole 0.75% gel. differential may be helpful in guiding assessment
Ninety-five percent of the patients reported de- and therapy. It is crucial to avoid treating patients
creased odor at 14 days. Anaerobic colonization with oral antibiotics when they are just colonized
was discovered in 53% of patients and eliminated and not infected to prevent side effects and emer-
in 84% of these after treatment. Patients reported gence of resistant organisms.
decreased pain at day 7, and exudate and cellulitis
were significantly decreased by study end. Be- MANAGEMENT OF EXUDATE
cause the cost of this product is significantly
higher than metronidazole 1% solution, nurses Because inflammation and edema are com-
may want to use the gel product initially to erad- monly present in these wounds, there tends to
icate odor, and then switch to the irrigation solu- be significant exudate. Dressings should be chosen
tion for maintenance. Systemic metronidazole to conceal and collect exudate and odor. It is
should not be used for local bacterial colonization essential to use dressings that contain exudate
and should be reserved for treatment of clinical because a patient who experiences unexpected
wound infection. drainage on clothing or bedding may experience
significant feelings of distress and loss of control.
Another topical antimicrobial agent is Iodosorb Specialty dressings, such as foams, alginates, or
gel (Healthpoint Ltd, Fort Worth, TX), an iodine starch copolymers, are notably more expensive
complexed in a starch copolymer (cadexomer io- than gauze pads or cotton-based absorbent pads.
dine). This product contains slow-release iodine However, if these dressings reduce the overall cost
and has been shown to decrease bacterial counts by reducing the need for frequent dressing
in wounds without cytotoxicity.30,31 Cadexomer changes, they may be cost-effective. Table 2 sum-
iodine is available in a 40-g tube and is applied to marizes dressing considerations when caring for
the wound in a one eighth inch layer. This product malignant wounds. Nonadherent dressings are op-
also provides exudate management in that each timal for the primary contact layer as they mini-
gram absorbs 6 mL of fluid. Some patients may mize the trauma to the wound associated with
complain of burning on application. dressing changes.

Use of charcoal dressings, which absorb and Seaman24 suggests nonadherent contact layers,
trap odor, may also be helpful in odor manage- such as Vaseline gauze, for the primary dressing
ment. Charcoal dressings may be used as either on the wound bed, covered with soft, absorbent
primary or secondary dressings. As these dress- dressings, such as gauze and abdominal pads, for
ings vary in their application and performance, secondary dressings to contain drainage. Dress-
package inserts should be reviewed before use. A ings are changed one to two times daily based on
basket of charcoal under the bed or table may also the amount of exudate and odor. This regimen is
help in ridding the environment of wound odor for ideal and cost-effective applied over a layer of
the home care patient.32 Use of peppermint oil or metronidazole gel. Menstrual pads may be advan-
other aromatherapy products, as well as cat litter,

190 S. SEAMAN

TABLE 2.

Dressing Choices for Malignant Wounds

Type of Wound/Goals of Care Dressing Choice

Low exudate Nonadherent contact layers:
Maintain moist environment Adaptic (Johnson & Johnson, New Brunswick, NJ)
Prevent dressing adherence and bleeding Dermanet (DeRoyal, Powell, TN)
Mepitel (MöInlycke Health Care, Göteborg, Sweden)
High exudate Petrolatum gauze (numerous manufacturers)
Absorb and contain exudate Tegapore (3M Health Care, St Paul, MN)
Weigh cost of product against benefits.
Amorphous hydrogels
The use of specialty dressings will not Sheet hydrogels
change the eventual outcome. Use of Hydrocolloids, contraindicated with fragile surrounding skin, may increase odor,
nonadherent contact layers and
absorbent ABD pads are cost-effective better with small lesions
and work well to contain exudate. Semi-permeable films, contraindicated with fragile surrounding skin, do not
Prevent dressing adherence in areas of
lesion with decreased exudate handle exudate at all
Malodorous wounds Alginates
Wound cleansing (see text) Foams
Reduce or eliminate odor Starch copolymers
Gauze
Soft cotton pads, ABD pads, over nonadherent contact layers, if indicated
Menstrual pads (excessive exudate), plastic backing will protect clothing, use

fragrance-free pads to avoid skin sensitivity.

Topical metronidazole (see text)
Iodosorb Gel or Pad (Healthpoint Ltd)
Charcoal dressings
Silver-based dressings

Use product appropriate for amount of exudate
Balance cost vs benefit
Change dressing at least daily, sometimes more often

Adapted and reprinted with permission.20

tageous as secondary dressings, not only because wound. These barriers protect the fragile tissue
of their excellent absorption, but also because the from maceration and the irritating effects of the
plastic backing blocks exudate and protects cloth- drainage. Dressings can then be held in place with
ing. Protection of the surrounding skin is another tape affixed to a skin barrier, or with flexible
goal of exudate management. netting, tube dressings, sports bras, panties, and
the like.
The skin around the wound may be fragile sec-
ondary to previous radiation therapy, inflamma- CONTROL OF BLEEDING
tion caused by tumor extension, repeated use of
adhesive dressings, or maceration. Although adhe- The viable tissue in a malignant wound may be
sive dressings may assist with drainage and odor very friable and bleed with minimal manipu-
control, their potential to strip the epidermis on lation. In addition, cancer patients may have co-
removal may outweigh their benefit. Using ostomy agulation defects related to their disease and or
skin barriers on the skin around the wound and treatments that increase their risk of bleeding.33
then taping dressings to the skin barriers is one Prevention is the best method for controlling
method of protecting surrounding skin from both bleeding. This involves gentle dressing removal
wound drainage and trauma from frequent tape and the use of nonadherent dressings or moist
removal. The barrier is changed every 5 to 7 days. wound products. On wounds with low exudate,
The skin can also be protected by applying a
barrier ointment or skin sealant around the

MALIGNANT FUNGATING WOUNDS IN ADVANCED CANCER 191

the use of hydrogel sheets or amorphous hydro- wound immediately upon dressing removal and
gels under a nonadherent contact layer may keep then wound care is performed once adequate local
the wound moist and prevent dressing adherence. anesthesia is obtained. Ice packs used before or
Even highly exudating wounds may require a non- after wound care may also be helpful to reduce
adherent contact layer to allow for atraumatic pain.
dressing removal. When dressings adhere to the
wound on removal, they should be soaked away Another option for topical analgesia is the use of
with normal saline to lessen trauma. If bleeding topical opioids, which bind to peripheral opioid
does occur, applying direct pressure for 10 to 15 receptors.41 Back and Finlay42 reported the use of
minutes is the first intervention. Local ice packs diamorphine 10 mg added to an amorphous hy-
may also assist in controlling bleeding. If pressure drogel and applied daily to the wounds of three
and/or ice is ineffective, several other options ex- patients with either painful pressure or malignant
ist.33–35 Hemostatic agents such as absorbable gel- wounds. All three were on systemic opioids. The
atin (Gelfoam, Pfizer, New York, NY), collagen patients noted improved pain control on the first
(Helistat, Integra LifeSciences, Plainsboro, NJ; day of treatment. Krajnik and Zbigniew43 reported
Avitene, Davol, Cranston, RI), collagen/oxidized the case of a 76-year-old woman with metastatic
regenerated cellulose (Promogran, Ethicon, Ir- lesions on her scalp that caused severe tension
vine, CA), and collagen or alginate dressings may pain. Ibuprofen 400 mg three times daily was
be applied under a pressure dressing. ineffective, and because the pain was in a limited
area, the authors applied morphine gel 0.08% (3.2
Gauze saturated with topical vasoconstrictors mg morphine in 4 g of amorphous hydrogel). The
such as epinephrine or cocaine may control bleed- patient’s pain decreased from 7 on a 10-point
ing, but the patient should be monitored for sys- visual analogue scale to 1 within 2 hours of gel
temic effects of these drugs. Application of sucral- application. Pain increased back to 6 at 25.5 hours
fate paste (1 g sucralfate tablet in 5 mL of water- post-application. Therefore, the gel was reapplied
soluble gel) may decrease widespread oozing. daily and maintained pain control with no side
Small bleeding points can be controlled with silver effects.
nitrate sticks. More aggressive therapy may be
necessary in patients with significant bleeding. Zeppetella et al44 showed efficacy of topically
These may include transcatheter embolization of applied morphine sulfate 10 mg/mL in 8 g Intrasite
the arteries feeding the tumor,34,36–38 direct punc- gel (Smith & Nephew, Largo, FL) in the treatment
ture therapeutic embolization,38,39 in which the of five hospice patients with painful pressure ul-
tumor is injected with embolic agents, intraarte- cers. The results of this pilot study were later
rial infusion chemotherapy and radiotherapy,40 or validated in a larger randomized controlled study
surgery if compatible with the palliative care goals by the same authors.45 Sixteen hospice inpatients
of the patient. Clinicians should not hesitate to with painful pressure or malignant wounds were
consider these options if they will improve the randomized to receive topical morphine as de-
quality of life in patients with a malignant wound. scribed above or placebo (water for injection 1 mL
in 8 g Intrasite gel) to their wounds. After 2 days of
PAIN MANAGEMENT treatment, patients entered a 2-day washout pe-
riod and were then crossed over to the opposite
There are several types of pain associated with group for 2 more days. Patients assigned a numer-
malignant wounds: deep pain, neuropathic ical rating score to the analgesia that they ob-
pain, and superficial pain related to procedures.16 tained in each 2-day period, the lower score indi-
The use of systemic analgesia is the hallmark of cating better pain relief. Topically applied
pain management in patients with these wounds morphine provided significantly lower scores
and pre-treatment with rapid-onset, short-acting compared with pre-treatment and placebo (P
analgesics should be considered before beginning Ͻ.001). The treatment was well tolerated. Lastly,
dressing changes. Local measures may also be Ballas46 noted success in treating two patients
instrumental in providing comfort. For manage- with painful sickle cell ulcers using either topical
ment of superficial pain related to procedures, crushed oxycodone or meperidine. Nurses should
topical lidocaine or benzocaine may be helpful.41 discuss this option for topical pain relief as an
These local analgesics may be applied to the adjunct to systemic treatment with the patient
and physician.

192 S. SEAMAN

ADJUNCTIVE THERAPIES ones.51,52 Caregivers may experience feelings of
helplessness and fear about caring for the patient.
Palliative care of the patient with a malignant The nurse can facilitate a trusting relationship
wound may include surgical debulking of fun- with the patient and caregivers by reviewing the
gating masses and resection of new nodules, or goals of care and by openly discussing issues that
chemotherapy and/or radiation therapy for tumor the patient may not have talked about with other
shrinkage and pain control.34,47–49 Topical chemo- providers. For example, it is helpful to acknowl-
therapy regimens can also help to shrink the tu- edge odor openly and then discuss how the odor
mor and thus ease local management.50 Although will be managed. Attention to the cosmetic ap-
these interventions will not cure patients of their pearance of the wound with the dressing in place
advanced cancers, they may extend life, ease pain can assist the patient in dealing with body image
and bleeding, and improve quality of life. The disturbances. Use of soft flexible dressings that
nurse should advocate for appropriate referrals for can fill a defect and protect clothing may be help
patients if these treatments are compatible with to restore symmetry and provide security for the
the palliative goals of care. patient.

PATIENT AND CAREGIVER EDUCATION AND Assisting the patient and the caregiver to cope
EMOTIONAL SUPPORT with the distressing symptoms of the malignant
wound such that odor and bleeding is managed,
The same education provided to patients and exudate is contained, and pain is alleviated, will
caregivers regarding basic wound care should improve the quality of life for these patients and
be provided to those with malignant wounds. contribute to the goal of satisfactory psychological
Handwashing, asepsis, dressing change procedure, well-being. Education must include realistic goals
control of odor and bleeding, and pain manage- for the wound. In these patients, the goal of com-
ment strategies should be presented and rein- plete wound healing is seldom achievable; how-
forced. Education must also focus on the psycho- ever, quality of life can be maintained even as the
social aspects of having a malignant wound. wound degenerates. Continual education and re-
Patients may experience grief, anxiety, embar- evaluation of the effectiveness of the treatment
rassment, stigma, and may withdraw from loved plan are essential to maintaining quality of life for
those suffering from a malignant wound.

REFERENCES

1. Young CV. The effects of malodorous fungating malignant 8. Mueller TJ, Wu H, Greenberg RE, et al. Cutaneous me-
wounds on body image and quality of life. J Wound Care tastases from genitourinary malignancies. Urology 2004;63:
2005;14:359-362. 1021-1026.

2. Lookingbill DP, Spangler N, Sexton FM. Skin involvement 9. Carroll MC, Fleming M, Chitambar CR, et al. Diagnosis
as the presenting sign of internal carcinoma. J Am Acad workup, and prognosis of cutaneous metastases of unknown
Dermatol 1990;22:19-26. primary origin. Dermatol Surg 2002;28:533-535.

3. Lookingbill DP, Spangler N, Helm KF. Cutaneous me- 10. Schwartz RA. Cutaneous metastatic disease. J Am Acad
tastases in patients with metastatic carcinoma: A retrospec- Dermatol 1995;33:161-182.
tive study of 4020 patients. J Am Acad Dermatol
1993;29:228-236. 11. Ivetic O, Lyne PA. Fungating and ulcerating malignant
lesions: A review of the literature. J Adv Nurs 1990;15:83-88.
4. Ambrogi V, Nofroni I, Tonini G, et al. Skin metastasis in
lung cancer: Analysis of a 10-year experience. Oncol Rep 12. Cohen PR. Skin clues to primary and metastatic malig-
2001;8:57-61. nancy. Am Fam Physician 1995;51:1199-1204.

5. Saeed S, Keehn CA, Morgan MB. Cutaneous metastasis: A 13. Wilson V. Assessment and management of fungating
clinical, pathological, and immunohistochemical appraisal. J wounds: A review. Br J Community Nurs 2005;10:S28-S34.
Cutan Pathol 2004;31:419-430.
14. Collier M. The assessment of patients with malignant
6. Cormio G, Capotorto M, Di Vagno G, et al. Skin metasta- fungating wounds - A holistic approach: Part 1. Nurs Times
ses in ovarian carcinoma: A report of nine cases and a review 1997;93(suppl):1-4.
of the literature. Gynecol Oncol 2003;90:682-685.
15. Grocott P, Cowley S. The palliative management of
7. Pitman KT, Johnson JT. Skin metastases from head and fungating malignant wounds – Generalising from multiple case
neck squamous cell carcinoma: Incidence and impact. Head study data using a system of reasoning. Int J Nurs Stud
Neck 1999;21:560-565. 2001;38:533-545.

16. Naylor W. Assessment and management of pain in fun-
gating wounds. Br J Nurs 2001;10(suppl 22):S33-S36.

MALIGNANT FUNGATING WOUNDS IN ADVANCED CANCER 193

17. Bowler PG, Davies BJ, Jones SA. Microbial involvement 37. Broadley KE, Kurowska A, Dick R, et al. The role of
in chronic wound malodour. J Wound Care 1999;8:216-218. embolization in palliative care. Palliat Med 1995;9:331-335.

18. Clark J. Metronidazole gel in managing malodorous fun- 38. Coldwell DM, Sewell PE. The expanding role of interven-
gating wounds. Br J Nurs 2002;11(suppl 6):S54-S60. tional radiology in the supportive care of the oncology patient:
from diagnosis to therapy. Semin Oncol 2005;32:169-173.
19. Bradley M. When healing is not an option: Palliative care
as the primary treatment goal. Adv Nurse Pract 2004;12:50-55. 39. Chaloupka JC, Mangla S, Huddle DC, et al. Evolving
experience with direct puncture therapeutic embolization for
20. Bates-Jensen BM, Early L, Seaman S. Skin disorders. In: adjunctive and palliative management of head and neck hyper-
Ferrell, BR, Coyle N (eds): Textbook of Palliative Nursing. vascular neoplasms. Laryngoscope 1999;109:1864-1872.
Oxford, Oxford University Press, 2001;204-244.
40. Murakami M, Kuroda Y, Sano A, et al. Validity of local
21. Haisfield-Wolfe ME, Baxendale-Cox LM. Staging of ma- treatment including intraarterial infusion chemotherapy and
lignant cutaneous wounds: A pilot study. Oncol Nurs Forum radiotherapy for fungating adenocarcinoma of the breast. Am J
1999;26:1055-1064. Clin Oncol 2001;24:388-391.

22. van Leeuwen BL, Houwerzijl M, Hoekstra HJ. Educa- 41. Sawynok J. Topical and peripherally acting analgesics.
tional tips in the treatment of malignant ulcerating tumours of Pharmacol Rev 2003;55:1-20.
the skin. Eur J Surg Oncol 2000;26:506-508.
42. Back IN, Finlay I. Analgesic effect of topical opioids on
23. Grocott P. The management of fungating wounds. J painful skin ulcers. J Pain Symptom Manage 1995;10:493.
Wound Care 1999;8:232-234.
43. Krajnik M, Zbigniew Z. Topical morphine for cutaneous
24. Seaman S. Dressing selection in chronic wound manage- cancer pain. Palliative Med 1997;11:325.
ment. J Am Podiatr Med Assoc 2002;92:24-33.
44. Zeppetella G, Paul J, Ribeiro MD. Analgesic efficacy of
25. Gomolin IH, Brandt JL. Topical metronidazole therapy morphine applied topically to painful ulcers. J Pain Symptom
for pressure sores of geriatric patients. J Am Geriatr Soc Manage 2003;25:555-558.
1983;31:710-712.
45. Zeppetella G, Ribeiro MD. Morphine in intrasite gel
26. Rice TT. Metronidazole use in malodorous skin lesions. applied topically to painful ulcers. J Pain Symptom Manage
Rehabil Nurs 1992;17:244-245,255. 2005;29:118-119.

27. Whedon MA. Practice corner: What methods do you use 46. Ballas SK. Treatment of painful sickle cell leg ulcers with
to manage tumor-associated wounds? Oncol Nurs Forum topical opioids. Blood 2002;99;1096.
1995;22:987-990.
47. van Sonnenberg E, Shankar S, Parker L, et al. Palliative
28. Poteete V. Case study: Eliminating odors from wounds. radiofrequency ablation of a fungating symptomatic breast
Decubitus 1993;6:43-46. lesion. AJR Am J Roentgenol 2005;184:S126-S128.

29. Finlay IG, Bowszyc J, Ramlau C, et al. The effect of 48. Fritz P, Hensley FW, Berns C, et al. Long-term results of
topical 0.75% metronidazole gel on malodorous cutaneous pulsed irradiation of skin metastases from breast cancer.
ulcers. J Pain Symptom Manage 1996;11:158-162. Strahlenther Onkol 2000;176:368-376.

30. Holloway GA, Johansen KH, Barnes RW, et al. Multi- 49. Seegenschmiedt MH, Keilholz L, Altendorf-Hofmann A,
center trial of cadexomer iodine to treat venous stasis ulcer. et al. Palliative radiotherapy for recurrent and metastatic ma-
West J Med 1989;151:35-38. lignant melanoma: prognostic factors for tumor response and
long-term outcome: A 20-year experience. Int J Radiat Oncol
31. Danielsen L, Cherry GW, Harding K, et al. Cadexomer Biol Phys 1999;44:607-618.
iodine in ulcers colonised by pseudomonas aeruginosa. J
Wound Care 1997;6:169-172. 50. Leonard R, Hardy J, van Tienhoven G, et al. Random-
ized double-blind, placebo-controlled, multicenter trial of 6%
32. Cormier AC, McCann E, McKeithan L. Reducing odor miltefosine solution, a topical chemotherapy in cutaneous
caused by metastatic breast cancer skin lesions. Oncol Nurs metastases from breast cancer. J Clin Oncol 2001;19:4150-
Forum 1995;22:988-999. 4159.

33. Gagnon B, Mancini I, Pereira J, et al. Palliative manage- 51. Piggin C. Malodorous fungating wounds: uncertain con-
ment of bleeding events in advanced cancer patients. J Palliat cepts underlying the management of social isolation. Int J
Care 1998;14:50-54. Palliat Nurs 2003;9:216-221.

34. Pereira J, Phan T. Management of bleeding in patients 52. Lund-Nielsen B, Müller K, Adamsen L. Malignant
with advanced cancer. The Oncologist 2004;9:561-570. wounds in women with breast cancer: Feminine and sexual
perspectives. J Clin Nurs 2004;14:56-64.
35. Grocott P. Controlling bleeding in fragile fungating tu-
mors. J Wound Care 1998;7:342.

36. Rankin EM, Rubens RD, Reidy JF. Transcatheter embo-
lisation to control severe bleeding in fungating breast cancer.
Eur J Surg Oncol 1988;14:27-32.