VOL: 97, ISSUE: 02, PAGE NO: 36
Jackie Lisle, BA, DN, RMN, SRN, NNEB, is district tissue viability adviser, Wakefield and Pontefract Community Health NHS TrustMalignant fungating wounds occur when a cancerous mass invades the epithelium, resulting in either a raised fungating nodular wound or an ulcerating crater. They are difficult to manage, which can be distressing for both the patient and the nurse.
Malignant fungating wounds occur when a cancerous mass invades the epithelium, resulting in either a raised fungating nodular wound or an ulcerating crater. They are difficult to manage, which can be distressing for both the patient and the nurse.
Disruption of the epithelial layer of the skin, which supports the blood and lymphatic vessels, can affect the blood, lymph, interstitial and cellular environments, causing bleeding and lymphoedema. Tissue hypoxia often causes necrosis, with colonisation or infection by anaerobic organisms resulting in malodour.
Fungating wounds can develop at sites other than the primary location of the tumour. Almost any cancer can develop secondary deposits in the skin, resulting in ulceration.
The areas most commonly affected include the breast, head, face, neck, genitalia or anal areas (Williams, 1997), and the lymph nodes of the groin and axilla (Rosen, 1980). If a malignant wound is evident on the surface of the skin, there may also be deeper tissue damage (Cooper and Cooper, 1993).
Fungating wounds produce large amounts of exudate. In some lesions the tumour may secrete a factor that increases vascular permeability, which could explain the excess production of exudate (Haisfield-Wolfe and Rund, 1997). In addition, the level of plasma proteins in exudate is generally similar to that of circulating blood but it can become concentrated, raising the osmotic pressure and drawing more water out of the vasculature (Buchan et al, 1980).
Collier (1997) supports the theory that the activity of protease in breaking down necrotic tissue also increases the amount of exudate.
Wound dressings are constantly evolving, encouraging the shift from emphasis on passive healing, using non-interactive wound contact materials, to active healing, which involves the use of products that promote the healing process. Krasner (1995) suggests that wounds can be categorised by their colour, with black signifying necrotic, yellow sloughy, red granulating and pink epithelialising.
There is consensus about the type of product to use for each wound category (Table 1). But what happens in cases when a wound does not fit neatly into one of these categories, or is too complex to be managed with conventional wound management methods and products?
Kenneth Jones, 84, noticed a swelling in the side of his groin. He was not concerned because he was not in pain and the lump measured only 1.5cm by 1.8cm and reduced under pressure.
Ten months later, however, he noticed that the lump had increased in size to 7cm by 5cm and was no longer reducible. His GP made an initial diagnosis of right inguinal hernia and referred Mr Jones for surgery. Almost two years later a biopsy of the swelling was taken. This confirmed that it was a malignant growth and that it was most likely to be a secondary deposit originating from an unknown primary site.
After the biopsy Mr Jones was referred for assessment and management of his surgical wound. At the innermost aspect of the 10cm incision was an open wound that measured 2cm by 1cm and was draining green exudate. The plan was for Mr Jones to receive palliative radiotherapy once the wound had healed. The treatment objective, therefore, was to encourage wound healing and control the exudate.
An alginate dressing was chosen for the primary dressing because it absorbs exudate and forms a gel on the wound surface, maintaining a moist wound environment. A polyurethane foam was selected as a secondary dressing because it absorbs exudate and allows water vapour to pass through the dressing.
This treatment regime continued for a month, by which time the wound had granulated. Mr Jones then had 15 radiotherapy treatments.
The wound had epithelialised by the time the radiotherapy sessions ended, but the community nurses continued to monitor Mr Jones on a monthly basis. In July 1998, Mr Jones reported a swelling in his right leg. An examination revealed that the leg was grossly oedematous, measuring 5cm wider at the ankle, gaiter and calf and 7cm wider at the thigh than the left leg.
The community nurses referred Mr Jones to a GP, who diagnosed lymphoedema secondary to the malignancy. Compression hosiery was prescribed, which helped reduce the oedema, but his the right side of his groin was swollen with non-blanching erythema.
In August, Mr Jones complained of pain, swelling, redness and a feeling of wetness in his groin. Examination revealed a sloughy wound measuring 5cm by 3cm, with erythema extending to 7cm by 4cm. The towel he had been using to absorb exudate was saturated.
When the wound was palpated, it felt nodular and was found to extend to 10cm by 5cm. It did not feel hot and the wound bed had a cheesy appearance. It was apparent that Mr Jones had a fungating lesion. The oncology team did not think it would respond to radiotherapy or chemotherapy, so they recommended the use of conventional methods of wound management.
The challenge was to manage a wound that was:
- Exuding about a litre of fluid a day;
- Malodorous, and attracting flies;
- Located in the crease of the groin;
- Of irregular shape and texture;
- Increasing in size every week.
The best option appeared to be an open-pouch colostomy system, and stoma adhesive was used to create an even surface on which to secure it. Mr Jones was able to empty the bag at regular intervals during the day; the odour was controlled through the use of systemic antibiotics and a commercial odour-reducing compound added to the bag. Citronella oil was burned to ward off the flies.
By this time, Mr Jones was in pain. The World Health Organization's three-step analgesia ladder was introduced (O'Neill and Fallon, 1997), starting with co-proxamol and moving on to morphine sulphate in the tertiary stage.
Throughout his illness, Mr Jones participated in the management of his wound and pain, and continued to visit his local pub daily until the week of his death one year after diagnosis.
- The patient's name has been changed