Epidemiology

It is difficult to accurately determine the numbers of patients being treated for these wounds as assessment data are not routinely documented in clinical practice. However, it is estimated that around 5–10% of all patients with a primary tumour near the skin surface or with metastatic cancer will develop this wound. One study conducted in the USA concluded that 5% of patients with cancer have skin involvement. Another survey undertaken in the UK used information collected retrospectively from radiotherapy and oncology units, and reported a monthly total of 295 patients with metastatic skin involvement with a projected annual figure of 2,417 patients in the UK experiencing a fungating malignant wound (Thomas, 1992) (25). Fungating wounds tend to develop in elderly patients (70 years and above) with metastatic cancer, who are in the terminal stages of their illness. Approximately 62% of fungating wounds will develop in the breast area and 24% in the head and neck area. A fungating wound however, can arise anywhere on the body (26). 

 

Aetiology

These wounds are the visible indicators of underlying cancer, and have a significant physical and psychological impact on the patients’ quality of life.

The skins epithelium and its blood and lymph vessels are infiltrated by a local tumour or metastatic cancerous cells. The increasing tumour size causes the capillary vessels to rupture, leading to tissue hypoxia and necrosis (27). Unless the malignant cells are controlled with chemotherapy, radiotherapy or hormone therapy, the fungation may spread outwards by local extension and as a consequence, cause damage through a loss of vascularity, proliferative growth and ulceration. Women still present at initial diagnosis with a malignant fungating wound. They may delay seeking help and try to hide the reality of the cancer, which highlights the huge impact and shame associated with such a wound on an intimate part area (27).

 

Clinical Signs

It most commonly occurs with breast cancer, but may also be found in skin, head and neck, vulva and bladder cancers. The lesions appear as a raised fungating lesion or as an ulcerated crater with a distinct margin (27). These wounds not only develop at the site of the primary tumour, but if the nodes of the groin or axilla are affected, ulceration may also occur at these sites (28).  Fungating wounds are often necrotic, sloughy or infected. There are usually excessive amounts of exudate which may have an offensive odour. Capillary bleeding may occur as the tumour size increases and erodes blood vessels. The bleeding may be heavy enough to cause anaemia. Lymphodeama (a chronic swelling of the adjacent limb(s), due to a failure of lymph drainage) may be present with breast, cervix or vulva cancers. It may be associated with loss of function of the affected limb (28). Necrotic tissue in malignant wounds is typically moist yellow slough. In the absence of exudate, there may be dry black eschar, but this is uncommon (29).  

 

Treatment

For most patients, healing is unlikely unless they responsd well to anti-cancer therapy, or if the wound is surgically eliminated. Most fungating wounds however, will continue to deteriorate over time and commonly has a devastating effect on physical and emotional well-being. They’re generally managed with palliative methods to control wound-related symptoms and associated pain (25). Infection and odour control is achieved by wound cleansing, debridement (best performed using autolytic and/or gentle mechanical methods as opposed to wet-to-dry dressings, which are traumatic and can cause significant bleeding on removal (29), and local antimicrobial agents. There is wide support for topical metronidazole, (has broad spectrum activity against anaerobic bacteria), to control wound odour. Charcoal dressings, which absorb and trap odour may also be helpful in odour management. While local colonization is treated with topical cleansing, debridement, and antibacterial agents, clinical infection should be treated with systemic antibiotics. Radiation therapy is well documented and can also be used to treat some malignant tumours’ with minimal damage to surrounding skin (29).