FUNGATING WOUNDS

1. FUNGATING WOUNDS Wound Care Study Day 28 September 2011 St. John’s Hospice Marie B. Rodden Practice Development Specialist Sister St. John’s Hospice

2. Fungating Lesions Definition “Fungating lesions are products of cancerous infiltration of the epithelium . . . which develop into a FUNGATING mass or ULCERATIVE lesion with subsequent infection, bleeding and maloderous exudate.” (Ivetic & Lyne1990)

3. Fungating LesionsOther definitions and descriptions “A fungating wound is essentially a mass of malignant cells that have infiltrated the epithelium and surrounding blood and lymph vessels.”(Moody & Grocott 1993) “A malignant, fungating wound occurs when tumour invades the epithelium and breaks through the skin surface.” (Dealey 1999) “Fungating and malignant wounds are caused by tumour infiltration of the skin and its supporting blood and lymph vessels.” (Grocott 2003)

4. Fungating Wounds – What are they? Development • 2° malignant cells infiltrating structures of skin from distant 1°. • Local advancement of a primary skin cancer itself (for example: squamous cell carcinoma or melanoma). • A deep primary tumour invading and eroding through the skin. (Adenocarcinoma Breast). (Naylor 2002)

5. Common Sites: Breast Head and neck Kidney Lung Ovary Vagina Colon Penis Bladder Lymphoma Leukaemia Fungating Wounds – no register of wounds5 - 15% of cancers result in a fungating lesion.

6. Fungating LesionsKey Points Differing schools of thought • Identification of specific tumours (special characteristic) • Potentiality • End Stage (Ivetic & Lyne 1990)

7. Fungating LesionsKey Points continued “Malignant wounds may present as either crater-like ulcers (destructive process) or a raised nodule similar in appearance to a cauliflower (or mushroom) and ‘fungating’ is the term sometimes used to describe a proliferative process.” (Carville 2005)

8. Fungating v Proliferation v of Cells “Cauliflower” v or Fungus Ulcerating Open Crater with margins Erodes Sinuses Fungating LesionsKey Points continued

9. Vascular Deficiencies Affects blood flow Poor cell perfusion Hypoxic regions Necrosis Fungating Wounds –Summary of Processes (Cell Level)

10. Fungating Wounds –Summary of Processes (Cell Level) 2) Absent or abnormal lymphatic vessels Increased interstitial fluid Increased extra vascular pressure Collapse of blood vessels Exudate

11. Fungating Wounds –Summary of Processes (Cell level) (3) Cell Proliferation Acidic pH of extra cellular fluid Interference with clotting mechanism Coagulation and bleeding Friable tissue

12. Fungating Lesions Outcomes of Process Moist Necrosis Colonisation Critical colonisation and /or infection Anaerobes Aerobes Volatile fatty acids Malodour and Exudate

13. Fungating LesionsSystemic Treatments • Radiotherapy • Chemotherapy – Miltofesine acts on cell membrane rather than DNA – Daily application first week then BD for 8 weeks. 3) Hormone therapy

14. Fungating Lesions “Current wound management based on moist wound healing – may have the potential to meet the needs of patients with fungating lesions even when healing is not an achievable goal.” (Grocott & Moody 1993) However, “Is there an alternative to moist wound healing in palliative care?” asks (McManus 2007).

15. “In palliative care, a wound that is maintained with a dry scab, allowing the wound bed underneath to remain dry, could enable a patient with a short prognosis to have a viable alternative to a complex dressing regime . . . “ (Winter & Scales 1963) “So if the wound surface can be dried to slow the rate of volume of exudate produced, some reduction in the discomfort and distress with very wet wounds may be achieved . . . “ (McManus 2007)

16. Fungating LesionsPriorities of Care • The patient’s perception of priorities. • Symptom control at the wound site. • “Non-healing” status.

17. Fungating LesionsWound Problems • The wounds are dynamic. • The size and shape of the wound may be difficult. • The wound may bleed. • The wound is often offensive. • The wound pours exudate.

18. Wound Problems – Local treatments at wound interface(continued) • Control of Bleeding Oral/topical anti-fribrinolytics – Tranexamic acid Alginates, Adrenaline 1:1000 Sucralfate paste 2g in 5 ml KY Jelly (Twycross 2001) or 1g mixed with KY Jelly (Emflorgo 1998)

19. Wound Problems – Local treatments at wound interface(continued) • Control of Infection Metronidazole Topical – (Anabact 0.8% gel) and/or systemic 400 mg x BD • Control of Odour Metronidazole and charcoal +/- silver dressings Sugarpaste and honey

20. Wound Problems – Local treatments at wound interface(continued) • Control of Exudate “3 functions required i) conservation of surface humidity at the wound interface. ii) reservoir capacity of exudate that is excess. iii) high moisture vapour transfer through the back surface of the dressing. Dressings need to be presented in metre rolls to accommodate large wounds and large amount of exudate.” (Grocott 2003)

21. Wound Problems – Local treatments at wound interface(continued) • Control of Pain - nociceptive or neuropathic? - topical and systemic route - nociceptive – topical opioids

22. Wound Problems – Local treatments at wound interface • Control of Pain(continued) examples: 20 mg diamorphine in 30 gms hydrogel x BD (Grocott 2003) 10 mg morphine “mixed in with most gels (inctr-palliative-care-handbook.wikidit.com 2011) 1 mg morphine to 1g hydrogel (Naylor 2003) 10 mg/1 ml morphine to 8 g sachet of intrasite (Aquaform) gel (Pcf3 2007)

23. Fungating LesionsPoints Re: Odour(Continued) Aerobic and Anaerobic Volatile Fatty Acids Exudate Malodour Putrescines Cadaverines

24. Fungating LesionsSome points on ODOUR “Evidence suggests that reaction to odours (especially the malodours from putrescine and cadaverines) is profoundly and deeply ingrained in human behaviour.”(Van Toller) and “we do not become desensitised to them through time. They are constantly detectable. (Alexander 2009)

25. Some points on ODOUR (continued) “For a significant minority of cancer patients the presence of a malodorous, exuding necrotic skin lesion can be a constant physical reminder that their disease is both progressive and incurable . . . “ (Naylor 2002)

26. References Carville K (2005) as cited in Alexander S (2009), Malignant Fungating Wounds:Epidemiology, aetiology, presentation & assessment, Journal of Wound Care, Vol 18, No 7, 2009. Dealey C (1999) Ed, The Care of Wounds: a guide for nurses, 2nd Edition, Blackwell Science, London. Emflorgo C (1998) Controlling Bleeding in Fungating Wounds, Journal of Wound Care, Vol 7, No 5.

27. References (continued) Grocott P (2003) The Palliative Management of Fungating Wounds, Address to Florence Nightingale School of Nursing, Kings College, London. Ivetic O & Lyne P A (1990) Fungating & Ulcerating Malignant Lesions: a review of the literature, Journal of Advanced Nursing 1990, Vol 15, No 1, pps 83-88. McManus J (2007) Principles of Skin & Wound Care: The Palliative Approach, End of Life Care, Vol 1, No 1, 2007

28. References (continued) Moody M & Grocott P (1995) Let us extend our knowledge base, Professional Nurse, Vol 8, No 9, pps 586-589. Naylor W (2002) Part I Symptom Control in the Management of Fungating Wounds, www.worldwidewounds.com. Naylor W (2003), Palliative Management ofFungating Wounds, European Journal of Palliative Care, Vol 10, No 3, pps 93-97, 2003.

29. References (continued) Twycross R (2001), Symptom Management in Advanced Cancer, 3rd Edition, Radicliffe Press, Oxford. Twycross R & Wilcock A (2007), Palliative Care Formulary, PCF3 Palliative Drugs Company Ltd. Van Toller S (1994) Invisible Wounds: the Effects of Skin Ulcer Malodours, Journal of Wound Care, Vol 3, No 2, March 1994. Winter G D & Scales J T (1963) as cited in McManus J, (2007), Principles of Skin & Wound Care: The Palliative Approach, End of Life Care, Vol 1, No 1, 2007.