Chapter 25: Wound management
Skip chapter table of contents and go to main content
Related theory
Malignant fungating wounds are associated with advanced cancer and often appear in the last 6 months of life, although they can develop earlier and the patient could have them for a prolonged period (Naylor [100]). There is often an absence of pain in the early stages of the tumour developing, which can result in a delay in the patient presenting with the problem and consequently lead to a delay in treatment (Benbow [14]). There are occasions when patients present for help when their wounds are advanced. It is thought that this may be through fear of the cancer diagnosis or embarrassment (Lund‐Neilson et al. [86]).
The wounds often present as malodorous, necrotic and exuding areas which have a devastating effect on a patient's quality of life. Patients have often already endured a long, distressing treatment journey and the wounds then act as a constant physical reminder that their disease is both progressive and incurable (Naylor [100]). Living with a fungating wound can have a profound impact on a patient's physical, psychological and social well‐being and on their family and friends.
Healing of these wounds is rarely a realistic aim unless there is a good response to treatment, such as radiotherapy or chemotherapy, or the wound can be surgically excised. Recent developments such as electrochemotherapy may slow progression in a carefully selected group of patients (NICE [105]). When palliative management of the wound is required, the concentration should be on addressing distressing and uncomfortable symptoms to minimize the impact of the wound on the patient, promoting comfort and enhancing their quality of life (Grocott [54]).
There are several case studies and articles with anecdotal evidence on the management of malignant wounds. However there is a dearth of formal research in this area. The wounds are often managed on a trial and error basis. This is contrary to good clinical governance which requires practice to be evidence based (Lloyd [80]). There are no formal recordings and exact statistics known for malignant wounds, and the statistics that are available have often been collected without consistent inclusion criteria (Alexander [3]).
It is estimated that malignant fungating wounds occur in approximately 5% of patients with cancer and 10% of patients with metastatic cancer (Seaman [128]). They often occur in patients over 70 years of age (Dowsett [34]) and some may be due to neglect and late presentation. The most common presentation of malignant wounds is seen in breast tumours metastasizing in the breast or chest wall (62%) (McDonald and Lesage [91]). Lung and gastrointestinal tumours and melanomas account for most remaining fungating wounds, although they can develop from any other type of malignancy, including head and neck, ovary, genitourinary or from an unknown primary (Seaman [128]). They have also been found in unusual areas such as the nailbed, scrotum, eyelid and ear (Moore [97]).
Malignant wounds in the perineal or abdominal regions can lead to sinuses or fistulae with internal cavities, such as the bladder, vagina and bowel, which then increase problems of malodour and exudate as body substances such as faecal fluid may leak through the wound (Dowsett [34]). Wounds in the head and neck can result in distortion of the face, infiltration of the buccal cavity, which may lead to dribbling of saliva, and a wound exit point around the chin area (Grocott [54]).
Marjolin's ulcer
A Marjolin's ulcer is an aggressive malignant tumour that creates an ulcer in a chronic wound or scar tissue. It has a high rate of local recurrence and metastatic spread (Choi et al. [23]). Marjolin's ulcers most commonly occur in burn scars, although they can develop in chronic pressure ulcers, venous stasis ulcers or skin graft donor sites (Malheiro et al. [89]). The exact cause is not known, however there is general agreement that the lack of blood supply and chronic inflammation and immunity in the scar tissue form a ‘cancerous environment’. The delicate, dry epithelium can be repeatedly damaged by slight injuries, movement over joints, flexion or prolonged itching. The regeneration of epithelium over this area is inferior and the persistent requirement for the marginal epithelium to regenerate and repair can eventually lead to neoplastic changes. The signs and symptoms of a Marjolin's ulcer can often be mistaken for infection, leading to a delay in diagnosis. The ulcers can present as indolent, flat, chronic ulcers, increasing in circumference and depth, with indurated and elevated margins and a granular base; there is often an increase in volume and consistency of exudate and malodour (Malheiro et al. [89]) (Figure 25.4). Biopsy confirmation is required to diagnose a Marjolin's ulcer to initiate prompt treatment to reduce the risk of metastatic spread. Treatment is by wide excision followed by chemotherapy or radiotherapy (Choi et al. [23]).
Figure 25.4 Marjolin's ulcer on a buttock arising in an area of previous skin graft or burn scar. Source: Choi et al. ([23]). Reproduced with permission of The Korean Society of Reconstructive and Plastic Surgeons.
A high index of suspicion is required to diagnose Marjolin's ulcer so diagnosis is often delayed. Any wound that is not showing evidence of healing should be biopsied to rule out Marjolin's ulcer.
