Chapter 25: Wound management
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Treatment options
Initial diagnosis and evaluation
Managing the wound is vital but will not cure or control the disease. Fungating cancers are as heterogeneous as any presenting cancer and the treatment of the underlying disease should follow the same systematic process of diagnosis and treatment planning. It is no longer the case that the management of a fungating lesion equates to symptom control and wound care alone, although these are vital components.
Malignant fungating lesions may present in the presence or absence of metastatic disease and it is this criterion that determines treatment intent. The presence of metastatic disease (American Joint Committee on Cancer [7]) signifies that treatment is no longer able to eradicate disease. Long‐term control is still a valid and realistic goal, however, with combinations of appropriate treatment.
The successful management of a fungating malignant wound requires comprehensive, accurate diagnosis and pre‐treatment assessment. It demands the involvement and co‐ordination of the complete multidisciplinary team (MDT) from the outset.
Evaluation should include a full history of the symptoms and clinical examination to assess the extent of skin and local muscle involvement. It may be appropriate to biopsy the tumour to give information about nuclear grade and hormone receptor status to decide the most appropriate treatment. Staging scans may be required to ensure there is no distant disease. MDT discussion will confirm treatment intent, whether it be curative or palliative control.
The presence of metastatic disease will affect the treatment plan as the accepted approach is to employ less intensive treatments when the aim is not cure. It should be remembered that cancer in secondary sites, such as with breast cancers, can be controlled for significant periods. As such, treatments that improve the symptoms of a fungating malignant wound will offer more benefit proportionately.
Fungating tumours may be locally advanced because they are aggressive in nature. The patient may reliably describe only a short history of symptoms. It is to be hoped that such tumours will respond to chemotherapy to downsize them. An alternative scenario may be that of a patient who has been aware of changes for a significant time, sometimes even years, but has not sought help for a variety of reasons. Such a history indicates a slow progression. However, a treatment‐naïve tumour may respond to systemic treatments.
Surgical considerations
Surgical approaches and the development of reconstructive techniques have increased the surgical remit and ability to remove larger tumours while maintaining good aesthetic results or reproduce increasingly natural‐appearing reconstructions following operations such as a mastectomy. The role of the surgeon at diagnosis is to confirm whether surgery should be the primary treatment of choice for a fungating cancer. Seminal work published in the 1940s argued that the presence of certain characteristics, common to fungating lesions, absolutely contraindicated surgery as the primary treatment. Haagensen and Stout ([58]) cited these, in relation to breast cancers, to be extensive local skin oedema, skin ulceration, fixation to the chest wall, fixed involved axillary nodes and satellite skin nodules. These remain accepted standards today. Rather, surgery should be employed as the definitive treatment following medical therapies.
In the presence of metastatic disease, the role of surgery to improve local control and palliate symptoms is unclear. Surgery in the breast cancer setting may often be extensive and may include plastics and thoracic teams to clear and resurface the area. Benefits may only be small. However, they may be of great importance to the patient living with a fungating lesion. Overall survival is unlikely to be affected.
Medical approaches
Neo‐adjuvant chemotherapy
Where treatment intent is curative and surgery is planned following medical treatment, full immunohistochemistry of the tumour enables medical oncologists to plan intervention with appropriate drugs and drug combinations. This will include standard chemotherapy, often in combination with newer targeted drugs. The success of the human epidermal growth factor receptor (HER2) monoclonal antibody trastuzumab is well documented and has led to further development of other anti‐HER2 agents such as pertuzumab and lapatinib, which are showing promise and increasing the rate at which medical oncology teams are seeing complete pathological responses to treatment. Other targeted therapies of note currently include everolimus and bevacizumab. Such evidence is obtained from trials in the neo‐adjuvant setting for all breast cancers and it is an extrapolation that the same responses can be expected with fungating lesions. Treatment response should be monitored both clinically and radiologically.
Neo‐adjuvant or primary endocrine therapy
The use of endocrine therapy alone in a frailer patient can be effective in downsizing and treating a locally advanced tumour. Often response is slower and the neo‐adjuvant phase may be longer. Endocrine therapies can also be used in conjunction with the targeted drugs described previously. Discussion regarding when and whether to intervene with surgery should be ongoing and include the patient.
Radiotherapy
Radiotherapy is a local treatment given to reduce the risk of locoregional recurrence. This is of paramount importance with a fungating lesion as the chance of such recurrence is higher due to involvement of lymphatics, skin and often muscle. The radiotherapy treatment destroys malignant cells and can reduce the size of the wound, alleviating symptoms such as exudate, bleeding and pain. Initially there can be a deterioration in the appearance of the wound as malignant cells die and skin reactions occur (Winnipeg Regional Health Authority [WRHA] [145]). Standard radiotherapy policies should be employed if the patient is being treated with curative intent. Research is not unequivocal and the question as to whether it should be accepted practice is unanswered. As the drive to personalize treatment continues this will be an important area of discussion.
Those fungating lesions that are deemed suitable for palliation only may well be improved and controlled by radiotherapy, which will improve a patient's quality of life. Unlike the use of surgery at this point it may be less demanding and more tolerable to the patient.
Electrochemotherapy
Electrochemotherapy is aimed at the treatment and palliation of primary skin cancers and melanomas, and cutaneous and subcutaneous metastases of areas of non‐skin origin. It combines the administration of a cytotoxic chemotherapeutic agent, such as bleomycin or cisplatin, with electrical pulses applied to the tumour, which enhances the permeability of the tumour cells and leads to cellular uptake of the drug (Marty et al. [90]). There is increasing evidence for the effectiveness of electrochemotherapy in reducing tumour volume and in managing symptoms such as bleeding and exudate. It appears to be effective with minimal and transient side‐effects. The treatment can be given in a single session in an outpatient setting, which is convenient and cost‐effective, and patients can be retreated if the tumour recurs (Grocott et al. [56]).
