Providing Appropriate Care to Patients Living With Malignant Wounds

  As wound care providers, our focus is usually on wound healing and prevention. However, with wound care expertise comes a tremendous opportunity to positively impact the quality of life of those patients who are living with malignant wounds. Often associated with pain, odor, bleeding, and an unsightly appearance, malignant wounds present both physical and emotional challenges for patients, caregivers, and clinicians. The goals in the care of these patients should include managing wound exudate, odor, bleeding, and pain; preventing infection; and promoting emotional welfare of patients and their families.

  Malignant wounds occur in up to 5% of patients living with cancer and 10% of patients living with metastatic disease. To date, the largest study examining the incidence of cutaneous involvement of internal malignancies was performed by Lookingbill and colleagues,¹ who retrospectively reviewed data accumulated over a 10-year period from the tumor registry at Penn State Milton S. Hershey (PA) Medical Center. Of 7,316 patients, 367 (5%) had cutaneous malignancies. Of these, 38 patients had lesions as a result of direct local invasion, 337 had metastatic lesions, and eight had both. A secondary analysis from the same registry found that 420 patients (10.4%) of 4,020 patients living with metastatic disease had cutaneous involvement.² In women, the most common origins of metastasis were breast carcinoma (70.7%) and melanoma (12%). In men, melanoma (32.3%), lung carcinoma (11.8%), and colorectal cancer (11%) accounted for the most common primary tumors. Mueller et al³ performed a meta-analysis of eight studies examining cutaneous metastasis of internal malignancies. Of 81,618 primary visceral cancers, they identified 2,369 (2.9%) cases of metastasis to the skin. Although breast, lung, gastrointestinal tract, and melanoma account for the majority of cutaneous metastases, these lesions may arise from any type of malignant tumor.⁴

Pathophysiology of Malignant Wounds

  Malignant wounds may occur from local invasion into the skin by a primary tumor or by metastasis from distant site. Local invasion may initially manifest as an inflamed area with induration, redness, heat, and/or tenderness, and there may be a peau d’orange appearance with fixation to underlying tissue. As the tumor enlarges, the skin may ulcerate. Conversely, with metastatic spread tumor cells detach from the primary site and travel via blood or lymphatic vessels, or tissue planes, to the skin, usually in the region of the primary tumor.⁴ This occurs most commonly on the chest, head, neck, abdomen, and groin. Due to the presence of malignant cells in the dermal lymphatics, initial presentation may be an erythematous rash or plaque, known as carcinoma erysipelatoides.⁴ More commonly, these wounds present as well-demarcated, painless nodules ranging in size from a few millimeters to several centimeters with a firm to rubbery consistency. These lesions may have deep red to brown/black pigmentary changes and may eventually ulcerate. Both locally invasive and metastatic lesions may initially be misdiagnosed as rashes, plaques, cellulitis, epidermal cysts, lipomas, or other benign conditions. However, unlike many benign skin problems, these lesions will not resolve and over time may ulcerate, fungate, drain, and become painful.

  As malignant wounds enlarge, changes in vascular and lymphatic flow lead to edema, exudate, and tissue necrosis. The resulting wound may be fungating, in which the tumor mass extends above the skin surface with a fungus or cauliflower-like appearance, or it may be erosive and ulcerative. The wound bed may range from pale to pink with very friable tissue to completely necrotic, and the surrounding skin may be erythematous, fragile, and tender to touch. There may be maceration due to unmanaged wound exudate. Because necrotic tissue is an ideal culture medium for bacterial colonization, there may be considerable malodor.⁵

  The degree of pain experienced by the patient depends on wound location, depth of tissue invasion and damage, nerve involvement, and the patient’s previous experience with pain and analgesia.⁶

Assessment of Malignant Wounds

  Ongoing comprehensive assessment of the patient and malignant wound is crucial to developing an appropriate treatment plan, recognizing wound complications, and adjusting the plan as findings change. Wound location, size, appearance, exudate, odor, and status of surrounding skin guide local therapy. Assessment of pain and other symptoms direct which measures should be taken to provide comfort. The potential for serious complications such as hemorrhage, vessel compression or obstruction, or airway obstruction should be noted so that the caregiver can be educated regarding their palliative management. Table 1 reviews important points for the assessment of malignant wounds and the associated rationale.

  Part of holistic assessment includes evaluation of how the patient and significant others are coping with the malignant wound and the cancer diagnosis. How the wound affects daily life and relationships as well as the availability and use of social support networks in the community should also be examined.

Management of Malignant Wounds

  The goals of care should include control of infection and odor, management of exudate, prevention and control of bleeding, and management of pain.^7-8 Abilities of the patient and caregiver must also be considered. There is limited published information on treatment effectiveness, which reflects the absence of evidence-based care in this area and the significant need for further research and dissemination of findings.⁹ Although articles regarding malignant wounds are based mainly on expert opinion and the personal experience of palliative care providers, this information can be useful to wound care clinicians when striving to provide the best care for patients. Table 2 reviews goals and treatment suggestions for patients living with these challenging wounds.

Promotion of Well-Being Through Education

  Living with a cancer diagnosis is traumatic enough without the added physical and psychological burden of a malignant wound.¹⁵ Lo et al¹⁶ interviewed 10 patients with malignant wounds and concluded that central issues that negatively affected quality of life were pain, social isolation secondary to exudate and odor, and ignorance of both patients and healthcare providers regarding appropriate wound care. Probst et al¹⁷ conducted a study of nine women living with malignant wounds secondary to breast cancer. Key findings included difficulty in dealing with the unpredictability of the wound, including odor, exudate, bleeding, and pain, and the embarrassment of having the wound, especially around family and when in public. Probst et al¹⁸ examined the caregiver experience and found that they described “shock, disgust, and nausea” when providing local care, and feelings of isolation and lack of knowledge in how to care for their loved ones. The main conclusion of these and other studies is that the key to improving quality of life for these patients is access to a wound care team or specialist who educates patients and caregivers on how to care for the wound with appropriate dressings, and how to control exudate and odor. Education must also focus on the psychosocial aspects of living with a malignant wound. The clinician can facilitate a trusting relationship with the patient and caregivers by validating feelings, reviewing goals of care, and by openly discussing issues that the patient may not have talked about with other providers, such as wound malodor. Attention to the cosmetic appearance of the wound with the dressing in place can assist the patient in coping with body image disturbances. Use of soft flexible dressings that can fill a defect and protect clothing may help to restore symmetry and provide security for the patient.

  Assisting the patient and the caregiver to cope with the distressing symptoms of the malignant wound, such that odor and bleeding is managed, exudate is contained, and pain is alleviated, will improve psychological well-being. Education must include realistic goals for the wound. In these patients, the goal of complete wound healing is seldom achievable; however, quality of life can be maintained even as the wound degenerates. Continual education and re-evaluation of the effectiveness of the treatment plan are essential to maintaining quality of life for those living with a malignant wound.

  Susie Seaman is on staff at Sharp Rees-Stealy Wound Clinic, San Diego, CA. She may be reached at susie.seaman@sharp.com.

References

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