Managing Fungating (Malignant) Wounds
Caring for a patient with a fungating malignant wound is challenging. The science of palliative wound care is still in its infancy, with little research to guide care for this type of wound. This article examines fungating wounds and recommended methods of care and symptom management.A fungating (malignant) wound is a mass of cancerous tissue that is spreading under the skin and eventually infiltrates the outside layer of cells, breaking through the skin surface to create a wound. There is the potential for massive skin damage, with gross disfigurement and loss of function. As the cancerous tumor grows, it blocks the supporting blood and lymph supply, starving the area of oxygen. This causes the skin and underlying tissue to die due to lack of blood flow (necrosis). Fungating wounds present as either a raised nodule or as an ulcerated crater with a defined margin. The raised nodules often resemble a cauliflower or fungus protruding from the skin. The necrosis can lead to inflammation and infection. Usually there is a strong smelling discharge, bleeding, and pain.
Thankfully, fungating wounds are rare, occurring in just 5 to 15 percent of cancers. These malignant lesions tend to develop in elderly patients, primarily those aged 70 or older, who are in the advanced stages of metastatic illness. They may develop during the last few months of life or be present for years. Fungating wounds rarely heal and often require palliative management. Nearly two-thirds of these wounds develop in the breast area and a quarter develop in the head and neck area. Other common sites are the kidney, ovary, vagina, colon, penis, and bladder. Head and neck fungating tumors can distort the face, while these growths in the genitourinary tract can cause fistulas involving the bladder, vagina, and bowel.
Not surprisingly, these destructive wounds can have a devastating impact on the patientís overall quality of life. The most common symptoms of a fungating wound include copious exudate, an offensive smell, pain, bleeding, and itching. These symptoms can cause embarrassment, social withdrawal, and isolation. Wound bleeding is common in fungating wounds. This occurs because the cancerous cells damage the tiny blood vessels, making the tissue very fragile, and platelet function is impeded within the tumor as well. The profuse, spontaneous bleeding can be distressing to patients and families. Should bleeding occur, pressure to the area should be applied immediately with a moist or non-stick dressing to avoid damaging the tissue further.
Meticulous skin care is imperative for comfort, cleanliness, and odor control. To avoid drying and irritating the skin, soaps should be avoided. A mild pH-balanced skin cleanser such as Aloe Vesta or Sensi-Care should be used instead. Dressings should facilitate maintenance of a moist wound bed, to prevent irritating delicate nerve endings. Hydrogels, hydrocolloids, foams, composite dressings, and calcium alginates are recommended. These type dressings also help control leakage or discharge. Wet-to-dry dressings are not recommended, as these can damage the periwound. A barrier cream such as Cavilon can be applied around the wound to protect surrounding skin. The dressings should be changed as often as necessary to control discharge and odor, but too frequent changes can exacerbate bleeding. Nonadherent dressings should be used to protect the fragile skin. Gentle irrigation of the wound with warm saline, as opposed to swabbing, can reduce pain and tissue damage with dressing changes.
What have been your experiences with these types of wounds?
What is a Fungating Wound?Last edit by Joe V on Jul 26, '12
VickyRN is a certified nurse educator (NLN) and certified gerontology nurse (ANCC). Her research interests include: the special health and social needs of the vulnerable older adult population; registered nurse staffing and resident outcomes in intermediate care nursing facilities; and, innovations in avoiding institutionalization of frail elderly clients by providing long-term care services and supports in the community. She is faculty in a large baccalaureate nursing program in North Carolina.
VickyRN has '16' year(s) of experience and specializes in 'Gerontological, cardiac, med-surg, peds'. From 'Under the shadow of His wings...'; Joined Mar '01; Posts: 12,044; Likes: 6,439.1Quote from wildcatfanrnthe worst fungating wound i have seen was a squamous cell carcinoma mass on an elderly woman's right shoulder. she was fiesty and independent and did not believe in going to doctors. she told me she kept "doctoring" the lesion on her shoulder over the years, but it kept growing and growing. finally it metastasized. the growth was so huge and necrotic with noxious seepage that her entire right arm and shoulder had to be removed. she eventually died on our swing-bed unit. such a sad case, and so unnecessary, because squamous cell carcinoma is easily treatable and easily removed in its early slow-growing stages.i can honestly say i have never encountered wounds like this. huge decubiti yes, this no. wow...0Jul 26, '12 by bestallaroundI once had a patient with one of these wounds from testicular cancer. It was described exactly as above. It was first a hollow wound that we were packing, but it grew quickly pushing outside of the skin until it was just one great big mass in his lap. It was almost as if his scrotum was just one huge wound. It was very foul smelling and drained terribly. We irrigated it frequently with Dakins solution. If we attempted to dab or gently swab the area, it bled, so we just continued the irrigations. Odor control was a huge issue. We made sure to dispose of all wound care supplies and linens that were soiled after each cleansing.1Quote from bestallaroundThis is truly horrific. Thank you for sharing.I once had a patient with one of these wounds from testicular cancer. It was described exactly as above. It was first a hollow wound that we were packing, but it grew quickly pushing outside of the skin until it was just one great big mass in his lap. It was almost as if his scrotum was just one huge wound. It was very foul smelling and drained terribly. We irrigated it frequently with Dakins solution. If we attempted to dab or gently swab the area, it bled, so we just continued the irrigations. Odor control was a huge issue. We made sure to dispose of all wound care supplies and linens that were soiled after each cleansing.0Quote from lovingtheunlovedSo sorry to hear that. It is very difficult for nurse caregivers to deal with these type wound situations.I have a patient right now with this type of wound. A squamous cell carcinoma. Unfortunately, she's terribly noncompliant and will probably lose her leg because of it.3Jul 26, '12 by Nascar nurse, ASN, RNI have a LTC resident with a wound such as you describe to her thigh (thought to be a liposarcoma). 5x6x3. We have had great success with gold dust powder. Gold Dust.
The hospice provider came up with this solution and it went from a draining, stinking mess with multiple dressing changes daily to a nice clean looking/smelling wound with only daily dressing changes. This wound has now been virtually unchanged in size for nearly a year - hasn't gotten better/worse - hasn't gotten infected. Yeah!2Jul 26, '12 by tewdlesWe see these too often in hospice. Very traumatic wounds typically for the patient, family, and nurses.
I love the info about gold dust, this is not something I am familiar with and will read with interest.
These are the wounds that sometimes erode an adjacent blood vessel causing the patient to exsanguinate in the home.0Jul 26, '12 by VivaLasViejas, ASN, RN GuideI've seen only one of these wounds, in an elderly nursing home resident with advanced breast CA. The wound basically involved the entire breast......started out quarter-sized and grew to the size of a tennis ball. The drainage was just horrendous, and the smell was unspeakable. Yet the resident refused to have the mastectomy that could've saved her life; her attitude was "I came into this life with two of these, and I'm leaving it with two". It wasn't an easy death, though, and I can't imagine what kind of pain she must have suffered.