What is a malignant wound?

Although the exact incidence is unknown, an estimated 5% to 10% of patients with metastases will develop a malignant wound (also called a cutaneous malignancy, fungating wound, ulcerating cancerous wound, tumor necrosis, or malignant cutaneous wound).¹ Malignant wounds usually occur in the last six months of life and are more likely to occur in older patients.² Malignant wounds can occur with various types of cancer but are more likely in breast, skin, lung, head and neck, colorectal, and gynecological cancer.³ Because nurses in all areas of clinical practice interact often with patients with cancer, they should be familiar with these wounds and ways of alleviating their complications.

Malignant wounds in general tend to have poor vascular perfusion patterns as well as poor clotting mechanisms. Malignant tissue tends to be disorganized and can often extend down into organs, creating fistulas and sinus tracts.

Many malignant wounds have a pattern of proliferative growth and at times ulceration. Often they are described as being cauliflower or funguslike in appearance.

One of the more common ways malignant wounds can occur is from an untreated skin cancer, such as a basal cell or squamous cell carcinoma, that has deteriorated.

A malignant ulcer can also occur when a tumor is left untreated and erodes through the skin. Untreated breast cancers can often proliferate into large malignant wounds by eroding through the skin.

Malignant wounds can also arise from metastatic deposits via the vascular or the lymphatic system. These malignant cells are then trapped by the skin capillaries and rapidly proliferate.³

Surgery for removal of cancerous lesions may cause seeding of malignant cells into the dermis, setting the stage for malignant growth to proliferate. This may be seen in breast cancer following a mastectomy.⁴

A malignant wound may also develop when a chronic ulcer undergoes changes that transform it into a malignant ulcer. This is seen in chronic wounds or scars (i.e., burn scars) that are of 25-40 years duration.⁴ This type of malignant growth within these chronic wounds is called Marjolin’s ulcer.

Among the most effective ways to treat malignant wounds are radiotherapy and chemotherapy. Often they can significantly reduce the size of malignant wounds and the complications associated with them.

Listening to patient priorities

Malignant wounds have a high rate of recurrence and tend to cause major alterations in patients’ physical and psychosocial well-being.5 Malignant wounds can result in many associated problems, including odor, bleeding, exudates, pruritis, and pain. Before starting treatment, nurses need to determine which problems patients consider most distressing. Even though bleeding may be more life-threatening, many patients may find the odor unbearable and need to have it resolved first. It may be possible to relieve many of the complications simultaneously.

Odor: Odor is one of the most distressing complications of malignant wounds. The malodor is usually associated with an “anaerobic bacterial cocktail.”⁶ Anaerobic bacteria, such as Clostridium perfringes, Bacteroides fragilis, and other anaerobic cocci, can produce strong odors.⁷ The very nature of the malignant wound tends to lead to the presence of necrotic material, which provides additional areas for anaerobes to “hide under.” These anaerobes can often be very hard to reach and eradicate. In some wounds with extensive necrotic tissue, the necrotic tissue itself can have an offensive odor.

Aerobic bacteria may be present, as well. Klebsiella, proteus, and pseudomonas can also produce distressing odors. Wounds that have a significant odor are usually polymicrobial and may contain both anaerobes and aerobes. Strikethrough exudate (exudate that’s soaked or leaked through the dressing on the outside) may also produce offensive odors, especially if the dressing is left on too long and the exudate is exposed to the air.

While environmental manipulation can be helpful, it’s important to try to alleviate the causative factor. Because many odors can be caused by bacterial growth and activity, any infection present needs to be eradicated and further episodes prevented. The use of systemic antibiotics, topical antimicrobials, or both may be indicated.

One of the most effective and frequently used topical antimicrobials is metronidazole (Flagyl) (0.75%-0.8%) gel. Spreading the gel liberally on the wound often eradicates the odor in 24-48 hours, particularly if the causative agents are anaerobes. For patients who can actually “taste” the odor, oral metronidazole may be useful.

Other topical antimicrobials that may be useful are silver preparations, such as silver sulfadiazine (Silvadene) cream and silver gel (i.e., SilvaSorb), and topical iodine pastes and gels (i.e., Iodosorb). Often rotating different antimicrobials can reduce odor on a more long-term basis. Another treatment that is making something of a comeback due to the emergence of antibiotic resistant organisms is honey. The hyperosmotic wound environment initiated by the honey serves as a deterrent to bacterial growth. However, more research is needed to clinically verify its effectiveness and use in malignant wounds.⁸

When odor is caused by bacterial invasion in necrotic tissue or to the necrotic material itself, it’s often difficult for topical or systemic antimicrobials to eradicate the bacteria. Debriding the necrotic tissue may be ideal, but some debridement methods, such as sharp debridement, carry risks: Sharp debridement may cause excessive bleeding in malignant wounds.

Autolytic debridement (trapping the body’s own enzymes with an occlusive dressing to break down necrotic tissue and rehydrate the tissue) can increase the exudate level significantly, another outcome that may not be desirable. For these wounds, charcoal dressings (i.e., CarboFlex, Actisorb) may provide some relief. Charcoal is an “adsorber,” which means that the molecules responsible for wound odor are bound to it.⁵

Other strategies to consider are —

• Frequent dressing changes and the use of sealed disposal areas
• Frequent bed linen changes
• Well-ventilated areas for dressing changes
• Frequent gentle cleansing of the wound with normal saline
• External room deodorizers
• Mentholatum (i.e., Vicks VapoRub) applied near the patient’s and caregiver’s nostrils
• Trays with kitty litter, baking soda, charcoal, and lava rock in the patient’s room
• Pouching of the wound with wound manager systems or ostomy/urostomy bags to contain the odor instead of dressings

Bleeding: One of the most important ways to deal with bleeding is to prevent it. Preventive measures include very gentle cleansing (with lukewarm normal saline and not under pressure). Do not use dressings such as moistened gauze or telfa, petrolatum, or paraffin tuille because they stick. Silicone dressings offer true “non-stick” and painless application and removal. Creams and gels, such as metronidazole, can be spread over silicone dressings. Avoid frequent, unnecessary dressing changes. Use moist wound healing by not allowing the dressing to dry out.

Bleeding can take place with the slow capillary “oozing” that occurs from the presence of friable and fragile blood vessels or dressing changes. In patients undergoing chemotherapy, possible decreased platelet function can also exacerbate the amount and frequency of bleeding.

Sucralfate (Carafate) suspension or paste can often be used to coat the surface of friable blood vessels, adding a barrier to prevent trauma-induced bleeding. Calcium alginate dressings, known to have hemostatic actions, have frequently been used. Recent research has found that they may not be as hemostatic as once thought: Mechanical damage and bleeding were found on very friable blood vessels within malignant wounds after the use of calcium alginate dressings,⁵ but more rigorous research is needed before calcium alginate dressings are eliminated for this purpose.

Although any bleeding from malignant wounds can be distressing for patients, it can be particularly frightening if it occurs spontaneously or profusely. Tumors that erode into the vascular system can cause life-threatening episodes of bleeding.

When a tumor erodes into a major vessel, causing serious hemorrhage, surgical intervention, such as cauterization, may be required.⁹ Topical epinephrine 1:1000 also can be used to reduce profuse bleeding,¹⁰ but only knowledgeable specialists should apply this therapy because critical ischemia can occur from excessive local vasoconstriction.¹¹

Oral antifibrinolytics, such as tranexamic acid (Cykloapron), can also be used to control severe bleeding. Tranexamic acid is usually given at doses of 500 mg in 5 ml of sterile water topically or orally 1 to 1.5 mg bid-qid for 10 days.¹⁰ Surgical hemostatic sponges can also be used to control sudden, profuse bleeding, but they are difficult to obtain outside the acute care setting. Silver nitrate sticks and topical thrombin can also be used; they are more readily available.

Because sudden or profuse bleeding can be so distressing for patients, it’s important to consider other interventions, such as —

• The use of dark (red, green, brown, or black) towels to absorb blood so patients cannot see large stains
• Prompt disposal of blood-soaked dressings and towels
• Administration of sedatives if patients demonstrate anxiety
• Rapid assessment and treatment of pain

Exudate: Malignant wounds frequently produce large amounts of malodorous exudate. Excess exudate is often caused by disorganized and hyperpermeable tumor vasculature. Tumor cells secrete a vascular permeability factor that in turn causes the microvasculature to be hyperpermeable to fibrinogen and plasma colloids.¹⁰ Many malignant wounds are chronic wounds and as such have an increased number of bacterial proteases (enzymes that break down tissue).¹² As these proteases break down tissue, liquefaction and more exudate can be produced.  Managing the exudates can be difficult. Two goals to remember: 1) keep the wound bed moist and 2) manage excessive exudate and prevent the breakdown of healthy tissue. A fine balance between these two goals must be achieved.

A foam or absorptive dressing such as hydrofiber is the dressing of choice for highly viscous exudate. Corrosive exudates may need a collection device, i.e., pouching system. A pouching system is also appropriate if a wound has greater than 150 ml draining in eight hours, if the exudates need to be rapidly removed, or if measurement of the amount of exudate is needed. Negative pressure systems, such as vacuum-assisted closure, are not advisable. Not only is profuse bleeding possible with negative pressure, but malignant growth exacerbation may occur.¹³

Infections can increase exudate levels significantly. Antimicrobials can indirectly decrease exudate production by acting to decrease the bacterial load.

Adequate periwound protection is vital during periods of high exudate production. Methods to prevent maceration and irritation include protecting the periwound skin with suitable alcohol-free barriers (liquids, pastes, or solids), placing thin hydrocolloid strips around the wound as a “window frame” to provide a taping surface away from the skin, minimizing the use of tapes, and considering alternatives to taping (nets, gauze, or self-adherent bandages) or using clothing to secure dressings.

Pruritis: The pruritis associated with malignant wounds is often described as a “creeping” or an intense itching sensation. It often develops as a result of tumor cells stretching the skin and irritating peripheral nerve endings. Pruritis can also develop as a result of skin irritation and excoriated skin from exudate or topical irritants. Fungal infections, which can be common in immunocompromised patients, are also a cause of intense pruritis.

The cause of pruritis must be accurately assessed to determine the appropriate treatment. Pruritis associated with fungal infections or excoriated skin will resolve with specific agents. Pruritis caused by topical irritants will resolve with discontinuation of the offending agent.

Generally, antihistamines will not relieve pruritis associated with tumor growth in malignant wounds.⁵ Transcutaneous electrical nerve stimulation (TENS) has shown promise but needs more rigorous study.⁵ The options to reduce the intensity of pruritis include —

• Hydrogel sheet dressings cooled in the refrigerator and applied several times daily
• Menthol creams applied to the area
• Baths or showers in cool or lukewarm water rather than hot water
• Use of low pH-balanced cleansers and moisturizers
• Avoidance of products containing alcohol, lanolin, or fragrance
• Avoidance of hot/spicy foods and alcohol, which increase histamine production
• Use of humidifiers (cool) in cool and cold months
• Use of lightweight, nonbinding clothing

Pain: One of the primary interventions for all patients with malignant wounds is to prevent pain. Nonadhering dressings (silicone dressings), gentle cleansing, and an adequate moisture balance at the wound surface should prevent unnecessary pain and discomfort.

Pain is a very common finding in patients with malignant wounds. Patients generally expect pain: A recent survey indicated that 80% of patients with chronic wounds experience pain.¹

Three types of pain are generally associated with wounds. Noncyclic acute pain is pain that occurs in a single episode. A sharp debridement or incision and drainage may cause this type of pain. Applying local and topical anaesthetic 10 to 15 minutes before a procedure can decrease or alleviate this type of pain. The second type of pain is similar, except that it’s cyclical or repetitive, like that occurring with each dressing change. Nurses and patients can plan for pain of this kind. Local anesthetics and analgesics are appropriate for this type of pain. Timeouts during dressing changes, very gentle cleansing and handling, and appropriate dressing techniques can all help alleviate cyclical pain. Appropriate dressing techniques include holding the skin down while removing an old dressing and gently removing the old dressing rather than quickly ripping it off.

The third type of pain associated with wounds is chronic wound pain. This is pain that has lasted more than a month and can be nociceptive (caused by stimulation of nerve endings) or neuropathic (caused by nerve dysfunction).¹⁴ Modification of dressing techniques, previously discussed, and pharmacological and nonpharmacological strategies can be used to manage chronic wound pain.

Pharmacological strategies include —

For nociceptive pain: Pain can be reduced by both opioids and nonopioids.

For neuropathic pain: Opioid and nonopioids can be used, but anticonvulsants, i.e., gabapentin (Neurontin), or antidepressants, i.e., amitriptyline (Elavil), are generally more effective.¹⁵

Topical analgesic applications: morphine 1 mg in 1 ml hydrogel mix.⁸

Nonpharmacological strategies include relaxation, imagery/visualization, distraction, and TENS.

Tackling psychosocial concerns

A malignant wound can have a devastating effect on patients and significant others. Many patients experience an alteration in body image, particularly if the wound is visible. Difficulties in sexual relationships often result,⁸ particularly if the wound is in an area such as the genitals or breasts. Malodor and exudate can compound difficulties for couples and be embarrassing for the patient.³

Embarrassment and decreased self-esteem may cause patients to withdraw from significant others and friends, leading to social isolation. Given that social support is a significant factor in patient coping, isolation can cause considerable depression in both patients and significant others.¹⁶

When planning an intervention strategy, assess patients and significant others thoroughly, looking at psychosocial and quality-of-life concerns, such as the cosmetic effects of the wound and dressing, body-image alterations, attitudes and feelings about cancer and treatment, coping strategies/style, beliefs and values and the meaning of illness, cultural issues, alterations in life related to the wound and dressings, and impact on significant others (relationship problems, sexual intimacy, and impact on role and functional ability). Also important to assess are financial issues, spiritual issues, information needs, support systems and networks, and expectations.

The literature does not provide much information on strategies to meet patient and family psychosocial concerns and needs; however, nurses must keep in mind the potential issues surrounding cancer and the complications of a malignant ulcer. Only in this way can we provide holistic and compassionate care to patients experiencing a malignant wound.