Cath Lab Digest

P atients with malignant wounds experience distressing complications including pain, odor, exudate, bleeding, edema, emotional distress, social concerns, functional compromise, and complications (ie, infection and fistulas).¹ Life expectancy after developing a cutaneous metastasis is variable but has been shown to be 21.7 months on average. A reproducible assessment of patients with malignant wounds is the cornerstone of treatment² that when obtained in order to implement wound symptom management measures can improve quality of life³ throughout that time period.

Malignant Wound Complications

Approximately 5% to 10% of patients with internal malignancies develop metastatic cancer that spreads to the skin (cutaneous metastasis).⁴ These wounds can progress despite aggressive oncology care because some patients neglect to seek medical assistance until the wound is advanced. Curative treatment is often not an option, although a range of palliative oncology treatments may be tried, including systemic therapy, radiation therapy, phototherapy, and surgery.⁵ Referrals to oncologists for palliative oncology care can be beneficial. Patients typically have variable responses to treatment, requiring simultaneous and subsequent wound management and various approaches according to assessment (see Table 1). Following the suggested paradigm^6-8 brings a focus to the objectives of any proposed wound care plan.

Treat the cause. The ability to treat the cause revolves around the correct diagnosis of the wound pain and its potential sources. The pain history begins with active listening to the patient's story, followed by specific questioning to enhance the information gathered. The patient is examined specifically for potential reasons for pain - eg, the tumor pressing on nerve endings and adjacent visceral organs, chemical agents released by tumor cells that irritates nerve endings, ischemia, inflammation, or increased swelling. Chemotherapy, pharmacotherapy, radiation, and surgery may eradicate or reduce the size of the tumor to relieve pain.^9,10

Patient-centered concerns. The clinician needs to focus on the patient's perspective of pain and its route cause. Because pain is a complex and highly subjective construct comprising multiple dimensions and modulated by the context and meaning in which pain emerges,¹¹ its management must incorporate the impact of body disfigurement, family burden, guilt, and patient shame. In particular, any assessment of patients with fungating wounds should address the immense psychological distress they can cause and highlight key factors critical to managing these complex wounds. Many fungating wounds are heavily exuding, malodorous, and bleed easily. Strategies that focus on managing these symptoms must be explored and recommendations for clinical practice determined accordingly (see Table 2).

Local wound care. Wound care needs to revolve around debridement, bacterial balance/prolonged inflammation, and moisture balance; it should not necessarily focus on healing. Fungating wounds rarely heal, so the ability to manage their unpleasant symptoms on an ongoing basis is increasingly important. One of the most distressing is malodor; the use of metronidazole preparations in the management of malodorous wounds is becoming more routine.^12-14 Research indicates that topical morphine and other local anaesthetics can be used to alleviate wound pain to promote comfort.¹⁵