Cath Lab Digest

A fungating lesion develops when an underlying tumor extends through the epithelium, leaving a visible marker of the underlying malignant disease and its advancement. As the tumor size increases, vessels such as capillaries rupture with resultant tissue necrosis, infection, and odor. Fungating lesions require complex management by the clinician, especially when odor, exudate, and pain are involved — the lack of such management can have a tremendous negative impact on the patient, deepening the sense of helplessness, poor self-image, and isolation from family and friends. The anticipation of pain with dressing changes further adds to their feelings of despair.^1-3

Case Study

History. Ms. S is a 66-year-old woman who presented to the ER with swelling and pain in the left upper extremity. She had not been medically followed for a reported 7 years but her medical history included ovarian cancer and obesity. On presentation to the ER, she had gross lymphedema in the left upper extremity. She also had a lesion to her left breast that measured 10 cm x 10 cm; she was managing copious amounts of purulent, foul-smelling drainage with rolls of paper towels. The periwound skin was edematous and painful and the base of the wound contained soft, black, necrotic tissue.

Ms. S was diagnosed with a deep vein thrombosis, medically managed with anticoagulants, and discharged to home care. She was referred to a lymphedema therapist, certified wound nurse, social worker, and the oncology department for further evaluation of left breast cancer.

Treatment. The goals for managing this fungating wound were not to heal but rather to decrease odor, contain exudate, and most importantly, address pain experienced during dressing changes. The lesion was cleansed with antibacterial soap and H₂O BID and metronidazole (250 mg) crushed tabs were applied to the lesion to reduce odor and non-sporing anaerobes. The pain and bleeding during dressing changes were minimized using Mepitel soft silicone mesh dressing (Mölnlycke Health Care, Norcross, Ga). The lesion was covered with calcium alginate and absorbent non-stick pads and secured with mesh netting. The soft silicone dressing was left in place for up to 7 days to provide a protective barrier between the wound and the outer dressings; thereby, eliminating trauma and pain to the wound bed with dressing changes. Ms. S only needed to remove and change the cover dressings as they became saturated with exudate, which she was able to do at home. She immediately reported a tremendous decrease in pain, odor, and bleeding using this combination of dressings.

Although exudate, odor, and bleeding were now well controlled, the rigorous course of chemotherapy and radiation produced itching and erythema to the periwound area. The clinical team began to use Mepilex Transfer soft silicone dressing (Mölnlycke Health Care) covered by an alginate, absorbent non-stick pads, and mesh netting. The soft silicone transfer dressing pulled exudate away from the wound sight and into a secondary dressing that was changed as needed. The addition of the transfer dressing promoted pain-free dressing changes and exudate management that allowed the periwound area to heal and decreased the itching and erythema.