Management of malignant cutaneous wounds in oncologic patients

Palliative oncodermatology: Management of malignancy-related cutaneous symptoms in the palliative care setting

Dermatologists play a critical role in interdisciplinary cancer care, and as the field of supportive oncodermatology has evolved, a new subdivision has emerged: palliative oncodermatology. In cancer patients awaiting definitive treatment, those unable to undergo surgery or other invasive interventions, and those in the terminal stages of their illness, there is a need for symptom-based, noncurative strategies that address symptoms of cutaneous malignancies as well as cutaneous complications of systemic malignancies. The integration of palliative care principles in the management of such cutaneous complications strives to alleviate suffering and enhance quality of life. Here, we review the complications associated with cutaneous malignancies and metastases, along with skin symptoms of systemic malignancies. We also explore treatment options that emphasize symptom relief and comfort, highlighting the role of dermatologists in managing these challenges and coordinating supportive care in palliative settings.

Cutaneous Metastasis of Triple Negative Breast Cancer: A Case Report and Review of Literature

Cutaneous metastases (CMs) from breast cancer are rare but represent a significant manifestation of advanced disease, occurring in a small group of patients. They often present metachronously and may resemble dermatologic conditions, complicating diagnosis. We report a 95-year-old woman with a history of ductal triple negative breast cancer (TNBC), initially treated with mastectomy and radiotherapy. Eight years post-mastectomy, she developed an erythematous and indurated skin lesion in the left axilla and one in the rachis. Histopathology confirmed metastatic carcinoma of the breast and CT scan revealed also pulmonary metastasis. Palliative treatment with topical imiquimod and supportive care was decided as the best treatment option due to the patient's very advanced age and comorbidities. The patient remains stable six months post-diagnosis. CMs indicate metastatic disease and require prompt recognition to avoid misdiagnosis. Dermatoscopy and biopsy with histological confirmation are the cornerstone tools for the diagnostic assessment. Surgical resections may be ideal for localized disease, but topical and/or systemic therapy is an effective alternative. Palliative care in combination with topical agents' administration offers symptom relief and maintains quality of life in the over elderly patients. Early recognition of CMs is crucial for accurate diagnosis and optimal management. A multidisciplinary approach ensures timely intervention, while treatment should be tailored to balance efficacy and quality of life, precisely in elderly patients.

Malignant Fungating Wounds in Locally Aggressive Cutaneous Squamous Cell Carcinoma: A Case Series

Despite surgical removal being considered the first-line treatment, managing high-risk squamous cell carcinoma (SCC) cases remains challenging and lacks uniformity as associated complications of less common secondary bacterial infections are underreported. The skin, as well as its appendages, constitute the first line of defense against infectious pathogens. In patients with locally aggressive skin cancers, susceptibility to infectious microorganisms is elevated due to skin lesions and immunosuppression resulting from chemotherapy, surgery, immunotherapy, and stem cell transplantation. Furthermore, immunosuppressed patient populations, when infected, often have extended disease duration and heightened disease burden. Malignant fungating wounds (MFWs), cancerous lesions that typically occur during the terminal stages of a patient's illness when tumors infiltrate the skin and surrounding tissue, may further complicate cases as they often can be misdiagnosed as abscesses or infections. Due to this, we sought to thoroughly characterize the disease progression, treatment efficacy, and risk factors of two patients with locally aggressive SCCs afflicted with MFWs and secondary Pseudomonas aeruginosa (P. aeruginosa)infections. We report two cases of cutaneous SCC (cSCC) in immunocompromised patients, one with HIV and the other a lung transplant recipient on chronic immunosuppression. Both cases were complicated by extensive tumor invasion, chronic infection, and multidrug-resistant P. aeruginosa. These cases highlight the aggressive nature of cSCC in immunocompromised individuals and the complexities of balancing oncologic treatment, palliative care, and infectious disease management.

Improving malignant fungating wound management among oncology nurses: a best practice implementation project

INTRODUCTION

Appropriate malignant fungating wound (MFW) care is challenging for oncology nurses, leading to increased stress, compromised care quality, and poor patient outcomes.

OBJECTIVE

This study aimed to address best practice barriers and develop evidence-based guidelines for MFW care.

METHODS

This project was guided by the JBI Evidence Implementation Framework, which follows a seven-phase process. Both nurses' skills and patient charts were audited to determine compliance with best practices for comprehensive MFW assessment, wound photo records, use of validated wound assessment tools, appropriate wound care, and patient pain and satisfaction. Bandura's social learning theory was used to guide the development of an online education program and an objective structured clinical examination for skill improvement to prompt behavior change in nurses. A follow-up audit was conducted to measure improvements in knowledge, skills, and self-efficacy among nurses to validate the effectiveness of the intervention.

RESULTS

The project resulted in improvements in all four evidence-based practice criteria: (1) comprehensive MFW assessments increased from 27% to 98%; (2) the inclusion of wound photos in medical records increased from 50% to 100%; (3) use of a validated wound assessment tool increased from 0% to 100%; and (4) appropriate interventions to manage wounds and maintain patients' quality of life increased from 50% to 90%.

CONCLUSIONS

The project integrated a flexible education program, multidisciplinary collaboration, and leadership support to empower nurses to effectively manage MFWs. In addition, Bandura's social learning theory was used to influence nurses' behavior and bring about sustainable changes to organizational culture and practices.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A205.

Quality of Life in Patients with Malignant Wounds Treated at a Wound Care Clinic

Background

Malignant wounds can present in up to 14.5% of patients with advanced cancer, significantly reducing quality of life (QoL). Management of malignant wounds is generally palliative, with the goal of improving or maintaining QoL. There is a lack of data on the impact of wound care clinics on QoL in patients with malignant wounds.

Objectives

We sought to assess the QoL in patients with malignant wounds attending a wound care clinic. We also aimed to describe the baseline QoL, trends in QoL, physical symptoms, and treatment modalities that affect QoL in patients with malignant wounds over time.

Methods

This retrospective observational study included 36 patients attending a wound care clinic at an oncologic hospital from 1/1/2016-4/1/2023. As part of the standard of care, these patients complete a Skindex-16 QoL survey at each visit. The Skindex-16 is a validated instrument to measure the effects of skin diseases on QoL. Data were extracted from the electronic medical record. Descriptive statistics, graphical methods, and random effects models for change were used to describe the patient population and the QoL measures over time.

Results

Of the 36 patients who completed at least one Skindex-16 questionnaire, 69.4% were female, and 50.0% developed malignant wounds from breast cancer, 30.5% from nonmelanoma skin cancer, and 8.3% from sarcoma. At the initial visit, 86.1% of patients had exudate associated with their malignant wound, 52.7% of patients had malodor, 63.9% had bleeding, 69.4% had pain, and 50% had pruritus. The mean baseline Skindex-16 score was 54.5, falling into the "extremely severe" category, with a mean score of 15.4, 18.8, and 20.3 for the symptoms, emotions, and functioning domains, respectively. Nineteen patients completed at least one additional Skindex-16 questionnaire at follow-up visits (visit two 52.8%, visit three 33.3%, visit four 19.4%, visit five or greater 13.9%). Compared to the mean Skindex-16 score at baseline, there was an 18.5 point improvement at visit 2 (95% CI: 3.3-33.7, p = 0.018).

Conclusion

Malignant wounds severely adversely affect patients' quality of life. However, patients experienced improved quality of life after being treated at a dedicated wound clinic.

The Promising Effects of Lattice Radiotherapy for Large, Fungating, or Ulcerating Breast Cancers: A Prospective Single-center Study

BACKGROUND/AIM

To evaluate the safety and efficacy of lattice radiotherapy (LRT) for large, inoperable breast cancers.

PATIENTS AND METHODS

In this prospective study, patients who underwent LRT for breast tumors that were ulcerating/fungating/extensively eroding the chest wall, and were ineligible/unwilling for surgery, were enrolled from May 2021 to Nov 2023. Baseline Eastern Cooperative Oncology Group (ECOG) status, pre- and post-LRT numerical rating scale (NRS), and post-LRT changes in quality of life (QoL) were recorded. Survival outcomes were reported at 6 months and 1-year. Median rates of survival and dosimetric parameters were calculated. Kaplan-Meier curves for overall survival (OS), cancer-specific survival (CSS), and failure of local control (LC) were constructed.

RESULTS

Ten patients (8 females) underwent LRT. The median age was 76 years (range=57-99 years) and the median ECOG performance status was 2.5 (range=1-4). The planned schedule was completed by 9/10 patients, accounting for a 90% compliance rate. Among patients with pain (n=7), NRS rapidly reduced from 7 (range=5-10) to 3 (range=1-6). The median equivalent uniform dose was 0.71 Gy (0.09-1.59 Gy). The actuarial rates of 6-month LC, CSS, and OS were 75%, 89%, and 61%, respectively, with only LC rate changing to 50% at 1 year. Two patients had local relapse at the six-month and 1-year follow-up, respectively, after having achieved a complete response at three months, and two others died of COVID-19 infection and ischemic stroke.

CONCLUSION

LRT was found to be effective and safe in palliating symptoms among patients with large inoperable breast tumors.

Silk fibroin biohydrogel composites for loading and ordered release of multiple active ingredients with enhanced bioactivity

Bioactive hydrogels are currently receiving significant attention. In this study, silk fibroin tyramine-modified gelatin hydrogels (SF-TG) with varying degrees of tyramine root substitution were explored. The physicochemical property and biocompatibility of low degree of substitution tyramine-modified gelatin hydrogel (SF-LTG) and high degree of substitution tyramine-modified gelatin hydrogel (SF-HTG) were compared. The results showed that SF-LTG possessed better mechanical property and higher biocompatibility. Thus, SF-LTG was selected as a bioactive matrix and loaded with basic fibroblast growth factor (bFGF); subsequently, curcumin-coupled chitosan rods (CCCRs-EGF) enriched with epidermal growth factor (EGF) were added to obtain SF-LTG-bFGF@CCCRs-EGF hydrogels. The results showed that SF-LTG-bFGF@CCCRs-EGF retained the basic structural and mechanical properties of the SF-LTG matrix gel material and underwent multiple loading and orderly release with different activities while displaying antioxidant, anti-inflammatory, antimicrobial, and pro-cellular proliferation activities and orderly regulation of activity during wound healing. Therefore, the SF-LTG-bFGF@CCCRs-EGF hydrogel is of great value in healing complex wounds.

Examination of the Odor-Eliminating Effect of a Deodorizing Spray on the Volatile Odorants of Malignant Wounds

PURPOSE

This study aimed to compare the odor components before and after spraying a deodorizing spray (DS) on volatile odorants in malignant wounds (MWs) in women with breast cancer; a secondary aim was to evaluate the deodorizing effect of the DS.

DESIGN

This is an observational study.

SUBJECTS AND SETTING

We investigated 3 patients who had MWs resulting from breast cancer. Participants were recruited from outpatient clinics in the Breast Surgery Department, University Hospital, Kanagawa, Japan.

METHODS

The target material was exudate-containing dressings collected from MWs. After collection, the odor components (air) were collected into a sampling bag by using a handheld pump. Then, after 5 sprays of a DS, air was collected in the same manner. All odor components were analyzed objectively by gas chromatography-mass spectrometry-olfactometry (GC/MS-O). The concentration in parts per million (ppm) of the main odor components in the air before and after spraying DS was compared, and the residual concentration rate (%) was calculated. Sniffing tests before and after spraying were also conducted to determine the subjective deodorizing effect of DS.

RESULTS

Of the possible hundreds of volatile odorants, 3 to 11 main components of volatile odorants were detected per subject. After DS spraying, the odorants dimethyl disulfide, dimethyl trisulfide, and benzyl alcohol were reduced according to GC/MS-O. The residual concentration of the following main odor components was also reduced: benzyl alcohol (30%), octanal (56%), p-dichlorobenzene (56%), isovaleric acid (56%), propylene glycol (63%), and nonanal (66%).

CONCLUSIONS

DS was effective against some volatile odorants in MWs, but no clear deodorizing effect was observed. Since there are individual differences in the type and number of odorants in MWs, the use of DS needs to be examined and verified in a larger number of cases.

Medical-Grade Honey Is a Versatile Wound Care Product for the Elderly

Introduction

Ageing of the global population has led to an increase in the demand for the treatment of wounds, especially considering the challenges of managing wounds in the elderly. Therefore, more effective treatment strategies need to be explored. In this article, we aimed to compare medical-grade honey (MGH) products with other wound care products and to provide guidelines on using MGH in wounds commonly found in the elderly.

Methods

Based on literature research and expert opinion, an overview of commonly used wound care products and their wound healing characteristics is provided. In addition, literature-based classification of wounds in the elderly and the recommendations for treatments are provided.

Results

Frequently used wound care products include povidone-iodine, enzymatic products, absorbing dressings, larvae, silver dressings, and MGH dressings. Supported by systematic reviews and meta-analyses, MGH dressings were identified as the most potent and all-round wound care product compared to the others. Next, we provided basic guidelines for managing the most common wounds in the elderly, both acute and chronic, and specified how and which MGH products can be used in these wounds.

Conclusion

MGH is a widely applicable, safe, easy-to-use, and cost-effective product to manage wounds in the elderly. In case of doubt, refer to a trained wound care specialist who can support the treatment of difficult-to-heal wounds.

A survey of UK nurses about their care of people with malignant fungating wounds

PURPOSE

To gain an understanding of the nursing professionals who treat people with malignant fungating wounds (MFW) in the UK and their current practices, including perceived barriers and facilitators to providing MFW care.

METHOD

An online anonymous questionnaire was created with questions about the role of nursing professionals who reported caring for patients with MFW, the number of people with MFW they regularly cared for, treatment aims, treatments used, and challenges faced. These questions were developed with professional input and piloted. Using a convenience sampling method, we collected responses from UK nurses by distributing the questionnaire via social media and through relevant professional organisations. The questionnaire was constructed in QualtricsXM software and analysed using SPSS.

RESULT

We received 154 questionnaire responses, with three-quarters from tissue viability nurses and the rest from community and other specialist nurses. The most important treatment aim reported was pain management, followed by odour management. Almost all respondents used antimicrobial and standard dressings for these patients, with a range of products reported. Poor access to MFW care training and lack of local and national guidelines were reported as barriers to providing care for people with MFW. Availability of dressings, access to training, and good communication processes were reported as facilitators.

CONCLUSION

This is the first study to explore MFW wound care practices in the UK. A range of nurses are involved in care delivery with variations in the treatments used. Lack of access to MFW care training, resources, and standardised guidelines may impede care delivery.

Malignant wound aetiology, diagnosis and management: a case series and literature review

OBJECTIVE

Malignant wounds develop when neoplastic cells invade the skin either locally or by lymphatic and haematogenous spread. They can present as hard-to-heal wounds and underlying causes include: primary skin cancer; metastasis of extracutaneous primary malignancy; malignant transformation of a hard-to-heal wound; iatrogenic injury; and cutaneous forms of cancers of non-skin origin. High clinical suspicion for a malignant wound should be confirmed with skin biopsy. The aim of this case series is to highlight a combination of both clinically clear cutaneous malignancies and not-so-obvious wounds caused by malignancy.

METHOD

This case series examines patients with malignant wounds of varying aetiology and appearance. For each case, we explain the pathophysiology, atypical features, diagnostic approach and treatment. We also discuss types of wound biopsy and general wound management principles.

RESULTS

Among the 11 cases analysed using descriptive statistics, median wound duration before presentation at our clinic was one year, while median age at presentation was 65 years. Our case series included the following diagnoses: cutaneous metastasis of invasive ductal carcinoma of the breast (n=2); cutaneous metastasis of colorectal adenocarcinoma (n=1); Marjolin's ulcer (n=1), basal cell carcinoma (BCC) (n=2), primary cutaneous squamous cell carcinoma (SCC) (n=1), metastatic malignant melanoma (n=1), cutaneous T-cell lymphoma (n=1), cutaneous angiosarcoma (n=1), Kaposi sarcoma (n=1) and recurrent tonsillar SCC with osteoradionecrosis (n=1); one case had both BCC and SCC.

CONCLUSION

Punch and excisional biopsies were the most frequently used diagnostic techniques. Local wound therapy addressed bleeding, malodour, exudate, pain and infection. However, wound healing is usually achieved once the underlying malignancy is treated. In advanced or metastatic disease, palliative wound care aims to prevent exacerbation of existing wounds and focuses on patient comfort.

Therapeutic Management of Malignant Wounds: An Update

OPINION STATEMENT

Malignant fungating wounds (MFW) are severe skin conditions generating tremendous distress in oncological patients with advanced cancer stages because of pain, malodor, exudation, pruritus, inflammation, edema, and bleeding. The classical therapeutic approaches such as surgery, opioids, antimicrobials, and application of different wound dressings are failing in handling pain, odor, and infection control, thus urgently requiring the development of alternative strategies. The aim of this review was to provide an update on the current therapeutic strategies and the perspectives on developing novel alternatives for better malignant wound management. The last decade screened literature evidenced an increasing interest in developing natural treatment alternatives based on beehive, plant extracts, pure vegetal compounds, and bacteriocins. Promising therapeutics can also be envisaged by involving nanotechnology due to either intrinsic biological activities or drug delivery properties of nanomaterials. Despite recent progress in the field of malignant wound care, the literature is still mainly based on in vitro and in vivo studies on small animal models, while the case reports and clinical trials (less than 10 and only one providing public results) remain scarce. Some innovative treatment approaches are used in clinical practice without prior extensive testing in fungating wound patients. Extensive research is urgently needed to fill this knowledge gap and translate the identified promising therapeutic approaches to more advanced testing stages toward creating multidimensional wound care strategies.

Managing malignant wounds in patients receiving palliative care

Malignant wounds are a complication of cancer and usually develop in patients with advanced disease. Physical symptoms associated with these wounds include pain, bleeding, exudate, malodour and pruritus, while patients may also experience various distressing psychosocial effects. The aim for nurses is to manage these physical symptoms and psychosocial effects, thus enhancing quality of life for patients and their families. This article discusses the symptoms and effects associated with malignant wounds, and explains what is involved in a wound assessment. It also outlines strategies that can be used to manage or eliminate wound-related symptoms and enhance patients' quality of life.