Fungating cancer wounds (malignant wounds)
Fungating cancer wounds may also be called malignant wounds. A fungating wound is when cancer that is growing under the skin breaks through the skin to create a wound.
As the cancer grows, it blocks and damages tiny blood vessels, which can starve the area of oxygen. This causes the skin and underlying tissue to die (necrosis). There may also be infection, and areas of the wound may become ulcerated.
Fungating wounds are rare, and most people who have cancer will never develop a fungating wound. They can develop in the area of the primary cancer (where the cancer started) or the secondary cancer or metastasis (when the cancer has spread to another part of the body). If a fungating wound does develop, it's most likely to happen with breast cancer, head and neck cancer and melanoma.
Symptoms of a fungating cancer wound
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People often find that they have several symptoms at the same time. The most common symptoms of a fungating wound include:
leakage or discharge
an unpleasant smell
Treatment for fungating cancer wounds
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Cancer is always the underlying cause of a fungating wound. Therefore treatments that reduce the tumour may also decrease the size of the wound and improve symptoms. The treatments that may be used will depend on the type of cancer, which part of the body is affected, and how advanced the tumour is. Commonly used treatments include radiotherapy, chemotherapy, hormonal therapy and surgery.
Radiotherapy treats cancer by using high-energy x-rays to destroy cancer cells while doing as little harm as possible to normal cells. It can help by shrinking the tumour and drying up excessive discharge from the wound. Sometimes people find their symptoms become worse straight after radiotherapy. The skin around the area may also become dry and red. These side effects are usually temporary, and should begin to improve after a couple of weeks.
Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. It's used to shrink the tumour that is causing the wound and so relieve any symptoms.
Some cancers, such as breast cancer, can be stimulated to grow by certain hormones. Hormonal therapy acts by altering the production of these hormones, or blocking their action, and can help slow the growth of the cancer. This can help improve symptoms.
Depending on the size and position of the tumour, it may be possible to remove it, either partly or fully. There can be a risk of bleeding as fungating wounds often cause damage to blood vessels, so an operation isn't always possible. Your doctor can discuss with you whether surgery is possible in your situation.
This is a new treatment, which can sometimes be used for fungating cancer wounds. It works by helping to control the growth of the cancer and the fungating wound that’s caused by it.
Chemotherapy is injected either directly into the tumour area or into the bloodstream. An electric pulse is then used to help the chemotherapy get inside the cancer cells. Once inside the cancer cells, the chemotherapy destroys them.
Electrochemotherapy may also help control bleeding, pain and discharge from fungating wounds. The treatment can be repeated if needed.
As it’s a new treatment (and still experimental) it’s not yet widely available. Your doctor or specialist nurse will be able to give your more information about this treatment if it’s suitable for you.
Controlling symptoms of fungating cancer wounds
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Although cancer treatments may help reduce the size of the wound, they are unlikely to heal it completely. Managing the wound is therefore very important in improving a person’s comfort and their quality of life.
Your nurses will do all they can to make sure that everything is being done to minimise the effects of the wound on you and your everyday activities. In order to do this, your nurse may ask the advice of a specialist nurse in wound care, often called a tissue viability nurse.
Leakage or discharge is probably the most common symptom of a fungating wound and often happens because of infection. Dressings that are very absorbent can be used with additional padding to help with this problem.
Some wound dressings can be left in place for a number of days, but this depends on the amount of fluid leaking from the wound and where the wound is situated. Changing the dressings regularly can help stop the discharge from building up. Sometimes, only the top layer of the dressing needs to be changed.
The discharge or leakage from a wound can make the healthy skin around it sore and red. It's often helpful to apply a barrier film or cream, such as Cavilon™, to the skin around the wound to protect it.
The presence of an unpleasant smell is common. It can be caused by infection, and many people find this symptom the most distressing.
A variety of different dressings may be used on the wound, which can help control an unpleasant smell. Some dressings contain silver, which can reduce the number of bacteria in the wound, and these can be effective in controlling the odour. These dressings can often be left in place for a number of days, depending on the volume of leakage. Dressings containing medical grade honey (Activon®) can also help to prevent bacteria growing in fungating wounds. Charcoal dressings can help filter any smell.
Antibiotics can help control any infection that may be present in the wound, which can help to reduce the smell. Applying antibiotic gels directly on to the wound can also help.
People often feel self-conscious about an unpleasant smell, particularly when in company. Air fresheners, odour neutralisers, environmental air filters and aromatherapy oils can help disguise unpleasant smells and help people feel more comfortable with friends and family. A few drops of an odour neutraliser such as Nildor® can also be applied to the outer layer of the dressing when it is changed. However; make sure the odour neutraliser doesn't come into contact with your skin.
Pain can be caused by the tumour damaging nerves or by dressings sticking to the skin. There are many different types of painkillers (analgesics) that can be used to help relieve pain. Taking painkillers regularly can often be more helpful, as it helps keep the pain away. Your doctor or nurse can give you advice about the best painkiller to use. If your pain isn't being controlled, let your doctor or nurse know so that they can adjust the dose or try a different painkiller.
If the pain is worse when the dressings are changed, let your nurse know as they may be able to choose a different dressing that suits your wound better. It may also be helpful to take a short-acting painkiller just before the dressing is changed.
Other things that may help are:
using non-stick dressings
soaking the dressing off slowly
using a local anaesthetic gel
using gas and air (entonox), which is a painkiller that's breathed in
using painkillers applied directly on to the wound in a gel (topical opioids).
Bleeding can be caused if the tumour damages (ruptures) small blood vessels. Many people can feel alarmed by the sight of blood. However, it's common for fungating wounds to ooze blood. It is important to tell your doctor or nurse if you notice bleeding, or a change in the amount of bleeding. This will allow them to take action to reduce or stop it.
Dressings that don’t stick, or non-stick inner dressings with removable outer dressings, can help reduce bleeding. Other things that may help include:
applying pastes on to the wound, such as sucralfate
using fibrous dressings such as Aquacel®. It’s best to wet these dressings before removing them, especially where the dressing is in contact with the wound edges. This makes the dressing easier to remove and helps to prevent bleeding around the wound edges.
For wounds that are bleeding heavily, you can use surgical dressings that help stop bleeding (haemostatic dressings). Also; applying a drug; such as adrenaline or tranexamic acid, to the area for short periods may help stop bleeding.
Itching can be an ongoing problem. It's caused when the skin is stretched and nerve endings are irritated. Unfortunately, this type of irritation doesn't tend to respond well to tablets that normally help relieve itching, such as antihistamines. However, things that may help relieve the itching are:
TENS (transcutaneous electrical nerve stimulation) machines, which stimulate nerves that carry non-painful messages to the brain (overriding and stopping the pain messages). TENS machines can also make the body release its own painkillers (endorphins)
dressings that keep the skin well hydrated, called hydrogel sheets
creams, such as menthol in aqueous cream.
If you are allergic to any dressings or adhesives, it's important to let your nurse or doctor know as this may be a cause of itching.
Some helpful tips for fungating cancer wounds
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Sometimes one of the most difficult things to deal with is where the wound is situated. Wounds can appear in awkward positions - for example, in the armpit - and so it can be difficult to find the right size and shape of dressing, and the best way of securing it. In these situations, trying different ways of holding the wound dressing in place can be helpful.
Some people may find that tubifast garments (a type of clothing bandage) help keep dressings on. Clothing containing lycra, such as crop tops, t-shirt vests or cycling shorts, may also help hold a dressing in the right position under clothing.
You may also find it useful to have extra supplies of dressings, especially at holiday times, or have pads that protect your bed at night.
Fungating cancer wounds can cause many feelings, including anxiety, embarrassment and depression. Many people feel isolated and worry about leaving the house. They may be worried or embarrassed if they have a wound that affects their outward appearance, or if the wound has an unpleasant smell. It can also be demanding on relationships as people can feel very aware of the wound on their body. You will probably be much more aware of the wound than other people. You and your nurse can decide on the most acceptable and comfortable way to dress your wound.
Some people find complementary therapies such as relaxation or aromatherapy helpful. Others find it helpful to talk things over with their doctor or nurse. Family members and close friends can also offer support. Our cancer support specialists can give you details of support organisations and counselling services in your area.
This information has been compiled using information from a number of reliable sources, including:
Grocott P, Robinson V. Skin problems in palliative medicine: nursing aspects. In Hanks, et al. Oxford Textbook of Palliative Medicine. 4th edition. 2009. Oxford University Press.
Watson, et al. Oxford Handbook of Palliative Care. 2nd edition. 2009. Oxford University Press.
Marty M, et al. Electrochemotherapy - An easy highly effective and safe treatment of cutaneous and subcutaneous metastases: Results of ESOPE (European Standard Operating Procedures of Electrochemotherapy) study. European Journal of Cancer Supplements. 2006. 4: 3-13
Alexander S. Malignant fungating wounds: managing pain, bleeding and psychosocial issues. Journal of Wound Care. 2009. 18 (issue 10): 418-425
Taylor C. Malignant fungating wounds: a review of the patient and nurse experience. Wound Care. 2011. December. 16 (issue 12): S16-S22
With thanks to Dr Patricia Grocott, Reader in Palliative Wound Care, and the people affected by cancer who reviewed this edition. Reviewing information is just one way of the ways you could help when you join our Cancer Voices network.