FUNGATING WOUNDS
Wound Care Study Day
28 September 2011
St. John’s Hospice
Marie B. Rodden
Practice Development Specialist Sister
St. John’s Hospice
1
Fungating Lesions
Definition
“Fungating lesions are products of
cancerous infiltration of the epithelium . . .
which develop into a FUNGATING mass or
ULCERATIVE lesion with subsequent
infection, bleeding and maloderous exudate.”
(Ivetic & Lyne1990)
2
Fungating Lesions
Other definitions and descriptions
“A fungating wound is essentially a mass of
malignant cells that have infiltrated the epithelium
and surrounding blood and lymph vessels.”
(Moody & Grocott 1993)
“A malignant, fungating wound occurs when
tumour invades the epithelium and breaks through
the skin surface.” (Dealey 1999)
“Fungating and malignant wounds are caused by
tumour infiltration of the skin and its supporting
blood and lymph vessels.” (Grocott 2003)
3
Fungating Wounds – What are they?
Development
1) 2° malignant cells infiltrating structures of skin
from distant 1°.
2) Local advancement of a primary skin cancer
itself (for example: squamous cell carcinoma
or melanoma).
3) A deep primary tumour invading and eroding
through the skin. (Adenocarcinoma Breast).
(Naylor 2002) 4
Fungating Wounds
– no register of wounds
5 - 15% of cancers result in a fungating lesion.
Common Sites:
Breast
Head and neck
Kidney
Lung
Ovary
Vagina
Colon
Penis
Bladder
Lymphoma
Leukaemia
5
Fungating Lesions
Key Points
Differing schools of thought
a. Identification of specific tumours
(special characteristic)
b. Potentiality
c. End Stage
(Ivetic & Lyne 1990)
6
Fungating Lesions
Key Points continued
“Malignant wounds may present as either
crater-like ulcers (destructive process) or a
raised nodule similar in appearance to a
cauliflower (or mushroom) and ‘fungating’ is
the term sometimes used to describe a
proliferative process.”
(Carville 2005)
7
Fungating Lesions
Key Points continued
Fungating
v
Ulcerating
Proliferation
of Cells
v
Open Crater
with margins
v
Erodes
Sinuses
“Cauliflower”
or Fungus
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Fungating Wounds –
Summary of Processes (Cell Level)
1) Vascular Deficiencies
Affects blood flow
Poor cell perfusion
Hypoxic regions
Necrosis
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Fungating Wounds –
Summary of Processes (Cell Level)
2) Absent or abnormal lymphatic vessels
Increased interstitial fluid
Increased extra vascular pressure
Collapse of blood vessels
Exudate
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Fungating Wounds –
Summary of Processes (Cell level)
(3) Cell Proliferation
Acidic pH of extra cellular fluid
Interference with clotting mechanism
Coagulation and bleeding
Friable tissue
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Fungating Lesions
Outcomes of Process
Moist Necrosis
Colonisation
Critical colonisation and /or infection
Anaerobes
Aerobes
Volatile fatty acids
Malodour and Exudate
12
Fungating Lesions
Systemic Treatments
1) Radiotherapy
2) Chemotherapy
– Miltofesine acts on cell membrane
rather than DNA – Daily application first
week then BD for 8 weeks.
3) Hormone therapy
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Fungating Lesions
“Current wound management based on
moist wound healing – may have the
potential to meet the needs of patients with
fungating lesions even when healing is not
an achievable goal.” (Grocott & Moody 1993)
However, “Is there an alternative to moist
wound healing in palliative care?” asks
(McManus 2007).
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“In palliative care, a wound that is maintained
with a dry scab, allowing the wound bed
underneath to remain dry, could enable a patient
with a short prognosis to have a viable
alternative to a complex dressing regime . . . “
(Winter & Scales 1963)
“So if the wound surface can be dried to slow the
rate of volume of exudate produced, some
reduction in the discomfort and distress with very
wet wounds may be achieved . . . “
(McManus 2007)
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Fungating Lesions
Priorities of Care
1) The patient’s perception of priorities.
2) Symptom control at the wound site.
3) “Non-healing” status.
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Fungating Lesions
Wound Problems
The wounds are dynamic.
The size and shape of the wound may be
difficult.
The wound may bleed.
The wound is often offensive.
The wound pours exudate.
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Wound Problems – Local treatments
at wound interface (continued)
1) Control of Bleeding
Oral/topical anti-fribrinolytics –
Tranexamic acid
Alginates, Adrenaline 1:1000
Sucralfate paste 2g in 5 ml KY Jelly
(Twycross 2001)
or 1g mixed with KY Jelly (Emflorgo 1998)
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Wound Problems – Local treatments
at wound interface (continued)
2) Control of Infection
Metronidazole
Topical – (Anabact 0.8% gel) and/or systemic
400 mg x BD
3) Control of Odour
Metronidazole and charcoal +/- silver
dressings
Sugarpaste and honey
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Wound Problems – Local treatments
at wound interface (continued)
4) Control of Exudate
“3 functions required
i) conservation of surface humidity at the
wound interface.
ii) reservoir capacity of exudate that is excess.
iii) high moisture vapour transfer through the
back surface of the dressing.
Dressings need to be presented in metre
rolls to accommodate large wounds and
large amount of exudate.” (Grocott 2003)
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Wound Problems – Local treatments
at wound interface (continued)
5) Control of Pain
- nociceptive or neuropathic?
- topical and systemic route
- nociceptive – topical opioids
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Wound Problems – Local treatments
at wound interface
5) Control of Pain (continued)
examples:
20 mg diamorphine in 30 gms hydrogel x BD
(Grocott 2003)
10 mg morphine “mixed in with most gels
(inctr-palliative-care-handbook.wikidit.com
2011)
1 mg morphine to 1g hydrogel (Naylor 2003)
10 mg/1 ml morphine to 8 g sachet of intrasite
(Aquaform) gel (Pcf3 2007)
22
Fungating Lesions
Points Re: Odour (Continued)
Aerobic and Anaerobic
Volatile Fatty Acids
Exudate
Malodour
Putrescines
Cadaverines
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Fungating Lesions
Some points on ODOUR
“Evidence suggests that reaction to odours
(especially the malodours from putrescine
and cadaverines) is profoundly and deeply
ingrained in human behaviour.” (Van Toller)
and “we do not become desensitised to
them through time. They are constantly
detectable. (Alexander 2009)
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Some points on ODOUR (continued)
“For a significant minority of cancer
patients the presence of a malodorous,
exuding necrotic skin lesion can be a
constant physical reminder that their
disease is both progressive and incurable
. . . “ (Naylor 2002)
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References
Carville K (2005) as cited in Alexander S (2009),
Malignant Fungating Wounds:Epidemiology,
aetiology, presentation & assessment, Journal of
Wound Care, Vol 18, No 7, 2009.
Dealey C (1999) Ed, The Care of Wounds: a
guide for nurses, 2nd Edition, Blackwell Science,
London.
Emflorgo C (1998) Controlling Bleeding in
Fungating Wounds, Journal of Wound Care, Vol
7, No 5.
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References (continued)
Grocott P (2003) The Palliative Management of
Fungating Wounds, Address to Florence
Nightingale School of Nursing, Kings College,
London.
Ivetic O & Lyne P A (1990) Fungating & Ulcerating
Malignant Lesions: a review of the literature, Journal
of Advanced Nursing 1990, Vol 15, No 1, pps 83-88.
McManus J (2007) Principles of Skin & Wound
Care: The Palliative Approach, End of Life Care, Vol
1, No 1, 2007
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References (continued)
Moody M & Grocott P (1995) Let us extend our
knowledge base, Professional Nurse, Vol 8, No
9, pps 586-589.
Naylor W (2002) Part I Symptom Control in the
Management of Fungating Wounds,
www.worldwidewounds.com.
Naylor W (2003), Palliative Management of
Fungating Wounds, European Journal of
Palliative Care, Vol 10, No 3, pps 93-97, 2003.
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References (continued)
Twycross R (2001), Symptom Management in
Advanced Cancer, 3rd Edition, Radicliffe Press,
Oxford.
Twycross R & Wilcock A (2007), Palliative Care
Formulary, PCF3 Palliative Drugs Company Ltd.
Van Toller S (1994) Invisible Wounds: the Effects of
Skin Ulcer Malodours, Journal of Wound Care, Vol
3, No 2, March 1994.
Winter G D & Scales J T (1963) as cited in
McManus J, (2007), Principles of Skin & Wound
Care: The Palliative Approach, End of Life Care,
Vol 1, No 1, 2007.
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