Malignant Wounds Research Articles

Challenges with Accruing a Study of Topical Opioid for Painful Malignant Wounds: Lessons Learned.

Challenges with Accruing a Study of Topical Opioid for Painful Malignant Wounds: Lessons Learned.

Fungating breast cancer and other malignant wounds: epidemiology, assessment and management

ABSTRACTMalignant fungating wounds are often associated with advanced malignancy especially breast cancer. There is no consensus regarding the optimal management of thiscommon condition. The ideal management of these patients requires a multidisciplinary and holistic approach. Malodour is one of the most distressing symptom and the use of topical metronidazole is commonly cited. Pain management requires an accurate assessment to treat the underlying cause and the WHO analgesic ladder is often used to guide pharmacologic therapy. Bleeding fungating wounds can be treated with natural hemostats, sclerosing agents, coagulants or other topical agents. Highly exudative wounds may require the use of specialized dressings such as alginates, hydrofibre and foam dressings or alternatively, highly absorbent pads. These recommendations are based on anecdotal evidence and small underpowered studies. Hence, larger clinical studies are warranted to determine the optimal management strategies for malignant fungating wounds.

The Point Prevalence of Malignancy in a Wound Clinic.

The aim of this study was to determine the prevalence of malignant leg ulcers and to identify the most frequent characteristics of such wounds. This study was a retrospective investigation of patients with chronic leg ulcers in a North American tertiary wound clinic. Between January 2011 and September 2013, a total of 1189 patients with lower extremity wounds, including 726 patients with leg wounds, were identified. A total of 124 of the 726 had undergone a biopsy of their atypical wound, 16.1% (20/124) of which were malignant. Patients with malignant wounds were older than patients with nonmalignant leg wounds (P < .0001), and the common location of the malignant wound was the anterior shin (odds ratio = 3.5). The limitation of this analysis is the lack of distinction between malignant transformation of wounds and de novo presentation of malignancies as chronic nonhealing wounds. Three distinguishing morphological features in malignant wounds were irregular borders (P = .0002), presence of hypergranulation tissue (P < .0001), and friable/bleeding wound surface (P < .0001). The frequency of malignant wounds in patients with chronic leg ulcers highlights the need for a systematic approach, which would involve biopsy of wounds to identify malignancy in this patient population early on.

Malignant Neoplastic Wounds: Clinical Management Performed by Nurses

Objective: Investigate the clinical management of patients with neoplastic wounds by nurses. Methods: This is an exploratory study, with qualitative approach, conducted in August 2014, with ten clinical nurses of a philanthropic hospital that provides care to patients with advanced cancer. Data were collected through semi-structured interviews and data analysis was performed using the Minayo’s Thematic Analysis Technique, which enabled the construction of one category and four subcategories. Results: The nurses’ knowledge on the clinical management of wounds is weak and has many weaknesses involving patients with advanced cancer. Conclusion: One evidenced the need to invest in continuing education and implementation of protocols that support greater autonomy of nurses in decision-making, ensuring legal support to these professionals to improve care for people with neoplastic wounds. Key words: Skin Ulcer; Wounds and Injuries; Oncology Nursing; Nursing Care.

Researching the lived experiences of cancer patients with malignant fungating wounds.

Researching the experiences of terminally ill patients with disfiguring wounds is likely to be a challenge anywhere, and this investigation came face-to-face with different attitudes on the part of both patients and nurses and doctors in England (the South-East) and Italy (Tuscany). To highlight the complexity of researching sensitive subjects and the difficulties encountered from the perspective of the researcher(s). Some 14 patients were interviewed. In England access was relatively straightforward, with nurses linked to the hospice doing most of the recruitment. Access was more difficult in Italy, with some doctors expressing opposition. How ethical is it to treat dying patients as subjects for research? How does research of this kind vary from one culture to another? Interviewees can find it therapeutic to talk about their experiences to a sympathetic listener--although the listening does pose a considerable strain on the researcher.

Mast cell, the peculiar member of the immune system: A homeostatic aspect.

The mast cell is a member of the immune system having a basic role in allergic (anaphylactic) reactions. However, it contains, synthesizes, stores and secretes lots of substances, which initiates other reactions or participates in them. These are in connection with the deterioration of tissue correlation, as malignant tumors, angiogenesis, wound healing, pregnancy and different pathological conditions. In addition - as other members of the immune system - mast cells can synthesize, store and secrete hormones characteristic to the endocrine glands and can transport them to the site of requirement (packed transport), or produce and employ them locally. The effect of mast cells is controversial and frequently dual, stimulatory or inhibitory to the same organ or process. This is likely due to the heterogeneity of the mast cells, in morphology and cell content alike and dependent on the actual condition of the targeted tissue. The cells are transported in an unmatured form by the blood circulation and are exposed to microenvironmental effects, which influence their maturation. Their enrichment around tumors suggested using them as targets for tumor therapy more than fifty years ago (by the author), however, this idea lives its renaissance now. The review discusses the facts and ideas critically.

Dried fruit extract of Terminalia chebula modulates the immune response in mice

Terminalia chebula, traditionally regarded as universal panacea, is known for its pleiotropic effects, including the effects on oxidative stress, malignant tumor growth, wound healing, and insulin sensitivity in Type 2 diabetes. This study reports the effect of dry fruit extract of T. chebula (TCE) on Th1/Th2-mediated immune responses in mice. TCE was administered orally for 10 consecutive days, after which mice were immunized with goat RBC (gRBC) or ovalbumin. TCE enhanced the expression of Th1 cytokine, interferon γ, decreased interleukin 4, and increased the number of plaque-forming cells in gRBC-immunized mice. The percentage of CD4+ cells and delayed-type hypersensitivity response also increased in these mice. Treatment is reported to increase lymphocyte proliferation and macrophage phagocyte response, but decrease nitrite production. The bone marrow cellularity and WBC count also increased in the treated mice. None of the group showed any sign of toxicity. The data indicate that TCE elicits a significant dose-dependent Th1 response.

The usefulness of Mohs’ paste for the treatment of a malignant wound caused by a giant intra-abdominal desmoid tumor

Here, we report the case of a 40-year-old male with a giant intra-abdominal desmoid tumor (DT). He was followed up for familial adenomatous polyposis since age 17 years because of positive family history. Three years before admission, he was diagnosed with an inoperable intra-abdominal DT. He underwent surgery for peritonitis and received hormone and cyclooxygenase-2-inhibitor therapies. Eventually, the DT enlarged and perforated the abdominal wall. He presented with malnutrition, >5 L/week of effusion, anemia due to bleeding, pain, and a foul odor, all of which were attributed to the malignant wound. He was referred to our department for chemotherapy with dacarbazine plus doxorubicin. Chemotherapy after admission proved to be intolerable and ineffective. To relieve the patient’s condition, we applied Mohs’ paste on the tumor surface. Thereafter, the volume of effusion decreased to <1 L/week. We encourage the use of Mohs’ paste as a safe treatment for DTs.

Odor Management in Fungating Wounds With Metronidazole

Odor is one of the main characteristics of malignant fungating wounds and is caused by the interaction of aerobic and anaerobic microbiota that colonizes and infects wounds. This odor has been described as intolerable and sickening. Antiseptics and antibiotics have been used to reduce local microbia

Cutaneous myiasis complicating basal cell carcinoma in a case of xeroderma pigmentosum

Myiasis is the infestation of live vertebrates (humans and/or animals) with dipterous larvae. It is known to infest patients with poor hygiene mostly in tropics with high fly population. The description of myiasis associated with cutaneous malignancy is infrequent in literature and very limited cases have been reported in patients of xeroderma pigmentosum (XP). We report a case of cutaneous myiasis complicating basal cell carcinoma (BCC) in a case of XP. The diagnosis of BCC was confirmed on histopathological evaluation. The maggots were identified as old world screwworm, Chrysomya bezziana Vill. of the fly family Calliphoridae. The malignant wounds were flooded with turpentine oil resulting in suffocation and death of maggots following which they were manually removed. Oral antibiotics and analgesics were given along with oral ivermectin.

Topical agents and dressings for fungating wounds.

Fungating wounds arise from primary, secondary or recurrent malignant disease and are associated with advanced cancer. A small proportion of patients may achieve healing following surgical excision, but treatment is usually palliative. Fungating wound management usually aims to slow disease progression and optimise quality of life by alleviating physical symptoms, such as copious exudate, malodour, pain and the risk of haemorrhage, through selection of appropriate dressings and topical agents. To review the evidence of the effects of dressings and topical agents on quality of life, and symptoms that impact on quality of life, in people with fungating malignant wounds. For this third update we searched the Wounds Group Specialised Register in August 2013; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. Eligible studies comprised randomised controlled trials (RCTs) or, in their absence, controlled clinical trials (CCTs) with a concurrent control group. Data extraction and risk of bias assessment was undertaken by one review author and checked for accuracy by a second. Four trials involving 164 people were included. One RCT in women with superficial breast lesions compared 6% miltefosine solution with placebo and found that miltefosine delayed tumour progression. The study reported that the time to treatment failure was significantly longer in the miltefosine group (median 56 days) than in the placebo group (median 21 days) (p value 0.007, log-rank test). A second trial compared topical metronidazole with placebo but the results up to the point of cross-over were not statistically significant. A third trial compared the effect of foam dressings containing silver to foam dressings without silver and found that more patients experienced decreased malodour in the foam with silver group than in the foam alone group (p value=0.049). The fourth trial compared the effect of manuka honey-coated dressings with nanocrystalline silver-coated dressings and found no statistically significant difference with regard to exudate, malodour and wound pain. All trials, however, had methodological limitations. There is weak evidence from one small trial that 6% miltefosine solution applied topically to people with superficial fungating breast lesions (smaller than 1cm) who have received either previous radiotherapy, surgery, hormonal therapy or chemotherapy for their breast cancer, may slow disease progression. There is also weak evidence to suggest that foam dressings containing silver may be effective in reducing malodour. There is insufficient evidence in this review to give a clear direction for practice with regard to improving quality of life or managing wound symptoms associated with fungating wounds. More research is needed.

Nurses in the provision of outpatient care for women with malignant fungating wounds in the breasts

This study aimed to analyze accounts of nurses who undertake the dressing of fungating wounds of women with breast cancer, and to outline contributions to the nursing care. This is qualitative research, carried out in November 2010 with interviews and thematic analysis involving five nurses from the outpatient department of a public hospital in the city of Rio de Janeiro, specializing in the treatment of breast cancer. Categories were elaborated corresponding to the practice of outpatient nursing; the cancer wound; and, indications for the nursing care. It is concluded that there is a need for specific knowledge in the area of oncology nursing, professional involvement, technical skill and autonomy, the forming of a therapeutic group, clinical attendance interfacing with the palliative approach, and collaborative work as a team.

Comparing the Effectiveness of Green Tea versus Topical Metronidazole Powder in Malodorous Control of Fungating Malignant Wounds in a Controlled Randomised Study

Aim: To test the efficacy of green tea with that of conventional topical metronidazole powder by comparing the rate of malodorous score reduction using the verbal numeric scale (VNS). Methods: This was a prospective randomised experimental study comparing two types of odour control agents used for treating malodorous fungating malignant wounds in a tertiary hospital in Singapore. Patients were randomised to either control (metronidazole power) or treatment (green tea) group and was follow-up with a daily dressing for a week by a designated nurse. Both patient and designated nurse would rate the malodorous score daily on a VNS of 0 (no smell) to 10 (worst smell that one can imagine). Results: Thirty cancer patients with malodorous fungating wounds were randomised into either treatment (n=15) or control group (n=15). The location of wounds were breast (n=24), neck (n=2), groin (n=2), spine (n=1) and anus (n=1). All patients in both groups showed improvement in odour control by Day 7. Treatment group was as effective as control group and there was no statistical significance (p&gt;0.05) to demonstrate which treatment is more superior. Conclusion: Green tea dressing is as effective as conventional topical metronidazole powder in controlling odour. Green tea is cheap, easily available and has no risk of drug resistance over long term use. Alternatively, it can also be used interchangeably with metronidazole powder to reduce the risk of drug resistance.

Curar o paliar: ¿qué cuesta más? Análisis de costes del tratamiento de una herida crónica en función de su finalidad

ObjectivesTo identify if there is a cost difference in the treatment of chronic wounds regarding to their aim, palliative or curative treatment. MethodThis is a longitudinal observational descriptive study performed in a Palliative Care Unit (UCP) and a Special Care Unit (UCE) both of which based within the Fundación Instituto San José in Madrid. The incidence and prevalence data of all the chronic wounds were analyzed retrospectively from nursing records of all the patients admitted to the UCP from 1st January 2011 until 31st July 2012. During the month of May 2012 data collection was obtained for a comparative cost analysis within both the UCP and UCE with regard to the treatment for chronic wounds. ResultsBetween 1st January 2011 and 31st July 2012, 863 patients were admitted within UCP. 34.47% of who were admitted with a one or more existing pressure ulcer(s). 3.7% of patients during this period developed a pressure ulcer during their hospital stay. Throughout the month of May 2012 our data found that the total average for dressing a chronic wound in UCP was 5.86±2.40 Euros whilst within UCE the cost rose to 8.07±3.77 Euros. The final cost for the treatment of a chronic palliative wound is displayed as 6.32±2.74 Euros and the treatment costs for healing a chronic wound as 7.05±3.43 Euros. ConclusionsBy gathering data regarding total costs of wound care, within the UCP the cost of malignant and palliative wounds were higher when compared to the chronic wounds within the UCE. With regard to the purpose of the treatment, the results do not establish a significant difference, but there are greater costs in the treatment of malignant and palliative wounds.

Neoplastic wounds and degenerescence

Between 5% and 10% of cancer patients develop malignant wounds. Cancer wounds can occur as a clinical entity, especially over the breast, with the development of painful, spreading cancer invasions of the skin.Marjolin's ulcers develop in open wounds after a long period, and form rare malignancies arising from previously traumatised, chronically inflamed, or scarred skin. Marjolin's ulcer is associated with malignant transformation of chronic ulcers, sinus tracts, and burn scars. Squamous cell carcinoma may be linked to a wide variety of medical and surgical clinical situations, such as chronic ulcers, sinuses, chronic osteomyelitis, radiotherapy, burn scars, chronic pressure ulcers, as well as cystostomy sites, and Fournier's gangrene scars. Melanomas, lymphomas, and other cancers can also be observed. Basal cell carcinoma is more frequently observed in ulcers associated with venous insufficiency. According to some reports, the ulcer should have existed for at least 3 years to evoke a diagnosis of degenerescence as opposed ulcerated tumour. Epidermoid carcinomas represent between 0.21% and 0.34% of cancers that develop over leg ulcers, but large series are still lacking. The current lack of epidemiological data could be rectified by more frequent evocation of the diagnosis and a policy of systematic biopsy of chronically open wounds.

Bacterial floras and biofilms of malignant wounds associated with breast cancers.

The risk of infections and the appearance of symptoms (e.g., odors) represent the main troubles resulting from malignant wounds. The aim of this study was to characterize the balance of bacterial floras and the relationships between biofilms and bacteria and the emergence of symptoms. Experimental research was carried out for 42 days on malignant wounds associated with breast cancer. Investigations of bacterial floras (aerobes, aero-anaerobes, and anaerobes), detection of the presence of biofilms by microscopic epifluorescence, and clinical assessment were performed. We characterized biofilms in 32 malignant wounds associated with breast cancer and bacterial floras in 25 such wounds. A mixed group of floras, composed of 54 different bacterial types, was identified, with an average number per patient of 3.6 aerobic species and 1.7 anaerobic species; the presence of strict anaerobic bacterial strains was evidenced in 70% of the wounds; biofilm was observed in 35% of the cases. Odor was a reliable indicator of colonization by anaerobes, even when this symptom was not directly linked to any of the identified anaerobic bacteria. Bacteria are more likely to be present during myelosuppression and significantly increase the emergence of odors and pain when present at amounts of >10(5) · g(-1). The presence of biofilms was not associated with clinical signs or with precise types of bacteria. No infections occurred during the 42-day evaluation period. This study provides a dynamic description of the bacterial floras of tumoral wounds. The study results highlight the absolute need for new therapeutic options that are effective for use on circulating bacteria as well as on bacteria organized in biofilm.

Morphological characteristics of and factors related to moisture-associated dermatitis surrounding malignant wounds in breast cancer patients

PurposePatients with malignant breast wounds (MBWs) have multiple symptoms. In particular, care for exudates or peri-wound moisture-associated dermatitis (MAD) is difficult. However, MAD has not been distinguished from peri-wound dermatitis. Therefore, care for patients with MAD has not been well established. The aim of this study was to describe morphological characteristics of MAD in MBWs and link morphological characteristics of MAD to related factors. MethodsWe conducted a qualitative descriptive study and a cross-sectional study. Data were collected by qualitative participant observation and structured interviews. The qualitative descriptive study was conducted using the ‘morphoqualitative analysis’ method. Data analyses were performed using qualitative research methods. In the cross-sectional study, the participants were classified into 2 groups for comparison: with MAD (MAD group) and without MAD (non-MAD group). ResultsCharacteristics of 24 MBWs were examined. Morphoqualitative analyses of data generated 17 subcategories and 3 categories. We could morphologically define MAD by findings of ‘radial shape matching the dressing’ and ‘half-fusiform shape over the dressing’. Regarding factors related to MAD, necrotic tissue type was significantly more severe in the MAD group than in the non-MAD group (p = 0.048). Wound exudate leakage was significantly more frequent in the MAD group than in the non-MAD group (p = 0.013). ConclusionOur study provides several points for nursing MBWs. Morphoqualitative analyses of MAD are quite important for evaluating possible causes of MAD as well as selecting effective interventions.

Coping with an exulcerated breast carcinoma: an interpretative phenomenological study

To explore how women living at home with a malignant fungating wound (MFW) cope with such wounds. To explore coping through the lived experiences of patients a methodological framework, using Heideggerian hermeneutic phenomenology and semi-structured interviews. Nine patients were interviewed from January until November 2009. The results are divided into two categories: 'living with a MFW' and 'feeling different'. These categories demonstrate how it is to live with the unpredictability, and uncontrollability of a MFW due to symptoms such as malodour, bleeding, exudate, pain and itching. The loss of control of the body boundary due to uncontrollable symptoms led to significant levels of distress and suffering for the patients. Different coping strategies were used to live with this wound. This study demonstrates how difficult it is to live and cope with a malignant fungating wound. Coping strategies, including going into isolation, or denying any issues, were used. When taking care of patients with MFWs, strategies need to integrate a palliative, holistic, empathic approach.

Malignant wound management in advanced illness

This article describes why this review is timely and relevant. To report on the recent research, which advances our understanding and practice of palliative wound care (wound-related pain and symptom management or wound palliation). This article describes the main themes in the literature covered by the article. The main themes include the problem of malodour and the palliative management of cutaneous and subcutaneous malignancy of skin and nonskin origins. The findings from an international survey of measures to combat wound malodour are reported, which indicate that malodour is one of the most distressing and difficult to manage symptoms associated with malignant wounds. A relatively novel palliative treatment for cutaneous malignancy, electrochemotherapy, is outlined, together with the growing evidence supporting its use. This article describes the implications of the findings for clinical practice or research. The findings of the wound malodour survey indicate that approaches to managing malodour are wide ranging, but ineffective. Collaborate research and development is needed with industry into interventions to combat malodour, which are based on the causal agents. The growing evidence of the effectiveness of electrochemotherapy, as an uncomplicated palliative treatment and method of managing symptoms, offers palliative care clinicians a means of managing the otherwise relentless progression of cutaneous malignancy.

In vivo wound healing activity and phytochemical screening of the crude extract and various fractions of Kalanchoe petitiana A. Rich (Crassulaceae) leaves in mice

Ethnopharmacological relevanceThe leaves of Kalanchoe petitiana A. Rich (Crassulaceae) are used in Ethiopian folk medicine for treatment of evil eye, fractured surface for bone setting and several skin disorders including for the treatment of sores, boils, and malignant wounds. Aim of the studyIn order to scientifically prove the claimed utilization of the plant, the effects of the extracts and the fractions were investigated using in vivo excision, incision and dead space wound models. Materials and methodMice were used for wound healing study, while rats and rabbit were used for skin irritation test. For studying healing activity 80% methanolic extract and the fractions were formulated in strength of 5% and 10%, either as ointment (hydroalcoholic extract, aqueous and methanol fractions) or gel (chloroform fraction). Oral administration of the crude extract was used for dead space model. Negative controls were treated either with simple ointment or sodium carboxyl methyl cellulose xerogel, while positive controls with nitrofurazone (0.2w/v) skin ointment. Negative controls for dead space model were treated with 1% carboxy methyl cellulose. Parameters, including rate of wound contraction, period of complete epithelializtion, hydroxyproline contents and skin breaking strength were evaluated. ResultsSignificant wound healing activity was observed with ointment formulated from the crude extract at both 5% and 10% concentration (p<0.01) compared to controls in both excision and incision models. In dead space model, 600mg/kg (p<0.01) but not 300mg/kg significantly increased hydroxyproline content. Fractions showed variable effect, with the chloroform fraction lacking any significant effect. Both 5% and 10% formulations of the aqueous and methanolic fractions significantly increased wound contraction, decreased epithelializtion time and increased hydroxyproline content in excision wound model (p<0.05) as compared to controls. These fractions were also endowed with higher skin breaking strength in incision wound model (p<0.01). ConclusionsThe present study provided evidence that the leaves of Kalanchoe petitiana A. Rich possess remarkable wound healing activities supporting the folkloric assertion of the plant. Fractionation revealed that polar or semi polar compound may play vital role, as both aqueous and methanolic fractions were endowed with wound healing activity.