500 Words on Pathogenesis and Manifestations of Fungating Wounds in Extensive Metastatic Cancer Fungating malignant wounds are a distressing

problem for a significant number of patients with advanced cancer. They may develop during the last few months of life or be present for a number of years. Fungating wounds rarely heal and often require palliative management. A fungating (malignant) 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 where the cancer started (the primary) or when the cancer has spread to another part of the body (the secondary or metastasis). A review of the literature has identified many physical, psychological and social problems associated with fungating wounds. The most frequently reported wound symptoms are exudate, malodour, bleeding and pain. Wound malodour is probably the most distressing symptom for patients, and is caused by bacterial infection in devitalised tissue within the wound. This can also be devastating for the patient's family and caregivers, as wound malodour may be constantly detectable and can trigger gagging and vomiting reflexes. The presence of a pervasive malodour can lead to embarrassment, disgust, depression and social isolation and may have a detrimental effect on sexual expression causing relationship problems Fungating wounds often produce excessive amounts of exudate which can be difficult to manage . Increased permeability of blood vessels within the tumour and secretion of vascular permeability factor by tumour cells are the most likely causes of high exudate levels ; exudate production may also be increased if infection is present. Large volumes of uncontrolled exudate may cause leakage from the dressing and staining of the patient's clothes . This again can cause significant psychosocial problems for patients and carers. There are a number of mechanisms that can cause fungating wounds to be painful. The tumour, for example, may be pressing on nerves and blood vessels, or there may be exposure of the dermis. Patients often describe their pain as a superficial stinging or painful ulceration. Painful procedures such as the use of an inappropriate cleansing technique or removal of a dressing which adheres to the wound bed may also impact on the pain experienced by the patient. Wound bleeding is common in fungating wounds. This occurs because malignant cells erode blood vessels, and may be compounded by decreased platelet function within the tumour. Profuse, spontaneous bleeding can be distressing for both patients and their carers , while damage to fragile tissues during dressing changes may exacerbate bleeding. The position of the wound may be a source of embarrassment and distress for the patient especially if it is in an area such as the breast or genitals, or an area highly visible to others, for example, on the face.

References
Young T. The challenge of managing fungating wounds. Community Nurse 1997; 3(9): 414. Haughton W, Young T. Common problems in wound care: malodorous wounds. Br J Nurs 1995; 4(16): 959-60, 962-3. Price E. Wound care. The stigma of smell. Nurs Times 1996; 92(20): 70-2. Fairburn K. A challenge that requires further research: management of fungating breast lesions. Professional Nurse 1994;9(4): 272-77. Collier M. The assessment of patients with malignant fungating wounds - a holistic approach: Part 2. Nurs Times 1997;93(46): suppl 1-4. Gallagher J. Management of cutaneous symptoms. Semin Oncol Nurs 1995; 11(4): 239-47. Van Toller S. Invisible Care 1994; 3(2): 103-05. wounds: the effects of skin ulcer malodours. J Wound

Hallett A. Fungating wounds. Nurs Times 1995; 91(47): 81-83. Haughton W, Young T. Common problems in wound care: malodorous wounds. Br J Nurs 1995; 4(16): 959-60, 962-3. Jones M, Davey J, Champion M. Dressing wounds. Nurs Stand 1998; 12(39): 47-52; quiz 55-6. Van Toller S. Invisible Care 1994; 3(2): 103-05. wounds: the effects of skin ulcer malodours. J Wound

Haisfield-Wolfe ME, Rund C. Malignant cutaneous wounds: a management protocol. Ostomy Wound Manage 1997; 43(1): 56-60, 62, 64-6. Grocott P. The palliative management of fungating malignant wounds. J Wound Care 1995; 4(5): 240-2. Davis V. Goal-setting aids care. Nurs Times 1995; 91(39): 72, 74, 76. Boardman M, Mellor K, Neville B. Treating a patient with a heavily exuding malodorous fungating ulcer. J Wound Care 1993;2(2): 74-76. Grocott P. Wound care - practical changes. Nurs Times 1993; 89(7): 64, 66, 68 passim. Manning MP. Metastasis to skin. Semin Oncol Nurs 1998; 14(3): 240-3. Grocott P. The palliative management of fungating malignant wounds. J Wound Care 1995; 4(5): 240-2.