Management of bleeding associated with malignant wounds

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.

Caring for Patients With Malignant Fungating Wounds: A Scoping Literature Review

PURPOSE

The aim of this scoping literature review was to identify current knowledge related to management of malignant fungating wounds (MFWs), gaps in this knowledge, and areas for future research.

METHODS

This was a scoping literature review.

SEARCH STRATEGY

Six electronic databases (Embase, MEDLINE, Cochrane (CENTRAL), CINAHL, Scopus, and Web of Science) were searched spanning the years 1987 and 2022. The initial electronic database search retrieved 6041 studies. The search is based on 60 articles published between 1987 and 2022, along with 14 additional studies were based on search of reference lists of key articles.

FINDINGS

Studies were divided into 2 main domains; the vast majority (65 of 72, 87.8%) focused on symptom impact, measurement, and management. The remaining articles (n = 9, 12.2%) focused on caring for patients with MFW; these studies focused on nursing care experiences and competencies, along with lay caregiver experiences. Findings indicated that instruments have been developed to evaluate symptoms of MFW but only a few have been validated. Most of the studies reviewed evaluated the influence of MFW on physical and psychosocial function. Local and systematic symptom managements such as modern dressings, wound care strategies, surgery, and radiotherapy as well as chemotherapy were found to be effective in alleviating symptoms. Findings also indicated that families and nurses encounter obstacles and burdens when caring for patients with MFW; limited studies were retrieved that investigated the competence and needs of nurses in their caring journey.

IMPLICATIONS

Future studies should focus on: (1) using better designs to evaluate and compare topical agents and dressings to control odor, (2) validating assessment tools specific to MFW, (3) qualitative studies designed to enhance understanding family and nurses' experiences, and (4) improving the nurse's ability to care for patients with MFWs and their responses to managing these challenging patients.

Risk factors for rebleeding and long-term outcomes in patients with head and neck cancer bleeding: a multicenter study

Background

Acute, catastrophic bleeding in patients with head and neck cancer (HNC) is challenging and also a burden for their families and frontline physicians. This study analyzed the risk factors for rebleeding and long-term outcomes in these patients with HNC.

Methods

Patients who presented to the emergency department (ED) with HNC bleeding were enrolled in this study (N = 231). Variables of patients with or without rebleeding were compared, and associated factors were investigated using Cox’s proportional hazard model.

Results

Of the 231 patients enrolled, 112 (48.5%) experienced a recurrent bleeding event. The cumulative rebleeding incidence rate was 23% at 30 days, 49% at 180 days, and 56% at 1 year. Multivariate Cox regression analyses demonstrated that overweight-to-obesity (HR = 0.52, 95% CI 0.28–0.98, p = 0.043), laryngeal cancer (hazard ratio [HR] = 2.13, 95% confidence interval [CI] 1.07–4.23, p = 0.031), chemoradiation (HR = 1.49, 95% CI 1.001–2.94, p = 0.049), and second primary cancer (HR = 1.75, 95% CI 1.13–2.70, p = 0.012) are significant independent predictors of rebleeding, and the prognostic factors for overall survival included underweight (HR = 1.89, 95% CI 1.22–2.93, p = 0.004), heart rate > 110 beats/min (HR = 1.58, 95% CI 1.04–2.39, p = 0.032), chemoradiation (HR = 2.31, 95% CI 1.18–4.52, p = 0.015), and local recurrence (HR = 1.74, 95% CI 1.14–2.67, p = 0.011).

Conclusions

Overweight-to-obesity is a protective factor, while laryngeal cancer, chemoradiation and a second primary cancer are risk factors for rebleeding in patients with HNC. Our results may assist physicians in risk stratification of patients with HNC bleeding.

[Management of patients with haemorrhage malignant wounds]

Patients with tumor wounds have many symptoms that impair their quality of life and their general condition. Hemorrhaging is one of them. It can be a challenge for the caregivers and the medical team and will have an impact on the patient. There is no consensus on the management of this symptom, but the literature provides some food for thought. Simple measures can be easily implemented depending on the patient's risk factors, the wound and the oncological context.

Palliative Wound Care: Less Is More

Palliative wound care is a philosophy of wound management that prioritizes comfort over healing and attends to the emotional distress these wounds can cause. Intervention strategies focus on management of symptoms such as pain, odor, bleeding, and exudate. Historic treatments such as honey, chlorine, and vinegar have gained renewed interest, and although well suited to the palliative setting, there is an increasing amount of research exploring their efficacy in other contexts. The lived experience of patients and caregivers facing these wounds is often stressful and isolating, and any treatment plan must address these issues along with the physical aspects of care.

Intervenções de enfermagem para pacientes oncológicos com odor fétido em ferida tumoral

Objetivo: identificar intervenciones de enfermería para el diagnóstico de olor fétido en herida tumoral. Métodos: revisión integradora de la literatura a partir de las bases de datos MEDLINE, CINAHL, LILACS e Cochrane, que resultó en la selección de 48 artículos científicos acerca de la temática investigada. Resultados: con base en las evidencias empíricas identificadas en los artículos incluidos en el estudio, se elaboraron 24 intervenciones de enfermería para el control y la reducción del olor fétido en heridas tumorales. Conclusiones: las intervenciones de enfermería presentadas en el estudio posibilitan la promoción de la calidad de vida al paciente con herida tumoral en cuidado paliativo. Como sugerencia posterior al Consejo Internacional de Enfermeros, se deben validar clínicamente para que su inserción se realice en el subconjunto terminológico cuidados paliativos para una muerte digna, de la Clasificación Internacional para la Práctica de Enfermería (CIPE®).

Subconjunto terminológico CIPE® para pacientes em cuidados paliativos com feridas tumorais malignas

Resumo Objetivo Desenvolver e validar um subconjunto terminológico, utilizando a Classificação Internacional para Prática de Enfermagem para pacientes em cuidados paliativos com feridas tumorais malignas. Métodos Estudo metodológico com revisão integrativa da literatura, que busca evidências empíricas relacionadas às feridas tumorais malignas e intervenções de enfermagem para manejo dos sintomas, nas bases de dados MEDLINE, CINAHL, LILACS e COCHRANE, recorte temporal de 2002 a 2015. Após cruzamento das evidências com termos da CIPE® 2013, baseado no Modelo 7 Eixos, foram elaboradas declarações de diagnósticos e intervenções de enfermagem, distribuídas de acordo com necessidades humanas básicas do referencial conceitual de Wanda Horta e avaliadas por peritos. Resultados Das 51 afirmativas de diagnósticos e 134 intervenções de enfermagem, 84,31% e 91,04% foram validadas respectivamente, sendo elaborado o subconjunto. Conclusão O instrumento poderá constituir-se numa referência de fácil acesso para enfermeiros, propiciando um cuidado da ferida baseado em evidências e linguagem de enfermagem unificada.