Fungating Lesion Breast Cancer

Fungating lesions often accompany advanced malignancies, especially breast cancer.It called as funagting lesion breast cancer. There is no consensus on the best way to manage this common condition. A multidisciplinary and holistic approach is needed for optimal patient care. Malodour (a very unpleasant smell) is a distressing symptom, with topical metronidazole commonly recommended. Pain management requires accurate assessment of the underlying cause, often using the WHO analgesic ladder for guidance. Bleeding wounds can be treated with various topical agents. Exudative wounds may need specialized dressings like alginates, hydrofibre, foam dressings, or absorbent pads. These recommendations are based on limited evidence, and larger clinical studies are needed to determine the best management strategies for malignant fungating wounds.

Statistics of Fungating Lesion Breast Cancer

In 2012 worldwide, there were an estimated 1.7 million new cases of breast cancer, accounting for 25% of all cancers in women, and 0.5 million deaths from cancer, representing 15% of all cancer deaths in women. Developed countries have seen a decline in the incidence and mortality of breast cancer since the 1980s and 1990s due to advancements in detection, earlier diagnosis (through population-based screening), and more effective treatment options. Despite these improvements, some women still present with malignant fungating wounds (MFWs) at initial diagnosis. Qualitative research by Heisey et al. explored reasons why some women delayed seeking treatment for their MFWs, identifying factors that contributed to this delay.

A non-lump-presenting breast symptom may be experienced by individuals who have had prior ‘false alarm’ experiences, meaning a history of previous breast complaints that were found to be benign. These individuals may not receive regular periodic health care or screening and may also have comorbid conditions such as fibromyalgia or chronic fatigue syndrome. Additionally, they may have a history of previous negative health-care experiences.

Women’s avoidance of health care has been attributed to various factors, including personal, psychological, and social variables. Lund-Nielsen conducted a qualitative study to understand the dynamics of women’s feelings and factors that contribute to delayed presentation. They described a complex phenomenon of escalating destructive processes that begin with feelings of disbelief and eventually lead to shame, reinforcing an inability to take action.

Occurrence of Fungating Lesion Breast Cancer

It is challenging to determine the prevalence of fungating lesion breast cancer patients because most regions do not collect this data. However, available studies indicate prevalence rates ranging from 5% to 15% in cancer cohorts. Thomas conducted a survey of 114 radiotherapy and oncology units in the UK. The reported locations of fungating wounds in this survey were as follows: breast (62%), head and face (24%), groin and genitals (3%), back (3%), and other areas (8%). The prevalence of fungating wounds in this study ranged from 5% to 10%, with 5% related to a primary tumor and 10% to metastasis. Probst reported a prevalence rate of MFWs as 6.6%, with breast cancer again being the most common site. Lookingbill also reported a prevalence rate of fungating malignant wounds of 5–10%, and prevalence rate of 14.5%.

It is presumed that fungating lesion breast cancer is more common in developing countries than in developed countries, but very limited data confirm this. The lack of public education and awareness, along with the absence of screening programs, leads to delayed presentation in poorer countries. A study from Nigeria found that among 212 breast cancer patients, 83 patients (39%) had fungating tumors, and 28 patients (13%) showed clinical evidence of metastatic disease.

Major Prevalence Symptoms in

Psychological, Sexual, and social impact of Fungating Lesion

Living with Fungating Lesions Breast Cancer can cause intense and distressing feelings. Fungating Lesions can have physical, psychological, and social impacts on patients’ day-to-day lives. Common symptoms associated with Fungating Lesions include malodor, pain, exudate, and bleeding. Patients may experience unpredictable and uncontrollable wound-related problem leading to a deep sense of vulnerability while living in a body that is constantly changing and cannot be trusted.

There is a strong correlation between symptom burden and the quality of life (QoL) in patients. Their study utilized a QoL questionnaire consisting of four domains: physical symptoms, psychological well-being, existential well-being, and support issues. Patients with MFW scored lowest in the physical symptoms domain. Pain, malodor, psychological issues, and old age.

Feel Embarrassment

Patients often feel embarrassed by odor and leakage, which can lead to poor self-image, increased introversion, and eventual self-isolation. To minimize embarrassment further, patients may resort to managing the wound themselves. However, self-remedies without expert help can be harmful, as noted by Lo et al. Some patients have been known to restrict water intake to decrease wound exudate or use toothbrushes to clean the wounds in the hope that the hard bristles will ‘damage’ the tumor and lead to a cure. Additionally, some patients report feeling embarrassed when dealing with physicians (especially male doctors) as they often need to expose their wounds and compromise their modesty. These feelings of shame can contribute to poor self-esteem.

Managing Fungating Lesion Breast Cancer

Managing Fungating Lesion Breast Cancer requires a complicated care regimen that can be very difficult to handle. Patients often have to adjust their daily activities to meet the needs of the wound. They must carefully plan to ensure they bring all sorts of dressing when going out and choose clothes that disguise bleed and leakage easily. These are just some of the issues patients have to deal with on a day-to-day basis.

Malodor (unpleasant smell)

Malodor negatively affects both psychosocial and physical well-being. A strong foul odor can cause involuntary gagging, vomiting, and a decrease in one’s sense of taste, leading to anorexia, reduced oral intake, and malnutrition.

Anxiety

Patients often experience anxiety. They worry that others may notice their symptoms, such as odor or leakage. The fear of becoming dependent on painkillers is a common concern. Some patients also fear death and being constantly reminded of their cancer and terminal illness due to the visibility of their Fungating Lesions. The lack of information and expert assistance in managing can exacerbate anxiety.

Relationship Issues

The effect of pain from cannot be underestimated, and researchers have extensively studied cancer pain. Cancer pain adversely affects every aspect of a patient’s life, from their ability to work and interact with others, to their ability to rest and heal from their illness. The breast plays a crucial role in the sexual and maternal image of women. Therefore, patients of the Fungating lesion breast cancer may experience significant guilt and body image issues as they feel unable to fulfill their roles as a mother or sexual partner.Many women report that their relationship with their partner is severely affected.

Women feel helpless

They may feel helpless and hopeless as the wound worsens, and seeking help from friends and family can lead to an overwhelming sense of burdening their loved ones. As it affects so many aspects of a patient’s life, it often results in depression when coping mechanisms are overwhelmed. It is important for mental health providers to screen for depression in these situations. Providers use questionnaires and checklists such as the Beck Depression Inventory to detect and assess the severity of depression.

Symptom management

Fungating wounds typically do not heal unless the malignancy responds to anticancer treatment, leading them to potentially worsen over time. Therefore, the focus of treatment is on improving symptom control. Several studies have confirmed that the most distressing symptoms are malodor, pain, bleeding, and excessive exudates.

In the management of fungating malignant wounds, healthcare providers frequently encounter problems such as malodor and pain. A study of 67 patients revealed that the most common symptom reported by patients was pain. The prevalence of pain was 31.3%, followed by 23.9% for mass effect, 19.4% for esthetic distress, 17.9% for exudation, 11.9% for odor, 6% for pruritus, 6% for bleeding, and 1.5% for crusting.

Causes of Malodor

Before developing anti odor treatment for patient, it is necessary to understand the causes of malodor. It is thought that the main causes of malodor in MFW are the proliferation of bacteria in malignant wounds and the resulting increase in their metabolic by-products.

• Aerobic and anaerobic bacteria produce devitalized tissue and a mixture of volatile agents, as well as a combination of amines and diamines like cadaverine and putrescine, which result from the metabolic processes of other proteolytic bacteria.
• Bacterial growth is promoted by stagnant exudate, particularly within a saturated dressing.
• Fungating wounds often contain dimethyl trisulfide, a compound with a strong and foul odor that is produced by bacterial decomposition.

Treatment

The systemic review suggested that metronidazole might reduce malodor compared to placebo in a small study included. In the third trial, there was no statistically significant difference in malodor, exudate, and wound pain when comparing the effect of manuka honey-coated dressings with nanocrystalline silver-coated dressings. The author concluded that all these trials had methodological limitations and there is insufficient evidence to give a clear direction

Oral metronidazole may combat malodor, but its use is discouraged due to concerns about antibiotic resistance and potential side effects such as peripheral neuropathy. Limited studies have reported yogurt as an alternative therapy for controlling wound odor.

Regular wound cleansing reduces odor by removing necrotic debris and decreasing bacterial count. Multiple techniques have reported this. If the wound is not friable and the patient is ambulatory, the patient can cleanse the wound in the shower, providing the added psychological benefit of feeling clean.

Many patients also use scented agents in an attempt to manage odor in their environment. Patients have tried commercially available air fresheners, scented candles, and other perfumed products. Some patients have relied on strategies such as using cat litter, shaving cream, or vaporizing essential oils like citronella, eucalyptus, orange oil, or bergamot to mask the smell of a fungating lesion.

Myths

There is no good evidence supporting the use of other interventions such as topical arsenic trioxide, essential oils, green tea extract, and hydropolymer dressings, which received a C grade recommendation for use in malignant wounds. Certain interventions, like antiseptic solutions, hydrogels, and debridement enzymes, are not recommended for use in malignant wounds to control malodor due to potential risks outweighing benefits . The challenges in research and management of malodor highlighted in the above reviews. To improve future studies in this area, researchers need larger sample sizes, double-blinding, longer follow-up periods, and standardized odor assessment tools.

Pain Mechanism

Fungating lesion cause pain through different mechanisms including:

• The tumor putting pressure on other body structures
• The growing tumor damaging nerves
• Swelling from impaired capillary and lymphatic drainage
• Infections
• Exposing dermal nerve endings
  Mismanaging wound dressing changes.

In managing pain, it is important to differentiate between nociceptive pain (pain caused by nerve endings) and neuropathic pain (pain from nerve dysfunction) as their treatment differs. Injuries involving the skin cause a ‘cutting’ or ‘burning’ pain. When the wound injures surrounding blood vessels, the patient may describe a ‘throbbing pain.’ If the wound affects the nerve through compression or infiltration by malignant cells, the patient may experience neuropathic pain. This type of pain is often described as a spontaneous burning pain with intermittent sharp, stabbing pains. It has also been described as ‘itching,’ ‘tingling,’ ‘smarting,’ or ‘stinging.’

Neuropathic pain often involves allodynia and hyperalgesia. Allodynia occurs when a nonpainful stimulus, such as the breeze of a fan, causes pain to be felt. Hyperalgesia, on the other hand, is the increased sensitivity to pain. These abnormal sensations result from chemical mediators that are produced through inflammation, infection, and ischemia, which then activate or sensitize nociceptors.

Pain Treatment:

One can manage pain using pharmacological or nonpharmacological interventions. Systemic analgesics play a crucial role in pain management, and healthcare professionals often use the World Health Organization’s analgesic ladder as a guide. Nonopioid analgesics such as paracetamol and nonsteroidal anti-inflammatory drugs like aspirin target the prostaglandin pathway. These medications are used for background or procedural pain either alone or in combination. If the pain worsens or persists, healthcare providers may add weak opiates such as codeine and tramadol to the treatment regimen.

Pharmacological Agents

Commonly used pharmacological agents include local anesthetic agents and Entonox gas. Local anesthetic agents, such as lidocaine, can be injected around a nerve to create a local nerve block or applied topically to the wound before dressing changes. Entonox gas, which is an analgesic gas containing 50% oxygen and 50% nitrous oxide, offers rapid but short-lasting pain relief. These agents are particularly helpful during painful procedures like dressing changes, with no long-term side effects.

Topical Opioids (Drugs that reduce pain)
Several case studies have reported that topical opioids exhibit analgesic effects. Only a few double-blind, randomized, placebo-controlled studies have been conducted so far, yielding conflicting results and being hindered by methodological limitations and small sample sizes. it is discovered that topically administered morphine alleviated pain linked to ulcerating wounds. However, studies by Bastami and Vernassie demonstrated no positive effects. A recent systematic review by Graham concluded that topical opioids are clinically effective and safe for managing inflammatory pain in wounds due to minimal systemic absorption.

Nonpharmacological methods

Nonpharmacological methods to relieve pain are equally important. These methods include specialized wound-cleaning techniques, wound dressing products, and complementary therapies. It is recommended to gently irrigate with warm 0.9% sodium chloride saline.

However, the use of certain antiseptic products such as hypochlorite solution, iodine, and acetic acid may cause tissue damage and pain. Patients frequently experience wound-related pain during dressing changes. Therefore, it is crucial to carefully select dressings that maintain a balance of moisture to prevent adherence of the wound to dressings, which can lead to periwound maceration, skin damage, and trauma during dressing removal.

Silicone dressings are designed specifically to allow for nonadherent and ‘pain-free’ removal of dressings. You can also find dressings that offer gentle and infrequent dressing changes. It is often advised to change dressings before they become saturated to prevent the spread of potentially corrosive wound exudate onto periwound skin.

Complementary Therapies

Although lacking good scientific evidence, complementary therapies may be useful for managing pain. These include relaxation therapy, massages, visualization, imagery, distraction psychotherapy, acupuncture, acupressure, biofeedback, hypnosis, and aromatherapy. These interventions have limited to no side effects and anecdotal reports suggest efficacy, making them worth trying in selected patients.

Causes of Bleeding

Malignant wounds bleed easily because their fragile vasculature or direct erosion of blood vessels by the tumor. Comorbid conditions often seen in cancer patients, such as thrombocytopenia from marrow infiltration or treatment-related marrow suppression, as well as vitamin K deficiency, can also increase the risk of bleeding. The granulation tissue matrix is often compromised by decreased fibroblast activity and ongoing thrombosis of larger vessels in infected and malignant wounds, making it vulnerable to trauma.

Treatment

Gently cleansing wounds and taking extra care during dressing removal can reduce the risk of bleeding. Other helpful measures include using appropriate dressings such as nonadherent and moisture balanced dressings, avoiding unnecessary dressing changes, and using caution with debridement.

If bleeding occurs, you can control it by using certain measures. These measures include

• applying direct pressure
• using natural hemostats (such as calcium alginates, collagen, and oxidized cellulose)
• coagulants (like absorbable gelatin powder or sponge or topical thrombin)
• sclerosing agents (such as silver nitrate, trichloroacetic acid)
• vasoconstrictors (like epinephrine)
• fibrinolytic inhibitors (such as tranexamic acid)
• astringents (like alum solution, sucralfate).

Other measures that can be considered (if compatible with palliative care goals) include embolization of feeding arteries, electrochemotherapy, or radiotherapy. Although terminal hemorrhage occurs infrequently (3-12% incidence), it can be very distressing for the patient, their families, and health professionals. Patients at risk, such as those suffering from head and neck tumors, should identify and forewarn themselves, together with their caregivers. Keep crisis medications such as midazolam at the bedside along with dark towels.

Exudate in Fungating Lesion Breast Cancer

Causes

Exudates causes inflammation and increased bacterial activity, vasodilation, and increased blood vessel permeability that allows fluid and cellular material to travel through blood vessel walls. It is important to manage this excess moisture to prevent the dressing from becoming adherent to the wound or creating an ideal environment for bacteria to grow. The ideal dressing should be able to absorb excess moisture and prevent leakage. For highly exudative wounds, you can use a nonadherent layer like Vaseline gauze as the primary contact layer, and cover it with soft, absorbent dressing such as gauze or abdominal pads as the secondary dressing.

Specialty dressing manufacturers such as alginates, hydrofiber dressings, and foams may find utility in specific cases, but healthcare providers must weigh the potential benefits of their use against their high costs.In extreme situations with high exudates, healthcare professionals could opt for highly absorbent pads based on diaper technology as an alternative. These pads are cost-effective, incredibly absorbent, and come with waterproof backings that shield clothing. It is important to avoid occlusive dressings covering large amounts of exudate as they can harm the surrounding skin.

Hydrocolloid strips can prevent the recurrent stripping of skin by applying them around the wound. Applying zinc oxide/petrolatum acrylate on the still intact skin surrounding the ulceration forms a protective barrier on the skin attachment sites.

Conclusion:

Fungating Lesions are common in relation to breast cancer despite recent advances in diagnosis and treatment. The symptoms can affect both the patient and caregiver physically, socially, and psychologically. There is a strong correlation between patients’ symptom burden. Wound care specialists play an important role in multidisciplinary oncological care providing education to the patient and caregiver and assisting in continuous assessment and management of these patients. In addition to specific anticancer treatment, management of malignant wound-related symptoms is equally important, especially when the tumor is no longer responding to anticancer treatment.

The four main symptoms are pain, malodor, excessive exudate, and bleeding. Management of these symptoms mainly relies on anecdotal evidence and small underpowered studies. Therefore, we need carefully designed studies to optimize management strategies and outcomes for these patients. A standardized and validated wound assessment tool for Fungating Lesion Breast Cancer is necessary to ensure inter-rater reliability and allow for inter-study comparison. A comprehensive management plan tailored to each patient’s physical and psychosocial needs, along with a holistic approach, is essential.

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