Which dressing would you recommend to apply to a malignant fungating wound in the area of the patient’s breast (advanced cancer, terminal phase)? The problem is threefold: bleeding, heavy exudate and malodour.
I would recommend using sodium hypochlorite 12.5-25% solution packing. By packing the wound with the solution soaked gauze, you will be able to manage the exudate, decrease the odor and gently clean the wound and remove any debris.
This is a very cost effective, efficient in managing the multiple problems of a wound such as a fungating cancer.
When removing the packing, moisten the material before the removal to decrease the potential for any bleeding and to decrease pain.
I would change it at least twice/day to stay ahead of the odor and drainage.
If the exudate is really voluminous, you can also use burn dressings to absorb the drainage. Use those dressings as secondary coverings.
I would recommend that you use metronizadol in gel. It is a good option for wounds of oncological origin.
Another option is the use of some carbone dressing. There are many in the market, it depends on the country. A problem can be the pain in the change of the dressings and the bleeding. You can combine this dressing of carbon with silicone type dressings (Mepitel).
Another off label option: Metronidazole tablets ground up and sprinkled in the wound bed can be useful to manage odor especially if the wound is very wet, which these often are. Cover dressings for these are challenging. Foam can be an option or something like Exudry. The sodium hypochlorite someone suggested is also effective and as mentioned cost effective. I just tend to be looking for ways to reduce dressing change frequency when possible in this scenario.
Another option for palliative treatment of problematic skin metastases and fungating tumours is electrochemotherapy. My unit has used this technique with breast cancers and skin cancers and our findings have been very encouraging. The areas slough off, so there is a wound present for a considerable period, maybe 2-3 months, but patients report a high degree of satisfaction and symptom relief. So far bleomycin has been the main chemo agent used in conjunction with the technique, but studies are under way to establish calcium chloride as a potentially less toxic alternative. If you treat a lot of breast or skin cancer patients, I would recommend that you have a look at ecletrochemotherapy as a very useful addition to your treatment options..
Please note - I have no conflicts of interest!!!
I thank you all for your answers! Unfortunately we don’t have the possibility for electrocemotherapy. I never thought about using metronizadol gel (or to ground tablets J). This is worth trying! It seldoms occurs that a patiinet with a malignant wound is admitted to our hospital, maybe once or twice a year, that is why we don't have much experience in treating such wounds.
When I wrote my question, we decided to cleanse the wound by irrigation with Microdacyn (1 % solution of HOCL and NaOCL), apply a silicon contact layer (Mepitel) and over it a charcoal dressing (Actisorb) + an absorbent dressing (Zetuvit plus). Dressing changes had to be performed daily (twice a day before this regime), there was hardly any more problem with bleeding and the malodour has been reduced a little but not entirely. The patient was discharged yesterday with instructions to the district nurse to continue with this regime.
Best regards, Hubert
USE DAKIN´S SOLUTION. LOOK INTERNET "HOW TO MAKE DAKIN´S SOLUTION.
My recommendation:
Clean lesion only with saline,put AquacelAg and cover with sterile gauze. Redressing daily for the first 3-4 days ( first two day you can change twice a day if necessary) following discharge,then every 3-4 days afterwards.
Best regards,N.Glavan
Dear Colleagues
I prefer a Modern Wound Management adapted on the wound and patient situation.
Depending on the exudation level:
high: primary dressing: superabsorber (eg Vliwasorb); secondary dressing, if deep or wound pockets: a silver alginate (eg Suprasorb A+Ag) or Ag hydrofiber (eg Aquacel Ag). alternative PHMB products (eg Suprasorb X+PHMB)
moderate exsudation with odor:
charcoal fibres with silver in an absorbent dressing (eg Vliwaktiv Ag Dressing or rope)
In Germany we do not prefer antibiotics locally. If we have a superinfection then may be antibiotics orally or iv are indicated.
Literature:
http://www.cancernurse.eu/documents/EONSMalignantFungatingWounds.pdf
Best regards
Martin Abel
We use 10 ml of chlor-hixdne with 500 ml NS for washing of the wound and local antibiotic ointment
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