Palliative Surgery for Advanced Fungating Skin Cancers
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Abstract: Advanced skin cancers sometimes develop complex wounds with associated pain, infection, malodor, massive discharge, and bleeding, which distresses patients and decreases his or her quality of life (QoL). The following cases presented large fungating skin ulcers that were treated with palliative abrasion along with wound resurfacing using free skin grafting. Palliative surgery allowed the patients to lead a more comfortable daily life at home with family. Simple palliative surgery can improve the QoL of terminal patients by reducing wound secretion, odors, and the risk of infection, and consequently, can improve nutritional status and their overall health condition.
Approximately 5%–10% of patients with breast cancer and advanced skin cancer will develop a fungating wound.1 If the cancer is in an advanced stage, curative treatment such as radical abrasion is often not preferred, but a range of palliative radiotherapy and drug therapy may be attempted.2 In these cases, a chronic complex wound that is typically infected, malodorous, and has massive discharge and bleeding, must be treated with local wound management techniques. The goal of treatment should be to optimize QoL in these terminal patients, but fungating wounds sometimes cause a patient distress and prevent him or her from living at home.3
Two cases of large fungating ulcers resulting from breast cancer and malignant melanoma, which were treated with palliative resection and free skin grafting, are presented. The outcome, in terms of improving each patient’s QoL, was successful in both cases.
Case 1: A 75-year-old woman had been examined at the Department of Surgery (Nagasaki Medical Center) complaining of a lump located on the right breast. Two tumors were identified: one measuring 10 cm × 9.5 cm at the right axilla and another measuring 7 cm × 6.5 cm in the right breast, both of which were hard, round, and protuberant. Histological analysis of a biopsy indicated nipple duct carcinoma. A surgeon evaluated the patient and recommended regular follow-up and treatment with cytotoxic and endocrine agents because the breast cancer was at an advanced stage. The tumors rapidly enlarged and developed a fungating wound over a 6-month period. The patient consulted the authors to manage the complex wound.
Upon examination the 23-cm x 21-cm hard tumor of the right breast had developed into a fungating wound with infection, had an unpleasant odor, and showed massive discharge and bleeding. Another 13-cm x 1-cm, hard, red, round, protuberant tumor with a firm underlying subcutaneous layer was revealed at the right axilla (Figure 1A). Computed tomography (CT) showed that the latter mass had invaded the pectoralis major muscle and periosteum of the ribs, but distant metastasis, including lung neoplasm, were not recognized at this time (Figure 1B). Analgesics and sedatives allowed the patient to walk and move, but the unpleasant odor, massive drainage, and local bleeding, which caused severe cachexia, malnutrition, and anemia prevented the patient from living at home.
Considering the nature and prognosis of the patient, surgery consisted of palliative amputation of the breast tumor along with wound resurfacing using free skin grafting, which was deemed to be the least invasive procedure to alleviate the problems.