Mr. Smith is a 62-year-old male with a protruding 6cm irregularly -shaped tumor on his left cheek, which is inoperable. His comorbid medical conditions include diabetes mellitus type II (DMII), hypertension, obesity, and malignant melanoma of the right cheek (with systemic metastasis to other organs). Although this case scenario is a fictitious patient, the photo below represents what his tumor may have looked like before opening up as a fistula at the inferior border (at 4 o'clock) on the photo - involving the mucous membrane of the mouth.
Image of tumor
Photo source: intranet.tdmu.edu.ua
Other relevant medical information about Mr. Smith includes:
Laboratory values: Hemoglobin (Hgb) 11.1 / Hematocrit (Hct) 42.0; White blood cells (WBC) 9.8; Electrolytes were all within normal ranges. Hemoglobin A1c (HgbA1c) 6.9; Fasting blood sugar 135.
Mr. Smith's medications include Metformin 500 mg (milligrams) orally twice a day, a baby aspirin (81 mg) orally once a day, atenolol 50 mg orally once a day, and a multivitamin once a day. He reports taking acetaminophen 500 mg orally every 4 to 6 hours as needed.
Pertinent social information: Mr. Smith had a girlfriend he lived with for more than ten years, but she left him after his cancer diagnosis, saying she "could not stay around to watch him die." He lives at home alone and is a Veteran with a history of having served two tours of combat duty. He also reports having several guns at home. Nothing is known about any history of post-traumatic stress disorder (PTSD), and the patient states he has not received care at his local VA, stating only that he "has closed that chapter of his life." He has home care nurses who visit him daily for wound care; otherwise, he cares for his wound himself.
Mr. Smith has had only one social visitor from his local church, but the patient asked them not to come back. When asked, "Why?" he said he was embarrassed by the wound odor, appearance, and amount of drainage he had to deal with during the visit. He has not left his house except for doctor's office visits and grocery shopping at a 24-hour grocery after midnight to minimize how many people see him.
Other clinical information and wound description: Mr. Smith's weight is 175 lbs.; his height is 5' 10"; his vital signs (blood pressure or BP, pulse, respiration, and temperature) are all unremarkable. The patient complains of pain at the tumor site and inside of their mouth near the tumor site at "8" on a scale of 1 to 10, which is constant and "achy" most of the time, but occasionally he experiences a sharp jabbing sensation.
The physical exam also demonstrated that Mr. Smith would not often make eye contact and was holding a folded towel against his right cheek near the tumor for exudate control. The tumor is protruding from his right cheek, approximately 3.0cm at the apex of the tumor. The size of the overall tumor/lesion is 6.0cm at the longest axis x 4.0cm at the widest axis and is irregularly shaped with periwound redness and irritation, and erosion at the inferior border around the 4 o'clock position (using the body as a clock, think of the head always at 12 o'clock and the feet at 6 o'clock). This area now has an open wound, which has been defined as a fistula tracking to and involving the mucous membrane of the mouth, currently draining copious amounts of clear to brownish liquid (slight sour odor from exudate). Mr. Smith also complains that it feels "raw" (very painful to touch) at the inferior border. Chewing on that side increases pain sharply ("up to a 10" on a pain scale of 1 to 10), and cold compresses seem to provide minimal and temporary relief (pain level is "3 or 4" on a scale of 1 to 10 when he has the most relief).
Pathophysiology of malignant fungating tumors: In some patients with advanced cancer, a tumor may protrude through the skin, which may or may not be operable. Some studies suggest that 5 to 19% of all patients diagnosed with malignant neoplasm will develop a metastatic cancerous skin lesion (Sibbald et al., 2011). Many metastatic breast cancers may result in cutaneous wounds on the breast/chest. Metastatic cutaneous lesions may be ulcerous (tend to look like craters) or fungating.
Fungating lesions result from infiltrating malignant cells into the skin, surrounding lymph vessels, and supporting blood vessels. They tend to have a nodular or cauliflower-like appearance that sits above the surrounding skin level. Approximately 62% of all fungating wounds will be found in the breast, and 24% of all fungating wounds will be related to head and neck cancers (Emmons & Dale, 2016). Pain, bleeding, persistent exudates, and odor are the most common complaints reported with malignant cutaneous lesions (Bergstrom, 2011). Still, these wounds also produce a great deal of emotional stress for patients and their caregivers due to the appearance of the wound (Emmons & Dale, 2016). These cancerous lesions may bleed easily (friable) because of the vascular involvement in the tumor, which often results in a poorly organized growth of new blood vessels within the tumor cells, which tend to leak (Recka et al., 2012).