Malignancy

Recommendations

Identify and Treat the Cause
1 Suspect malignancy when chronic ulcers that receive appropriate wound care do not heal. Level of Evidence
Not Assessed
2 Perform a biopsy of intact skin that demonstrates the features of skin cancer near the edge of the ulcer. Level of Evidence
Not Assessed
3 Manage primary skin cancers surgically (treatment of choice). Level of Evidence
Not Assessed
4 Explore all treatment options for metastatic lesions and develop a care plan focused on patient comfort. Level of Evidence
Not Assessed
5 For nonhealable or maintenance wounds, provide support, pain control and modified local care (conservative debridement, bacterial and moisture reduction) Level of Evidence
Not Assessed


Address patient-centered Concerns
6 Communicate (patients, family, caregivers) to establish a social support system with realistic expectations for healing and to prevent leg ulcer recurrences. Level of Evidence
Not Assessed
7 Assess / Control pain and optimize activities of daily living Level of Evidence
Not Assessed


Provide Local Wound Care
8 Assess and document the wound at regular intervals. Level of Evidence
Not Assessed
9 Optimize local wound care: debridement, inflammation / infection control, and moisture balance. Consider biopsy of appropriate active (including biologicals) & adjunctive therapies if the wound is not healing at the expected rate. Level of Evidence
Not Assessed


Provide Organizational Support
10 Consult appropriate disciplines to maximize healing (e.g. mobility and nutrition). Level of Evidence
Not Assessed


Background

Approximately 5 to 10% of individuals with cancer may experience a malignant wound.
Ulcer may be the presenting sign of a primary skin cancer, or less commonly, it may represent metastatic disease. Primary skin cancers that most often present as ulcers are basal-cell carcinoma, squamous-cell carcinoma, melanoma, and cutaneous T-cell lymphoma. Angiosarcoma, merkel-cell carcinoma and Kaposi sarcoma may also ulcerate. Metastatic lesions are most commonly associated with primary squamous-cell carcinoma; breast, lung or renal carcinoma; or melanoma arising in the skin or elsewhere.

As long-term immunosuppression in transplant recipients increases the risk of skin cancer, malignancy should be suspected in a transplant recipient presenting with an ulcer. An ulcerating squamous-cell carcinoma (Marjolin’s ulcer) may also develop in chronic wounds, including venous ulcers. It may not be possible to ascertain the length of time the ulcer has been present, but many ulcerated basal-cell or squamous-cell carcinomas have been present for at least several months.

Clinically, the base of an ulcerated skin cancer is indistinct, but the borders may be raised, rough or scaly, with prominent telangiectasia and changes consistent with chronic sun exposure in the surrounding skin. An ulcerated melanoma may or may not have a pigmented border. Features indicating malignancy include rapid lesion enlargement despite appropriate care; pain; bleeding; and often a rolled wound margin. A biopsy should be performed on chronic ulcers that do not respond to appropriate wound care to rule out malignancy. The biopsy should be taken from intact skin demonstrating the features of a skin cancer near the edge of the ulcer.

Surgical excision is the treatment of choice for primary skin cancers. As healing may not be possible for metastatic lesions, palliation may be a more appropriate goal. All treatment options should be explored. Local wound care management challenges include odour, exudate, bleeding and pain. The care plan for metastatic lesions needs to consider patient comfort, the ability of the patient and caregiver to manage wound care, and the availability of home care.

References

Essential Publications
1 Malignant Melanoma excision margins Quality Indicator
 Type: RCT
Thomas JM, Newton-Bishop J, A’Hern R, Coombes G, Timmons M, Evans J, Cook M, Theaker J, Fallowfield M, O’Neil T, Ruka W, Bliss JM.Excision margins in high-risk malignant melanoma. The New England Journal of Medicine 2004; 350(8): 757-67
In this RCT excision margins of 1 cm were compared with 3 cm margins. It was found a 1 cm margin of excision was associated with a significantly increased risk of locoregional recurrence and a reduced overall survival rate.
2 Malignant Ulcers Quality Indicator
 Type: Narrative Review
De Conno F, Ventafridda V, Saita L. Skin problems in advanced and terminal cancer patients. Journal of Pain and Symptom Management; 1991: 6(4) 247-56.
No recent articles have been found on this important topic of skin problems in this population. The little currently known about the epidemiology and physiopathology of malignant ulcers in the advanced phase of cancer is presented and approaches to management are also provided. However it is clear that controlled studies are needed to provide new information regarding new technologies and drugs for preventing and treating skin lesions in cancer patients.
3 Malignant melanoma – Chemoimmunotherapy Quality Indicator
 Type: Systematic review
Sasse AD, Sasse EC, Clark LGO, Ulloa L, Clark OAC. Chemoimmunotherapy versus chemotherapy for metastatic malignant melanoma. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD005413. DOI: 10.1002/14651858.CD005413.pub2.
The purpose of this review was to determine the effect of chemoimmunotherapy (chemotherapy and immunotherapy) compared to chemotherapy alone in metastatic malignant melanoma patients. 18 studies containing 2625 patients were included in this review. Chemoimmunotherapy did not significantly improve survival rate and was associated with increases in both hematological and non-hematological toxicities.
4 Malignant melanoma – Early diagnosis Quality Indicator
 Type: RCT
de Gannes GC, Ip JL, Martinka M, Crawford RI, Rivers JK. Early detection of skin cancer by family physicians: A pilot project. J Cutan Med Surg 2004;8(2):103-109.
The purpose of this study was to determine if education can improve the ability of family physicians’ to diagnose skin cancers. The intervention group was provided with an educational video while the control group was not. Family physicians who received education scored higher on a post-intervention quiz than the control group, but this difference was not statistically significant.
5 Malignant melanoma – Isolated limb perfusion Quality Indicator
 Type: Systematic review
Lens MB, Dawes M. Isolated limb perfusion with melphalan in the treatment of malignant melanoma of the extremities: a systematic review of randomised controlled trials. Lancet Oncol 2003;4(6):359-64.
The efficacy of isolated limb perfusion for treating malignant melanoma of the extremities is evaluated in this review. Isolated limb perfusion is the local surgical delivery of high doses of chemotherapeutic or immunochemotherapeutic agents. The authors found that prophylactic isolated limb perfusion does not significantly impact survival and do not recommend its routine use.
6 Malignant melanoma – Personality Quality Indicator
 Type: Prospective Correlation study
Canada AL, Fawzy NW, Fawzy FI. Personality and disease outcome in malignant melanoma. Journal of Psychosomatic Research 2005;58(1):19-27.
In this study, the role of the patient’s personality on the outcome of early-stage malignant melanoma was evaluated. The researchers found that personality was a poor predictor of disease outcome and disease biology had a significant impact on prognosis.
7 Malignant melanoma – Psychoeducation Quality Indicator
 Type: RCT
Boesen EH, Ross L, Frederiksen K, Thomsen BL, Dahlstrom K, Schmidt G, Noested J, Krag C, Johansen C. Psychoeducational intervention for patients with cutaneous malignant melanoma: A replication study. J Clin Oncol 2005;23(6):1270-77.
The purpose of this study was to evaluate the effect of psychoeducation on malignant melanoma patients’ psychological distress and ability to cope. Psychoeducation consisted of health education, problem-solving skills, stress management, and psychological support. The authors found that psychoeducation can help decrease stress and improve coping ability, but there was no apparent clinical relevance.
8 Malignant melanoma – Quality of life Quality Indicator
 Type: Systematic review
Cashin RP, Lui P, Machado M, Hemels MEH, Corey-Lisle PK, Einarson TR. Advanced cutaneous malignant melanoma: A systematic review of economic and quality-of-life studies. Value Health 2008;11(2):259-71.
In this review, the impact of interventions, consisting of drugs and screening, on quality of life in malignant melanoma patients was evaluated. Treatments and screening for malignant melanoma generally were not cost-effective, and no significant differences or improvements in quality of life were found in any of the various treatments.
9 Malignant melanoma – Sunscreen Quality Indicator
 Type: RCT
Lee TK, Rivers JK, Gallagher RP. Site-specific protective effect of broad spectrum sunscreen on nevus development among white schoolchildren in a randomized trial. J Am Acad Dermatol 2005;52(5):786-92.
The purpose of this study was to determine the effect of sunscreen on nevus development in white schoolchildren. Children who used sunscreen had significantly fewer nevi on the trunk than children who did not use sunscreen. This difference was more noticeable in freckled children compared with children without freckles.
10 Malignant melanoma - Tamoxifen Quality Indicator
 Type: Systematic review
Lens MB, Reiman T, Husain AF. Use of tamoxifen in the treatment of malignant melanoma: Systematic review and metaanalysis of randomized controlled trials. Cancer 2003;98(7):1355-61.
The effect of tamoxifen combined with different chemotherapy regimens was evaluated in this review. Tamoxifen does not significantly improve the patient’s response to treatment or survival rate when used in combination with chemotherapy.


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