Management of Fungating Oral Cancer: A Case Report

Fungating growths of cancer are associated with social stigma and fear, and hence, they are mostly underreported [1]. Fungating growths are accompanied by excoriation of the surrounding skin, intense malodor, profuse fibrinous or purulent drainage, bleeding, severe pain, and psychosocial dysfunction for the patients as well as distress and anxiety for their family members or caregivers [2,3,4]. Malodor associated with fungating growth is also a very distressing feature of fungating masses causing substantial psychological distress for the patient and their family members including social isolation of the patient [5]. Yet malodor management remains suboptimal. The odor emits from fungating growths of cancer are often proven to be resistant to intervention, making odor elimination an important clinical challenge. Infections associated with fungating cancer growths are treated indiscriminately with oral or intravenous antibiotics although the literature clearly shows no benefit of prophylactic antibiotic therapy for preventing systemic infection [6]. In this paper, we discuss how we managed local wound infection and malodor associated with the fungating wound including the definitive treatment of a fungating growth of an oral cavity cancer patient. We believe that this report will benefit the reader in the management of cancer with fungating growth.

We report here the management of a patient with squamous carcinoma of the oral cavity with fungating growth. The patient was a 47-year-old woman referred from the peripheral health center. The patient otherwise had a good general condition with no associated comorbidity and been leading an independent daily activity. The patient presented history of local wound treatment at the local peripheral health center. The patient was admitted through the outpatient department. On examination of the patient, there was a fungating growth involving the right-side buccal mucosa with involvement of the skin of lower face/check, almost the whole lower lip, the right-side upper lip, mandible, and the floor of mouth but not affecting the mobility of the tongue with malodor emitting from the fungating tumor. There was no associated cervical lymphadenopathy in spite of having the fungating growth. Thus, the TNM stage of the patient was T4N0M0. The patient also complained of a severe pain. Upon admission, local wound care with silver dressing and topical application of metronidazole cream twice daily was started. After 36 hours, the malodor almost completely disappeared and the patient reported reduced exudate with improved tumor appearance. The patient well-being too improved. Systemic or oral antibiotic was not given for this patient. Basic investigations were all normal except hemoglobin 8.2 g/dl. This patient could ultimately undergo definitive curative treatment. Figure 1 shows the fungating tumor, and Figure 2 shows postoperative day 10.

Figure 1:

Figure 2:

Cancer presenting with fungating growths is mostly seen in areas of breast (49%), neck (21%), chest (18%), and head (13%) [7,8]. Fungating growths in the head and neck regions especially oral cavity cancer pose a unique management challenge. Moreover, there is a paucity of information in the literature with regard to the management of cancer with fungating growths of head and neck regions [9]. Being head and neck onco-surgeons, this is surprising as time to time we keep on coming across cancer with fungating growths and most of these cases are erratically treated. So, because of the poor understanding, infections associated with fungating wound of cancers are treated indiscriminately with oral or intravenous antibiotics. And this is a consistent pattern of practice among the care providers of cancer with fungating growths resulting in high misuse of antibiotics; however, the benefits of prophylactic antibiotic therapy for preventing systemic infection have never been proven even in the setting of bacterial colonization [6]. Moreover, despite bacterial colonization in the fungating wound, there is no evidence that these odor-producing bacteria result in systemic infections or septicemia [6]. Initially, people thought systemic antibiotics will reduce the odor of fungating wounds via their bactericidal properties. But several studies have now demonstrated a lack of odor improvement or wound appearance with the use of the systemic antibiotics [10,11]. Thus, avoiding the indiscriminate use of systemic antibiotic is important for a cancer patient in order to avoid the side effects of systemic antibiotics which can be significant and can exacerbate chemoradiation therapy–related adverse effects.

On the other hand, it is well known that topical antibiotics do not cause systemic effects like vomiting, nausea, peripheral neuropathy, elevated creatinine, elevated liver enzymes, or antibiotic-specific allergies. Topical metronidazole by killing anaerobic bacteria has been shown to be effective in odor reduction resulting in patient well-being [12,13]. Further studies have also re-enforced that topical metronidazole brings about reduction in bacteriology profiling and in the process improves the odor [14,15].

Topical dressings are also important for cancer patients with fungating wounds as they decrease bacterial counts in necrotic tissue through their absorptive or antimicrobial action, and this results in control of odor and exudate [16]. Topical dressings suitable for treating head and neck cancer with fungating wounds are charcoal dressing and silver dressing. Charcoal dressings are good for fungating tumors with much necrosis as they are thin and porous in nature. Charcoal dressings rapidly absorb tumor exudate preventing surrounding tissue maceration [17,18]. Like charcoal dressing, silver dressings are also good for fungating tumors with much necrosis. Silver dressings have shown to have higher bactericidal properties than charcoal dressings with better pain relieve and similar efficacy on reducing odor as charcoal dressing [19–20].

As evidences have shown no benefit of systemic antibiotic in the management of cancer with fungating growths, we should manage these fungating wounds with topical treatments like ointments/creams and local wound dressings. Indiscriminate use of systemic antibiotic should be avoided. Topical metronidazole is the appropriate treatment for the management of malodor arising from the local superinfection in the fungating growths. Topical dressings such as silver dressings and charcoal dressings reduce the malodor, exudate, and pain with minimal side effects.