Malignant wounds: Innovative tool helps clinicians assess severity of symptoms

September 1, 2008

Clinicians should aim to improve the symptom management of malignant wounds, particularly in cases of advanced cancer. One proposed tool to do this is the Toronto Symptom Assessment System for Wounds (TSAS-W). In a pilot study, TSAS-W demonstrated that malignant wounds were the most symptomatic class of wounds.

Key Points

Toronto - Clinicians here have developed a tool to assess the severity of symptoms caused by malignant wounds, and they urge other clinicians to use the tool to treat malignant wounds in patients.

The Toronto Symptom Assessment System for Wounds (TSAS-W) is a patient-completed questionnaire that assesses the pain and polysymptom burden of all wound classes, including malignant wounds.

"Malignant wounds are classic examples of nonhealing wounds," says Vincent Maida, M.D., a palliative medicine specialist at the William Osler Health Center in Toronto and assistant professor at the University of Toronto.

In an interview here at the World Union of Wound Healing Societies, a global meeting of woundcare specialists, Dr. Maida says clinicians should strive to improve the symptom management of malignant wounds and other wounds, as they severely reduce a patient's quality of life.

In a prospective pilot trial, TSAS-W demonstrated that malignant wounds were the most symptomatic class of wounds, and occurred in 14.2 percent of cancer patients. Breast cancer was the leading cause of malignant wounds, accounting for 47.1 percent of all malignant wounds. Pain was the most common and severe symptom experienced, followed by exudation, mass effect, esthetic distress, odor, pruritus and bleeding.

Wounds involving the perineum and genitalia had the highest degree of symptom distress, as measured by the global wound symptom distress (GWSDS), generated by summing all 10 TSAS-W parameters.

"We currently don't have tools to help us track our progress and guide our treatments," Dr. Maida tells Dermatology Times.

"TSAS-W may allow for this, as well as facilitate clinical audits. Furthermore, it may also facilitate research in wound pain and symptom management," he says.

The broad range of wounds, along with high rates of prevalence and incidence identified in this study, reflects that wounds represent a significant management issue for patients with advanced illness.

Dr. Maida says there is a need for advancement in modalities and measures aimed at risk assessment, prevention and goal-oriented management.

ALM of the foot

One of the subtypes of melanoma that is not well understood is the acral lentiginous melanoma (ALM) of the foot.

In a review of 26 cases that were found in a register at a large tertiary care hospital, Ivan Bristow, M.Sc. (Oxon), a lecturer at the University of Southampton School of Health Professions and Rehabilitation Sciences in Southampton, England, and his colleagues identified 19 females and seven males with ALMs. Patients were ages 38 to 96.

The typical location of the lesions was in the plantar area in about two-thirds of instances (65 percent). The average time of patients recognizing a lesion to seeking medical advice was 13.5 months. The mean thickness of lesions at diagnosis was 3.55 mm. Patients described experiencing symptoms such as bleeding, ulceration and color changes.

ALMs occur, on average, in patients over 60, and there is usually a delayed diagnosis associated with ALMs, according to Mr. Bristow, a member of the advisory board of the Journal of Foot and Ankle Research. The delayed diagnosis has been associated with a poorer prognosis.

"There are increasing numbers of patients who present very late," says Mr. Bristow, noting the tumor is uncommon and is a tumor that particularly affects the feet.

"We need to increase awareness around this type of melanoma so that is it is recognized earlier, when the tumor is thinner," he says.

Interestingly, nearly a quarter (23 percent) of ALMs had been misdiagnosed as lesions such as diabetic foot ulcerations, fungal infections, warts and other foot pathologies. ALMs can have varied presentations, Mr. Bristow says.

"They can masquerade as something else to the untrained eye," Mr. Bristow says. "Some clinicians may see it as a lesion that they want to debride. It can have a varied presentation."

Indeed, ALMs are often caught in a visit to the podiatrist, Mr. Bristow says.

"They are usually discovered accidentally by a podiatrist and thought to be a trauma that has occurred on the foot," Mr. Bristow says.

In many instances, Mr. Bristow says, the patients might have been to see several healthcare providers before receiving an accurate diagnosis of an ALM.