Article Title: Pressure Injury Progression and Factors Associated With Different End-Points in a Home Palliative Care Setting: A Retrospective Chart Review Study
Authors: Artico M, D’Angelo D, Piredda M, et al
Journal: J Pain Symptom...
By Ron Sherman MD, MSC, DTM&H
This week I was asked about using maggot therapy for treating a tumor that eroded through the skin, causing a foul-smelling, necrotic draining wound. This is not an uncommon question, and it touches upon several important elements of biotherapy, as well as palliative wound care in general. This is also a timely subject because of the upcoming (third) Annual Palliative Wound Care Conference.
Let’s first explore the approach to this clinical situation. Then we will look at the data concerning maggot therapy for necrotic tumors.
Good palliative wound care – like good health care in general – begins with addressing our patients’ needs and desires (acknowledging, though, that their needs do not necessarily match their desires). Next, we must put our own goals for the patient into perspective. Finally, we integrate the two sets of objectives, and prioritize.
For palliative wound care, the priorities are often: debridement, pain control, drainage and odor control, infection control, and anxiety control. Safety, simplicity, and cost-containment are often additional considerations. Complete wound healing (or, in this case, cure of cancer) may be desirable, but nevertheless designated as “low priority” if unlikely to be achieved. Still, wound healing does not have to be left off the palliative wound care list of objectives entirely. Indeed, good wound care – with debridement, control of drainage and infection, and pressure relief – often lead to improved healing . . . especially when co-factors such as nutrition and anemia are also optimized.
So what are appropriate goals for the patient referred to me, and how can maggot therapy fit into the picture? The objective for this patient was pain, odor and drainage control, through debridement of the necrotic tumor and soft tissue. Tumors themselves are living, but when they outgrow the local blood supply, they may become ischemic and die. Additionally, as they grow they may erode into the skin or subcutaneous tissue, causing necrosis of the normal soft tissue, as in this case. Maggot debridement works by dissolving only dead tissue, not living tissue, so it will dissolve and debride the necrotic tissue but not the healthy skin nor the viable tumor cells. In other words, maggot debridement therapy (MDT) is not a cancer cure; it is only for management of necrotic tumors and wounds.
There are no published controlled clinical trials of maggot therapy for necrotic tumor or palliative wound care; but there are several insightful case reports and case series that specifically address this (2-6). Additionally, there are many published studies outside the strict definition of palliative wound care which, nevertheless, describe the efficacy of maggot therapy for attaining the same goals that we have in our palliative wound care patients: debridement, infection control, pain, odor and drainage control, etc. They are too numerous to discuss here . . . it should be the topic of a full-length review. Let it suffice to say that MDT should definitely be a consideration not only for limb salvage and debridement of problematic wounds, but also for the symptomatic relief of painful, draining, foul-smelling wounds, whether or not the patient is in hospice. MDT is simple, inexpensive and safe enough that it should not be withheld for any reason unless more effective alternatives are available, contraindications are present, or the patient declines therapy.
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Sherman RA, Shapiro CE, Yang RM. Maggot therapy for problematic wounds: uncommon and off-label applications. Adv Skin Wound Care. 2007; 20:602-10.
Armstrong DG, Salas P, Short B, Martin BR, Kimbriel HR, Nixon BP, Boulton AJ. Maggot therapy in "lower-extremity hospice" wound care: fewer amputations and more antibiotic-free days. J Am Podiatr Med Assoc. 2005; 95:254-7.
Steenvoorde P, van Doorn LP, Jacobi CE, Oskam J. Maggot debridement therapy in the palliative setting. Am J Hosp Palliat Care. 2007;24:308-10.
Jones M, Andrews A, Thomas S. A case history describing the use of sterile larvae in a malignant wound. World Wide Wounds: the Electronic Journal of Wound Management Practice. 1998. Available at: http://www.worldwidewounds.com/1998/february/Larvae-Case-Study-Malignant.... Last accessed: September 1, 2011.
Nordström A, Hansson C, Karlström L. Larval therapy as a palliative treatment for severe arterioscleortic gangrene. Clin Exp Dermatol. 2009; 34:e683-5.
Armstrong DG. Palliative Advanced Wound Care. Vein Industry News. 2009;2. Available at: http://www.veindirectory.org/magazine/article/palliative_advanced_wound_.... Last accessed September 1, 2011.
About The Author
Ron Sherman MD, MSC, DTM&H has led a long career at the forefront of biotherapy, pioneering the development of medicinal maggots for over 25 years. He is now retired from his faculty position at the University of California, but continues to volunteer as Director and Board Chair of the BTER Foundation, and as Laboratory Director of Monarch Labs.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.