文章 APA Nicodème, M., Dureau, S., Chéron, M., Kriegel, I., Trenchand, M., Bauër, P.

, & Fromantin,
I. (2021). Frequency and Management of Hemorrhagic Malignant Wounds: A
Retrospective, Single-Center, Observational Study. Journal of Pain and Symptom
Management, 62(1), 134-140. https://doi.org/10.1016/j.jpainsymman.2020.11.031
內文 APA Nicodème et al., 2021
作者/年代 (Nicodème et al., 2021)
研究目的
研究方法
研究結果
整合
可以運用 01. The problem of malignant wounds bleeding is mainly described in the context of
的地方 palliative situations.1,2 The frequency of hemorrhagic episodes in these wounds is
poorly documented, with no precise description according to whether the bleeding is
minor or major. The evaluation of their impact on the physical and mental state and
the survival of patients already weakened by cancer is also poorly documented. The
quality of care is impaired by the lack of recommendations on what to do depending
on the type of bleeding.3, 4, 5 However, a large number of solutions are proposed in
the case of hemorrhages in acute wounds (traumatic, surgical) or chronic wounds
(bedsores, ulcers, diabetic foot wounds).6,7
02. 惡性傷口出血問題主要是在安寧療護的背景下描述的。1 , 2 這些傷口出血事件
的頻率記錄很少，沒有根據出血是輕微還是嚴重進行準確描述。對於它們對身
體和精神狀態以及已經因癌症而虛弱的患者的生存的影響的評估也鮮有記錄。
由於缺乏根據出血類型採取何種措施的建議，護理品質受到影響。3 , 4 , 5 然
而，對於急性傷口（外傷、手術）或慢性傷口（褥瘡、潰瘍、糖尿病足傷口）
出血的情況提出了大量的解決方案(Nicodème et al., 2021)。
03. Malignant wounds are secondary sites of primary cancers evolving as skin metastases
or ulcerated primary skin tumors, especially if there is a delay in their management.8
They are characterized by infiltration of the dermis (induration, orange peel,
erythema) or the appearance of subcutaneous nodules which evolve over a variable
period of time into skin ulcerations. The prevalence of tumor wounds, all locations
combined, is estimated to be between 5% and 10% depending on the studies.9, 10, 11
A study carried out in Switzerland in 2009 estimates the prevalence of tumor wounds
at 6.6% among people with metastatic cancer. The most frequent locations are the
breasts, the ear, nose and throat (ENT) sphere, the groin fold or the axillary hollow,
genital lesions, followed by the trunk or abdomen.11 They can develop in different
ways: externalize themselves to the skin like a fungus (so called “fungating wounds”),
spread superficially or dig and cause cavities, sometimes deep.1
04. 惡性傷口是原發性癌症發展為皮膚轉移或潰瘍性原發性皮膚腫瘤的繼發部位，
特別是如果治療延遲的話。8 它們的特徵是真皮浸潤（硬結、橘皮、紅斑）或出
現皮下結節，這些結節在不同的時間段內演變為皮膚潰瘍。根據研究，所有部
位腫瘤傷口的盛行率估計在 5% 到 10% 之間。9 , 10 , 11 2009 年在瑞士進行的
 一項研究估計，轉移性癌症患者中腫瘤傷口的盛行率為 6.6% 。最常見的部位
是乳房、耳鼻喉 (ENT) 球體、腹股溝皺襞或腋窩、生殖器病變，其次是軀幹或
腹部。11 它們可以以不同的方式發展：像真菌一樣外化到皮膚（所謂的「蕈狀
傷口」）、淺層擴散或挖掘並導致蛀牙，有時很深(Nicodème et al., 2021)。
05. Malignant wounds are a direct result of the oncogenic process. Their evolution does
not depend on care, but on this oncogenic process, on anticancer treatments delivered
and on the patient's response to these treatments. Care therefore aims to control the
symptom issues linked to the wound (e.g. flows, odors), to prevent risks
(haemorrhagic, infectious) or more rarely, to accompany the healing process if
possible.12,13
06. 惡性傷口是致癌過程的直接結果。它們的演化並不取決於護理，而是取決於致
癌過程、抗癌治療以及患者對這些治療的反應。因此，護理的目的是控制與傷
口相關的症狀問題（例如流血、氣味），預防風險（出血、感染），或更罕見
的是，如果可能的話，伴隨癒合過程(Nicodème et al., 2021)。
07. When it grows, the tumor is highly vascularized because of neoangiogenesis. This
blood circulation within the tumor mass is anarchic, as is the development of the
tumor itself. As a result, the tumor tissue that makes up the wound is friable and can
bleed easily, which differentiates it from other chronic wounds. In addition, the mass
can invade and damage vessels or exert enough pressure to rupture them. But the risk
of bleeding can also be increased by the general evolution of the disease. Hepatic
damage can lead to hepatocellular failure, resulting in a clotting factor deficiency that
increases the risk of bleeding. Acute or chronic renal failure can lead to a disorder of
platelet function. Tumor infiltration into the bone marrow may increase the risk of
thrombocytopenia. Procoagulant activity in solid tumors may increase fibrinolysis and
lead to clotting disorders. Similarly, disseminated intravascular coagulation, which is
associated with certain solid tumors, can cause hemorrhage through consumption of
platelets and clotting factors.14
08. 當腫瘤生長時，由於新血管生成，腫瘤高度血管化。腫瘤塊內的血液循環是無
政府狀態的，腫瘤本身的發展也是。因此，構成傷口的腫瘤組織很脆弱，容易
流血，這與其他慢性傷口不同。此外，腫塊可能會侵入並損傷血管或施加足夠
的壓力使其破裂。但出血風險也會因疾病的整體演變而增加。肝損傷可導致肝
細胞衰竭，導致凝血因子缺乏，增加出血風險。急性或慢性腎衰竭可導致血小
板功能失調。腫瘤浸潤骨髓可能會增加血小板減少症的風險。實體瘤中的促凝
血活性可能會增加纖維蛋白溶解並導致凝血障礙。同樣，與某些實體腫瘤相關
的瀰漫性血管內凝血可透過消耗血小板和凝血因子而導致出血(Nicodème et al.,
2021)。
09. These wounds are often described as complex to manage because of the symptom
issues they induce and their impact on the patient's general condition and quality of
life. A study conducted in Canada in 2005 - 2006 on 472 patients in the palliative
phase reported that 67 patients had malignant wounds, including the presence of
nodules and induration in 33% of cases.15 In this study, the consequences related to
 the presence of these lesions most frequently found were pain (31%), mass effect
(24%), esthetic impact (19%), exudate (17.9%), odor (11.9%), pruritus (6%), bleeding
(6%), and crusting (1.5%).15 These results are consistent with other observations in
smaller patient cohorts. Nevertheless, when wounds are ulcerated (excluding nodules
or skin indurations), odors and bleeding are more frequently reported symptoms.16,17
Not all of these symptom issues are present at the same time and bleeding is not the
most frequent event.
10. 這些傷口通常被描述為難以處理，因為它們會引起症狀問題及其對患者一般狀
況和生活品質的影響。2005 年至 2006 年在加拿大對 472 名安寧療護患者進行的
一項研究報告稱，67 名患者有惡性傷口，其中 33%的病例存在結節和硬結。15
在這項研究中，最常見的與這些病變存在相關的後果是疼痛(31%)、腫塊效應
(24%)、美觀影響(19%)、滲出物(17.9%)、氣味(11.9% )、搔癢（6%）、出血
（6%）和結痂（1.5%）。15 這些結果與較小患者群體中的其他觀察結果一致。
然而，當傷口潰爛時（不包括結節或皮膚硬結），氣味和出血是更常見的症
狀。16 , 17 並非所有這些症狀問題都會同時出現，出血也不是最常見的事件
(Nicodème et al., 2021)。
11. This relatively low frequency of bleeding on a wound with a low prevalence
(compared to other chronic wounds) may explain the lack of data on the hemorrhagic
malignant wound, in addition to the difficulty to conduct prospective clinical trials in
patients in palliative or terminal phase of cancer.
12. 發病率低的傷口（與其他慢性傷口相比）出血頻率相對較低，可能解釋了出血
性惡性傷口數據的缺乏，以及在姑息或終末期臨床試驗患者中(Nicodème et al.,
2021)。
13. In 2009, Alexander S published a review of the literature on malignant fungating
wounds, covering the period 1990-2009. It concludes that people with this type of
wound have a poor prognosis and a reduced life expectancy (<6 months).11 However,
the author underlines that with the progress of treatments and the increase of cancer
patients’ life expectancy, the proportion of patients with a malignant wound can only
increase.
14. 2009 年，Alexander S 發表了一篇關於惡性蕈狀傷口的文獻綜述，涵蓋 1990-
2009 年期間。結論是，患有此類傷口的人預後較差，預期壽命較短（<6 個
月）。11 然而，作者強調，隨著治療的進步和癌症患者預期壽命的延長，惡性
傷口患者的比例只會增加(Nicodème et al., 2021)。
15. The impact of bleeding associated with malignant wounds on the patient's general
condition and anxiety seems to call for more attention to be paid to them to progress
toward the formulation of hypotheses and effective procedures.
16. 惡性傷口相關的出血對患者一般狀況和焦慮的影響似乎需要更多的關注，以製
定假設和有效的程序(Nicodème et al., 2021)。