High-Frequency Generator in Wound Healing of Marjolin's Ulcer After Carcinoma Resection

High-Frequency Generator in Wound Healing of Marjolin’s Ulcer After Carcinoma Resection Pascale Mutti Tacani,1,* Rogério Eduardo Tacani,2 Aline Fernanda Perez Machado,3 Débora Montezello,4 João Carlos Guedes Sampaio Góes,5 Angela Gonçalves Marx,6 and Richard Eloin Liebano7 1 Physical Therapy Department, Brazilian Institute of Cancer Control (IBCC), Sao Paulo, Brazil. Physical Therapy Department, São Camilo University Centre, Sao Paulo, Brazil. Physical Therapy Department, Paulista University (UNIP), Sao Paulo, Brazil. 4 Nurse and 5Medicine Departments, Brazilian Institute of Cancer Control (IBCC), Sao Paulo, Brazil. 6 Physical Therapy Department, Angela Marx Clinic, Sao Paulo, Brazil. 7 Physical Therapy Department, Federal University of Sao Carlos (UFSCAR), Sao Paulo, Brazil. This work was presented at II Brazilian Conference of Physiotherapy in Oncology, June 2011, Goiania, Brazil. 2 3 Marjolin’s ulcers (MU) are skin malignancies that form over burn injuries. These very aggressive ulcers can result in functional and wound healing impairment, and require a well thought out treatment plan. Physiotherapy offers resources to help promote recovery of these patients, as described in this case report, in which the patient with a history of burn in the lower limbs evolved to malignancy 32 years later. This patient underwent tumor resection of the left foot, with recurrence and lymphadenectomy. Physical therapy included the application of high-frequency generator (HFG) for wound healing and exercises for functional recovery. The treatment lasted for many months and resulted in the improvement of the surgical wound areas, pain, swelling, sensitivity, strength muscle, and gait. It was observed that the use of HFG can be a tool in the tissue repair of surgical wound after the resection of MU; however, further studies need to be carried out to suit parameters and ensure safety of cancer patients. Pascale Mutti Tacani, MSc Submitted for publication July 21, 2017. Accepted in revised form October 29, 2017. *Correspondence: Physical Therapy Department, Brazilian Institute of Cancer Control (IBCC), Alcantara Machado Avenue, 2576. Mooca, Sao Paulo, SP 03102-002, Brazil (e-mail: pascale.tacani@hotmail.com). Keywords: skin ulcer, physical therapy modalities, carcinoma, squamous cell, wound healing, burns, lower extremity INTRODUCTION Marjolin’s ulcer (MU) is a rare and often aggressive pathology in which skin ulceration and malignancy occur in regions chronically inflamed, scarred, or traumatized.1,2 The previous burn scars represent 76% of the patients whose condition evolve to squamous cell carcinoma (SCC) in 71% of cases, usually in the fifth decade of life. The lower extremities present higher incidence of SCC (41%) and the treatment becomes a challenge due to the greater aggressive- ADVANCES IN WOUND CARE, VOLUME 7, NUMBER 5 Copyright ª 2018 by Mary Ann Liebert, Inc. ness of carcinoma and high recurrence of metastases (35%). Generally, there is a need for wide local excisions, skin grafting or flaps in wound closure, and eventually, chemoradiotherapy.1,2 These may bring consequences to cancer patients, leading to problems of scarring, functional alterations, pain, lymphedema, impairment in occupational activities, and poor quality of life, which may require physiotherapy to complement their recovery.1,3 There is poor investigation on follow-up and the conditions under DOI: 10.1089/wound.2017.0757 j 165 TACANI ET AL. 166 which the patients survives after the control of MU, especially because they may have delayed wound healing, infection, necrosis, pain, and functional impairment.1 The use of physical agents can improve wound healing4 and skin transplants viability5 and it has been growing as a complementary method to topical and medication agents to treat some complicated wounds.6 The High-Frequency Generator (HFG) operates on alternating current of high frequency (1.000– 200.000 Hz), low intensity (60–100 mA) with a tension between 6 and 40 kV depends on the body resistance (about 10.000 Ohms). The passage of the current through the glass electrode, which has rarefied air or neon gas inside, promotes the ionization of these gas molecules, represented by sparking effects and then, produces ozone around the area. The ozone produced is very instable and during the application of the HFG over the skin surface, this molecule easily decomposes in oxygen (O2) and atomic oxygen (O). The formation of these atomic oxygen molecules influences the biochemical events of cellular metabolism and promotes antimicrobial, bactericide and fungicide effects.4,6,7 These properties accelerate the tissue repair and can control the infection process as showed by some experimental4,7 and clinical studies6,8 described on Table 1. CLINICAL PROBLEM ADDRESSED The main effects of the physical agents are that they can stimulate cellular metabolism, cellular growth, and angiogenesis,4–7 but there is no consensus if they can stimulate tumor growth in humans, as well.3,5,9 However, several benefits have been showed to cancer patients, as reduction of pain, mucositis, necrosis, hematoma, and lymphedema.3,5,9 To the best our knowledge, there is no information about the treatment of chronic wound by HFG after MU resection. Therefore, the objective of this article is to present a case report of a man who developed a complicated wound after MU resection and which was treated by HFG. CASE PRESENTATION This case presentation was approved by Ethics Committee of Brazilian Institute of Cancer Control (IBCC) and, the patient authorized the use of his data and images through an informed consent. A 59 years-old male patient, swarthy, incomplete basic education level, worked as a watchman, smoker, sedentary, body mass index of 24.66 kg/m2, hypertensive, and Hepatitis C. He suffered second and third degree steam burns in the lower limb extremities in 1975 at age of 25, and a skin graft was performed on left foot. In 2007, 32 years later, he presented a SCC on left foot diagnosed as MU. In October 2008, a resection was performed followed by a reconstruction of flexor digitorum longus muscle, subcutaneous cell tissue, and skin using a myocutaneous flap. In December 2008, a new and wide excision followed by skin graft was performed due to tumor recurrence. It evolved to necrosis, Table 1. Experimental and clinical investigations about high frequency/ozone effects Authors Study Type 4 Sousa et al. Experimental In vivo Mice male Excisional wounds Objective Description Outcomes HFG was less effective than laser but 04 groups (n = 10 each one) better than control; improves G1 Control angiogenesis and fibroblast G2 HFG proliferation at earlier phases of G3 Laser 5 J/cm2 G4 Laser 8 J/cm2 wound healing. Ozone reduced the total of Experimental group (n = 35 teeth). To evaluate in vitro the antimicrobial Prebeg et al.7 Experimental In vitro microorganisms 89.3%; S. aureus Control groups: Positive/Negative efficacy of ozone delivered to infected 94.0%; S. epidermidis 88.6%; control (n = 5 teeth each one). Ozone Human tooth root root canals of extracted teeth by E. faecalis 79.7%. Ozone was more was applied by special KP syringe of Enterococcus faecalis, special KP syringe of Ozonytron—a effective than NaOCl for both high frequency ozone generator. Staphyloccocus aureus, high frequency ozone generator Staphyloccocus, but less effective for Staphyloccocus epidermidis E. faecalis. Korelo et al.6 Clinical Prospective To explore the application of HFG in the Patients n = 8, 49.6 mean age; Pressure The HFG/Ozone improved wound healing by the tools used: PUSH Tool p = 0.04, ulcer Grade II/III treatment of pain, scarring, and Pilot study Patients with PSST p = 0.02, Planimetry and ImageJ Control n = 2 surface areas of pressure ulcers Pressure Ulcer p = 0.02 HFG group n = 6 10 consecutive days Tacani et al.8 Clinical Retrospective To analyze the prevalence of surgical Total evaluated 123 patients (medical Five patients with seven dehiscence Patients with postoperative wound dehiscence and their reports) were treated with HFG two times a dehiscence respective physical therapy treatment 44.6 Mean age week in the plastic surgery postoperative 93.5% Woman 7–19 sessions until complete wound period. healing 9.8% Presented dehiscence (n = 12) To evaluate in a macroscopic, histological and histomorphometric manner the healing process of cutaneous wounds in mice HFG, High-Frequency Generator; NaOCl, sodium hypochlorite; PSST, Pressure Score Status Tool; PUSH, Pressure Ulcer Scale for Healing. HIGH-FREQUENCY GENERATOR IN WOUND HEALING resulting in a surgical debridement and the postoperative wound remained opened. In February 2009, he was submitted to lymphadenectomy, due to metastasis, of the paraaortic, iliac, inguinal, and obturator foramen lymph nodes with myocutaneous flap reconstruction of the tensor fasciae latae and it followed well. After 1 year being treated once a week by wound care, the nurse team referred him to the physiotherapy in February 2010, when he was evaluated for first time. He presented five surgical wounds in the medial region of the left foot and ankle, which were measured with transparent thin film adhesives and sterile and then traced for digitization and area calculation using the ImageJÒ software (Fig. 1). Four of the wounds were oval <10 cm2 in area and deeper than the fifth wound that was 40 cm2 in area and uniformly shallow. All of them presented pink color, pale, with a little quantity of fibrin around the borders, and there was no odor, secretion, or infection signs, neither necrosis. Around the wounds following was observed: dry skin and depigmented hypochromic stains; moderate edema with no pitting; estimate volume of lower limb (Disc Method): right side = 2,831.44 mL 167 and left = 2,970.70 mL; anesthesia (tactile and thermal); hypoesthesia (pain) in lumbar vertebrae 5/sacral vertebrae 1 (L5/S1) showed by magenta monofilament of 300 gf (Semmes Weinstein Monofilaments); pain score 9 VAS (Visual Analog Scale); deficit of muscular strength for flexion and extension of hallucis; abduction; thigh flexion (grade 3); and dorsiflexion (grade 4) in the left side, limping gait compensated by the quadratus lumborum muscle. The treatment consisted of the application of the HFG—SkinnerÒ with a frequency of 1,700 Hz, tension of 8 kV in the air and 100% of amplitude (80 mA of maximal intensity). A sparking technique with a saturated electrode was used for 10 min in the larger wound and for 5 min in the other four smaller wounds, two times a week, as seen in Supplementary Video S1 (Supplementary Data are available online at www.liebertpub.com/ wound). After the HFG, a simple dressing with oil-based essential fatty acids (DersaniÒ) was applied by a nurse. Following, the patient was instructed to perform resistance exercises with the left lower limb and gait training. A total of 48 sessions were held in 2010 and improvement was observed in the edema volume (left = 2,863.46 mL), sensitivity (orange monofilament of 10 gf), pain (VAS score 0), muscle strength (grade 4 and 5), gait (reduced compensation), and in the wounds. All of them were more colored, without fibrin, with a good aspect and the wounds 4 and 5 closed. The treatment continued in 2011 with 36 sessions, when the wound 2 closed, the wound 3 reduced and divided itself in two, the wound 1 reduced a little more and all of them maintained good aspects without complications. In 2012–2013, 32 sessions were carried out (only 16 per year) and the wound 3 almost closed in 2012, but in 2013 grew up again, as the wound 1, that grew up in 2012 and reduced again in 2013. The percentage reduction in wound area (cm2) is shown in Table 2 and Fig. 2. Table 2. Reduction in the wound area during treatment expressed as percentage (%), year and general mean Reduction (%) Wound Figure 1. Tracing of the wounds for digitization and measurement using the ImageJÒ software. 1 2 3 4 5 Mean per year General mean 2010 -41.60 -82.75 -45.90 -100 -100 -74.05 -84.0277 2011 2012 2013 -57.64 -100 -71.20 -100 -100 -85.77 -59.91 -100 -87.39 -100 -100 -89.46 -66.51 -100 -67.61 -100 -100 -86.82 Figure 2. Evolution of the wound areas during the treatment. Wound 5 closed in August 2010; wound 4 in November 2010; and wound 2 in December 2011. Figure 3. Images show the wounds in (a) August 2011, (b) December 2011, (c) June 2012, (d) December 2012, (e) April 2013, and (f) December 2013. 168 j HIGH-FREQUENCY GENERATOR IN WOUND HEALING The images were obtained only from August 2011, when wounds 4 and 5 had already closed. The conditions of skin and wounds are illustrated in Fig. 3. In December 2013, the patient was discharged from physiotherapy and was referred to being assisted by a wound care team in a public health service near his home. Until this time (December 2013), there was no sign of tumor recurrence or infection. 169 KEY FINDINGS  HFG contributes for the healing process of chronic wounds.  A long-term treatment was required and best results were found during the first 18 months.  It is necessary to know more about the HFG on tissues harboring tumor, but in the case presented there was neither tumor recurrence nor infections. DISCUSSION MU represents a great challenge due to the impact caused by the complications in postoperative scarring, as described in the case presented. Moreover, a chronic wound may be evolved to recurrence, because of its association with MU.1,2 With these characteristics wound management is hard and may require more resources such as physiotherapy to manage the patient and wound.6 HFG uses ozone as mechanism of action, which has germicide, bactericide, and antiseptic properties by stimulating the oxygen metabolism and activating the immune system.4,6–8 These effects were considered on the choice of a safe physical agent to apply over the wounds that once already had cancer,7,9 and furthermore, it helped in tissue repair, wound closure/reduction, and prevention of infections.4,6–8 The case report presented had percentage of reduction about 84% considering all wounds, 68% to wound 3 and 56.41% to wound 1, which was similar to Korelo et al.6 with 68.27%, but in our case a longterm treatment was necessary. This was probably because our patient had a chronic wound even more complicated by previous burn, surgeries, scar tissue, and lymphostatic fibrosis, hindering the development of an appropriate wound healing cascade. Moreover, the best results were seen during the first 18 months of treatment corroborating with Sousa et al.4 who observed better effects of HFG in all phases of tissue repair when compared to the control group, and only in the initial phase when compared with low-level laser therapy (LLLT). Maybe it would be interesting to apply the HFG during the initial steps of wound healing and then LLLT, but the use of HFG was preferred to avoid tumor growth, as shown with LLLT in the literature.9 HFG can be used as a promise tool in the tissue repair of surgical wound after MU resection. However, further studies need to be carried out as a double blind randomized controlled trials, using a sham treatment with identical supporting physical therapy and associated treatments, to determine HFG effects and dose response to improve the outcome. INNOVATION HFG contributes on the tissue repair with reductions between 40% and 100% of chronic wounds after MU resection. ACKNOWLEDGMENTS AND FUNDING SOURCES The authors would like to acknowledge the nurses and physiotherapy students who worked with them on IBCC between 2010 and 2013. All authors declare that there were no funding sources for this study and they approved the final article. AUTHOR DISCLOSURE AND GHOSTWRITING The content of this article was expressly written by the authors listed. No ghostwriters were used to write this article. ABOUT THE AUTHORS Pascale Mutti Tacani, MSc, is a physiotherapist and Coordinator of the First Postgraduate International Program of Physiotherapy in Oncology in Mexico. Rogério Eduardo Tacani, MS, is a physiotherapist and Coordinator of the Postgraduate Program of Dermato-functional Physiotherapy in Sao Paulo, Brazil. Aline Fernanda Perez Machado, MSc, is a physiotherapist and specializes in Plastic Surgery. She is a doctoral student and is a professor at Paulista University, Sao Paulo, Brazil. Debora Montezello, MBE, is a nurse specializing in Hospital Administration and is Professor of the Sao Camilo University Center. João Carlos Guedes Sampaio Góes, PhD, is a plastic surgeon and Director of IBCC and Sampaio Góes Clinic, both in Sao Paulo, Brazil. Angela Gonçalves Marx, PhD, is a physiotherapist and specializes in Oncology. She is Director of Angela Marx Clinic in Sao Paulo, Brazil, and creator of the LinfoterapiaÒ Method. Richard Eloin Liebano, PhD, is a physiotherapist and PostDoctoral fellow in Physiotherapy and Rehabilitation Science at the University of Iowa and Professor of the Postgraduate Program in Physiotherapy of the Sao Carlos Federal University in Sao Paulo, Brazil. 170 TACANI ET AL. REFERENCES 1. Copcu E. Marjolin’s ulcer: a preventable complication of burns? Plast Reconstr Surg 2009;124:156e– 164e. 2. Elkins-Williams ST, Marston WA, Hultman CS. Management of the chronic burn wound. Clin Plast Surg 2017;44:679–687. 3. Tacani RE, Machado AFP, Goes JCGS, Marx AG, Franceschini JP, Tacani PM. Physiotherapy on the complications of head and neck cancer: retrospective study. Int J Head Neck Surg 2014;5:112–118. 4. Sousa RC, Maia Filho AL, Nicolau RA, Mendes LM, Barros TL, Neves SM. Action of AlGaInP laser and high frequency generator in cutaneous wound healing. A comparative study. Acta Cir Bras 2015; 30:791–798. 5. Atalay C, Yilmaz KB. 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Abbreviations and Acronyms HFG IBCC LLLT MU SCC VAS ¼ ¼ ¼ ¼ ¼ ¼ high-frequency generator Brazilian Institute of Cancer Control; low-level laser therapy Marjolin’s ulcer squamous cell carcinoma visual analog scale