Long-term treatment of Equine Sarcoid in a mare

Elsa Kanner, St. George’s University 9 April 2014

Presented Feb 20, 2014- 19 year old female intact Warmblood - 13 years of treatment for severe sarcoids- Problem list: sarcoids

Importance of equine sarcoid for veterinarians

- Most common equine tumor- Accounts for over half of all equine skin tumors- No “one size fits all” treatment

http://balancedecosolutions.com/product/sarcoid-cleansing-salve

What are equine sarcoids?

-Locally invasive fibroblastic skin tumors -Arise between ages 3-6 -Common locations: head, ventral abdomen, limbs

Dr. Hackett “Cutaneous Neoplasia” lecture

Causes of equine sarcoid cont

-3 requirements for sarcoid formation: 1) Exposure to Bovine Papillomavirus 2) Genetic predisposition

3) Skin infection/open wounds

bovine papillomavirus in a cow

6 types of equine sarcoid

http://www.wetherbyvets.co.uk/info/Factsheets/Horse/24_269968.shtml

1) occult (flat) 2) verrucous (wart-like) 3) nodular

4) fibroblastic 5) mixed 6) malevolent

Differential diagnoses for equine sarcoid

http://info.mannapro.com/mannaproanimalcareblog/

equine papillomaviruspythiosishttp://veterinarynews.dvm360.com

-Infectious: - papilloma (viral) - pythiosis (fungal) - habronemiasis “summer sores” (parasitic) - staphylococcal folliculitis (bacterial)

Differential diagnoses for equine sarcoid

http://www.northfloridaequine.com/heel-bulb-laceration/

granulation tissue

-Inflammatory: -granulation tissue -granuloma

-Neoplastic: -squamous cell carcinoma (SCC) -fibroma/fibrosarcoma -cutaneous lymphoma -mast cell tumor (MCT) -melanoma

Diagnosis of equine sarcoid

-Presumptive diagnosis: - clinical presentation

-Definitive diagnosis: -histopathology -consider exacerbation by biopsy-induced trauma

Dr. Hackett “Cutaneous Neoplasia” lecture

H&E stained photomicrograph of an equine sarcoid

Back to our case report...

- Sarcoids started in 2001, at approx age 3 - Initial lesions were occult (flat) in 2 spots on left

flank - Seen by RDVM, no treatment at that time - During 2002 sarcoids became more aggressive

and patient was referred to CUHA

http://tailsfromprovence.com/2013/05/22/sarcoids-ugh/

Representative occult sarcoid, no pictures of our patient until 2009

Treatments and results

date treatment type exact treatment

2003-2007 Surgical removalCautery + SMZ’s to control

infection

2007-2009 Immunotherapy EqStim

June 2009 Immunotherapy Pythium

January 2010 Immunotherapy BCG

January - April 2010 Chemotherapy #1cyclophosphamide and

doxorubicin

April 2010 Surgical removal #1 surgical debulking

Treatments and results cont.

date treatment type exact treatment

May 2010 Chemotherapy #2 cyclophosphamide and vincristine

January 2011Surgical removal #2 +

immunotherapy surgical debulking + Xterra

November 2011 Surgical removal #3 surgical debulking

September 2012 Surgical removal #4 surgical debulking

July 2013Surgical removal #5 +

immunotherapy surgical debulking + autologous

implantation

February 2014Surgical removal #6 +

chemotherapy surgical debulking + intralesional

cisplatin & carboplatin

2007-2009: EqStim -Mechanism of action: Injections with P. Acnes to stimulate immune system

-Result: moderate control of tumors during this time period, but became ineffective and was discontinued

back

June 2009: Pythium immunotherapy

-Mechanism of action: Vaccinate with Pythium Insidiosum to stimulate immune system

-Result: worked for 3 months (June - September 2009), but became ineffective and was discontinued

backlesions in June

January 2010: BCG

-Mechanism of action of BCG (Bacille de Calmette et Guérin) : human TB vaccine used to stimulate immune system

- Results: ineffective, stopped after 1 month (February 2010)

FebruaryJanuary back

Jan – April 2010: First systemic chemotherapy

-Mechanism of action of chemotherapy: target tumor cells systemically with cyclophosphamide and doxorubicin

- Results: - Slight improvement in tumor surfaces, no reduction in size

back

http://www.indiamart.com/asterpharma/oncology-anti-cancer.html http://www.indiamart.com/asterpharma/oncology-anti-cancer.html

April 2010: first surgical debulking -Mechanism of action: remove necrotic tissue/large tumors for comfort of the patient

- Result: temporary reduction in tumor size

April before surgery April during surgery April post surgery

back

May 2010: Systemic chemotherapy #2 - Mechanism of action: target tumor cells systemically with cyclophosphamide and vincristine

- Result: tumors growing aggressively, protocol discontinued

May June

back

http://www.indiamart.com

www.hospira.com

January 2011: Xxterra + surgical debulking # 2

-Mechanism of action of Xxterra: Bloodroot powder + zinc chloride to stimulate the immune system locally at the tumor site

- Results of Xxterra: successful on small tumors, but painful, so discontinued

January pre surgery January during surgery back

July 2013: Autologous implantation -Mechanism of action: Pieces of sarcoid removed, frozen, and surgically re-implanted to stimulate immune system

- Result: temporary reduction in tumor size

back

http://liquidnitrogentank.com/CT20_Tank.php

liquid nitrogen tank to freeze pieces of sarcoid before implantation

February 2014: surgical debulking # 6 + first intralesional chemotherapy

-Mechanism of action of intralesional chemotherapy: target tumors more locally with Cisplatin and Carboplatin

- Result: temporary reduction in tumor size

February pre surgery February during surgery

next

http://www.indiamart.coml

Costs, prognosis, questions

-Current CUHA bill: > $14,000.00 - Prognosis: - Poor for resolution of lesions -Questions: -Quality of life?

Conclusions - Treatments did not work in our patient

- Related to her immune system?

- More research needed about this disease & treatments

http://www.ourdailyjourney.org

Resources 1- Larson, Erica. "Evidence-Based Equine Sarcoid Treatments Reviewed." The Horse 19 Apr. 2012: n. pag. Print.

2- Rohrbach, Barton W., VMD, MPH, DACVPM, et al. Effects of adjunctive treatment with intravenously administered Propionibacterium acnes on reproductive performance in mares with persistent endometritis. Journal of the American Veterinary Medical Association. Volume 231, Number 1, July 1 2007, pp. 107-13.

3- Mendoza, Alberto L., Robert L. Glass, and Richard D. Hansen. Pythium Immunotherapy. Board of Trustees, Michigan State University, assignee. Patent 12/647,971. 30 June 2011. Print.

4- United States. Centers for Disease Control and Prevention. Division of Tuberculosis Elimination. World Health Organization. Issues Relating to the Use of BCG in Immunization Programmes - A Discussion Document. N.p.: n.p., 1999. Print.

5 - Larson, Ken. "Xxterra." Larson Laboratories. Vetline, Inc., n.d. Web. 5 Apr. 2014.

6 - Espy, Benjamin M.K. "How to Treat Equine Sarcoids by Autologous Implantation." AAEP Proceedings 54 (2008): 68-73. Print.

7 - Taylor, S., and G. Haldorson. “A Review of Equine Sarcoid.” Equine Veterinary Education 25.4 (2013): 210-16. Print.

Acknowledgements Thank you to:

Dr. Richard Hackett Dr. Hayley Lang Students & faculty of Cornell University for being so welcoming to St. George’s and Ross students.

Questions?