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Long-term treatment of Equine Sarcoid in a mare Elsa Kanner, St. George’s University 9 April 2014
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Presented Feb 20, 2014 - 19 year old female intact Warmblood - 13 years of treatment for severe sarcoids - Problem list: sarcoids
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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
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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
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Causes of equine sarcoid -Aetiology: Bovine papillomavirus (BPV) types 1 & 2 -Interesting tumor: -Only known cross-species papillomavirus infection -Infection with BPV alone not enough to cause tumor http://calfology.com/library/wiki/wartsahttp://calfology.com/library/wiki/wartsand-papillomas bovine papillomavirus in a cow
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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
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6 types of equine sarcoid http://www.wetherbyvets.co.uk/info/ Factsheets/Horse/24_269968.shtmhttp://www.wetherbyvets.co.uk/info/ Factsheets/Horse/24_269968.shtml 1) occult (flat)2) verrucous (wart-like)3) nodular 4) fibroblastic5) mixed 6) malevolent
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Differential diagnoses for equine sarcoid http://info.mannapro.com/mannaproanimalcareblog/ equine papillomavirus pythiosis http://veterinarynews.dvm360.com -Infectious: - papilloma (viral) - pythiosis (fungal) - habronemiasis “summer sores” (parasitic) - staphylococcal folliculitis (bacterial)
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Differential diagnoses for equine sarcoid http://www.northfloridaequine.com/heel -bulb-laceration/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
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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
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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
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History of our patient cont - Referred to CUHA in 2003, treatments managed by RDVM: -2003 - 2007 -Cautery : effective for short periods, sarcoids regrew. -SMZ started to control skin infections. Continued to present. -2007 - 2009 -Equi-salve : to soothe skin -Eq-stim: every 1-2 weeks or EOD for 3 treatments : immunostimulant
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Common treatments for equine sarcoid -Surgical removal -Laser removal -Cryotherapy -Intratumoral Hyperthermia -Radiotherapy: ionizing radiation to kill neoplastic cells -Chemotherapy: Cisplatin injections/beads -Immunotherapy: -Topical Acyclovir - Topical Immiquimod “Aldara” -Topical Bloodroot extract “Xxterra”, “Sarc-off” -Bacillus Callmette-Guerin (BCG) Injection -Autogenous Vaccines and Sarcoid Implantation -Vaccination w/chimeric virus-like particles
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Common treatments for equine sarcoid, highlighted those attempted in our patient -Surgical removal -Laser removal -Cryotherapy -Intratumoral Hyperthermia -Radiotherapy: ionizing radiation to kill neoplastic cells -Chemotherapy: Cisplatin injections/beads -Immunotherapy: -Topical Acyclovir - Topical Immiquimod “Aldara” -Topical Bloodroot extract “Xxterra”, “Sarc-off” -Bacillus Callmette-Guerin (BCG) Injection -EquiStim -Autogenous Vaccines and Sarcoid Implantation -Vaccination w/chimeric virus-like particles
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Common treatments for equine sarcoid, highlighted those attempted in our patient -Surgical removal -Laser removal -Cryotherapy -Intratumoral Hyperthermia -Radiotherapy: ionizing radiation to kill neoplastic cells -Chemotherapy: Cisplatin injections/beads -Immunotherapy: -Topical Acyclovir - Topical Immiquimod “Aldara” -Topical Bloodroot extract “Xxterra”, “Sarc-off” -Bacillus Callmette-Guerin (BCG) Injection -EquiStim -Autogenous Vaccines and Sarcoid Implantation -Vaccination w/chimeric virus-like particles
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Treatments and results datetreatment typeexact treatment 2003-2007Surgical removalCautery + SMZ’s to control infection 2007-2009ImmunotherapyEqStim June 2009ImmunotherapyPythium January 2010ImmunotherapyBCG January - April 2010Chemotherapy #1cyclophosphamide and doxorubicin April 2010Surgical removal #1surgical debulking
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Treatments and results cont. datetreatment typeexact treatment May 2010Chemotherapy #2cyclophosphamide and vincristine January 2011Surgical removal #2 + immunotherapysurgical debulking + Xterra November 2011Surgical removal #3surgical debulking September 2012Surgical removal #4surgical debulking July 2013Surgical removal #5 + immunotherapy surgical debulking + autologous implantation February 2014Surgical removal #6 + chemotherapy surgical debulking + intralesional cisplatin & carboplatin
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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
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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 back lesions in June
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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
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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.htmhttp://www.indiamart.com/asterpharma /oncology-anti-cancer.html http://www.indiamart.com/asterpharma /oncology-anti-cancer.htmhttp://www.indiamart.com/asterpharma /oncology-anti-cancer.html
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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 surgeryApril post surgery back
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May 2010: Systemic chemotherapy #2 - Mechanism of action: target tumor cells systemically with cyclophosphamide and vincristine - Result: tumors growing aggressively, protocol discontinued MayJune back http://www.indiamart.com www.hospira.com
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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 surgeryJanuary during surgery back
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September 2012: Surgical debulking # 4 - Result: temporary reduction in tumor size September pre surgerySeptember during surgery back
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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
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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 surgeryFebruary during surgery next http://www.indiamart.coml
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Costs, prognosis, questions -Current CUHA bill: > $14,000.00 - Prognosis: - Poor for resolution of lesions -Questions: -Quality of life?
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Conclusions - Treatments did not work in our patient - Related to her immune system? - More research needed about this disease & treatments http://www.ourdailyjourney.org
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Lessons learned - No current therapies for sarcoids that are this severe. - Research ongoing - still looking for a breakthrough in this disease. - Extraordinary client & patient
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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.
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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.
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