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An Update on Sarcoids – Novel Intralesional Treatments
Hollis A.
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Introduction
Sarcoids continue to present a clinical challenge, and the vast number of potential treatments reflects that there is no one treatment suitable for every case. Tigilanol tiglate is licensed for the treatment of mast cell tumours in dogs, and intralesional tigilanol tiglate has been described for the treatment of a single sarcoid (and a squamous cell carcinoma) [1]. A relatively simple treatment to administer, it has a number of potential advantages over other intralesional treatments. It is described as a ‘tumour agnostic’ drug, making it potentially suitable for any tumour type, and its administration leads to an acute inflammatory response at the treatment site with immune cell recruitment and disruption of the tumour vasculature. Intralesional administration leads to the rapid onset of haemorrhagic necrosis of the tumour, subsequent sloughing of the lesion with full re-epithelialisation of the defect and a good functional outcome [1]. Compared with cisplatin and carboplatin, there are fewer concerns for the health and safety of those administering the drug and handling the horse after treatment, and its method of action should allow for successful treatment of any lesion with sufficient tumour bulk to facilitate accurate intralesional injection.
Materials and methods
Fourteen horses and 18 sarcoids received intralesional tigilanol tiglate for the treatment of sarcoids at Cambridge Equine Hospital, University of Cambridge. Of these, five sarcoids had received other treatments prior to referral, including radiotherapy, laser surgical resection, intralesional treatment (mitomycin C and cisplatin), and electrochemotherapy (with cisplatin). Intralesional tigilanol tiglate injections were administered according to the previously described protocol, using a carefully calculated dose per volume of the tumour to achieve the reported 35% v/v of tumour [1] but increasing the dose up to a maximum of 4 mg if required to achieve this v/v administration. Twelve horses were treated under routine standing sedation following the administration of mepivacaine to provide sufficient local anaesthesia. Two horses were treated under general anaesthesia to facilitate treatment due to the temperament of the horses and the location of the lesions (one lesion was located on the medial aspect of the right ear, and one was located on the palmar aspect of the right carpus, Figs 1 and 2). Total dose administered in one treatment ranged from 0.4 mg to 4 mg of tigilanol tiglate. All horses were maintained on i.v. flunixin meglumine for a minimum of 24 hours following treatment, and on oral flunixin meglumine or phenylbutazone for ongoing analgesia as required. Follow-up treatments were administered if the initial treatment did not lead to regression of the lesion. All owners agreed to long-term follow- up of the cases via WhatsApp photographic updates.
Results
Rapid onset of haemorrhagic necrosis was observed in all treated lesions (Fig 3). All horses were noted to be quiet for 24– 36 hours after treatment. All but one lesion developed significant local swelling and oedema, and three horses required i.v. dexamethasone to provide additional anti-inflammatory effects due to the magnitude of the associated swelling and discomfort. One lesion did not respond to a first treatment, and the owners declined further intervention. Five horses and six sarcoids received more than one treatment with tigilanol tiglate. Of these, five sarcoids had received various treatments prior to referral, and one was a naïve periocular lesion. Two horses developed local lymph node abscessation following treatment, both of which resolved with supportive care. One horse developed jugular vein thrombophlebitis (the treated lesion was distant to the jugular vein). One horse that underwent surgical resection before injecting tigilanol tiglate into the margins developed a very wide slough ventral to the lesion that required more significant wound care over a prolonged period, although healing was complete and a good functional outcome was achieved (Figs 4–6). One horse is still having ongoing treatment, but appears to be responding well to date. In those horses wherethe lesion resolved, a good functional and cosmetic outcome was achieved, even after multiple treatments (Figs 7 and 8). However, one lesion has recurred approximately 11 months after an apparently successful treatment.
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Affiliation of the authors at the time of publication
Department of Veterinary Medicine, University of Cambridge, Madingley Road, Cambridge CB3 0ES, UK
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