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3 March 2002
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CE Article #5 (1.5 contact hours)
Refereed Peer Review
Common Equine
Skin Tumors
KEY FACTS
Mississippi State University
■ Small equine sarcoids should be Jenny M. Foy, DVM
monitored carefully; larger Ann M. Rashmir-Raven, DVM, MS, DACVS
tumors and those undergoing Michael K. Brashier, DVM, MS, DACVIM
morphologic changes should be
treated aggressively.
ABSTRACT: Sarcoids, squamous cell carcinomas (SCCs), and melanomas are three of the
most common dermal neoplasms that occur in horses. Sarcoids are the most common and
■ Squamous cell carcinomas can frequently affect the legs, ventral trunk, and head. They are believed to be the result of infec-
be locally invasive and tion with bovine papillomavirus or a similar agent. SCCs are the second most common equine
metastatic. skin tumor and commonly affect the eye, adnexa, and external genitalia. Ultraviolet radiation
contributes to the occurrence of this tumor, affecting nonpigmented, hairless areas of the
■ Melanomas should be carefully body and predominantly occurring in paints, Appaloosas, and albinos. Equine melanomas are
monitored even though they are the most common skin tumor in horses with a white or gray coat. They are believed to be the
slow-growing and nonmetastatic. result of abnormalities in melanin metabolism. Many equine skin tumors respond to appropri-
ate therapy, which may include surgical debridement or excision coupled with the use of select
chemotherapeutic agents, immunostimulants, radiation, brachytherapy, and cryotherapy. Early
recognition and treatment will produce the most satisfactory outcome.
D
ermal neoplasms are the most common equine tumors, of which sar-
coids, melanomas, and squamous cell carcinomas (SCCs) are the most
common. The causes of cellular transformation are multifactorial (e.g.,
viral infections, trauma, inflammation, ultraviolet radiation). Sarcoids are the
most common of the three tumors. They are nonmetastatic but frequently recur
locally. They occasionally undergo locally aggressive growth that can make it
hard to differentiate them from SCC, proliferative granulation tissue, cutaneous
habronemiasis, and other conditions. SCC is the second most common tumor,
generally occurring on nonpigmented areas of the skin and mucous membranes.
Metastasis can occur, making early diagnosis important. Melanomas occur most
commonly in gray-coated horses. Although they are usually benign, malignant
transformation can occur. With early diagnosis and treatment, equine skin
tumors can often be treated or managed successfully.
SARCOID
Sarcoids are the most common skin tumors in horses. They are locally inva-
sive, nonmetastatic, fibroblastic tumors composed mainly of connective tissue.
Sarcoids rarely regress spontaneously.1–3 These tumors usually affect horses 1 to 6
years of age, although they have been reported in horses older than 15 years of
age. Sarcoids can occur on any part of the body, either singly or in clusters. The
ventral abdomen, limbs, and head, especially around the eyes, pinnae, and com-
Compendium March 2002 Equine Skin Tumors 243
Clinical Presentation
missures of the lips, are most commonly affected. In Sarcoid tumors generally appear with linear or focal
northern climates, lesions occur predominantly on the dermal thickening that has a pale color and a firm tex-
head and abdomen. In warmer climates, the limbs are ture due to fibroblastic proliferation and the small num-
more often involved. 1–3 Lesions frequently occur in ber of capillaries within the tumor. The epidermis varies
traumatized areas.1,2 Sarcoids may be related to scar tis- from thick, rough, and hyperkeratotic to ulcerated.3,9
sue and the rapidly dividing cells that heal the wound.4 Sarcoid tumors can also occur in the subcutaneous tis-
Although the etiology of equine sarcoid tumors has sue as firm, movable masses with an intact covering of
not yet been definitively established, there is ample evi- skin.10 Four distinct forms of sarcoids are recognized.
dence to support a viral agent, including transmissibil- Less severe types can quickly progress to more aggressive
ity, occurrence in an epizootic form, and the tendency forms, especially if the area is traumatized.3
for lesions to occur at previous wound sites. 1–4 A Occult sarcoids seem to favor the skin around the
genome closely resembling bovine papillomavirus has mouth, eyes, neck, and other relatively hairless areas of
been consistently isolated from equine sarcoid tissue. the body, including the medial aspects of the forearm
Although patent viral particles have not been conclu- and thigh. These lesions manifest as a slightly thickened
sively demonstrated with electron microscopy or anti- area of skin with a mildly roughened surface that is
body testing, in a recent study, tissue sections from sar- devoid of hair. These sarcoids are generally slow-grow-
coids revealed viral DNA by polymerase chain reaction ing. Occult sarcoids can progress to verrucous (warty)
in the dermal layer within the fibroblasts of the tumor. growth or, if traumatized, may develop into fibroblastic
Bovine papillomavirus DNA was also detected in 65% lesions.1,3 As long as occult sarcoids remain in a static
of the samples of normal skin obtained from sarcoid- state, the tumor should be left untreated to avoid pro-
affected horses.5 This finding may indicate that bovine gression to a more aggressive lesion.1
papillomavirus infects the skin of horses and remains in Verrucous sarcoids show a predilection for the face,
a latent phase within the fibroblasts of the dermis until body, groin, and sheath areas. Lesions are generally
some other factor triggers transcriptional activation. small, rarely exceeding 6 cm in diameter, with a dry,
This would explain the high incidence of tumor recur- horny surface and a cauliflowerlike appearance (Figure
rence after surgically complete excision because surgical 1). These tumors are generally slow growing and
trauma may induce proliferation and expression of become aggressive only when injured. Any type of
latent virus, resulting in regrowth of the tumor.5 Flies, insult can cause a rapid change to a fibroblastic sarcoid
shared grooming equipment, and common rubbing over variable areas of the lesion.1
posts may be transmission routes.3,6 Predilection sites for nodular sarcoids include the
Clinical studies suggest a genetic predisposition for groin, sheath, or eyelid. These lesions are generally sub-
244 Equine Compendium March 2002
Treatment
Figure 3—Fibroblastic sarcoid on the right distal hindlimb. There is a wide range of treatments available for equine
sarcoids; no one therapy has been shown to be universally
cutaneous, easily movable nodules (Figure 2). Occa- effective in eliminating sarcoid tumors. The treatment
sionally, dermal attachments prevent movement of the modality selected is determined by location, size, and
tumor relative to deeper tissue. The skin over larger aggressiveness of the tumor; clinical experience; and the
nodules may become thin and ulcerate followed by the availability of services, equipment, and facilities.12 Tumor
progression of the tumor to a fibroblastic character. regrowth is a common occurrence regardless of the
Any trauma to the area may produce similar results.1 treatment modality used.
Fibroblastic sarcoids are usually found on the groin, Equine sarcoids removed by conventional surgical
eyelid, lower limbs, previous wound sites, and sites of excision have been shown to have a 50% to 64% recur-
other sarcoid types subjected to insult. Fibroblastic sar- rence rate, with most regrowth occurring within 6
coids are variable in appearance. Some are well-circum- months. 1 Surgical excision is better used to reduce
scribed, fibrous nodules in the dermis covered by intact tumor volume and improve the killing efficiency of
epidermis, and others are large masses with ulcerated combination therapies. When using surgical excision, a
surfaces that hemorrhage easily and are often covered 0.5- to 1-cm-diameter margin of normal tissue is rec-
by purulonecrotic debris (Figure 3).1 These lesions usu- ommended.1,12 This often results in a large skin defect
ally have an aggressive nature and will spread locally in in areas with little skin mobility and slow epithelializa-
the dermis. The fibroblastic sarcoid will often resemble tion. Application of a split-thickness skin graft may
exuberant granulation tissue.3 facilitate epithelial covering of the wound and result in
Diagnostic differentials that must be considered when a faster healing, reduced production of excess granulation
sarcoid is suspected vary widely and include dermatophy- tissue, and improved appearance.1,3,12
tosis, linear hyperkeratosis, blisters, burns, rub marks, Cryotherapy with liquid nitrogen is a cost-effective
papillomatosis, hyperkeratosis, SCCs, fibromas, neurofi- treatment in many cases. The sarcoid is destroyed by ice
bromas, equine eosinophilic granulomas, melanomas, crystals that form inside the cells, rupturing the walls
pythiosis, fibrosarcomas, and lymphosarcomas.3 and killing the tissue.4 It is strongly recommended that
tissue freezing be monitored using implanted tissue
Diagnosis temperature probes.1 The use of at least two or three
Although biopsy of occult, nodular, and small verru- freeze–thaw cycles is necessary. Healing is by second
cous tumors is often not recommended to avoid chang- intention or delayed closure, which may result in scar-
ing the morphology and behavior of a lesion, definitive ring and hair depigmentation.1,3
246 Equine Compendium March 2002
Figure 4A Figure 4B
Figure 4—Fibroblastic sarcoid before (A) and after (B) application of AnimexTM. This lesion healed without further complications.
Carbon dioxide laser excision and ablation of sarcoid the surrounding healthy tissue intact. A rapid response
tumors allows accurate dissection with minimal damage to the salve is usually noticed, and the lesion sloughs in
to surrounding tissue, uncomplicated healing, and 7 to 10 days (Figure 4). We consider this product to be
excellent cosmetic results1,12; however, laser excision the treatment of choice for small sarcoids that can be
should still be combined with other treatment modali- easily bandaged. Similar products are also available. A
ties to avoid tumor regrowth.4 topical treatment that contains a caustic chemical plus
EqStim (nonviable Propionibacterium acnes ; Neogen an extract of the bloodroot plant (XXTERRATM, Lar-
Corporation, Lansing, MI) has shown good results. Pro- son Laboratories, Inc., Fort Collins, CO) has also been
tocols differ widely, including intralesional and/or intra- used and is believed to change the antigenicity of the
venous injections given once weekly for 6 to 8 weeks. sarcoid cells so the immune system recognizes them as
Susceptible lesions generally show improvement after two being foreign, resulting in tissue rejection.4
to three treatments and eventually necrose and slough.13 A topical ointment (AW-3-LUDES, D.C. Knotten-
There are many topical products available for treating belt, Division of Equine Studies, Leahurst, Neston,
sarcoids. Daily topical application of the antimetabolite South Wirral, UK) has shown some success in treating
5-fluorouracil and podophyllin, an irritant cathartic, has sarcoids. It contains a variety of heavy metals and the
been used to treat patients with sarcoids. This treatment antimitotic compounds 5-fluorouracil and thiouracil.14
must be continued for 30 to 90 days.1,10 5-Fluorouracil The ointment is administered on successive or alternate
is a fluorinated pyrimidine antimetabolite that interferes days for three to five treatments. A response should be
with nuclear DNA biosynthesis, leading to cell death or evident in the following 5 to 10 weeks and will be
increased susceptibility to the immune system.1,10 noticed as preferential necrosis and sloughing of the
A bloodroot extract that contains Sanguinaria sarcoid tissues.14
canadensis, puccoon, gromwell, distilled water, and Various radioisotopes have been used for interstitial
trace minerals (AnimexTM, NIES Inc., Las Vegas, NV) brachytherapy of equine sarcoids. Permanently
has been used to treat various types of skin lesions, implanted seeds of radon-222 or gold-198 and remov-
including sarcoids. It is an escharotic salve that pene- able needles of radium-226, cobalt-60, or iridium-192
trates the lesion, killing the affected cells while leaving have been used.15 The principal advantage of radiother-
248 Equine Compendium March 2002
MELANOMA
Melanomas are common tumors that can occur in
horses and mules of any coat color, but incidence is
much higher in gray and white horses.3,33,34 Arabians,
Thoroughbreds, and Percherons may be at increased
risk for developing this disease.33,35 In one study of 264
gray-skinned horses in France, the prevalence of
melanomas in the overall population was 31.4%. The
incidence, size, and number of melanomas was signifi- Figure 8—Melanoma lesions on the underside of a horse's tail.
cantly correlated with age, with a prevalence of 67% for
ages older than 15 years.36 Other sources suggest that
approximately 80% of all gray horses will develop one Clinical Presentation
or more melanomas at some location by 15 years of Ninety-five percent of melanomas are slow-growing
age.3,34,37 There appears to be no gender predilection for and show no signs of regional or distant metastasis.
these tumors. The most common areas of the skin These tumors are of little clinical significance except
affected are underneath the tail (Figure 8) and external when they inhibit the use of riding tack or interfere
genitalia. 38 Other regions less commonly affected with urination, defecation, and coitus.37 Melanomas
include the ear, eyelid, neck, parotid salivary gland, commonly appear as black or gray, solitary, discrete,
guttural pouches, lips, and limbs. 3,33,34,37 When firm, spherical or flat nodules in the skin or subcutis
melanomas do occur in horses of other colors, they may and may have a pedicle. Tumors frequently coalesce,
be at greater risk for becoming malignant (Figure 9).6 and hundreds or more variable-sized nodules may be
The etiology of melanomas in horses has not been present without affecting the well-being of the horse.
clearly defined. It is thought that melanomas in old gray Many small tumors may be present, producing a cob-
horses are due to disturbed melanin metabolism, leading blestone appearance.3,34 Overlying skin may be intact or
to the formation of new melanoblasts, or to increased may be slightly alopecic. Lesions may ulcerate and pro-
activity in resident melanoblasts, resulting in a focal area duce a black, tarry discharge.3
of pigment overproduction in the dermis.6 Controversy Occasionally, melanomas will exhibit slow growth for
exists as to whether exposure to increased levels of ultra- several years followed by a sudden rapid growth phase
violet radiation may play a role in the pathogenesis of associated with malignant transformation of the tumor.
melanomas in horses. 6,33 Because of their frequent These tumors become locally invasive and may metasta-
occurrence in shaded body regions, sun exposure may size.37 Sites of metastasis include regional lymph nodes,
not be a risk factor for melanoma formation. However, lungs, liver, serosal surfaces, spleen, kidney, brain, bone,
reducing solar exposure in predisposed horses may be and heart. If the tumor metastasizes to internal organs,
warranted. clinical signs will be determined by the affected organ.
252 Equine Compendium March 2002
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ARTICLE #5 CE TEST
CE
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1. Equine sarcoids are believed to be associated with
_______________ or a similar virus.
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horses affected by squamous cell carcinoma of the penis and pre-
a. equine herpesvirus c. morbillivirus
puce. Equine Vet J 32(5):406–410, 2000. b. bovine papillomavirus d. lentivirus
27. Jones DL: Squamous cell carcinoma of the larynx and pharynx
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28. Walker MA, Schumacher J, Schmitz DG, et al: Cobalt-60 radio- of developing sarcoid tumors relative to all other
therapy for treatment of squamous cell carcinoma of the nasal breeds?
cavity and paranasal sinuses in three horses. JAVMA a. Appaloosa c. standardbred
212(6):848–851, 1998. b. Arabian d. quarter horse
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4. Biopsy of latent sarcoids should be avoided because
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a. they may hemorrhage profusely and result in acute
31. Yeatts R, Engelbrecht NE, Curry CD, et al: 5-Fluorouracil for
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254 Equine Compendium March 2002
6. Which of the following contributes to SCC develop- 9. The most common growth pattern exhibited by
ment? melanomas is
a. solar radiation a. rapid growth with aggressive metastasis.
b. pigmented skin b. slow growth for many years with no signs of metas-
c. bovine papillomavirus tasis.
d. gray haircoat c. slow growth for many years with a sudden growth
spurt and metastasis.
7. What tissue is most commonly affected by SCC d. none of the above
metastasis?
a. lymph node c. heart 10. Which of the following is recommended for treating
b. lung d. brain equine sarcoids?
a. surgical excision alone
8. The development of melanomas in older gray horses is b. cimetidine
associated with c. topical antimicrobial agents
a. increased exposure to ultraviolet light. d. intralesional cisplatin