Which oncology conditions constitute an urgent or ... · Some conditions such as carcinoma of the eyelid, penis or vulva and some Figure 1: This case of malignant sarcoid illustrates

Which oncology conditions constitute an urgent or emergency

sufficient to warrant a visit and/or treatment during the current

COVID-19 lockdown?

Through TRIAGE we can decide which cases are an emergency and which can

be dealt with remotely with advice and support. Triage also allows us to

determine the priority of the patients treatment based on the severity of their

condition or their likelihood of recovery with or without treatment.

The current COVID-19 situation in the UK means that veterinarians need to

make sensible, balanced and rational decisions that protect human lives and

consider the specific needs and welfare of the animal. Every veterinarian will

have their own personal boundary when considering these aspects and that

should be respected. However, commercial interest cannot be considered to

justify the risks or the breaking of rules relating to the COVID-19 disease

threat.

Under the current circumstances video, photograph or verbal information can

be used to make an initial TRIAGE assessment of any particular case.

These assessments can be guided by the veterinarian to give a faster initial

assessment than would normally be the case with standard visit methods. Of

course, this is limited and constrained by the quality of information provided.

Assessment must always include the signalment: age, breed, sex (reproductive

status), and colour. Weight and height should be established and recorded for

every case that is assessed remotely.

It is essential to establish the owner’s complaint and a full history must be

taken– it is even more important when remote assessments are being made as

co-morbidities might be missed. The animal might be pregnant and so

chemotherapy might be specifically contraindicated. Routine procedures such

as worming, and vaccinations are also important in every case. The horse may

have Equine Metabolic Syndrome (EMS) and so may not be a suitable

candidate for steroid treatments. It may already be receiving oral analgesics

that might alter the choice of supporting medications.

An inadequate video with blurred accompanying photographs and a panicked

owner serves little use at all. Remote case assessment of a case should be

regarded as a SECOND-BEST option. It is easy for an owner to remain focussed

on the immediate most obvious sign whilst ignoring the rest of the horse.

Remote TRIAGE must be carried out carefully and support should be provided

to the owner to ensure the correct pictures / videos or verbal information can

be obtained for ALL cases.

Even given our current limitations, the patient is entitled to a full assessment.

This type of consultation will have a charge applied to it and should not be

carried out gratis. It is important that we avoid long term changes in attitudes

to our services and that we maintain the value of our professional expertise.

Almost all cancer cases will get worse if left for any significant length of time.

Some conditions such as carcinoma of the eyelid, penis or vulva and some

Figure 1: This case of malignant sarcoid illustrates the risk of ignoring a serious case.

The horse had bleeding ulcerated fibroblastic sarcoids for over 3 years. The owner "treated the case" with herbal supplements but became concerned when the bleeding did not stop one morning. The horse was clearly profoundly anaemic and had a clotting defect. Clinical examination also identified pyrexia. It required urgent attention. The sarcoid was not the immediately urgent part of this! COMORBIDITY is often difficult to establish from a telephonic communication / consultation.

more aggressive sarcoids can progress very rapidly and these do warrant

timely intervention. Others such as early melanoma, occult and verrucose

sarcoid and mast cell tumours are slower and seldom become critical over a

shorter time period.

• Given their slower and more chronic nature with an insidious

progression, there are only a few absolute emergencies that arise from

any oncological condition. However, tumours are often ignored by

owners, and in some cases the tumours can break away from the body

leaving a haemorrhaging site. This can also be very irritating for the

horse as the mass pulls on adjacent tissues. Significant (arterial) or

profuse (venous) bleeding warrants very urgent attention. Other lesser

bleeding warrants an early intervention and a visit is usually required.

• Ulcerated or large tumours (for example either sarcoid or carcinoma)

should be assessed individually. Initial remote assessment is feasible –

don’t forget to get other information about the case so a proper

professional assessment can be made. There is no point in assessing a

small localised tumour and then prescribing treatment which may not be

in the animals overall best interests when considering the age, breeding

status and co-morbitity.

Figure 2: Whilst this tumour was clearly very chronic and the horse had been coping well in spite of the size of the malignant melanoma. Ulceration of the tumour resulted in significant blood loss and additional inflammation and pain resulted in a rectal impaction or obstipation. This might then result in colic and of course COLIC whether caused indirectly by tumour or not is always an emergency.

Figure 3: A part of this huge complex lesion sloughed away abruptly resulting in bleeding and pain as the weight of the tumour pulled on the adjacent structures and skin. This is an obviously urgent case.

Figure 4: Clearly this case had been neglected for a long time, but the owner phoned to report that it was suddenly very uncomfortable. And was rubbing its eye. A decision was taken to visit the horse immediately and a large corneal ulcer was identified. Had the wrong decision been taken, the eye might well have been lost. Daily assessments could be made by the owner but communication in this kind of case is paramount particularly in the face of our current circumstances.

Figure 6: Despite the obvious chronicity of this carcinoma, this is still an urgent case requiring attention as soon as practicable since it will get bigger and become even more destructive.

Figure 5: A sudden deterioration in the status of the eye necessitated a call to the veterinarian. Remote guided assessment and photographs confirmed that the horse required urgent attention. A sub-palpebral lavage system was inserted to allow the owner to treat the horse remotely Tumour treatment was delayed until the corneal ulceration had been resolved. Daily photographic updates were submitted. Clearly the culmination of a slowly advancing case precipitated an emergency situation requiring physical attendance. The horse should be hospitalised for this if possible, for both further assessment of the carcinoma and for treatment.

Slow growing localised occult or verrucose sarcoids are not usually an

emergency! These can be assessed photographically or by video link either

from concurrent “whatsapp” type applications that allow the owner to be

guided in real time by the consulting veterinarian.

REMEMBER that you have your own opinion as to what is urgent and

what is not; this is intensely personal. The veterinarian must decide the

balance between human safety and animal welfare; this is an individual

matter and we all need to respect differences of opinion. Furthermore,

we MUST avoid commercial poaching in the interests of a particular

practice or individual. If a new client approaches you to attend his / her

horse it is right to ask who their usual vet is and to contact that vet

before making any consultation at all. One vets human safety concern

and professional obligation to society / government may be another vets

“opportunity to poach” and gain commercial advantage. The best

advice is to LOOK AFTER YOUR OWN CLIENTS IN YOUR OWN WAY and

avoid any suggestion of professional supersession or commercial gain.

As far as we know horses are not liable to COVID-19 infection and so are

not “unsafe” apart from acting as a potential fomite; this includes the

skin surface and harness, buckets, etc handled by the owner.

Figure 7: The owner of this horse knew that the medial thigh lesion was present last autumn but had not noticed the enlargement until the spring hair loss. Owners are often “blinkered” to the primary complaint so a simple telephone consultation with the owner is often not enough. However, careful enquiry using a Whatsapp consultation revealed that further lesion were obvious in the axillary region. These multiple verrucose sarcoids could be assessed remotely and a plan made to treat the case once the lockdown was lifted. If this was later in the summer this case could become urgent and in any case guidance should be provided on the management – avoidance of irresponsible treatment methods and fly control are important points. A guided Whatsapp consultation examination to show all the most susceptible sites would help this case a lot!

RISKS V BENEFIT?

• Human Safety V Animal Welfare

o The risk of Coronavirus is bilateral! The owner can spread virus to

the vet and the vet can spread it to the owner directly or by

fomite transmission.

o No information regarding indirect contact with the horse acting as

a fomite is available. IF IN DOUBT…. DON’T RISK IT!

o There is NO horse in the world under any circumstance that is

worth a human sacrifice; owners may feel differently and have

little regard for the health and safety of the veterinarian / nursing

assistant.

o Is the visit / intervention essential to avoid animal welfare

compromise? This is a very personal decision both for the vet and

the owner.

• Can the procedure to be performed properly and safely with sensible

social distancing or is it inevitable that some compromise will occur.

o Is it possible to take an assistant to handle the horse rather than

the owner?

o Advice regarding headcollars and other restraint must be given.

o Is the working environment likely to compromise social

distancing? It is probably safer to carry out procedures outside

the box in open air than in a closed environment.

o In this event it is sensible to take appropriate precautions (mask,

eye protection, gloves and handwashing products). Hand washing

facilities MUST be made available; gels and gloves should be used

routinely.

o Minimise the risk by planning carefully and maximising efficiency

including time in contact. PROTECT YOURSELF within reasonable

professional boundaries. REMEMBER that these boundaries are a

personal matter.

• Is veterinary attendance needed to complete the treatment or can some

of them be done by the handler / owner?

o Is further treatment going to become increasingly difficult? E.g.

some sarcoid treatments must be applied by vets only and some

become significantly more problematic as the course of treatment

continues. The animal may require sedation! Can this be done in

advance of the vet arrival to ensure minimal risk to owners and

vets?

• Will delay, postponement or cancellation of the visit compromise the

long-term heath, and welfare of the patient?

o If yes, then a visit is required

o If no, the reasons for the visit should be reconsidered

Here are a few cases for you to test your opinion against that of Derek

Knottenbelt!

CASE 1: This 14-year-old Welsh Section 5 Stallion was known to you

have sarcoids for many years; individual lesions have been treated by

various methods including ligation, AW5 and surgical / laser surgical

removal. In February he was brought in from the filed to get ready for

his stud season. The sarcoid around his ear had, in the owner’s words,

“exploded” into what can be seen here. Notice the family involved and

the outside working environment

COVID Question 1: Is this an emergency warranting an immediate visit?

YES / NO

COVID Question 2: Given the long history of the case can this be safely

left alone until restrictions are lifted on the COVID isolation – possibly

until August when his stud season is finishing? YES / NO

COVID Question 3: Which of the following would you do?

a. Give the owner advice on how to place a ligature around the

fibroblastic pedunculated portion.

b. Make an emergency visit and surgically excise the main lesion

c. Admit the case to the clinic for surgical management and

concurrent local chemotherapy

CASE 2: This breeding

Thoroughbred stallion was found to

have several scrotal sarcoids as

shown during his pre-breeding

check. Nothing was reported last

year, and it is thought that there

was nothing present in the autumn

of 2019.

COVID Question 1: Over how long

would you expect this to become a very serious problem?

a. NEVER

b. 1 week

c. 1 month

d. 3 months

e. 6 months

f. 1 year

COVID Question 2: In your opinion does this warrant immediate intervention?

YES / NO

COVID Question 3: Which of the following would you tell the owner?

a. This is trivial and does not warrant intervention either now or

anytime soon

b. This is a potentially dangerous situation and it should be dealt with as

soon as it is safe to do so, preferably this week.

c. The fly season is approaching and we really need to deal with it

before then to avoid progression / exacerbation and potential

transmission, so let’s see if we can make a suitable plan that

minimises the risk to us all and is in the best long-term welfare

interests of the horse.

d. Let’s deal with it when his breeding season is finished in August.

Case 3 : This 12-year-old gelding is

presented to you by Whatsapp

communication from a third party who has

a horse in the same livery yard. She does

not own the horse but is worried about the

case on welfare grounds and she is worried

that her horse will “catch the sarcoid”. She

states in her email that the owner has tried

lots of “treatments” over the last 5 years

and is currently relying on dietary turmeric

and tea tree oil and a dietary herbal mix.

The owner has been trying to encourage

others in the yard to use these prophylactically. The horses are due to be

turned out 24/7 shortly into the same fields during the coronavirus pandemic.

She offers to pay for your visit and treatment for the horse.

COVID Question 1: Which of the below options would you carry out?

a. Tell the 3rd party to mind her own business, stay at home, protect the

NHS and save lives

b. Tell the 3rd party to just keep her horse away from this one and if

necessary, move to another yard when the lockdown is lifted.

c. Offer to treat the horse because it is an emergency and must be treated

as soon as possible

d. Ask the 3rd party who the vet is that usually attends the horse and

contact him / her to discuss the case and if that is not known give her

advice on how to protect her horse from potential sarcoid transmission.

COVID Question 2: Do you believe this to be an emergency warranting a

veterinary visit at this time? YES / NO

COVID Question 3: Given the current lockdown conditions, assuming that in a

phone call to you the owner now asks for your advice, which of the following

are aspects worth sharing with the owner? You can choose more than one

option here.

This case has been neglected and the current treatment option is not wise

x

This case warrants urgent euthanasia because it will get worse if left and we can’t visit a chronic case at present

You can set up a surgical intervention that will be carried out in the field with your nursing assistant in the next week or two to remove the bulk of the problem and so reduce the risk of fly attack and transmission.

Institute strong fly control measures including keeping the horse in during the day time, and avoiding contact with other horses when turned out

x

Advise that a vaccine can be made and that this will solve the problem both for this horse and for any others in the yard

Carry out reasonable isolation for the horse and treatment will start as soon as the lockdown is lifted.

x

Treatment should start as soon as possible since the fly season is approaching and that will create a potential problem both for the horse and for other horses in contact with it.

x

Treatment is required and we will need to do something and that we will try to make this as efficient and safe as possible.

x

CASE 4: A 9-year-old riding club pony is

reported to have a dirty sheath with some

sheath swelling. The rider (a 12-year-old girl)

has also reported to the parents that there is

some blood on the sheath and the pony is

kicking out increasingly and is also inclined to

bite at his sheath. On telephone enquiry the

owner reports that he has a bleeding mass on

his penis that she sees when he urinates.

The pony has been in the owner’s possession

for 4 years and is a top-class pony with high

expectations.

COVID Question 1: Under the current lockdown is this an emergency

warranting an immediate visit? YES / NO

COVID Question 2: Can this be treated without direct veterinary attention?

YES / NO

COVID Question 3: Which of the following options would YOU take?

a. Dispense some TMS meantime and wait until the lockdown is lifted

b. Arrange for euthanasia based on the pictures and the owner’s

description since this avoids any further need for direct risk contact.

c. Arrange for an immediate visit and carry out a standing distal

phallectomy using your own nursing staff to assist

d. Prescribe some Efudix to be applied once daily and oral piroxicam at 80

mg total dose q 24h. Tubes of sedative are also prescribed, and all

medications are posted out with instructions and advice to send in

weekly pictures.

e. Arrange for the horse to be hospitalised or referred for detailed

assessment and appropriate treatment, thus avoiding the need for any

risky visits.

CASE 5: A 5-year-old grey gelding is reported by email to your practice to have

developed a sticky black discharge from a mass around her anus. Photographs

sent in response to your receptionist’s request are shown here. The owner is

aware that these tumours have been present for a while but one of them has

“exploded” and the mare is slightly uncomfortable and is reluctant to pass

droppings. She is seen to strain and has shown mild signs of abdominal

discomfort.

COVID Question 1: Do you consider this an emergency warranting a visit during the lockdown.?

YES / NO

COVID Question 2: Could this reasonably be managed remotely over the next 3 months? YES / NO

ANSWER THE PRIORITY FOR THESE CASES.

REMEMBER: This is a personal decision but my own decision is highlighted

when your “answer is checked). Please bear in mind that considerations such

as time of year at the present time and the management method may make a

difference to your decisions. If you would like to comment on these cases

please feel free to contact us – we actively welcome participation and we are

setting out to try to give as much support as we can at this troubled time for us

all. We remain open to providing whatever support we can to practices and

individuals.

You can send us the comments and answers to any of the questions and we

will assess them and engage in dialogue with anyone who is interested!

Case A: A 9-year-old grey Thoroughbred mare used as a general riding horse

having retired from racing as a 3-year-old. Maintained in a livery yard of 40

horses of a similar nature and spending days turned out and nights in stable.

COVID PRIORITY IMPLICATION MY DECISION

EXTREME EMERGENCY VISIT REQUIRED

HIGH

URGENT VISIT REQUIRED

MEDIUM VISIT REQUIRED but CAN BE LEFT UNTIL CONVENIENT

LOW CAN safely be left until lockdown is lifted xx ,

Case B: A 13-year-old Irish Cross gelding. He was known to have cut his

fetlock in January 2018 and the wound has never healed well. He is not lame

and the neighbouring practice (now closed) has repeatedly cut off the

‘granulation tissue’ and provided dressings including manuka honey.

Maintained in a private yard of 3 horses on full livery and spending days

turned out and nights in stable.



HIGH

URGENT VISIT REQUIRED xx


LOW CAN safely be left until lockdown is lifted

Case C: A 4-year-old Pony mare used as a general riding horse bought last

year (2019) with a known history of a small but obvious sarcoid on its left

axilla. It was reported on the PPE certificate and is excluded on its insurance

certificate. Usually maintained in a livery yard of 9 horses of a similar nature

and since the COVID-19 issue he has been turned out 24/7 with all 9 of the

others.


EXTREME EMERGENCY VISIT REQUIRED HIGH

URGENT VISIT REQUIRED XX



Case D: A 7-year-old bay Thoroughbred X showjumper gelding also used as a

general riding horse bought “unwarranted” without PPE in September last

year (2019). Maintained in a livery yard of 14 horses of a similar nature and

spending days turned out and nights in stable. The small area was described

by the seller as a ‘rub mark from the head collar’. A friend of the current

owner said she thought it looked like a wart or a sarcoid. It has not resolved

and in spite of the use of Camrosa and turmeric the lesion seems to be

getting slowly bigger.





xx


Case E: A 7-year-old Arab cross mare used as a general riding horse.

Maintained in a livery yard of 19 horses of a similar nature and currently

turned out 24 7 with daily checks from the yard owner. During the latest

check, the yard owner has reported to the owner that there are seemingly

some areas of scaling on the inside of the thigh which she suspects may be

ringworm. She has sent photographs taken of these lesions to the owner

who then contacts you with a request for ringworm treatment to be

dispensed.





xx

LOW CAN safely be left until lockdown is lifted ,

Case F: A 16-year-old RDA pony gelding noted to have a “bloody” patch on

his lower eyelid. It has been there for some time but today he is showing

some signs of pain and photophobia. He is currently stabled 24/7 but is not

working due to COVID-19 lockdown on the stables and the RDA activity.

EXTRA [FUN] QUESTIONS FOR YOU:

1. What is your diagnosis of the palpebral lesion?

2. What cardinal features can you identify that could help with the

diagnosis?

3. What further tests could you carry out here to help with the diagnosis?

4. Write a professional report for inclusion into a referral letter describing

the corneal lesion

5. List 3 possible differentials for the corneal changes

6. The picture below shows the other eye of the horse. Is this normal and

can you identify any pathology? If so, can you relate these to the right

eye pathology






Case G: A 9-year-old coloured mare used as a general riding horse. She had

been bought from a ‘traveller’ some 6 months years previously and has no

other history of any disease or accident. During the lockdown, the owner has

been reading some back copies of Horse and Hound and has read an article

on MELANOMA. She becomes alarmed by the black area on the lower eyelid

of the mare that has been present since she bought the horse and phones

you for urgent advice. She has noticed that recently there has been some

watering and a sticky discharge in the eye. After a 30-minute discussion with

the owner you request a photograph and advise the owner that there will be

a charge for your advice.

COVID Question 1: What is your diagnosis here?

COVID Question 1: Is there anything about this that worries you? (did you notice the comorbidity –

the melanotic naevus is incidental but te carcinoma is a significant finding warranting attention)



HIGH


MEDIUM VISIT REQUIRED but CAN BE LEFT UNTIL CONVENIENT BUT IT MUST BE SEEN


Documents

Which oncology conditions constitute an urgent or ... · Some conditions such as carcinoma of the eyelid, penis or vulva and some Figure 1: This case of malignant sarcoid illustrates