Cytology: Tom Petty Was Right, The Waiting IS The Hardest Part

Summer has definitely arrived in the Bay Area.  It's 55 degrees and I am watching pea soup fog pour through the Gold Gate, obliterate the Bay, and rush up the hill toward me with a ferocity that would give Stephen King pause.  The hills behind the house, which barely mustered the energy to green up in winter's drought, have reverted to buff bone once again and even with fog catching in the window screens and pooling in my succulents' folds, it's getting crispy out there in the tall grass.  The calendar may say June, but my body says, "Put on your down puff, damn it!"

It is summer, though, and the fact that Stella is lying next to me as I type this, a little knocked out from her afternoon benadryl, but quietly content after eating dinner, astounds me.  After that first visit to the local vet, it was impossible to imagine getting through the weekend, let alone summer.

On Thursday, December 12, our local vet told me it would take a couple of days to get the histology report back on the fine needle aspirate but she was off on the weekend, so it would be probably be Monday before we would know what was happening with our girl.  Four days seemed like a torturous stretch for someone who has an imagination designed for lightless corners, but there was absolutely nothing to do but wait.  In an effort to protect Stella from the potentially life threatening effects of the suspected mast cell tumor, the vet started Stella on 10mg Pepcid, an H2 blocker, and 20mg Benadryl.  I walked Stella back to the Egg with a sick feeling in the center of my belly, unable to feel her leash between my palm and fingers because my hands were numb.  Shaking, I texted my sister, Sheri.  I texted Jim.  I crawled into the back of the egg and hugged Stella, who was so relieved to be out of the vets office, she let me.  I sniffed her fur and kissed her belly, letting her lick my face (she's a licker not a fighter) and nibble my chin.  She seemed just like the Stella we have always known and loved.  She didn't seem any different to me than she did 18 hours prior, before finding the tumor.  And yet, there we were, firmly and forever having crossed that indelible line between "before" and "after".

For the folks who are reading this because they are going through the cancer experience with their dog, I want to stop for a second and say just how important it is to listen to your gut when dealing with your vet.  If you have any reservations whatsoever about the care you are getting, find another doc.  Go onto yelp!, call friends and family members for recommendations, ask other dog owners in your community who they see.  Time and quality of care is of the essence.  Stella's tumor was large and seemed to have sprouted overnight, which implied to me that it was aggressive and fast moving.  She did not have the time for us to partner with a vet in whom I did not have confidence.  We needed to ensure that she was in the best hands to get the best care possible so that we could arrest the progression of her disease as soon as possible.

That afternoon, amidst the still sealed boxes and piles of our life's possessions strewn throughout the new house, I made an appointment for the next day at a vet hospital in Lafayette, about a 30 minute drive inland, to get a second opinion on Stella's condition.

The vet we saw on Friday afternoon reconfirmed the possibility that the mass was a large mast cell tumor and raised Stella's dosage of benadryl and pepcid.  She palpated it gently, eliciting another yelp from Stella, but because irritated mast cell tumors run the risk of degranulating, she declined to aspirate it again. She did tell us that the placement and size could make it difficult to remove with clean margins and that she would most certainly not do the surgery herself, but hand us off to a board certified surgeon.  After aspirating a few other new lumps that (much to my relief) were only fat, we headed back west.

On the way home, Stella and I took the two lane shortcut from Orinda to Berkeley through Tilden Park.  It was a cold day, winter sunlight weak and sharply angled, packs of dry leaves tumbling across the road.  When I pulled over at Inspiration Point, Stella started to wiggle and cry with excitement, knowing we were going to walk Nimitz Way.  We were told to no longer use her harness because the top edge sat up against the mass, but I also had to be careful to keep her collar above it, too, so we broke cardinal doggie law and I walked her down the paved trail off leash.  This was like Giftmas, her birthday, and dinner time all rolled up into one and Stella ran with total abandon from one gopher hole to the next, sniffing and huffing and snorting every molecule.

That night, Jim and I were supposed to go to his company's Christmas party in the city, the tech company's annual to do (although how they could out do the strippers with donuts at CCP's back in 2009, I had no idea).  I had a gorgeous black dress and Jim had a new Armani suit he had bought for my nephew's wedding at the end of the month.  It was going to be a fabulous night...and I just couldn't do it.  I felt so excruciatingly tired, so weary, I couldn't imagine talking with a few hundred strangers.  But, damn, if Jim didn't look stunning for the both of us:

Day two of the waiting period and we were determined to be distracted, to get out of the house, to get outside the worry.  There was so much to do in the new house, it wasn't difficult to stay busy.  We had no groceries, no curtains in the bedroom.  We needed paint for the kitchen wall.  We needed a new toilet seat, a towel bar for the bathroom, a rug.  It was cool enough for Stella to come with us in the Egg, so she was a happy girl bouncing from Berkeley to Emeryville to Oakland.

I was standing in a Saturday packed Home Depot staring at bathroom hardware when my cell phone rang.  Jesus, it was loud in there.  I held the phone to my ear with my shoulder while cupping my hands over my ears, madly trying to find a quieter spot to get the news.  It wasn't our vet, but her new partner, a recent UC Davis grad.
"Well, we got the histology report back.  It's mast cells. Sorry."
"That's what we were afraid it would be.  So it's a mast cell tumor?"
"It looks like it.  Yes."
"Can you tell me what the histology report says specifically?"
"Can you just come pick it up on Monday?"
Are you kidding me? No, I can not wait till Monday.  "This is very important to us and I'd like to know what is says specifically so that I can talk it over with my brother, who is a vet."
"Well, I can just print it out for you and you could pick it up right now.  I'll be here for another 5 minutes or you could pick it up on Monday."

We were thirty minutes away from the office and I felt a panic spreading through my chest like a hot wave.

"Can you email the histology report to me now?" I asked, my voice beginning to loose the facade of calm.
"I'm the only one here and I really don't know how to do that.  It will be here for you Monday morning if you want to pick it up then."
"Can I walk you through how to email a .pdf?" At that point I was fairly sure I could teach cold fusion if it would get the histology report into my hands. "This is serious for our girl and we would really like to get moving on her treatment depending on what that histology reports."
"I can try."
"Please try.  We would really, really appreciate you trying.  So appreciate it.  Please." And then I started sobbing.  Standing between two burly dudes in front of the toilet paper holders and robe hooks, both of Jim's hands on my back, I hung up and wept.

I didn't want to be a bitch.  Seriously. But, within reason and with respect, you have to ask for what you need.  In as nice a way as possible, certainly, of course, but your dog can't advocate for his or herself.  If we couldn't speak up for Stella, who would?

Five minutes later, I received an email with the fine needle biopsy histology report attached:

Source / History: This is a sample from a 4 cm mass that is round and firmly attached to the proximal left shoulder. It has been present for one month or so.

Microscopic Description: The sample is moderately cellular. It contains primarily disrupted cells. The intact cells are most consistent with poorly granulated mast cells and spindle cells. The mast cells are moderately pleomorphic and occasionally multinucleated. There is a moderate number of eosinophils seen. A small amount of blood is noted. There is some azurophilic extracellular material found.

Microscopic Interpretation (Cytology): Probable mast cell tumor

Comments: Many of the cells are disrupted, precluding a more definitive diagnosis. The sample is most consistent with a mast cell tumor. The cells appear poorly granulated when intact and moderately pleomorphic. Recommend removal with histopathology and evaluation of the draining lymph nodes for any evidence of metastasis.

And with that, 72 hours of tense waiting came to a close and we finally knew what we were dealing with.  Stella had a malignant mast cell tumor. 

Pyoderma, Otitis, and Pododermatitis: On Labs and Food Sensitivities

WARNING: This post contains graphic photographs of Stella's skin infections.  One person's fascinating medical info is another person's gory nightmare.  If you are the latter, you might want to skip this post.

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Stella was and remains an incredibly easy dog to train. In classic labrador fashion, she has always wanted to please us, those big brown eyes scanning for positive reinforcement. More importantly, however, this dog lives to eat. Biscuits, jerky, bananas, popcorn, turkey slices. Fancy dog bakery cookies or cheap-o milk-bones.  Human, dog, or cat food. Even better? Cat poop (aka: kitty crunchies)!  Early crate training was invaluable to us for keeping Stella safe.  Until she learned to wait and ask before eating, it was a challenge to keep her from hoovering up anything and everything in her path. Stella was an indiscriminate scarfer right from the get go.

At ten weeks old, she was terrified of walking down the stairs from the main floor of our house to the front entryway, so I put tiny bits of turkey jerky on each step and then waited for her at the bottom.  Stella cried while taking a tentative step towards the first piece of jerky, unable to resist following her nose, then took a colossal header down the carpeted stairs, rolling ears over little fat butt, somehow managing to snatch each piece of jerky as she flew by.  I caught her at the bottom, telling her what a good, brave girl she was, then chased her up the stairs to do it all over again.  She never again balked at the top.

A few days later, we brought her to the park down the street to try out the recall we had been practicing in the living room.  Jim and I stood 50 feet apart, each with a pocket full of jerky, as Stella sniffed the grass between us.  I held out my arm, opened my hand to show a nibble of jerky, and called her name.  She came flying towards me, her soft ears flapping up and down wildly, like Dumbo about to take flight, her mouth open in what looked like an insane smile (I so wish I had filmed that).  She made a bee line for the jerky, then stood in front of me, wagging her tail, begging for more.  Jim called, "Stella, come!"  She whipped around, the name-jerky connection visibly clicking.  Seeing his outstretched hand, she bolted back to him, ears flapping, mouth wide open, tongue bouncing, her tail wagging furiously.  Back and forth she flew between us, jerky nibble to jerky nibble. We carried bits of treats with us everywhere those first few months, but she had it down right from that first day.  Snacks trumped all distractions.  Stella would do just about anything for food.

Even with all the reading and training classes, vet visits and dog advice we solicited along the way, we had a huge, gaping hole in our parenting skills: nutrition.  I can't believe how many years it took for me to understand the role food played in her her odd health quirks.  I can't believe the crap we gave her to eat those first few years!

Stella always had soft poops.  We tried adding different fiber sources (green beans, pumpkin, psyllium, inulin), all resulting in various degrees of diarrhea disaster. We tried yogurt (hello, gas!). We tried probiotic powder (nothing).  We just assumed that was how her gut was designed and because we lived up in the woods, easily being able to pick up her poop in dainty little plastic bags wasn't an issue (boy, oh, boy would that change when we moved to Atlanta).

At about a year old, Stella went to stay with her Oma for a few days.  When she returned home, her normally pink puppy belly was completely black.  It didn't seem to bother her, but the skin was dark and rough.  My brother said it was probably yeast and, sure enough, after a week of soaks in an anti-fungal solution, it receded.  This would happen just about every time she visited her Oma and we thought there must be something environmental up at her house to which Stella's skin was sensitive (we discovered much later, when Jim's mom told us how much Stella loved her grilled salmon, that she was getting table scraps at her Oma's house.  No wonder she freaking loved going to Vail).

Then came the red, crusty, ulcerated circular patches on her belly.  They would appear in waves, sometimes just one, sometimes a half dozen of them.  Again, they didn't seem to bother her, and she didn't lick or notice them at all.  My brother was certain they were Staphylococcus pseudintermedius infections, perhaps even an allergy to the staph itself.  Sure enough, a course of antibiotics would clear it up, but it wouldn't be too long till they returned and we would start the process all over again.

The circular infections on Stella's belly

Summer of 2007, when Stella was two years old, she started to lick her feet.  On closer inspection, she had red, bulbous sores between or adjacent to her toes.  As it was high summer, Stella's vet thought she had caught a few foxtails in her paws and dug around to remove any foreign matter.  He found none (poor little girl!).  More antibiotic followed and they cleared up nicely.  But just like the sores on her belly, they returned at seemingly random times.  When they popped up the following winter, I knew for certain it wasn't foxtails.  Another call to my brother (our hero) and he named them for what they were: Interdigital pododermatitis.

Example of small pododermatitis, emerged after feeding Stella food that contained turkey

Up until this point, her local vets had been dealing with the various infections as they popped up, but we hadn't put together that they were all symptoms of a single, whole body issue.  Her vets simply said, "Labs have skin issues," but it was beginning to dawn on me that there had to be a connection between what she was eating and the multiple staph infections she was regularly experiencing.  We peeled off treats and the Natural Balance turkey tube that she loved so much (that was a sad day for Poopy, but, jesus, why were we giving her snacks loaded with sugar?), we ceased buying the ridiculously expensive handmade cookies from the boutique dog bakery in Boulder and banned the milk bones.  Per Scott's recommendations, we moved her to a single, novel protein source dog food (lamb and rice).  The infections dod not disappear entirely, but they seemed to be less severe and less frequent.

Skip forward to Spring 2010.  We had been living in Atlanta for nearly a year and Stella had been doing pretty well on Natural Balance Limited Ingredient Potato and Duck dry dog food (for three years, we had been skipping from one protein source to the next when the staph would pop back up).   I opened a new bag and could immediately tell something was different about the kibble.  It smelled different and the color of the kibble was much lighter.  Sure enough, the ingredient list now showed duck meal ahead of duck meat and included potato protein, an ingredient that had not been in the recipe prior.  Ugh.  Within two weeks, Stella not only had a belly full of red staph coins, but pododermatitis between her toes.  Enter Dr. Stacy!  She looked over our girl and declared, "Food allergies!"  With two words, she confirmed what I had been suspecting all along.  Plus, we finally had a name to those nasty ulcerated sores on her belly: pyoderma.  Dr. Stacy referred us to an allergy specialist, Dr. White, who patiently guided us through the months long elimination diet required to weed out aggravating foods.

What did we learn?  Stella can not tolerate poultry of any kind (including hydrolyzed chicken protein), beef, venison, salmon, rice (brown or white), wheat, or corn, most Omega 3 fish oils (cod especially).  These foods set off an inflammation process in her body that permits an over growth of yeast on her belly (and sometimes in in her ears, known as otitis) and allows Staphylococcus pseudintermedius to turn ugly on her belly and between her toes.  What protein does her body accept easily?  Bunny!

We began feeding Stella Royal Canin hypoallergenic Rabbit and Potato dry dog food in early 2011 and the change was incredible.  No more staph infections anywhere (apparently, we should have let Stella catch and eat those bunnies she has been chasing all these years!).  Whew!  It hasn't been without kinks. Three summers in a row, Royal Canin ran out of the rabbit based food and we had to suddenly feed Stella an alternative diet (each time resulting in a bloom of pyoderma, yeast, and pododermatitis requiring antibiotics).  Last year, Royal Canin suddenly changed their recipe/formula by adding hydrolyzed soy protein and removing whole rabbit entirely (it now contains rabbit meal only).  The shift obviously changed how it tastes or feels, because Stella immediately started licking her mouth uncomfortably after eating (though she still tore into it as if we were starving her by making her wait SIX WHOLE HOURS between meals).  Honestly, I am not convinced it's a high quality product (Royal Canin was involved in the massive 2007 melamine pet food recall), but it did eliminate Stella's frequent need for antibiotics.

Of course, we're now tossing that to the wind by home cooking for her, but that's a subject for another post.

I can't help but wonder if there is a connection between Stella's life long issues with inflammation/allergies and her early bout and continued fight with mast cell disease.  Those little cells that have so much to do with inflammation, allergy, and tissue growth seem to have been working overtime her entire life.