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.

December 11, 2013: Discovery Day

I didn't realize how hard it would be to look back on that day in December when we discovered her tumor and write about it.  Stella has now shallowly outlived all initial prognoses and as days turn to weeks turn to months, I have reached a tentative detente with her cancer (though I still give it the side eye and refuse to lay down arms).  When I look at my sweet girl today, I can see her as the big personality she is rather than frantically searching for signs of something amiss or only seeing her as  a collection of difficult health crises rising up to swallow her whole.  A few quiet weeks with no imminently mortal dangers have permitted this brief period where I can look at the experience and write about it without grief overwhelming and obliterating everything I do.  Who knows when that will change?  For now, as I type this, Stella rests her head on my leg and whines for another walk, another meal, any kind of attention that involves a ball or perhaps stalking squirrels ("But don't pet me, for god's sake!  Ugh!"). The fact that she's up and about making her little noises and insistent demands sets the clocks and proves that, this day at least, all is well in our little neck of the woods.

Leprachaun Movers, a group of really big Irish ex- rugby players, showed up on December 10th to move us the 1 mile from our old house to the new house.  Stella loved them immediately, each stopped to pet her and even throw the ball a few times (nothing pleases me more than a big dude who makes coo-ing noises to my girl).  She did really well that day, even though it could have been confusing for her.  We had been coming over to the new house for a couple of weeks by then, feeding her dinner where she would be eating from the move on, and all her beds were in place so she always had a good comfy spot to safely sit out of the chaos.

It took about ten hours, but by the end of the day, all the boxes were in the right rooms, all the furniture was in place, and we collapsed into bed in the guest room, which I had set up the day before so that we could be out of the wood floor fumes.

I don't remember much about the next day.  Jim went back to work and I am sure I walked Stella and then got to work on the boxes.  There was still a lot to do over at the old house and our dear friend Craig was over there helping us patch nail holes and repaint.  I do remember talking to my girlfriend Jenny on the phone about how happy I felt and what a relief it was to be beyond the blues that were brought on by the other house, that we could finally just land and be happy here. 

It was pretty late when we finally went to bed. I was already undressed and Jim was somewhere else when I realized Stella was really going at her neck.  I was sure either dust from the move or the fumes from the new hardwood floors were being a bother.  I got down on the floor with her and I could feel immediately that her neck was warm. What she was scratching was a hard swollen lump the size of a freaking orange on her neck, close to where it meets her chest.  Jesus Christ, what the hell was that?  The skin beneath her heathered yellow hair was a fierce, angry red and it was very hot to the touch.  I felt a catch in my heart come loose and I knew, I knew it was a tumor.  It was a big fucking angry tumor.  In a panic I called out to Jim and he came running from the bathroom, frightened by the tone of my voice.  "Stella has a lump," I cried, very close to hysteria, but doing my utmost to remain calm.  "There is a really big lump on Stella's neck."

"Let me feel it." Jim was not a stranger to my inclination towards hyperbole. "Jesus, that is big."

"We need to take her to the emergency vet right now, Jim.  Right now."

"She doesn't seem to be in distress.  She seems fine.  It might be a spider bite."

"It could be a spider bite or she could be having an allergic reaction to something.  But, I think it's a fucking tumor." In case you haven't caught on to the fact yet, I swear like a sailor.

When we took a step back form her, we could clearly see it protruding from her neck, pushing the hair around her normally pretty Elizabethan collar in a messy, awkward manner.  How had we not seen this before?  How had we not felt this before?  I ran my fingers along her old incision regularly and never felt anything, but it never dawned on me to palpate just up and over six or ten inches.  

I hit the internet like it would save my life, googling tumors, spider bites, allergic reactions, you name it.  There was no sleeping for me.  At about 4am, I came up onto the main floor, lay down on the couch in the darkness and surrounded by cardboard boxes, sobbed till I was wrung out, dehydrated and exhausted.  When 8am finally rolled around, bleary eyed and hoarse, I called the local vet and the receptionist said we wouldn't be able to be seen that day.  I protested in the most polite manner I could muster, sleep deprived and a little nutty with worry.  She said if I just came around 11 and was patient, she would see about fitting me in around other patients.  I thanked her, overwhelmed with relief, and then gave in a took an ativan.  

The local vet did finally see me that first day.  She said the same exact thing that Dr. Stacy did back in 2011, "I don't like the look of that."  When she tried to palpate beneath it, Stella squealed and I had to squelch a scream.  She decided to take a fine need aspirate biopsy of it, and after feeling as if she didn't get a good sample the first time, pricked her again.  She said the slide was too bloody for her to have a look at it, but that it's proximity to her pre-scapualar lymph node made her think it was lymphoma.  And with that, she sent us home. 

I walked out of the vet office feeling utterly lost and rudderless, not knowing what the hell I could do for our girl and feeling sure certainty that we were going to loose her.  I called my sister and wept.

20/20 Hindsight: All The Little Signs

Looking back over last Autumn, it's hard not to feel that we should have known something was amiss with Stella's health.  Hindsight lends itself to self flagellation and guilt, a lot of guilt, because there were a half dozen posts along the way, each shooting small sparks of information that, alone, didn't seem like much, but when collected, morphed into a well lighted map pointing to big trouble.

Since moving to California in the beginning to 2013, we had being living in a classic Berkeley Hills 1939 bungalow.  I use the term "classic" in the real estate sense.  We're talking moist, few updates, and stinky.  Really, really stinky.  By last fall,  I was obsessed with finding a new place for our family to live.  Stella and I still walked our miles in the morning and around the neighborhood in the evening, but practically every other waking moment was dedicated to scouring rental ads, writing introductory emails, fielding calls, meeting homeowners, and driving through neighborhoods.  If I had lifted my head, I would have noticed that Stella was sleeping a bit more.  When I did see her wonked out on our bed, I chocked it up to the heat or her now being eight and officially an "elder dog".

Then one morning, Stella balked at the start of our walk. She does grow bored when we take the same route repetitively, something she protests by walking very, very slowly (then when I drive her somewhere new, even the same day, she pulls my shoulder out).  I figured she was bored out of her skull by our morning walk up the hill, because she flat out refused to go forward.  We ambled home and she went back to napping.

Never bored with a stick!

I did notice that she was breathing a bit harder when we would walk uphill.  My brother called this exercise intolerance and he said to take her in to see her local vet.  The local vet who we had seen once before in the spring when we first arrived did some blood work, looked her over, and said she seemed fine, just an older dog starting to show signs of slowing down.  This was tossed out in between her narrative about her children, her dogs, her office remodel, her employees.  A little voice in the back of my head said, "Find a new vet."  I will never again ignore that voice.

In November, Jim and I took Stella to our favorite dog friendly resort on the rough Mendocino coast, situated on a wide estuary where the Big River meets the Pacific Ocean.  Stella started to cry with excitement the moment we turned off Highway 1 (honestly, we are just as excited as she is and spend the last fifteen miles of the drive ooh-ing and ahh-ing at every new view of the immense surf).  She loves riding in the Canine Cruiser, a large outrigger canoe with the perfect spot where she can lie down with her paws over the lip of the boat and watch harbor seals, river otter, and cormorants.  It was a beautiful weekend where we walked on the highlands above the water, hiked beside the river, read in bed, and just checked out from the world (no cell phones!  No internet!).

Stella in the Canine Cruiser

After returning home, I noticed Stella was pretty itchy.  I assumed she had picked up fleas at the inn, even on flea and tick preventative, but I never found any buggers.  Then I thought perhaps the sand or the river water may have bothered her skin.  Perhaps she ate something while we weren't looking (exacerbating her food allergies).  I bathed her carefully, but the itching continued intermittently.

Sometime around Thanksgiving, Stella started to scratch at her ears.  This has happened before when she gets a little yeast growth (that's a labrador for you).  But when I looked in her ears, they looked normal.  No brown goop, no red, tender skin.  They looked clean and healthy.  But still she bothered at them and was shaking her head more frequently.  I put her through a week long course of ear cleaning and steroid/antifungal ointment just to be sure.

One night, while Jim and Stella were playing around in the kitchen, she let out a sharp, painful yelp and backed away from Jim.  That sound always elicits a fiercely overprotective, overblown maternal response me.  Jim will tell you (as he has, unfortunately, most often been at the receiving end of my reactive fury), I turn into a demolish-the-neighborhood Godzilla type when Stella is injured in any way.  I shrieked, "What the fuck?"
"I have no idea."
"Did you pull on her ear?"
"I don't think so.  I was just grabbing at her neck."
"Well, don't do that!"
"Jesus, Beth, we were just playing."
"Sorry!  I'm sorry!  I just hate that something hurt her."

Yeah, I know.  I'm working on that.

In late October, I had found a new house for us to move into and I started packing like mad ahead of our early December move in date.  We would have the new house for two weeks before moving in so that I could clean, paint, and do the little tweaks that would make the rental our home.  That first week in December, new floors had recently been put in and they were off gassing like mad, but I opened all the windows and went to work with Stella by my side.  It was a very busy time.

When I think back now, I can not help but wonder had life been a little less hectic, would I have noticed all the little signs and seen the big picture?  Would I have recognized that when Jim was playing with her neck, he had actually pinched an incipient tumor? Would I have looked a little deeper as to why she was scratching that left side of her neck and chest, why her ears were bothering her?  For god's sake, why did I let my little girl lie in her bed on newly polyurethaned floors?!?

This sense of "jesus, we should have caught this sooner, we should have seen what was happening, we should have done something, anything, earlier" and "what did I do to cause this?!?" are apparently a common feelings among pet owners after a grim diagnosis. Many dog owners I've spoken with who are going through similar health struggles with their dogs were initially hit with an outsized sense of responsibility and guilt over their dog's illness.  When we, the people who given them their everything in life, miss some of their cues, of course we take it to heart as a failing on our parts.  In that first couple of weeks after The Discovery, I carried that lead weight in the center of my belly and it grew heavy tendrils through every moment of every day, rendering sleep difficult and eating next to impossible. The sense that I had let Stella down and would now loose her quickly colored every day like a tablespoon of ink or blood in a glass of pale milk.  I would wake up at 5am (inconceivable to those who know me), silently move to the living room (in this new, foreign house), lift the shades and watch San Francisco's night lights shimmer and wink, grief like an illness in full fever wracking my body.  I couldn't get comfortable and I couldn't find respite.

But, here's the thing.  Dogs, for the most part, carry their discomforts silently and stoically for a long time.  It's easy to see the picture on the jigsaw when all the pieces are perfectly placed, but it looks like a mess of visual noise when you first open the box.

History, Part One

We weren't in the market for a dog when my girlfriend Jen called in early 2005 to say that she had seen a poster up at the local feed store advertising a litter of yellow lab puppies.  She was finally starting to think of getting a new dog a few years after her big fluffy girl had passed away and would I want to go with her to look at the litter?  Really,  I was just going to go along as a supportive friend. Who wouldn't love to snuggle puppies, given the opportunity?

I called Jim and told him where we were headed and he responded seriously, "So, we're getting a puppy?"
"No, god, no.  I'm just going along with Jen."
"Uh-huh.  Right.  Don't you think this is something we should talk about before you go see them?  Because once you see them, we're getting a puppy."
"No.  I know The Deal."

The Deal was an agreement that neither of us (well, more specifically I) would ever surprise the other by bringing a new pet home. There would be a conversation about what a dog would mean for our family, our budget, our house. There would be advanced consent.  Jim and I both had mothers who had a history of acquiring dogs (or in my case, raccoons, pidgins, squirrels, cats, sheep) without first talking it over with their significant other and we both found the idea pretty disrespectful and not a little inappropriate. Plus, in 2005, I was still out on the road three weeks out of five and had just released a new record that looked to have long legs.  Serious changes would have to be made in order to accomodate a dog and I wasn't sure I would ever want to make them.

When Jen and I turned onto the dirt road to the house, we were met by a lean, very pretty labrador.  Sasha was a bundle of energy, barking at the car and then dropping her ball at our feet as we walked to the house.  We met Laura, who, with her husband and two daughters, whelped the puppies in the house, and she introduced us to the kids.  Holy. Moly.

I admit now, babies don't do much for me.  Yeah, your kid is cute.  Puppies, on the other hand, touch a deep place of overwhelming love in my body.  You know that scene in a horror movie where the monster is shown kindness for the first time and the cold, black heart that has hitherto sat like a dead stone in his chest suddenly and unexpectedly beats for the first time, spreading color and life? That's what seeing, touching, sniffing those puppies was like for me and as I sat with Sasha's litter I was reminded, once again, that Jim often knows me better than I know myself.

They were about four weeks old, so small and fat and doughlike, all making that high pitched squeaking sound puppies make before they develop their bark.  They desperately wanted to get at Sasha, who evaded their little squirming bodies while continuing to drop the tennis ball on my head from above.  One of the boys peed on me while another, a girl, chewed through my sweater.  Another made little, tiny teeth punctures in the skin of my hands. We talked with Laura, who really took the time to get to know us, to see if we would be good people for her little ones.  I insisted that I was just there to support Jen, but I am sure abject desire was written all over my face.

Sasha and her puppies in the whelping box

I returned to see the puppies twice more, once with Jim and then once alone.  Laura was amazing, teaching them "outside" and housebreaking them at an impossibly young age.  They followed her around like she was their pied piper and they were happy, playful dervishes.  It was a strange sensation to suddenly not care if I ever traveled again, if I ever got another standing ovation or even made another record.  I wanted to bring one of these little balls of soft yellow fur into our home and I knew, deep in my bones, that she would make us a family.  I wasn't the kid in college who had a dog, the first in your group of friends to try out that responsibility (as someone who, at 18, sometimes struggled just to get fully dressed and fed, those people amazed me).  This was very, very new.  Maybe that's what it feels like to discover you want to have a baby, be a mother, raise a person, step out of your own, narcissistic role as the sun and dedicate yourself to another living being.  Maybe it's just that the objects of my maternal drive have four legs instead of two and you can crate them when they behave badly.  I hear CPS looks down on that with regular kids, but what do I know?

In the end, Jen didn't end up taking one of the puppies, but Jim and I did.  Our puppy was the last to leave her family because I was still madly working my way through a long planned midwest tour when she turned eight weeks.  She cried on my lap the entire ten minute drive home and then cried non-stop in her crate that first night, shocked by being away from the only family she had ever known, desperately lonely without her mommy and sister Sunny (who remained with Laura).  I cried most of that first morning out of sheer exhaustion.  We were quite the pair.

Jim and I chose the little yellow girl with the cowlick ridge down her nose and chest, the one with the outrageously expressive eyebrows and no trouble with eye contact. We named her Stella, looking forward to opening the back door and, a l a Marlon Brando, screaming, "Stella!" (we're dorks, whatever) And just as I thought, her presence brought Jim and me closer, turned a newly purchased house into our home, and made us the family that I always quietly hoped, but never dared imagine, I would have.

Stella's first day at home with us

Harbinger: 2009's Mast Cell Tumor

WARNING: This post contains graphic photographs of Stella's surgical incision.  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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We were fairly shocked to discover that the tiny bump on Stella's chest was not a sebaceous cyst as we had initially been told, but actually a mast cell tumor.  Stella was immediately scheduled for surgery a few days later and we started her on 20mg pepcid, a Histamine-2 blocker, and 50mg Benadryl, the traditional antihistamine.

Honestly, back in that little examination room, when Dr. Stacy started telling us about mastocytoma, I utterly checked out.  I'm sure I had a serious look on my face and nodded along at the appropriate times while she spoke, but I did not hear a word she said. All that echoed through my brain was a chorus of "CANCER! CANCER! CANCER!" I very quickly became useless as a functioning advocate for Stella and am so thankful that Jim was in the room, because as we were walking out of the vet hospital, I turned to Jim and said, "Jesus fucking christ, Stella has cancer.  Our little girl has cancer."
"She said it is very small and looks as if she'll be able to get all of it."
"Stella has cancer."
"Beth, Dr. Stacy is going to remove it and that will be that."
"What?"
"It's small and it's been there a long time, so she doesn't think it's aggressive."
"When did she say she doesn't think it's aggressive?"
"Five minutes ago."
"Really?"
"Really."
"Oh..." And then I burst into tears out of relief and sobbed so hard I gave myself a nosebleed.

We took Stella home, loved her up, and walked the hell out of her down by the duck pond (Sea Squirrels!).  She was dopey from the Benadryl, but seemed no worse the wear, and when Tuesday rolled around, we skipped her breakfast (the horror!) and brought her over to Village Vets.  When I handed her leash over to Kat, I once again burst into tears (by this time, they were very used to this behavior on my part).  I know, I know, you're not supposed to do this, as it stresses out your dog, but Stella's a lab.  She'll happily skip off with whomever is holding her leash, and that morning was no different.  She didn't even look back.

I was amazed to discover that Stella wouldn't even have to spend the night and that we would be able to pick her up that very evening.  The year before, out of the blue at the age of 5 1/2 (well out of her puppyhood), Stella ate two stuffed toys and required gastrotomy surgery to remove the two plus quarts of stuffing and toy fabric. Village vets kept her for three nights as a precaution.  This surgery couldn't be too bad, right?

When we picked her up that evening, Stella was pretty much whacked out of her mind and beside herself with discomfort.  Not pain, per se, but obvious discomfort.  Stella, we would learn, gets a truly dysphoric response to opiate pain killers.  Unlike, say, her mommy, who on narcotic pain meds gets all warm and fuzzy and happy and blissed out, Stella wants to crawl out of her skin.  I helped her into the Egg, and she cried the entire way home.  Once home, her big black pupils dilated to full tilt boogie, she wandered around the house, making the most pitiful noises.  I went into a panic, my belly turning over, but Dr. Stacy told me not to worry, that she would snap out of it as the pain meds wore off (anyone ever take just a leeeetle too much acid back in the day?).  I then worried about her being in pain, but this didn't end up being the case.  Once the fentanyl wore off, she was a little slow, but back to being the Stella we knew and loved (who wined for food and walks and balls and squirrels).  Within a day, Stella had bounced back from the surgery and acted like nothing had ever happened.  She never bothered her incision and we gave up on the inflatable donut collar within a few days (it was resting on the top of the incision, aggravating it).  Her resilience was astounding.

Stella in her blow up donut collar (much better than the cone of shame)

Now, ready to see the incision?  It's a doosey!

Even though the tumor, on the surface was pretty teeny, the trick to a successful excision surgery is making sure one doesn't leave behind a single, microscopic cancer cell.  The only way to do that is to also remove a certain measurement of unaffected, healthy tissue from all sides of the tumor (called "clean margins").  Leave a single malignant mast cell in place and that one tiny fucker will replicate and start the process all over again.  Dr. Stacy said she was able to get wide, clean margins (+5cm) from all angles except for the behind the tumor, where she ran up against the chest wall (1mm).  When the pathology report was returned the following week, it showed that all margins were good and clean, so Dr. Stacy was confident she had removed it all safely.

So, what did the pathology report show?  It was, indeed, a malignant mast cell tumor, but it was a graded as a low 1, non-invasive, and had a 0 mitotic index (please see the glossary of terms for explanations).  Basically, if you had to have a mast cell tumor, this was the best possible type to have.  Dr. Stacy said that was probably it for treatment, that it was considered "cured", but to keep an eye on the incision site out of caution, because that would be where another mass would turn up if there were any cells left behind.  For the next two years, I continued to run my finger along her incision scar and we brought her in every time a new lump or bump showed up (and she was really starting to collect them by 7 years old), but they were always benign lipomas (fatty tumors).  I blithely believed Stella was in the clear and put the whole concept of mastocytoma behind us.  Lalalala!

Prologue: Part Two

Two days later, Stella, Jim, and I, still exhausted and a little manky from the drive, all crowded into the examination room at Village Vets of Decatur.  Dr. Stacy Stacy (yes, a woman named Stacy married a man whose last name is Stacy) examined Stella and let us know that she didn't feel anything unusual in Stella's anal glands. It was a false alarm!  I burst into tears and Jim hugged our yellow girl (who squirmed and protested).  But when I pointed out that her sebaceous cyst seemed a little red and crusty, Dr. Stacy immediately said, "I don't like the look of that."  She carefully did a fine needle aspirate biopsy, just a teeny prick of the bump, and took it back to do a stain.  We waited, confused by the ricochet of concern, relief, and concern.  Stella had had this bump for more than two years, probably closer to three.  The first vet we saw back in 2009 said it was a sebaceous cyst, nothing to be concerned about.

When Dr. Stacy returned, she said the stain showed signs of mast cells, a strange presentation (this would come to be a recurring theme), but certainly mast cells and that it was, in all likelihood, a malignancy.  We wouldn't know for sure till it was removed and it needed to be removed as soon as possible.  I had been reading up on adenocarcinoma compulsively for 72 hours and in a split second, I felt my perspective shift like a twist on a rubik's cube.  Not the dreaded adenocarcinoma, that's good, but now we were dealing with something called a mast cell tumor.  Either way, Stella had cancer.

If you're reading this now, chances are your sweet dog has been diagnosed with a mastocytoma or mast cell disease.  Like me, you probably went to the intertubes and discovered reems of vet info on the disease, tons of pharmaceutical promotional materials, hundreds of frightening medical studies, a handful of canine cancer support messageboards (the dearth of which still surprises me), and just a few personal blogs charting one's experience with the course of this cancer.  Mast Cell Disease is a frustrating diagnosis because it truly is the chameleon of cancers.  According to DVM360, mastocytoma is the most common dermal malignancy in dogs, but it can look and act radically different from dog to dog.  One dog can live for years after simple surgery, yet another dog will immediately develop another tumor and perish rapidly.  Sometimes dogs grow only small dermal tumors that never do any damage at all and can be removed without incident like an on-going game of whack a mole.  Other times, rampant mast cells invade lymph nodes, metastasize into the spleen, and wreck havoc on a dog's vital organs.  In some dogs a mast cell tumor can sit quietly for years.  In others, a single tumor degranulates out of the blue causing irreparable shock.

The treatment choices are many, from fairly inexpensive to budget busting (we joke that we should keep our credit card in a holster) to downright lifestyle changing (I discovered I really don't care about having cable tv or eating out as long as Stella is ill).  There are specialists that can be seen: internists, surgeons, oncologists, radiologists, nutritionalists, naturopaths, acupuncturists, palliative care vets and, sadly, the doc who may specialize in euthanasia (if you want to have those last moments at home).  Sometimes this can involve traveling to other hospitals, or even a far off teaching hospital (many states have a university vet school where speciality clinics are used as teaching facilities).

There are choices to be made that are heart wrenching, but necessary, and everyone has to make them based on very personal criteria.  How much money can I spend on my dog's treatment?  How much treatment do I want to pursue?  When is enough, in the end, enough?  Should I home cook for my dog?  How much time can I take off from work to make the 200+ mile round trip drive to the vet teaching hospital for diagnosis and treatment?  Can I bear to watch my beloved dog endure short term discomfort for long term survival? How much does the three week course of daily radiation cost?!? If I choose one chemotherapy over another, will I decrease the chances of her surviving? How much diarrhea can I handle cleaning up off the rug?  Am I making the right choices?  Jesus, are my choices making this worse for her?  Is today her last day?

Five years after first feeling that curious little bump, for the benefit of Stella's wellbeing and much to the potential annoyance of every vet and specialist we cross paths with in the Bay Area, I have learned to be persistent, to take notes and have my questions ready.  I have learned to not just passively take all the information given in the hope that I am being a compliant and easy going doggie mommy, but to engage my vets and use up every second of my scheduled time to be sure my concerns are addressed.  When your loved one's health (or your own, for that matter) is critical, no question is to stupid to ask and understanding the ramification of every surgery, drug or procedure can demystify the entire, overwhelming process.  No one knows Stella better than Jim or me.  No one will fight harder for her than we will.

Today, in the end of May 2014, we are still neck deep in the weeds.  Early crises (I'll get to those later) have, thankfully, passed but Stella's fight continues and she has already outlived her initial prognosis by a few months.  Some days my anxiety over her illness threatens to demolish the slender peace I have grown from uncomfortable seed.  Some days a whole new cancer related health issue pops that has to be addressed with swift determination (I am still not sure how best to feed her in a way that will diminish her gastric discomfort).  Other days, Stella seems just like Stella.  She may be a little slower, more inclined to nap, but she still positively lives to eat, pulls the entire walk to Blake Garden, obsessively checks each and every gopher hole and freshly turned up dirt pile, chases bad squirrels, barks at the mule deer, and fills our life with so much joy.  Today, at the very least, Stella is happy, hungry, and, most importantly, comfortable.

So, I'm here on the interweb to document what we've experienced, what are still experiencing, in the hope that if you are going through this cancer fight, you know there is someone out there who has experienced something similar and that you are not alone.