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. 

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.