samedi 17 juillet 2010

ENVA d'Alfort, Day 6, An education I don't want

Sam joins me

Today was harder. Baccarat seemed a little sadder, but maybe that is only because I might be. Perhaps she was the same. They always ask me how I find her each time I visit with her; some days (I can say that now; it has been a week that she has been hospitalized), she seems more perky; some days, she seems deflated, resigned, sad.

Or, that is I who feels that way.

It's the wait now that is hard. I can see that now. In the early part of the week, we were busy. We were busy with the first echocardiograms and sonograms, blood tests and x-rays. Then, I was busy calling pharmacies looking for Fraxiparine (a form of Heparin) and going to get it. Then, I was busy getting Rapide's blood drawn and taking it to the lab out here for the D-dimer test. And, finally, I was busy waiting for the results of all the tests, busy being with Baccarat when I could, or driving to and from the CHUVA at the Ecole Nationale Vétérinaire d'Alfort (l'ENVA d'Alfort).

Yesterday, we learned that there is certainly a tumor under the 5 cm blood clot clearly visible in the right atrium, or l'oreillette droite, of her heart.

At its size, it fills the chamber, and it protrudes through the tricuspid valve into the right ventricle, as well as nearly covering the valve of the vena cava, from which blood returns to the heart to be pumped to the lungs for oxygenation before being returned to the left heart to be pumped into the body. Watching the images on the echocardiogram machine, you can see that there is still blood flow, but it is severely restricted through the tricuspid valve, with some blood backing into the vena cava when the tumor shifts toward the valve. Baccarat is fatigued from a lack of oxygenation, and this is why she cannot walk very far at any time, and shouldn't. Calm and rest are the best thing for her, as well as staying cool, so that the demands on her heart are kept to a minimum. It looks like depression.

Now I think of all those days before she stopped eating, when I called to my husband or Sam to come see how cute she was, appearing to deal with the terrible heat with grace, when she was actually suffering from a tumor of the heart. It wasn't cute at all. It was the earliest signs of what could be a hemangiosarcoma, the least cute thing imaginable for a dog. Since there is no question that there is a tumor, the best we can hope for is a hemangioma, the non-malignant form. If it is an hemangiosarcoma, they will close without removing the tumor because it is an highly aggressive, high-grade soft tissue sarcoma that metastasizes very rapidly throughout the body, attacking the blood vessels. According to the Canine Cancer Awareness Organization:
Hemangiosarcoma is insidious, as it attempts to build it's own blood vessel network, making blood blister like formations which disrupts normal organ function. It is commonly in the advanced stage before detection, making it virtually a silent killer.

It's once you know your dog has a heart tumor that you know the signs that would have helped you help your dog much sooner had you known them, but you must forgive yourself because it is rare. It is especially rare in 4-year-old Labrador Retrievers, although their cousins the Golden Retrievers and German Shepherds are the two breeds most likely to develop this kind of cancer.

I asked before Sam and I left today if I had understood correctly that if the biopsy shows the tumor to be malignant that they simply close, leaving it in place. The young student, who is usually as quiet as Sam can be, spoke. He told me that it is the case because it metastasizes so rapidly and is not considered treatable. They can try chemotherapy, but in most cases, it will not save the dog.

"Et, ça, cette forme de cancer, elle s'appelle comment encore?" He answered me, but I couldn't retain the word. I was embarrassed. It happens when I don't actually want to be having to hear something. A friend who is a breast cancer specialist tells me this is typical; they know that as soon as they say "cancer", the patient can hear only 1 of 5 words. She modulates the way she speaks to help the patient hear and retain more. I had to ask again and force myself to pay attention to the reply, begging my brain to remember.

"Hémangiosarcome, si c'est malign. Hémangiosarcome. C'est rare."

I only remembered that it began with "h" and ended in "sarcome" by the time we were out on the street. It was alright. I had understood enough, I have a doctor at home to ask, and Google. I could find it again, now that I knew what to look for, and it turned out to be an education I wish I never needed.

According to the information on the Canine Cancer Awareness Organization's site, which cites current clinical studies at The Animal Cancer Center at Colorado State University and The University of Pennsylvania, Department of Clinical Studies, there are three types of hemangiosarcomas, dermal, hypodermal and visceral, with the type where tumors form in the heart or on the spleen being visceral, or the most lethal form of hemangiosarcoma. Again, from the CCAO site:
Visceral Hemangiosarcoma accounts for 2% of all reported malignancies and up to 5% of all noncutaneous tumors in dogs. Although these numbers seem small, they have a significant impact on dogs, since this form of cancer kills. The spleen and the right atrium of the heart are the most common sites of occurrence of visceral Hemangiosarcoma. Dogs may have nonspecific signs such as lethargy, loss of appetite, weight loss or more specific signs such as difficulty breathing, pallor, or abdominal fluid. Regardless of the site of origin, visceral Hemangiosarcoma is locally invasive and highly metastatic. Up to 25% of dogs with splenic Hemangiosarcoma have cardiac Hemangiosarcoma and up to 63% of dogs with atrial Hemangiosarcoma have metastatic disease. Metastases commonly affect the lower mesentery, lungs, and brain.

This was terrifying to read. Baccarat's tumor is in the right atrium, although the spleen, or la rate, is normal without any sign of metastases at present. She had all of the nonspecific signs of a hemangiosarcoma except the pallor. When she was first seen at our nearby clinic, the vet found her pale, but by Monday, the vets at the CHUVA did not, and they still do not, although they check her gums regularly. Her lungs also do not show signs of metastases. Her brain has not been scanned. She could, nonetheless, not yet have developed metastatic disease. I turned to my husband, who was stretched out on the sofa, his back in an analgesic position, watching the Tour de France.

"C'est difficile à penser que la tumeur ne soit pas maligne quand tu lis sur le hémangiosarcome," I said.

"Ca n'a pas l'aire bon," he replied. I nodded and looked back at the computer screen, scanning the words for something that said "bénign". There was nothing. I Googled benign heart tumors, and I found information on myocardial tumors on
Myocardial tumors refer to tumors that specifically affect the heart. These types of tumors are rare, and when they do occur, they tend to occur in older dogs. Benign tumors are masses of tissue that do not metastasize, whereas malignant tumors metastasize throughout the body. Abnormal tissue growth arising from the blood vessels in the heart can be malignant, as with hemangiosarcomas — rare, rapidly reproducing tissue growths; or they may be benign, as is the case with hemangiomas — harmless growths consisting mainly of newly formed blood or lymph vessels.

"Il y a aussi des hémangiomes," I said to my husband. "C'est la forme bénign, et ce sont des masses faites des vaisseaux sanguins ou lymphatiques récemment formés, mais dans l'atrium, c'est peut-être plutôt un myxome à ce moment-là. Ca existe aussi, et les symptoms sont pareils."

"Même l'amaigrissement?"

"Oui, car il y a aussi un manque d'apétit." I returned to reading the first site. "En plus, il y a plusieurs signes qu'elle n'en a pas. Avec un hémangiosarcome, l'ascite à la même apparence que le sang, et la liquide dans son ventre c'est du sérum, plutôt taché du sang. En suite, c'est souvent accompagné par un coagulation dissimulée intravasculaire, ou CDI, ce qu'on vient d'apprendre qu'elle n'a pas avec le D-dimer. Aussi, son sang coagule normalement tandis que le sang dans le cas d'un hémangiosarcome ne coagule pas. Elle ne sagne pas visiblement non plus, comme du nez, par exemple. C'est peut-être bénign après tout, et elle est si jeune," I added, hopefully.

"Peut-être," he said, before drifting off to sleep, while I continued to read, trying to convince myself that her chances were as good that it was benign as that it was malignant from all the things she doesn't have, such as liquid in her abdomen that looks like blood, a blood disorder called disseminated intravascular coagulation (DIC), which did not show up from her D-dimer results, blood that does not coagulate (they found her coagulation rate normal last evening), and no visible bleeding, such as nosebleeds. And she is young for a malignant cancer, they say.

Before I left her with the two students, who were preparing to take blood again, the young woman told me again that they are doing everything they can to move up her surgery date from the 27th to next week. It all depends on being able to get the person who runs the cardiopulmonary bypass machine, which are "pumps are operated by allied health professionals known as perfusionists in association with surgeons who connect the pump to the patient's body." See Wikipedia, Here in France, a perfusionist is called a "pompiste", and there are few of them to begin with, but particularly few available in the vacation months of July and August, with the first availability being July 27th.

I suppose the only way they can move the date up is to beg someone to make him or herself available when they are already fully booked, which I hope the surgeon and the veterinary cardiologists can succeed at doing. It is especially hard when they cannot charge for their time. They are doing this for the glory of clinical science and from their humanity.

Baccarat needs them now, but she will wait patiently, if she must. But, she is getting depressed, as kind as and attentive as everyone treating her is, and as much as we go to spend visiting hours with her every day they have them. It's hard to be in the hospital, away from everything and everyone you know.

Hang in there Baccarat. Nous t'aimons si fort.

When we left, Sam was hungry. I was, too. If Baccarat didn't want her "very appetizing pâté", we wanted something.

"I think there are some brasseries that way," I said to Sam, pointing across the avenue Générale de Gaulle, towards the grocery store, where I had done my shopping the other evening. Sam looked off down the avenue.

"There's one there," he said. "But, there are probably nicer places in Paris." I thought about getting back on the bike and heading into the city for lunch, which would be nice, and then I thought about Audouin, waiting for us at home. "Wait, we're where? On the southeast side of Paris?" He shook his head. "There's not really anything there."

We crossed the avenue and passed an animal supply store and the post office, turning in to where the grocery store is.

"There's the Casino."

"Do you want sandwiches or something there?" I asked, not trying to sound enthusiastic and glancing around for signs of the village center and a place to sit down for lunch.

"Not really."

I turned left onto a road that branches off the traffic circle at the entry to Maisons-Alfort, and we walked along, past a fruit and vegetable stall, a boulangerie all in pink, with tables on the sidewalk, and on under the train overpass, past some sort of restaurant, Japanese I think, closing for renovations, and on a bit farther, scanning the storefronts and awnings, the street signs, looking for signs of something promising.

"Mom," said Sam, interrupting my search. "Where are we going?"

"I don't know, Sam. We're looking for where the shops and cafés are. There must be some." I looked across the street, and there was a wine bar ahead, and some tables set up on the sidewalk, the storefronts set back from the sidewalk. "Like that, there's something there. What is it?"

We saw the word "bagels" at the same time, and Sam grinned.

"We'll go there?"

He was already crossing the street, toward bagel, ham and cream cheese sandwiches, Vitamin Water, milk shakes and cousins of Frappucinos.

"Who'd have thought a place like this would be here, in Alfortville?" he mused, reading the chalkboard menu on the wall.

"See, Sam," I said, "sometimes you don't know where you are going, and then you find what you would have been looking for, I mean, if you knew it were there."

"What's pastrami?" he asked. I realized we'd been away from New York for a long time and explained. He listened and decided on the ham and cream cheese.

We sat, alone, up in the mezzanine at the rear of the shop, Sam still feeling chilled from the ride in, and probably the emotion, the unseasonable temperatures in the 70s, a breeze, and maybe from being hungry.

"I haven't had cream cheese since we went to London," he said, chewing his sandwich.

London. That was a little more than 2 years ago. I nodded, trying to remember where he'd had cream cheese, but he interrupted my effort to remember, saying, "Maybe I'll go to New York after my license, Mom. I can eat food like this, get to know the art world there, and work on my photography full-time, get a job at Element. If it doesn't work out, I'll do my law degree."

"Don't you eat that stuff when you go to that American restaurant -- what's it called? And aren't there bagel and cream cheese places all over near your old school?" Of course there are, but they aren't on every street corner, everywhere you look, whenever you happen to want one. "And, you know, they have bagels in the Marais, the authentic Jewish bagels."

"Yeah, but they're braided and have poppy seeds." His attention was back from NYC.

"They probably have plain ones, too. Or at least just with sesame seeds."


He's still a New Yorker somewhere in his soul, and bagels are always in NYC, where they are everywhere, anytime you want one, with whatever you want on it, where they were when he was a child. Anywhere else, well, they're a reminder, a symbol for what they are: part of an unretrievable past. And when we understand that the past is unretrievable, we may chose to understand that the only thing left it to greet the future and live today.

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