Page last updated: 7/16/05

RECOMMENDED FOLLOW-UPS, RADIOLOGY TESTS / IMAGING STUDIES, OTHER DIAGNOSTICS FOR ACC PATIENTS

A) Introduction:
Due to the propensity for acinic cell carcinoma to recur or metastasize (grow in a different area from original tumor site), we strongly recommend a vigilant program of follow-ups and diagnostic tests for all acinic cell carcinoma patients. The need for this vigilance increases even more with a history of:

a. large primary tumor (2 cm. or larger) before removal
b. multiple primary tumors
c. insufficiently removed primary tumors
d. tumors surgically removed without adequate “clean margins”
e. any noted or suspected residual disease
f. presence of tumor in lymph nodes or blood vessels
g. any known or previous (local) recurrences
h. any known or previous metastases (distant/distinct sites from primary tumor site)
i. diagnosis of high grade variety (often indicated by poorly differentiated/ undifferentiated pathology results, but also by noted speed of progression)

The final item on that list indicates a MUCH more aggressive form of the cancer, and requires IMMEDIATE and AGGRESSIVE treatment. The low grade form of ACC is less aggressive in terms of speed, but still has great likelihood for recurrences or metastases, often MANY years later. Recurrences 20-30 years after primary tumor removal are not unusual for this cancer. Recurrences after 5 years are common. These facts often go unrecognized in the literature, and the persistence of this cancer is often underestimated.

These tests/exams also NEED to be done for FIRST TIME patients, around the time of primary tumor diagnosis, or soon thereafter, to insure that there are not already other tumor sites. It is not unheard of, especially for the high grade strain, for there to be multiple tumor sites diagnosed at same time as primary.

While we are recommending a vigilant program of follow-ups and diagnostics, we also want to take note of a couple of concerns or challenges which may affect the specific timing and choice of tests:

1) There are treatment methods for dealing with ACC tumors. But the conventional methods are essentially focused on local control of that specific tumor site. At this time (6/05) there are no curative systemic (whole body) treatment options. Some physicians would argue that doing frequent radiology testing (and therefore potentially diagnosing tumors early) will have little impact on long term survival in most patients. We at ACCIC however feel that early diagnosis of any tumor sites at least gives one the opportunity to treat them when they are smaller and less advanced. AND, we feel that the quicker you control tumor sites locally, the more you decrease the likelihood of future recurrences or metastases. Larger more advanced tumors are both harder to eliminate, and have more likelihood of recurrences and metastases. So we stand behind our suggestions for routine diagnostic testing (“surveillance”).

2) At this point in time there are numerous Radiologic (and other diagnostic) exams which can be ordered with the intent of finding cancer sites, or noting changes in previously known ones. These tests use different technologies, some of which are better at finding things in different areas. Some of them are also less likely to find smaller or low grade tumors, which is often how ACC starts out. Often one test will see certain things, and another test will see other ones. And sometimes there are false negatives and false positives. This can lead to the suggestion that a cancer patient should get LOTS of different tests, to cover all the bases. But many physicians will be reluctant to order too many tests, which have similar purposes. The financial and insurance aspect may be a part of this as well. And the patients as well may be reluctant to request too many tests.
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We at ACCIC feel that there are some tests and exams that should be done for (essentially) all ACC patients on a regular basis. But there are others where the individual aspects of the case (and the patient) can affect the choices of which tests to run and when to run them. There are also aspects of technological advances, and test availability in your geographic location that play into these choices. We have tried to give you enough information below to help you make informed decisions in this area.

B) Standard Follow-Ups and Radiology Exams should (or could) include the following:

1) Physical exams of head and neck area by oncologist or ENT/Otolaryngologist (assuming primary site was in parotid gland, or other head and neck site.) To check for possible recurrences. Usually also includes visual exam of throat.

2) Physical exams (if possible) of any areas where there were previous cancer sites. To check for possible recurrences.

3) Blood Tests: These are usually done at every follow-up (depending on your frequency of followups). They should include things such as White and Red Blood Cell Counts, Platelets, and a "Metabolic Series", including things like Bilirubin, Calcium, Glucose, Cholesterol, Creatinine (among others). These are not cancer specific tests. But they are run to make sure that your basic organ systems are operating. Problems found may or may not be cancer-related. There are a number of “cancer series” blood tests your physician can order as well. Different hospitals or doctors may have a different series they want to run. These tests may be used to detect a couple of general categories of abnormalities . The first category is “tumor markers”. These are substances which can indicate presence or activity of certain cancers. While there are some markers which are highly indicative for certain cancers, there are no specific tumor markers for Acinic Cell Carcinoma. There are some markers which could potentially indicate presence of the pancreatic or breast cancer versions of the cancer (or perhaps ACC in other organs). And they could indicate if a cancer is growing or regressing (such as AFP levels for pancreatic cancer.) But they are not ACC specific markers. The second way that a blood test can indicate cancer (or increased cancer growth) is by finding abnormalities in the body CAUSED by cancer or tumor presence, or growth, and its’ affects on bodily functions. The blood and metabolic series I described first could find an indicator of those kinds of problems. They can also help indicate cancer REGRESSION. Another VERY important role for blood tests is to indicate problems caused by treatments or medications. It is important to monitor patients for possible side effects caused by the treatments themselves. The blood tests can also show improvements/changes in those side effects. These types of measurements are critical during treatment periods.

4) Urine Tests: These are not generally part of an ACC patient’s standard follow-up. But they may be ordered by your physician(s) to check your general health, or to look for similar kinds of “markers” as found in blood tests. Sometimes a urine test may be ordered to see if you express certain abnormalities that might make you eligible (or not) for certain cancer treatments.

5) MRIs and/or CT Scans of Prior/Current Tumor Sites:
(Magnetic Resonant Imaging and Computed Tomography Scans)
If you have had a tumor in a specific area, you will usually get follow-up radiology studies of the area in question. This will usually be done both prior to and following surgery, radiation, chemotherapy or other treatments. These studies are then run at different intervals, to determine if a particular tumor has grown, decreased in size, recurred, etc. The timing on these scans varies, depending on the case specifics. If a tumor has been treated, seemingly successfully, you will probably run an MRI or CT Scan of the area initially every 6-12 months. If there is active disease, three month intervals (or less) are more likely. After some period of cancer control, the frequency of these site-specific follow-ups will likely decrease.

MRIs and CTs each have their advantages and disadvantages. MRIs generally image soft tissues better than CT scans. But CT can see details of bones better. MRIs may show more details in general, but not in all cases. The MRIs (usually) take longer to run, and therefore patient motion can distort results. So for example, MRIs are not as good for lung tumors, due to patient breathing and heart movement. (Newer MRI machines are faster, and so this may become less of a consideration in the future.) MRIs also show interference from metal objects (such as orthopedic hardware). There are other variables such as tumor type and tumor location (or surrounding tissue), which determine which type of test is specified.

There are also some safety issues in making the choice between MRI and CT. MRI is generally considered a safer modality, having to do with both the imaging system itself and the intravenous contrast agents sometimes used. We explore this in more detail in the “Whole Body Screening” section below. In the case of individual occasional studies done to evaluate tumor change or possible recurrences… we do not feel that the safety factor outweighs any considerations for diagnoses. One should choose the study (or studies) that will give you the most reliable diagnostic answers.
These two imaging tests (MRIs and CTs) may each be ordered in different situations. Sometimes both types of study are ordered.

6) Studies of the Chest/Lungs:
Lungs are one of the two most likely locations for metastases for this cancer. This is much more likely for the high grade/aggressive variety. But if someone has low grade ACC with higher risks for recurrences, or with previous metastases, the lungs are at significant risk for involvement as well. We at ACCIC DEFINITELY recommend periodic radiologic chest studies for all ACC patients. But with regard to exactly which imaging methods and when, there are some details to be aware of and consider.

6A) Chest X-Rays: We had been recommending every patient who has had Acinic Cell Carcinoma get a chest X-Ray at least once a year. This was also based on widespread recommendations among physicians for a long time. However, we now have considerable evidence that Chest X-Rays often/usually do not show early stage or smaller tumors, low grade or low metabolic activity tumors (such as low grade ACC) as well as tumors hidden behind the heart. They likely will show up more advanced/larger tumors, or high grade versions of ACC, but that is not 100% certain either. If it is determined that the lung tumor(s) you have are visible on chest X-Rays, and they can be used as a reliable method of evaluating growth change, then they may be utilized. They also may be utilized in some cases to monitor NON-CANCER lung disease or pulmonary problems, perhaps related to the cancer. Otherwise, for routine “surveillance” for ACC patients, they are probably a waste of time and money in most cases. Certainly they are not a good choice for screenings or surveillance for early stage disease. Instead...

6B) CT Scans of the Chest (with contrast) are clearly a more sensitive test to diagnose lung nodules/metastases, especially small or early stage tumors and low grade or low metabolic activity tumors (like low grade ACC). There have also been advances in CT technology, so that some machines/methods are even better than others. This includes both spiral (or helical) scans and multislice CT or multidetector CT (MDCT). These machines have better chances of diagnosing small tumors. At this time we are recommending periodic CT SCANS OF THE CHEST for all ACC patients, and most especially patients with higher risks for metastases. In most cases, this would be once annually.

There are some other imaging options of WHOLE BODY/FULL BODY tests that may diagnose these kinds of tumors. Chest/Lung CT scans could possibly be part of a Whole Body series, instead of being run separately. (See Whole Body section below.) But, one needs to be sure that IF a whole body study is ordered, that it will give JUST AS DETAILED and SENSITIVE views of the lungs (and small low grade tumors) as the Chest CT.

There are also some other factors to consider in terms of the frequency of these tests…
As we mentioned above, there are some potential risks with CT scans, likely more so with frequent ones. CT Scans give off approximately 100 times more radiation than conventional X-Rays. That is still generally considered to not be very much radiation, but it is possible that frequent CT scans could actually induce disease. At this point data to support this is limited, but it is being studied and taken into consideration. The most significant data on this subject up until now has to do with Atomic Bomb survivors in Japan. And it is noted that cumulative exposure (after numerous radiologic procedures) is more likely to have higher risks. The risks of secondary cancer inducement are likely extremely low for the average cancer patient, but increase with repeated exposure to various tests. In most cases for ACC patients the potential benefits should outweigh the potential risks. But we do feel a responsibility to inform our readers that there may be some risks posed by frequent Chest CT scans (or Whole Body CT scans discussed below). For that matter, there are potential risks even with frequent plain film X-Rays and various nuclear medicine studies. These risks should be taken into consideration when deciding how frequently to run radiology tests. Frequency and quantity of tests should take case specifics and individual patient history into consideration. We encourage readers to do more research on these subjects, especially as more data becomes available.

As stated above, in cases with any significant chance of metastases, we would recommend annual Chest CT studies. But in other cases with good local primary tumor control, and no recurrences (for 5-10 years, depending on the case), once every two years is probably adequate. We do not want to make an absolute statement on this. SO…we recommend that the frequency of these screenings be left up to the discretion and concerns of the patient and their physicians. This should be based on a number of factors, including the individual’s cancer history, risk for lung metastases, age, general health, prior radiation exposure to chest, etc. If you already have had aggressive or metastatic ACC disease, we strongly suggest annual Chest CTs (or perhaps whole body CTs or PET/CT combos that include the chest). If there is active or previous lung disease, these studies should probably be done even more frequently, dependent on your growth patterns and treatment monitoring needs. For people with active lung tumors, or aggressive high grade metastatic disease in any location, most physicians would order studies every two to three months. In some cases, where your tumor(s) are visible by standard Chest X-Ray, intervals between 12 months could perhaps be done with those.

• Additional CT Scan Notes:
• Older model CT scanners take cuts/slices (pictures) individually. In those cases, you need to make sure that the scans are done with FINE CUTS, in order not to miss very small tumors (or small changes in tumor size or number).
• The newer generation CT scanners take images in a spiral fashion (continuous images), so specifying fine cuts is generally not necessary.
• The newest technological development in CT scanners is multislice CT or multidetector CT (MDCT). This has several more advantages, including: a) data acquisition is so rapid that the scanning of the entire lung can be performed during a single breath-hold; b) continuous acquisition of thin slices allows improvement of image quality; c) MDCT may help reduce the radiation dose to patients.
• We recommend that whenever you go to a radiology test, you bring a document for the radiology technician and reading radiologist. Among other things (noted below more specifically), this document should clearly state that “Acinic Cell Carcinoma is often a VERY slow growing cancer. Fine cuts are required to diagnose early stage tumors and changes in previous ones. ANY SMALL CHANGES OR SMALL POSSIBLE TUMORS ARE RELEVANT.” This note is applicable for ALL imaging tests.
• If you choose to do annual or periodic WHOLE BODY CT SCANS or COMBINATION PET/CT Scans (discussed below), that would likely rule out the need for separate Chest CT Scans (or Chest X-Rays for that matter). But you need to determine if the lungs are viewed in as much detail as possible. If not, then you may want to do the additional separate Chest CT.
• Whole Body tests in most cases will not give as detailed/reliable views of specific areas. But the technology is improving, and certain machines may. The important thing is to make sure that lungs are viewed in as much detail as possible. And to choose the test(s) that will give you that result.
• It MAY be that in the near future Whole Body MRIs (see below) could also replace the need for separate spiral Chest CT scans. We do not have data to support this yet.

6C) MRIs of the Chest (or Whole Body MRIs):
Up until now, MRIs have NOT been considered the best tool for diagnosing lung tumors, due to the slow speed of the MRI machine. Patient movement from breathing, as well as heart beating, results in “motion artifact” (a blurry image). There have been recent advances in MRI technology, which have also greatly increased the speed of image acquisition. The newer systems have been reported to image the entire body with good quality and sensitivity to detect disease within a 15-minute period. According to 2004 published data that includes “acceptable image quality of the lungs”. We are not sure if it is good enough to detect tumors less than 1 cm, which the CT scans CAN. And even the fastest machines still get artifacts from patient movement. Part of this is also dependent on how still the individual patient can be. There is not enough support yet to recommend MRIs for lung screenings, and certainly Whole Body MRIs are not widely used or accepted for this application. It also seems that to achieve any level of detail would require the newest “3 Tesla Magnet” machines, which are not commonly available as of 2005. But the applications of MRI are expanding, and it may be that in the not too distant future, new machines will have greater roles. These are questions to keep in mind, and ask YOUR doctors and YOUR radiologists, about the machines (and tests) available at your facilities. As time progresses, there will likely be even more advances (either with MRI or other technologies) to allow for more detailed testing, greater speed, and less patient risk. And the faster machines will be more widely available. When we are assured that an MRI of the chest can achieve the same results as CT, this may be a better (and safer) imaging test. But we certainly cannot say that is true YET (7/05).

6D) Low Dose Radiation Scans (Chest Radiography):
This is another test for imaging lungs and potential lung tumors. This may be the most detailed study currently available. However it is not widely used or available at this time. The radiation doses to patient are not much higher than for CTscans. And results are being studied. IF this test is available where you are (and covered by your medical insurance), then this is worth looking into and comparing it with CTscans, with regard to both diagnostic capabilities and radiation exposure question. You should discuss this option with your physician(s).

6E) Summary on Chest Studies: The key here is that ACC does metastasize to lungs; very often with high grade/aggressive version of cancer, and also in cases where the low grade/less aggressive type has higher risk factors (such as large primary tumor, lack of complete removal of primary, repeat recurrences or other metastases). If you have a low grade ACC case which has had multiple recurrences or metastases, or has been active in your body for 20 years or more, it is quite likely that it will eventually migrate to the lungs. Chest X-Rays are clearly not the best way to find early stage or small tumors. They should show larger tumors in most cases, and perhaps higher grade ACC nodules, but this is not certain. For monitoring changes in known larger tumors, X-Rays MAY be adequate (if they show your tumors). CT Scans of Chest in some form seem to be the most available tool for diagnosing lung tumors, at this point. (This could perhaps be part of a Whole Body Series, as described below.) But one has to make sure that if a Whole Body Scan is done, that it will provide at least as much detail (and image very small tumors) as individual “fine cut” or “spiral” CTscans. Frequent CT scans do come with some higher risk of radiation exposure than conventional plain film X-Rays. This is why it is advised by some physicians to use Chest X-Rays in intermediated studies (if needed) between (annual) Chest CTs. But it is generally accepted that risks from CT inducing cancer are far lower than the risks for potential recurrences/ metastases of a pre-existing one. The other option for chest studies MAY BE Low Dose Radiation Scans. This will likely give even greater detail, and likelihood of diagnosis of small tumors. But this is not as widely available as CTscans and is still being evaluated. MRI technology is improving and may be available in some locations where it is used in this application. But we do not have enough data supporting this application, and likely it MRIs will not provide the accurate detail of CTscans or Low Dose Radiation Scans. We hope that new developments in imaging/radiology will lead to tests that can diagnose early stage tumors of this type with more accuracy, more speed and less risks. In the meantime, get the studies you (and your advising doctors) agree are most warranted, based on your individual history and concerns.

7) WHOLE BODY/FULL BODY SURVEILLANCE / SCREENING TEST OPTIONS:
We at ACCIC generally recommend full body “screening” or “surveillance” for ALL ACC patients. (The actual correct term is “surveillance”, which refers to tests performed on people who have a propensity for (or are at higher risk for) a certain disease. “Screening” refers to detecting unsuspected disease in healthy people”. However, the latter term has grown to be used commonly for both descriptions.) The question of frequency of running these types of tests is up for discussion. In general, we would recommend ANNUAL surveillance tests for all ACC patients. But they have to be undertaken with the awareness that they may not always find everything, or be completely reliable. In general whole body screenings/surveillance are not as detailed as studies focused on specific areas. On the other hand, technologies keep improving, and whole body tests are becoming more sensitive (and quicker). We also understand that there are sometimes financial and logistics considerations. And, with some tests, there are questions raised about patient safety with frequent exposure. (These are likely very low risks, but still something to consider, especially when considering long periods of repeated tests.) There are also factors to consider related to how much treatment plan would change even if new cancer locations are discovered.

Due to all these factors, we cautiously recommend annual surveillance for all, but feel that once every two years (or maybe even longer) is probably adequate for very low risk cases. Those would include cases of SMALL (under 2 cm) salivary gland primary tumors that were completely removed without cell spillage, had clean margins, no lymph or blood vessel involvement, were only present for short period before excision, etc. Also, if those patients received post-operative Fast Neutron or Heavy Ion radiation, those same cases would likely fall into the “lower risk” category (but not completely without). Cases who had the prior risk factors but did NOT get Fast Neutrons or Heavy Ions MAY be at lower risk, but certainly at greater risk than those who had Radiation. Higher risk cases of low/medium grade ACC (larger tumors, local recurrences, incomplete tumor removal, lymph involvement, no post-op radiation or only conventional radiation) SHOULD definitely get the annual whole body surveillance. And cases of High Grade (poorly differentiated cells on pathology or obviously aggressive/fast growing clinical course) ACC should UNQUESTIONABLY get Whole Body surveillance at least once a year. (They should also get other more specific tests to cover all bases.) In some cases, surveillance may be ordered more frequently than that, depending on the aggressive of the cancer. NOTE: These are general guidelines, and express OUR OPINIONS, with a number of generalities. Each case should be considered on an individual basis.

The next question is WHICH Whole Body/Full Body surveillance tests to order. And at this time that is not as clearcut as it might seem…

7A) Full Body Bone Scans: Bones are the second most common site for ACC metastases. This is a test that we had been recommending for EVERY acinic cell carcinoma patient on a routine basis. We were recommending once a year. If the patient has had aggressive or widespread bone disease, a large tumor, or previous metastases of any type, this test is even more important (and may even be run more often). With the increasing availability of Whole Body PETscan/CTscan combo test, the Bone Scan IN MOST CASES is probably redundant. There may be a rare occasion where a Bone Scan will pick up something overlooked by PET/CT combo. This might include a relatively superficial area of bone change where there was active bone remodeling, where the isotope used in bone scan enhances this better. At this point we would say that if you are getting annual Whole Body PET/CT combo as a surveillance test, you probably do not need to get a Bone Scan additionally. The exception we would make is if the patient has already had bone metastases. In those cases, the extra test should be considered, just to make sure you are screening everything thoroughly. For other patients, IF cost is not a consideration, and you really want to be thorough and vigilant, getting the Bone Scan is essentially without risk. IF you are NOT getting annual PET/CT combos, then we definitely recommend annual Bone Scans.

Another Whole Body testing option starting to become available is Whole Body MRI. In the past, MRIs generally did not image bones as well as soft tissues, and therefore were not the best test to visualize bone details. BUT this technology is improving, and it may be that newer (more powerful) MR machines will do a fine job in this area. But this technology is not proven (or widely available) yet. You can discuss this with your local radiologist (or wait to hear more from us). IF whole body MRIs are available for you, the question needs to be answered as to whether they will provide as much detail (for small or low grade tumors) as Bone Scans. If the answer is not definitively yes, then we would still recommend ALSO getting the Bone Scans.

Bone Scan Notes: For cancer screenings, this is a whole body test to look primarily for new sites, which if found, would need to be followed up by more specific studies. The test is a “nuclear medicine” test, and involves injection of a small amount of radionuclide. A full body scan will “light up” (show enhancement of) any problematic sites in bones, not necessarily just cancer sites. If a specific area attracts the radionuclide/shows enhancement, subsequent more detailed studies (MRIs or CT scans) should be done of the area in question. There is no preparation required for Bone Scans. You will however need to arrive for the test 2-3 hours in advance. You will receive an injection, and then need to wait while it makes its’ way through your system. You will be encouraged to drink lots of fluids and empty your bladder frequently.

There is virtually no risk from this test. The radioactive isotope is eliminated from your body within 24 hours, and is not considered dangerous (although it does contain about 200 times the amount of a standard X-Ray). That sounds like a lot, but it is not enough to be dangerous to adults. Some doctors will advise patients not to have close contact with pregnant women, babies and young children until the day after the scan. You may not be able to breast feed during that period either, primarily because you would be holding the baby close. If there is a possibility you may be pregnant, you may not be able to undergo a bone scan. This is because the radionuclide could cross the placenta and affect the baby.

7B) Whole Body PET Scans: This is another full body test, and also falls under the “nuclear medicine” category. It also utilizes a radioactive isotope, with another “tracer” substance attached to it. In testing for cancer, that is FDG or fluorodeoxyglucose, a form of glucose, which is attracted to tumors. PET scans can be used to detect various biologic activities. For cancer patients, they are used to detect active tumor growth anywhere in the body. A PET scan can potentially show tumor growth before it causes symptoms, which (due to slow growth characteristics in most cases) could make it very valuable for ACC patients. It can also distinguish between live and old (dead) tumor material, as well as distinguish between “more active” and “less active” disease. However, slow growing tumors with lower metabolism are not noticed as well by PET, and specifically slow growing pulmonary (lung) nodules may go unnoticed. (See more in “Notes” section below.) In general, we had been recommending annual PETscans for all ACC patients. However, based on the fact that many early stage and low grade tumors are not seen, we are raising the question of the usefulness of this test for all ACC patients. At this point we DO feel that PETscans can be a useful tool, when combined with other diagnostics. But not used as the only method.   And now there is a new technology becoming more prevalent which COMBINES PETscans and CTscans. (See below.) That test is likely more useful for ACC patients specifically, if you can get it. We DO feel that PETscans (or PET/CT combos) are even more recommended for any patient who has had aggressive or widespread disease, a large tumor or tumors, or previous metastases. If you cannot get a Whole Body PET/CT combo, then PETscans should be run with the addition of Full Body Bone Scans, and either Chest CT scan or Whole Body CT scan (with detailed chest views). There is also now the additional potential option of Whole Body MRI to consider. If that becomes more widely available (and reliable), a PETscan in addition may still be advisable. But we do not yet have enough data to make any definitive recommendations on this.

Note: Some physicians may be reluctant to run both full body Bone Scans and Pet Scans. At this point, in our experience (if you are not running a Whole Body PET/CT combo), they are both warranted, as some radiologic studies reveal some things and not others. We definitely know of cases where PET has not seen tumors that appeared on Bone Scans or CTscans. And the reverse is also sometimes the case. However, if you get PET/CT combo, Bone Scans are seemingly not required in most cases.

Notes about PET scans:

1. PETs are not 100% reliable, but can be a valuable tool as part of a series of screening procedures.
2. It is important that PETscans be handled by experienced technical and medical personnel. While this technology has been available since about 1999 in many places, it is still more likely to be found (and executed properly) in major cancer centers or academic/teaching hospitals.
3. Due to the sensitivity of the test, the pre-test procedures for patients are very critical, and if not handled properly, increase the odds for inaccurate results.
4. Patient must obey strict dietary restrictions prior to exam.
5. Patients must be relaxed and immobile for at least an hour after injection, prior to exam.
6. Patient must urinate prior to exam, and try to empty as much urine as possible.
7. Even when handled properly, there may be false positive or false negative results with PETscans.
8. Small tumors may get undiagnosed.
9. Low grade or slow growing tumors may also remain undiagnosed until of significant size or activity.
10. Despite these possibilities, we still feel this test can be an extremely useful tool for cancer patients and physicians (in conjunction with other methods). One can potentially catch any new tumor growth anywhere in body early, before it starts causing symptoms, And the PETscan can point the radiologist to suspicious areas that might otherwise go unnoticed. It also can be valuable in evaluating whether a previously known tumor is showing more or less activity after treatment.
11. IF you do get PETscans: Any areas of suspicious “increased uptake” should be treated as possible cancer locations, and more definitive radiologic studies (or other diagnostic tests) should be done of those areas. If you get a PET/CT combo, then the CT is evaluating those regions at the same time. You may still require some other studies, but the CT will give more data immediately.
12. The radiation dose from PETscans is equivalent to about two X-rays. The isotope is quickly eliminated from your body, and is reportedly not dangerous. To be safe, it is recommended not to get too close to infants or pregnant women for a few hours after scan. It may be that pregnant women should not get PETscans. But ask your physician or radiology department.
    
    7C) Whole Body CT Scans: This is recently becoming more available, and could in some cases be a better choice than PETscans for whole body diagnostics. (They both have their benefits.) Whole Body CT can give detailed views of the entire body.  And the newer machines can provide even greater detail, with shorter scan times (and therefore lower radiation exposure).  PROS: It can detect small tumors throughout entire body (although it MAY not find them all). CONS: It does not specifically target tumor metabolism. It gives a fairly high dose of radiation to entire body, and there are potential risks associated with that (although they are likely very low). But this factor can affect the frequency you want to run this test. In any case, there is now a new radiologic option that may be a better choice than Whole Body CT alone…
    
    7D) Combination PET/CT Scans: A relatively new application of previous technologies, and becoming more widely available. This may be the most advantageous whole body screening for ACC patients at this time. It gives the benefits of searching for tumor metabolism combined with the more precise scanning of the CT. AND, if there is a questionable spot found with one technology, it can immediately be compared easily with the other one. (Separate PETscans and CTscans are harder to align and compare.) There is data to indicate that the combination technology can identify tumors much smaller than those identified by CT alone. It has been known to detect tumors as small as 2mm in size. Early data also shows that a PET/CT further improves the possibility of discriminating between a benign process and cancerous tumor. However, with the full body CTscan you are still facing the higher radiation dosages. We have given some guidelines about recommended frequency earlier. Based on those, the choice of how often to run these diagnostics should be made on a case by case basis. This test would replace separate Full Body PET Scans or CT Scans, and in general replaces the need for a separate Bone Scan (see details under Bone Scan). And it would replace a separate CT of the chest (as long as you make sure they are getting good detailed views of lungs). This is probably the best whole body screening test available at this time. However: It is still not widely available. And, because it is a new test in most places, it may not be covered by your medical insurance. There also is another Whole Body surveillance test which may be available soon, and worth considering…
    
    7E) Whole Body MRIs: This is recently getting to be more seriously considered as a Whole Body Surveillance Test for cancer patients. Higher power machines (with stronger magnets) are slowly becoming more prevalent. And a strong case has been made by some in favor of using them for Whole Body screenings. In the past, MRI has been found to be good at detecting disease in certain organs, but not quite as good in others. In recent studies with newer machines, the reliability and accuracy of MRI at detecting diseases in liver, brain, spine, pancreas, and kidneys, were extremely high and imaging of the lungs was reasonable. But optimal imaging of the heart, breast, and colon still requires further development (also to see small-volume disease). Nonetheless, imaging of all the latter mentioned organs was described as being at a diagnostically “acceptable” level. As of 6/04, the manufactured MRI systems had evolved to the point of being able to view the entire body with good image quality and sensitivity to detect disease within a 15-minute period. Whole body, high-quality MRI screening is now more feasible than it ever has been in the past. We do not know how available (or how easily ordered) this test is as of June, 2005, or whether it is a better tool than Whole Body PET/CT for early stage tumor diagnosis, especially of low grade cancers like most ACC cases. But it is something to keep in mind. More information below…
    
    7F) Comparing Whole Body MRIs and CT Scans (as well as Whole Body PET/CT combos):
    Some data indicates that MRI will find small early stage tumors in many cases betterthan CT scans. That is VERY important in the case of ACC, which often can grow slowly, silently and without causing symptoms for many years. Because both whole body CT and MRI screening are relatively new concepts, limited data has been collected comparing the 2 methods. However, there is some concern in the medical community that whole body CT screening leads to a large number of questionable findings. And we know for sure that PETscans routinely have questionable findings. Of the recent data that HAS been collected, overall, MRI has been found to discover more lesions and correctly characterize disease, whether benign or malignant, than CT. MRI has been shown to be superior to CT for examining specific regions of the body such as the head, abdomen, and pelvis. In the past, the biggest exception to this rule has been imaging of the lungs, performed better by CT than MRI, largely due to the time required for scans (although MRI technology is advancing to address this problem). CT has generally been considered to image bones in more detail than MRI, which is better at most soft tissues. And CT remains the optimal imaging technique for visualizing small arteries, such as the vessels that supply blood to the heart, but there will likely be improvement for MRIs in all these areas in the (possibly near) future.
    
    A case can also definitely be made for the safety advantages of MRI over CT scans, having to do with both the imaging system itself and the intravenous contrast agents sometimes used. MRI does not give patients any radiation exposure. This may be more of a consideration for patients doing periodic/regular whole body screenings. MRI utilizes a powerful magnetic field and radiofrequency energy which have not been shown to cause cancer or fetal abnormalities, unlike the ionizing radiation (x-rays) used in CT, that is a known cause of cancer and fetal anomalies. (The most likely possible radiation-induced disease would be bone marrow problems with subsequent leukemia.) It is important to note that although x-rays are known to cause cancer, the exact risk of cancer from receiving CT scans, and even repeat CT exams, is unknown.) While radiology study radiation doses are all low level, with repeated exposure to numerous radiology tests over many years, the risks definitely increase. The intravenous contrast agents used routinely in MRI are also considerably safer than those routinely used in CT, with regards to possible kidney injury and allergic reactions. There are also more risks associated with the actual physical injection of contrast with CT than with MRI. (Having said all this, the risks (for CT) are likely all low, and many many patients receive these exams every day all over the world.) In almost all cases, the gains cancer patients can get with ANY of these tests far outweighs any risks. And for most ACC patients, the risks for causing a subsequent cancer are likely much less than the risks of an ACC recurrence or metastasis. We would however recommend MRIs over CTs for pregnant women, and those with poor kidney function or a history of allergies (in cases where either test can work).
    
    There is limited published material on this new application of MRI technology. It seems that in order to perform high quality whole body MRIs, high resolution machines using parallel imaging are required. And most likely “3 Tesla magnet” machines. These are certainly not widely available. AT THIS TIME, Whole Body MRI is a developing technology, and most medical professionals would/could not recommend it over Whole Body CT for their patients.  If/when the choice between Whole Body MRI and Whole Body CT really is a viable and comparable one (in terms of the diagnostics), then making the choice for the safer method would unquestionably be a reasonable one. For Acinic Cell Carcinoma patients, especially those concerned about the radiation risks posed by Whole Body CTscans, the Whole Body MRI screening may be a viable alternative in the future. And, with the information we have, it looks that it may be a better diagnostic test than the individual Whole Body CT especially for certain areas. But not for lungs at this point (as well as some of the other areas outlined above).
    
    In the limited studies published comparing Whole Body MRI and Whole Body PET/CT, the MRI results look promising as well. Sensitivity in the area of lymph node metastases may be limited. The addition of the PET scan to the CT, which can detect tumor metabolism/activity may be a factor which is important to consider. But we need more data on this question. Perhaps, in the future a Whole Body MRI will be able to be done in conjunction with the Whole Body PETscan, and we will be able to benefit from the best of both technologies. On the other hand, it may be that the latest generation of MRI machines will be able to diagnose early stage small tumor growth as well as PETscans (or better). For now (and until we present more definitive information here), we recommend raising these issues in discussion with your physician(s).
    
    8) Needle Biopsies / Fine Needle Aspirates:
    If Radiology tests find a suspicious or suspected tumor mass, there are decisions to be made. Sometimes the radiology itself is a good indicator of whether the nodule/mass is tumor or not, and (especially in the case of PETscans), if it is a malignancy. But more often the imaging only denotes a mass, and what that mass is, is not determined. If the patient has had prior recurrences or metastases, assumptions are often made that the mass is likely the same histology (same type of cancer). And a treatment plan is devised based on that ASSUMPTION. But it is still an assumption, and you do not know for sure. To determine with more certainty what a mass actually is, there are two options: One is to perform a surgical procedure, removing the tumor (or as much as possible) and then perform pathology tests on the tissue removed. The other option is to perform a Needle Biopsy (also called a Fine Needle Aspirate or FNA). This is performed by inserting a needle into the mass and extracting very small pieces of tissue, which are then sent to the pathology lab for diagnosis. Some tumors (near the surface usually) are relatively easy to biopsy. For that matter, very small tumors/masses near the surface can often be easily excised completely. Other tumors, deeper in the body may be more challenging. Often CTscans are used to image the tumor and guide the placement of the needle (“CT guided needle biopsies”). But some tumors are located in areas where performing a needle biopsy is too challenging or there is too much risk of injury to the patient.
    
    We highly recommend needle biopsies be performed on undiagnosed PRIMARY tumors whenever possible. This specifically applies to larger or more challenging masses that cannot be easily COMPLETELY excised with clean margins. That is so that the patient and physician know what they are dealing with prior to primary surgery. Many ACC cases are only diagnosed after surgery, and that sometimes proves to have been a mistake. Knowing the histology of a malignant cancer prior to surgical procedure, can affect the details/goals of the surgery, or for that matter IF surgery is the best treatment option at all. For primary parotid gland tumors, for example, this may affect the choice of superficial or complete parotidectomy, neck dissection, etc. Some tumors in fact may be more safely and effectively treated with Fast Neutrons ONLY (without surgery). Or, surgery could be planned knowing that Neutrons will follow later (and therefore be able to avoid potential damage to things like facial nerve, when it is involved). These kinds of choices are very important, and can greatly affect the patient’s clinical course later.
    
    Unfortunately, for most people reading this (NOW), you will already have had your primary tumor diagnosis. But you may be faced with the choice of whether or not to biopsy a recurrence or metastases. In general, at ACCIC we would advocate performing needle biopsies whenever possible, with some exceptions.
    Those would include:
    a) Risk of injury to patient.
    b) Undue risk of spreading disease.
    c) In cases where it is extremely likely that the diagnosis is another recurrence or metastases (after the patient has had several).
    
    The reason we recommend these procedures is twofold:
    1) To be sure that you are treating the right thing with the right method(s).
    2) To be able to utilize tissue from current sites for immunohistochemistry tests, possible chemosensitivity testing, etc.
    
    A few notes about Needle Biopsies:

• There is some risk of cell spillage, or spreading of microscopic disease during the needle biopsy. Most oncologists will tell you that this risk is low. But there is some risk nonetheless.
  
• Sometimes one does not get a good sample of cells from a needle biopsy. So you could end up with a false negative result in the pathology report (or an inconclusive result.)
  
• Even with a good biopsy sample, there may be errors in pathologic identification of the tissue. (This is a problem with ACC in general.) Sometimes larger samples are needed than one gets in an FNA.
  
• Most needle biopsies (especially of salivary gland sites or tumors close to the surface) are performed under local anesthesia, with the patient awake. Even biopsies performed at greater depths are usually done with local anesthesia. Sometimes, despite the anesthesia, these can be uncomfortable, or even quite painful. That is not the intention, but it can happen.
  
• Despite these possibilities, the potential advantages of finding out the histology before surgery (especially of primary tumor) are still recognized, and usually justified
  
  9) Other Tests: Due to the ever-expanding fields of medical technology and radiology/medical imaging specifically, new diagnostic methods are regularly being improved and developed. It may be that your physician will recommend a test that we have not mentioned, for your individual case. Or you may utilize one or more of the methods described here, with some results or experiences you feel we should know about. Please feel free to email us about your experiences (especially if you think they would be useful for others) or with information about any new technologies being used on ACC patients.
  
  10) Self Exams and Notation of Symptoms: In addition to the Physical Exams by physicians and Radiology Tests described above, one of the most valuable tools for early diagnoses of recurrences or metastases is the patient themselves. Be aware of any new “bumps or lumps” (in your head and neck area especially for patients with previous salivary gland tumors). Be aware of new pains or symptoms ANYWHERE in your body. If these are significant, periodic, chronic or worsening (and not just a one time thing), they should be reported to your physician immediately, and diagnostic tests should likely be ordered. If a questionable nodule is discovered, in many cases, a needle biopsy should be ordered to assess if it is ACC or something else. One of the classic mistakes with this cancer is leaving tumors hanging around your body, when they could have been diagnosed and removed (or otherwise treated) in early stages.
  
  
  C) General Radiology Prep Notes:
  For some of the radiology tests we have recommended, there will be a set of pre-test instructions that your Radiology Department should get you in advance. Sometimes they will be mailed to you, and sometimes they will call you. We recommend ASKING when the test is scheduled, if there ARE any pre-test instructions (just in case they forget to tell you). Some tests will require you to not eat or drink (except clear liquids or water usually) for some period of time prior to exam. Some exams will require you to arrive an hour or two (or more) early to receive an injection of some sort. Some tests will require you to drink “contrast medium” at home in advance and/or at the hospital prior to exam. Sometimes allergies you have will affect the contrast medium they can give you, so you need to inform technicians about this in advance (shellfish allergies are one of the indicators). (They should ask you about this on their own of course.) Some tests (such as PETscans) will require you to be VERY still and quiet for at least an hour prior to exam, with almost no movement before and during test. In many places they will want to give you a mild sedative for this reason. If you receive the sedative, you will need to have someone to bring you to and from the hospital. There will be many other details about the tests that your hospital should inform you about. You can read more details about diagnostic tests on the Diagnostics and Followups page of this website.
  
  
  D) Things To Bring To Your Radiology Tests:
  In addition to bringing yourself (and someone to drive you if that is necessary), and adhering to any pre-test instructions you were given… We recommend bringing these items:
  
  1) Any Radiology Films (or DVD digital copies) of previous Radiology Studies that are not on file at the place where your test is being done. The Radiologists use these tests to compare changes between studies. So if they are trying to assess change in a known tumor (or to see if current suspicious areas were there earlier), they need the previous films. If the tests were performed at the same hospital, they will have access to them. But if you had them done somewhere else, they may not. Specifically required are the most recent previous versions of the SAME test that you are running today. So for example; if you are getting a Chest CTscan today, you need to bring your most recent Chest CT, if it was not done at that institution. If you did not have a Chest CT previously, but you had a Chest X-Ray or PETscan, bring those as well (or any other studies that showed the Chest/lungs). We DO recommend that if you can get these tests sent to the new testing place by the previous testing place in advance, that is better than leaving your own copies. But if that has not happened, leave your copies for the radiologists to use as comparisons. But BE SURE TO LABEL THE ENVELOPES AS: “PATIENT COPIES – RETURN TO PATIENT”. And write your address and phone number(s) on the envelope. Also, ask how and when you will get the films/CDs you leave back. And get a phone number and name in case you need to follow up on this.
  
  2) Instructions / Notes Memo for Radiologists and Technicians:
  We recommend bringing some neatly typed PAPERWORK to the exams, which can help the technicians and radiologists do a better job with your diagnostics. The physicians who ordered your test(s) filled out a very short form, which usually gives very limited information about your case. In many cases this is adequate. But if you bring more details, it can often help in making sure nothing gets missed. Not only are there variables in how some tests are run…the films (or digital pictures) are read by human beings. Reading these images is not an exact science, and is surprisingly subjective. If they have more information, they may be inclined to utilize it in their reading of your studies. SO…We encourage patients to write up a document (Memo) to hand to Radiology Technicians (for them and to pass along to Radiologists). We recommend that the “Memo” include the following (in order):

1. Your Name, Date of Birth, Patient ID #, etc.
   
   
2. The exact name of today’s Study, including body location(s) (and other details). (eg. “CTscan of the Head and Neck with contrast”) THIS IS ALSO TO MAKE SURE THAT YOU ARE GETTING THE RIGHT TEST.
   
   
3. The main reasons for today’s study. (Evaluation of tumor change / screening for possible recurrences / screening for possible metastases / etc.) This should also include any SYMPTOMS which may be indicating things the study should look for. You should also include any recent cancer history that is specifically relevant for this test. (More detailed/general history comes later.)
   
   
4. For low grade ACC cases: A note which is very prominent, reading:
   “Note: ANY CHANGE or POSSIBLE TUMOR EVIDENCE, EVEN EXTREMELY SMALL, IS IMPORTANT, as this can be a VERY slow-growing (and potentially slowly regressing) cancer (Acinic Cell Carcinoma).”
   
   
5. If it is a study that images (or includes) either lungs or bones, also write “Acinic Cell Carcinoma is known to metastasize most frequently to bones or lungs.”
   
   
6. A short list of previous comparison studies, with dates (the two most recent previous identical studies) that they can use to compare with current one.
   
   
7. A list of other recent possibly relevant studies, with dates. For example, if you had a PETscan a month ago, and you are now doing a full body CTscan, the PET may be relevant, and they should be made aware of it. Or if you ran a Bone Scan, which showed increased uptake in your spine, and you are now getting an MRI of the Spine, reference the Bone Scan.
   
   
8. IF you had tumor(s) previously noted in recent scans, then it helps to copy the relevant text EXACTLY from previous radiology reports. That way they can compare the areas referenced specifically. (You could also attach copies of the report(s)).
   
   
9. A summary/overview of your cancer history. Enough so they have the basics.
   j) If you need copies of the films / DVDs from TODAY’S STUDY sent anywhere (or extra copies for yourself), note that at the end of memo. (And try and arrange to get those copies for yourself before you leave. It is usually easier THEN than later.)
   
   
10. Include your address and phone number.
    
    
11. THANK THEM for taking the time to read your document.
    

E) Summary on Diagnostics / Radiology Tests / Followups:
Acinic Cell Carcinoma is usually a slow growing cancer. If recurrences are caught early, when they are small, we at ACCIC feel that you stand a better chance of getting rid of them completely, and not having more recurrences or metastases later. We should note that (unfortunately) at this time (7/05), there are no curative systemic treatments known for this cancer. So sometimes you may find metastases/ recurrences, but not have any good (permanent) way of treating them. Some physicians would conclude that early stage diagnostics are therefore unjustified. We cannot agree with that. It is our experience that the tumors that hang around for awhile are the ones that cause more problems. And at least if you diagnose tumors early, there MAY be better or more options for getting rid of them, than when they are larger. There are numerous physical methods (surgery, radiation (many types), RadioFrequency Ablation, Lasers etc) for dealing with small tumors. So doing these follow-ups and diagnostics can protect you from potential nightmares in the future.

We feel that there are certain diagnostic exams that are easily recommended, and without much discussion. Other diagnostics, especially with regards to radiology are sometimes not as clearcut as to which are the best exams, and how often to perform them. And there are choices between getting one or another. As a general statement, we would say that Whole Body tests available now will usually not give as detailed results as most individual tests. So a combination of whole body surveillance and individual more focused studies is suggested in order to maintain a vigilant regimen of diagnostics.


F) A Summary of Follow-Up and Test Recommendations:

Physical exams of head and neck area by oncologist or ENT/Otolaryngologist.
Do at every follow-up (assuming primary site was in parotid gland, or other head and neck site.)

Physical exams (if possible) of any areas where there were previous cancer sites. Do at every follow-up.

Blood Tests: Routine blood and metabolic panels should be done at most follow-ups, and definitely during treatment periods.

MRIs and/or CT Scans of Previous/Current Tumor Sites: The most detailed imaging studies possible should be performed pre-treatment and post treatment. After that, they should be performed periodically. Frequency is dependant on case specifics.

CT Scans of the Chest (Lungs): At this point, this is the best imaging study for revealing small or low grade lung metastases. Some newer machines give greater detail, and are more likely to diagnose small or early stage tumors. These include spiral (or helical) scans and multislice CT or multidetector CT (MDCT). If these machines are not available, “fine cuts”should be specified. We generally recommend annual studies of chest. However, risks of repeated radiation exposure should be considered. So for low risk cases of low grade ACC, the interval may be extended, subject to case specifics. IF a patient is getting Whole Body PET/CT or Whole Body CT surveillance studies, they could include the Chest CT (as long as it is as detailed/sensitive as individual CTs described above).

“Low Radiation” Radiographic Studies of Chest:
This may be an even more precise study for diagnosing lung tumors. It is not widely used or available at this time. If it is offered, it should be compared with CT scan with regard to both risks and potential for diagnoses.


WHOLE BODY SURVEILLANCE STUDIES:

Combination Whole Body PET/CT Scans: A relatively new application of previous technologies, and becoming more widely available. This may be the most applicable whole body screening for ACC patients at this time. In general we recommend annual screenings. However, in low risk cases of low grade ACC, interval between tests may be extended, subject to case specifics and patient concerns. Exposure to increased radiation from Whole Body CT may be a consideration for some. And the issues of long term repeated exposure should be taken into consideration.

Whole Body Bone Scans: If Whole Body CT or Whole Body PET/CT combo are not utilized, we recommend that this test be performed annually. However, in low risk cases of low grade ACC, this interval may be extended, subject to case specifics. If Whole Body MRI is used for surveillance, we still recommend performing Bone Scans in addition (at this point). Areas of “increased uptake” on Bone Scans should be further investigated with more detailed MRI or CT studies.

Whole Body PET Scans: While this test can be useful for many cancer patients, and for certain applications, it also has some drawbacks. At this point, we feel that a PETscan by itself is not the most reliable, especially for diagnosing small or low grade tumors. It can give both false negatives and positives. PET CAN be utilized for larger tumors and to assess change in metabolic activity of known tumors. And PET can be useful in conjunction with other imaging methods. We DO advocate use of combination PETscan/CTscan combination for whole body surveillance (at this time). IF you cannot perform those combo tests, PET may be useful in addition to separate Whole Body CTscans (or CTs of Chest), Whole Body Bone Scans, or Whole Body MRIs.

Whole Body CT Scans: When Whole Body PET/CT combo scans are not available, separate Whole Body CTscan and Whole Body PETscan may be utilized. But when not done concurrently, the combined data is not as easily evaluated. However this is still better than PETscans alone. Once again, if this method is used, we would generally recommend annual tests. In cases of low grade and low risk ACC, the interval may be extended, based on case specifics and patient concerns of radiation exposure. Frequent repeated exposure to radiology exams should be taken into consideration, as cumulative effects of low dose radiation could potentially cause problems.

Whole Body MRIs: This is not yet commonly available. It should be a safer technology than Whole Body CT (or most other studies), as it does not use radiation. Indications are that it could be a more accurate/sensitive study for many parts of body. This is dependent on the machine, and at this time there are parts that are still more clearly imaged with CT. IF Whole Body MRI is offered to you as an alternative to above studies, it can be considered. But ability to image very small or low grade tumors as well as details of lungs and bones needs to be assessed. So, if there is any question, Chest CTscans and Whole Body Bone Scans should be additionally ordered. PETscans should also be considered in conjunction with the MRI, if possible.

Summary on Whole Body Surveillance:
- The best current option seems to be Whole Body Combination PETscan/CTscan.
- IF that is not available, second reasonable option would be separate Whole Body CT (with detailed lung study included), in addition to Whole Body PETscan. Whole Body Bone Scan could be done in addition, but in most cases it should not be warranted.
- Third Option might be Whole Body MRI (if available). This MAY be a better option than whole body PET/CT in the future. If bones and/or lungs are not very detailed, additional Whole Body Bone Scan and Chest CT may be required.
- In general at this time, localized studies are more accurate and see more detail than whole body studies. Anything questionable found on Whole Body studies will likely need to be examined in more detail with more localized diagnostics.
- Whole Body Studies (other than MRI) all expose patient to very low doses of radiation (some more than others). Over time, if one gets MANY of these tests, there are higher potential risks for inducing disease. This should be taken into consideration on a case by case basis.


OTHER DIAGNOSTICS:

Needle Biopsies (Fine Needle Aspirates): Should be performed on undiagnosed PRIMARY tumors whenever possible. This applies to all unknown suspicious masses/nodules of any significant size, and especially to salivary gland (and specifically parotid gland) undiagnosed masses. The exception might be very small nodules near the surface that can be COMPLETELY excised with definitively clean margins. In those cases, the excision itself may also be the biopsy. For potential recurrences or metastases, we recommend needle biopsies whenever possible. Patient risks should be taken into consideration. When there have been multiple recurrences or metastases in same (or similar) locations, then the assumption of progressive disease may be made in lieu of needle biopsy. All needle biopsies should be followed by detailed pathological examination and identification of biopsied tissue.

Self Exams and Notation of Symptoms: In addition to the Physical Exams by physicians and Radiologic Imaging Tests described above, one of the most valuable tools for early diagnoses of recurrences or metastases is the patient themselves. Report any suspicious “bumps”, “lumps”, recurrent or progressive symptoms to your physician(s), and have them evaluated SOONER RATHER THAN LATER.

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E) (Summary Continued)
We hope that in the future, through the advancement of diagnostic technologies, that it will become clearer and easier to make definitive recommendations on these subjects. In the meantime, we have tried to provide you with the latest information and most informed recommendations.

We at ACCIC feel that it is important to keep informed about the latest advances in radiology, and which exams will potentially yield the most accurate results for ACC patients. (So check back with us from time to time to see if there are updates to this page.) We do feel that questions of risks created by the tests themselves should be considered, based on the most recent studies and data, as well as the specifics of each patient’s case and concerns. And the frequency of tests should be considered with regard to this. But this should not keep ACC patients from getting the studies and follow-ups they need in order to catch new tumor growth as early as possible. Patients however need to consider these questions and make appropriate balanced choices for themselves.

By the way, if you haven't read the "Patient To Do List" page of the ACCIC website (at www.aciniccell.org), check it out. Some of this information is there. But there are also a number of other items related to case management in general that could be useful for you.

By the way, if you haven't read the "Patient To Do List" page of this website, we recommend reading that as well. A bit of this information is included there. But there are also a number of other items related to case management in general that could be useful for you.

There is also a short “summary” version of this information. You can read that on the “Patient To Do List” page, or go directly to the "Diagnostics /Follow-Ups To Do - Summary" page.   Please check “last updated” dates to make sure you are reading the most recent information.

Note: The information provided on this website is for informational and educational purposes.  It is not licensed medical advice.  It is not intended as a substitute for professional health care.  Any medical advice provided (even when given by health professionals, or with corroborating data) is offered as an opinion. The reader is advised to make medical decisions in conjunction with licensed health professionals.

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