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1-17 Palpable Fine Needle Aspiration Biopsy: Procedure, Techniques, and Specimen Handling Amy Ly, M.D.

Indications for FNA
Procuring the Specimen
Test platforms/processing and triage

Please see separate organ sections for reporting and terminology details.

GOALS/EXPECTATIONS:

What you are expected to do: Pathology trainees will be expected to perform FNA procedures on patients and prepare specimens under supervision of an attending cytopathologist. Residents may perform procedures under supervision of an approved Cytology Fellow after Fellow has demonstrated competency. Trainee performance will be evaluated and documented.

Daily Schedule:

8am-9am: Attend Cytology Consensus Conference (may not happen every morning). Residents should ask the Cytology Fellows to be included in the group text pages.

9am-12pm: Be available and prepare for FNA procedures.* Review and signout with attending your assigned cytology specimens when not on an FNA procedure.

12pm-1pm: Attend Outs sessions or similar.

1pm-5pm: Be available and prepare for FNA procedures.* Review and signout with attending your assigned cytology specimens when not on an FNA procedure.

  • The Cytopathology division at MGH runs the Fine Needle Aspiration Biopsy Clinic located on Wang-270. The FNA Clinic sees patients in 45-minute appointments from 9am-noon and 1pm-5pm Monday-Friday (i.e. 9:00am, 9:45 am, 10:30am, etc.). No patients are seen during the noon-1pm lunch hour, or on weekends. Appointments are booked by the Cytopathology Main Desk (Diane White and Bernadette Femino). Introduce yourself to the Main Desk and ask them to page you with updates to the FNA schedule. Prepare for appointments by making sure the FNA Clinic supplies are stocked and reviewing the patient’s history in CAS/LMR prior to patient’s arrival.
  • We also occasionally perform FNA on in-patients at bedside. A cart containing a microscope and FNA kit are wheeled to the patient’s room for these procedures. The FNA cart is located in the Cytopathology Prep Lab (Warren-1).

HOW IS THE FNA ROTATION DIFFERENT FROM OTHER PATHOLOGY ROTATIONS?

You will directly interact with patients, talking with them and performing physical exams. You will learn how to obtain tissue samples from patients using a thin needle while they are awake. You will learn multiple methods to prepare tissue samples for evaluation. Unlike in the gross room, no scalpels are used and not all specimens are fixed in formalin. WHAT IS FINE NEEDLE ASPIRATION (FNA)?

FNA is a tissue sampling procedure that uses a thin needle (defined as 22 gauge or thinner). FNA is used to evaluate palpable superficial masses, both solid and cystic. FNA is also used to sample abdominal fat for amyloid testing. The needle is inserted through the skin into the mass to extract cells. The patient is awake during the procedure, but the biopsy site may be numbed with local injection of anesthetic such as lidocaine.

FNA can also be performed under image-guidance (e.g. ultrasound, CT) to evaluate deep-seated, nonpalpable radiologic abnormalities such as in the lungs or liver. FNA done using endoscopy or bronchoscopy to evaluate sites such as pancreas and mediastinal lymph nodes. The patient is often sedated in these settings and the procedures are performed by non-pathologists.

Because the needle used is so much thinner than the ones commonly used for core biopsy (which can be as large as 8 gauge), the tissue obtained in FNAs consists of tiny fragments that often cannot be discerned by the naked eye.

Review “Introduction” video on http://www.papsociety.org/fna.html.

Materials and Supplies

All the equipment needed to perform an FNA (see Table) is small and lightweight enough to be hand-carried in one container. As a result, FNAs may be performed virtually anywhere on demand. The equipment occupies only a small area of table space when laid out for specimen preparation.

Review “Equipment” video on http://www.papsociety.org/fna.html.

FNA Equipment List

1. Syringe holder (10 mL Cameco syringe pistol or equivalent)

2. Disposable sterile 10 mL plastic syringes

3. Disposable sterile needles with transparent hubs (23g and 25g, 1.0 to 1.5 inches long)

4. Alcohol swabs

5. Sterile gauze pads

6. Glass slides with frosted end for labeling

7. Fluid transport medium (e.g., sterile RPMI, saline, formalin)

8. Local anesthesia and needle/syringe to administer (e.g., 2% lidocaine, 27g/1 cc)

9. Alcohol fixative (commercial spray fixative or jar filled with 95% ethanol)

10. Gloves (preferably non-latex)

11. Pen/pencil for labeling slides (e.g., Leica pen, blue marking pencil)

12. Plastic slide holders or slide trays (for transporting slides)

13. Rubber-topped blood-draw tube for “flip” technique.

FNA Procedure for sampling a palpable mass

Steps for a successful fine needle aspiration (FNA):

Decide if an FNA should be performed Consent the patient for the procedure Position the patient and immobilize the lesion Sample the targeted lesion adequately Prepare the sample for evaluation, including appropriate allocation of material for ancillary studies as necessary Provide post-procedure instructions to the patient


Decide if an FNA should be performed

All patients presenting to us for an FNA have been referred by a clinician. Review the patient’s clinical history and relevant imaging studies before seeing the patient. Perform a focused physical examination to confirm that the lesion is indeed palpable and an FNA is clinically appropriate. While feeling the mass with your fingers, take mental notes on its size, shape, and relationship to any significant structures like large blood vessels. This information guides how you will approach sampling the lesion (e.g., the length of needle to use, vascular areas to avoid).

Sometimes the mass will be marked on the patient’s skin by the referring clinician.

If you have trouble finding the mass, the patient may be able to show you where it is.

During the brief examination, take a moment to ask whether the patient has any history of bleeding disorder or if s/he is on blood thinners.

If the lesion is not palpable or cannot be safely sampled, do not perform an FNA. An alternative is to evaluate the patient and perform the FNA procedure using ultrasound guidance. (See “FNA using Ultrasound” Supplement.)

Consent the Patient

Describe the FNA procedure in detail to the patient, including its purpose and potential complications. Allow the patient to ask questions. Confirm the patient’s name, date of birth, and site to be biopsied. Have the patient sign the procedure consent form.

Sample dialogue with a patient for obtaining consent for the FNA procedure:

“Hello Mr. Smith, I am Dr. Ly from the Department of Pathology. I understand that Dr. Jones has sent you here for a fine needle aspiration biopsy of a mass on your arm. Our goal is to determine the diagnosis for the mass. Let me explain what the procedure involves. Feel free to ask questions at any point.

I will use a very thin needle to sample the mass. The needle is the same size or smaller than the ones used for blood draws. I will insert the needle into the mass and move the needle back and forth for about 15-20 seconds. I usually do this 2 or 3 times, which means 2 or 3 separate needle sticks. I may need to do it a 4th time if I think additional material will help us make a diagnosis. We will take a small break after the 1st or 2nd needle stick so I can quickly check how much material we have by looking under a microscope. This is not to make a diagnosis, but rather it is a quantity check to make sure there is enough material to evaluate.

Every patient’s experience with this procedure is different. Most patients feel a pinprick when the needle goes through the skin just like during a blood draw. While the needle is moving back and forth, most patients feel a pulling sensation or dull pressure or soreness. I can inject lidocaine into the skin over the lump to numb the area. It will be an additional needle stick and you may feel a temporary burning sensation that lasts up to 30 seconds. If during the procedure you experience pain that you cannot tolerate, I will stop and take the needle out.

This procedure has a few minor risks that you should be aware of. The most common are bleeding and slight bruising. After each needle stick, my assistant will apply firm pressure with a clean gauze pad to minimize bleeding. Infection is another possible complication, but I clean the skin well with alcohol before each needle stick to minimize the chances of this happening.

Do you understand the purpose of this procedure and the risks involved? Do you agree to having this procedure? If so, please confirm for me your full name and date of birth, and sign this consent form.”

Prepare the Equipment

Universal safety precautions must be observed during the biopsy procedure and while handling the harvested tissue specimen.

You must prepare the tissue sample immediately before it dries/clots. You will make smears from the sample, and may rinse the needle and allocate material for special studies if necessary. Label several clean glass slides with at least 2 patient identifiers (e.g., name, date of birth, medical record number). Open a jar of alcohol slide fixative. Open a sterile test tube and fill it halfway with saline. Open a small jar of formalin. Place these materials on your table workspace.

Load a syringe onto the syringe holder and attach a needle. Commonly, 23g and 25g needles measuring 1.0 to 1.5 inches long are used. Choose the shortest needle that reaches the deepest area of the lesion from the skin. For example, if the bottom edge of the mass is 1 inch beneath the skin, choose a 1 inch needle, not a 1.5 inch needle. Loosen the needle cap and set the equipment down in a convenient location.

Position the Patient and Immobilize the Mass

Position the patient such that s/he is comfortable and the lesion can be palpated and immobilized (i.e. held fixed in place by the fingers of your non-dominant hand so it does not move around while you are sampling it). Ideally, have the patient lie on his back; this is a safe position in case of a vasovagal response and the patient passes out during the procedure. Support the patient’s body with pillows, rolled up sheets/towels, or foam shapes. Changing the patient’s body position can dramatically affect the accessibility of the lesion. Breast lumps are usually best appreciated with the patient’s arm raised above the head. Neck masses easily felt in the sitting position but may completely disappear when the patient lies on his back.

If the mass is beneath a band of skeletal muscle, position the patient such that the muscle is relaxed and pull or push the muscle aside. Inserting a needle through skeletal muscle is painful for patients, and will clog your needle, preventing you from obtaining a good sample.

Plan ahead how you will immobilize the mass – try different configurations with your fingers (of your non-dominant hand) on the mass. Also plan the angle at which your needle will be inserted into the mass. For many lumps, inserting the needle perpendicular to the skin surface is adequate. Clean the skin with an alcohol swab. If local anesthesia is to be given, start by injecting 0.5 cc to 1.0 cc of 2% buffered lidocaine subcutaneously at the biopsy site. Additional lidocaine can be given at any subsequent point if the patient is uncomfortable. Sensitive areas such as the nipple/areola complex should receive more lidocaine up front (e.g. 2 to 3 cc). Allow a few minutes for the local anesthesia to take effect. Caution: With small nodules (e.g. < 5 mm), injecting too much lidocaine can cause enough skin swelling that your fingers can no longer feel the mass distinctly.

For all patients, but particularly those who decline lidocaine, offer your hand and encourage them to squeeze it during the procedure. This helps to alleviate discomfort and pain.

Review “Special Problems,” “Technique,” and “Stabilizing the Instrument” videos on http://www.papsociety.org/fna.html.

Sample the Mass

Review “Needle Movement” video on http://www.papsociety.org/fna.html.

Once the mass is fixed with the non-aspirating hand, clean the skin with an alcohol swab at the planned needle entry site. Remove the loosened needle cap and stabilize the aspirating hand by resting the syringe barrel against the thumb or forefinger of the non-aspirating hand. A steady hand ensures precise needle placement. Push the needle through the skin into the mass in one motion, and pull back the syringe plunger to generate several cc of suction. At this point, it is no longer necessary to stabilize the aspirating hand. Maintain the vacuum until you are just about to remove the needle from the patient. With a straight wrist, quickly move the needle back and forth in a sawing motion (“excursions”) for no longer than 15-20 seconds (approximately 40-60 excursions) along the original needle trajectory. (For vascular lesions such as thyroid, 2 to 5 seconds is recommended.) Make sure the needle does not exit the patient. Each time the needle advances into the lesion, its cutting tip dislodges small tissue fragments; this cutting action is essential for a successful FNA. Slow needle action will yield less material, and no needle movement at all movement will yield a non-diagnostic sample in solid masses. The vacuum in the syringe helps tissue fragments travel up the needle shaft. Keep the needle tip within the mass to avoid diluting the sample with adjacent non-lesional tissue. As you perform your excursions, you may see material accumulating in the needle hub. If blood rapidly enters the hub, withdraw the needle immediately and apply pressure to the site with gauze.

Sampling with thinner needles (25g or 27g) is preferred for vascular organs like the thyroid, and for fibrous lesions like a fibroadenoma of the breast. When sampling a densely fibrotic mass, your excursions should be more forceful.

Review “Sampling of Different Nodule Parts” video on http://www.papsociety.org/fna.html.

An FNA procedure typically involves inserting the needle into the mass 2 or 3 times (“passes”) to obtain several samples. The center of the mass is often sampled on the first needle pass with the needle approximately perpendicular to the skin. You can try other areas of the mass on subsequent passes, especially if the initial material is necrotic, cystic, or non-diagnostic. Sample the mass along its long axis to obtain more cellular specimens.

To sample more than one area within the mass on one needle pass, withdraw the needle tip to a superficial location, then change its angle of entry to enter a different area of the mass. “Fanning” allows for sampling of a larger area: after each excursion, when the needle tip is in a superficial location, change its angle of entry slightly until the entire region of interest is sampled. Avoid changing direction when the needle is deep in the lesion. This results in tissue tearing and hemorrhage, which compromises the diagnostic yield of subsequent passes.

Remove the needle from the patient after the last excursion or when you see material or blood in the hub, which can occur in < 15 seconds. Release the vacuum in the syringe before withdrawing the needle from the patient. Withdrawing the needle from the patient when there is still negative pressure in the syringe will force aspirated material up into the syringe barrel, and it cannot be used to make smears (you can still retrieve it by rinsing the needle as described below). Hold firm pressure to the biopsy site with gauze for several minutes, longer if there is a history of coagulopathy or blood thinners. The patient or an assistant should perform this step, because the aspirator needs to prepare the sample immediately.

Prepare the sample

Make Smears

There are multiple ways of preparing direct smears from the aspirated material retrieved from the needle and needle hub. Because aspirated material will vary in quantity and quality from case to case, it is important to be familiar with several different techniques.

Review “Expulsion onto slide,” ”Flip Technique,” “Basic Smearing Technique,” “Dividing Material,” and “Problem Material” videos on http://www.papsociety.org/fna.html.

Fix the Smears

Generally, at least one alcohol-fixed and one air-dried smear should be made from each needle pass. The advantages of each fixation method are shown below. Air-dried smears should be dried quickly to avoid drying artifacts. When fixing with alcohol, submerge the smear in 95% ethanol immediately after it is made to avoid air-dry artifacts.

For information about making cell blocks from smears, see "Reserving Material for Ancillary Studies" and "Making a Cell Block from a Smear" on our sample preparation page.

Air-dried Smears Alcohol-fixed Smears
Useful for Rapid Evaluation? Yes; stain on-site with DiffQuik. Superior nuclear detail.
Yes; stain on-site with Toluidene blue Rapid on-site evaluation (if a modified Ultrafast Pap stain, toluidine blue, or rapid H&E stain used).
Yes; allows for evaluation of lesions with background material
Advantages Enhances cellular pleomorphism. Superior nuclear detail.
Fast and easy to perform. Less air-drying artifact and enlargement.
Better for evaluating background material and cellular cytoplasm (e.g., mucin, cartilage) Better for evaluating squamous lesions.
Better for visualizing some organisms such as mycobacteria (“negative images”).


Assess Specimen Adequacy

  Rapid on-site evaluation of smears can be performed.  This is the Cytology equivalent of frozen sections.
  Choose 1 or 2 cellular slides for immediate evaluation.  If air-dried, stain using Diff-Quik and do not coverslip.  If alcohol-fixed, stain using Toluidine Blue and coverslip.  Evaluate the slides under the microscope and determine whether the quantity and quality of the material present is sufficient for diagnosis.  Determine whether obtaining material for ancillary studies will be helpful (e.g. flow cytometry, cell block for IHC).

Diff-Quik Staining Procedure: 5 dips in methanol, 5 dips in DQ-I solution (with eosin), 5 dips in DQ-II solution (with methylene blue), 5 dips in tap water to rinse. Observe the stained material. If it is red/brown/orange, dip again in DQ-II and rinse in tap water. If the material is blue/purple, staining is adequate. Dry back of slide with paper towel and review it under the microscope without coverslip. Background material and cytoplasmic quality are accentuated with this stain. Nuclear membrane irregularities may not be as obvious as on alcohol-fixed material. Cells appear larger and more pleomorphic than if alcohol-fixed.

Toluidine Blue Staining Procedure: Remove slide from jar of alcohol and place on tabletop face-up (cellular material is on top surface). Using eyedropper, place 1-2 drops of Toluidine Blue solution onto slide. Coverslip and remove excess fluid using capillary action by tilting slide onto its edges. After allowing stain to penetrate for 30-60 seconds, dry back of slide and evaluate under microscope. Nuclei will appear dark blue with this stain. Background material and cytoplasmic quality are usually not well-visualized.

Waste Disposal: Discard used tap water and stains into dedicated plastic container using funnel. Container is located under the counter in left cabinet.

How to Handle Cyst Aspirations

If the mass is cystic, you will see fluid filling the syringe barrel under negative pressure. Aspirate as much fluid as possible from the cyst; pushing on the mass can assist with this. The fluid can be discarded if appropriate (e.g., clear fluid from a breast cyst) or deposited directly into a container for subsequent processing. The patient is re-examined, and any residual mass sampled on a subsequent pass.

Avoid performing an FNA on a given site more than 3 to 4 times at one clinic visit. Repeated biopsies increase tissue hemorrhage, reducing diagnostic yield. It is better to have the patient return in several days for a repeat FNA.

Rinse the Needle and Reserve Material for Ancillary Studies

To harvest as much of the sample as possible, rinse the needle into a liquid medium. Place the needle tip in a container of medium and draw a small amount of liquid into the syringe by pulling back on the plunger. Then expel it back into the container by pushing in the plunger. Gently repeat this a few times. Excessive force may mechanically damage cells.

The needle can be rinsed with several different media. We use saline, formalin, and/or SurePath fixative. The medium you choose will depend in part on what ancillary studies you anticipate will be needed. In our lab, the most versatile sample is the needle rinse in saline.

Type of Preparation Ancillary Test
Flow Cytometry Cell Block Cytogenetics (Karyotyping) FISH DNA-based Molecular Test Immuno-histochemistry
Smear No Yes No Yes Yes Yes
Formalin-fixed cell block No Yes No Yes Yes Yes
ThinPrep or SurePath fixative No Yes No Yes Yes Yes
RPMI/saline Yes Yes Yes Yes Yes Yes
needle rinse

Post-Procedure Information for The Patient

Evaluate the patient before allowing her to stand up. If she is dizzy or light-headed, have the patient remain supine longer.

Give the patient a copy of “Fine Needle Aspiration Biopsy; Post-Procedure Instructions for Patients.”

Example of parting words to the patient:

“The final report should be ready in a few days and the results will go directly to Dr. Jones, who will then contact you.  The report may take a little longer if additional tests are needed.  Here are some instructions and information for you to take with you.  You can go about your daily routine, including showering and swimming.  If you have a small amount of bleeding later today, apply an ice pack for 20 minutes to help stop the bleeding.  You might feel some soreness; this will go away in a few days.  In the meantime, take Tylenol if you are uncomfortable.  Also, the lump might seem bigger than it was before; this is due to some swelling from the procedure.  The lump will return to its original size within a week or so.  If you see signs of infection such as fever and redness/pain/discharge at the biopsy site, or if there is persistent bleeding, call Dr. Jones’ office.


Variations on Biopsy Technique

For information on "feeling with the needle", and further info about technique variations and preparing/procuring the specimen see our procuring the specimen page.

Zajdela Technique

The FNA biopsy can be performed without suction (the Zajdela or “French” technique) using only the needle or the needle attached to a syringe, with the plunger either pulled out part way or completely removed. The needle hub or syringe is held like a pen in the aspirating hand, which is stabilized by resting the wrist on an available fixed surface (e.g., exam table, a part of the patient’s body). Without suction, the amount of material harvested is typically lower, but the preparations are also less bloody. This method places the aspirating hand closer to the sampled mass, which allows more needle control and superior tactile perception of the tissues penetrated by the needle. It is especially useful when sampling very small or very vascular lesions.

Review “Zajdela’s Technique” video on http://www.papsociety.org/fna.html.


Sampling two or more distinct areas in a mass in one needle pass

More than one area in a mass may be sampled using just one needle pass. Sample the first area as usual. Then withdraw the needle tip to a superficial location (e.g. dermis) while maintaining vacuum and without exiting the patient. Change the needle’s angle of entry to redirect it to a different area and sample by performing excursions. Repeat as required.


Sampling a large region in a mass in one needle pass

A larger area in a mass may be sampled using just one needle pass using a technique called “fanning.” After each excursion when the needle tip is in a superficial location, change its angle of entry slightly until the entire region of interest is sampled. Changing the needle direction while the needle is deep in the lesion is to be avoided as it can cause tissue tearing and hemorrhage, which will then compromise the diagnostic yield of subsequent passes.


How can I practice sampling masses by FNA?

You can practice sampling with the syringe holder, with or without ultrasound, using phantom body parts. We have a simulated neck and a simulated breast in the FNA Clinic for this purpose.

You can practice French technique for sampling by taking home a syringe and a few needles. Some suggested surrogate targets: fruits, vegetables, raw meat.


POTENTIAL Complications

Minor pain, bleeding, and bruising are most common. A significant hematoma develops occasionally. Malignant lesions tend to bleed more than benign ones. Stop any bleeding by applying firm pressure to the biopsy site for several minutes. This is sufficient even in patients with coagulopathy. Some patients experience a vasovagal response; prevent falls in case of fainting by positioning the patient supine on the exam table.

Pneumothorax can rarely occur when aspirating a lesion near the chest wall. The patient will experience immediate chest and/or shoulder pain. The risk is greatest in thin patients. Choose a needle trajectory that is tangential to the rib cage to reduce the risk.

Table 8.4 frequency of Pneumothorax as a Complication of Fine Needle Aspiration (FNA) of Superficial (Palpable) Lesions

Authors Cases of pneumothorax Total FNAs Incidence of pneumothorax (%)
Catania et al24 13 74,000 1:5693 (0.018)
Gateley et al25 7 not given 1:1000 (0.10)
Goodson et al26 1 285 1:285 (0.35)
Kaufman et al27 4 1666 1:417 (0.24)

Needle stick injury to the aspirator may occur whenever the needle tip is exposed. Avoid such injuries with vigilance and attention to the location of the needle tip at all times. Always exercise universal precautions.


Management of Adverse and Unexpected Events

1) If the needle enters an artery, bright red blood shoots into the syringe barrel in a pulsatile fashion. Immediately remove the needle from the patient and apply firm pressure with gauze to the site for several minutes. Submit the blood in the syringe for cell block preparation.

2) If the patient experiences neurologic symptoms (e.g., radiating pain or tingling), stop the procedure and remove the needle. Prepare any sample already procured and observe the patient. This condition is transient. Wait for the symptoms to resolve before attempting additional sampling. If the patient experiences extreme/intolerable pain (e.g., schwannomas are quite painful when aspirated), abort the procedure and suggest repeat sampling with sedation.

3) If the patient has a change in heart rate or experiences difficulty breathing, call a code (x6-3333).

4) If the patient moves unexpectedly during the procedure, you may accidentally stick yourself with the needle. Reduce the risk of a needle stick injury by keeping the needle tip inside the patient and removing the needle from the patient only when it is safe to do so.

5) If you are stuck by a contaminated needle: a) stay calm, b) wash injury with soap and water, c) pat dry and apply bandage, d) apply pressure through bandage if still bleeding, and e) call Occupational Health for instructions (x6-2217).

6) Document any patient complications of FNA and their resolution in the medical record.


Where to Drop off specimens and FoRMS for ancillary studies

Cytology Requisition- Cytology Lab (yellow form)

Cell Block- Cytology Lab (same yellow form as Cytology Requisition)

Flow Cytometry- Cytology Lab (fill out separate form available in Lab)

Microbiology- Cytology Lab (fill out separate form available in Lab)

Cytogenetics- Frozen section lab (Blake 3). Specimen must be put in media available from grossing area.

EM- Currently no separate EM form used. Obtain a small vial of glutaraldehyde from the frozen section lab (Blake 3) in freezer compartment of small fridge. Allow the media to thaw 5-10 min at room temperature, and then deposit the specimen in the media. Photocopy the Cytology Requisition, place the copy in a specimen bag with the sample, and leave the bag in a small white container labeled “EM for Warren 5” on shelf inside the fridge door.



ADDITIONAL forms

Completed FNA Template - leave with Souad Mouni for typing (Warren 105).

CYTOLOGY FELLOWS ONLY: INSTRUCTIONS FOR PATIENT FOLLOW-UP You will keep an individual log of the FNA procedures you perform during your Cytology Fellowship year. You will also be expected to contact each patient by telephone within 5 working days of the FNA procedure to ask the patient about his/her post-procedure symptoms and their management/resolution, and to obtain feedback about their overall experience with the FNA procedure.


Sample dialogue with patient at the end of FNA appointment:

CytoFellow: Would you mind if I called you in a few days to check in and see how you are doing?

Patient: Okay.

CytoFellow: What would be a good phone number for me to reach you at?

Patient: 617-555-1212.

CytoFellow: Thank you.

Sample follow-up telephone dialogue with patient after FNA procedure:

Cyto Fellow: Hi Mr. Smith. This is Dr. Kerr from MGH. I performed the FNA biopsy procedure on your [body site] last Wednesday. I am calling to see how you are doing. Did you have any discomfort or pain at the biopsy site? How was your overall experience with our FNA team/the biopsy procedure? Etc.


Document the following information using an Excel file spreadsheet using the corresponding column headings (underlined):

1. Patient MRN

2. Date of FNA procedure

3. Body site sampled

4. Was patient amenable to being called?

5. Date of phone call to patient

If patient was successfully contacted, record the following:

6. Complications

When the patient got home, did s/he experience pain (if so, record severity using scale of 1 to 10), bleeding, or bruising? If so, how did s/he treat the symptom(s)? Did symptoms resolve? (e.g. “I had pain 6 out of 10 that evening, but it went down to a 2 out of 10 after I took some Tylenol, and was gone the next morning.”)

7. General Comments

Patient feedback regarding overall experience (e.g. “I was happy that you could see me so soon.”)


Sample Excel sheet

Patient MRN

Date of FNA

Body site

Ok to call?

Date of Phone Call

Complications (pain, bleeding, bruising)

General Comments

9406822

1/1/2012

Left arm

Yes

1/4/12

Pain overnight (7/10), relieved with ice pack, no pain next day, slight bruising

“Dr. Chebib was really nice.” “I appreciate you checking in.”



Recommended Reading


Cibas, E. S. and B. S. Ducatman (2009). Cytology : diagnostic principles and clinical correlates. Philadelphia, PA, Saunders/Elsevier.


Ali, S. Z. and E. S. Cibas (2010). The Bethesda system for reporting thyroid cytopathology : definitions, criteria, and explanatory notes. New York, Springer.


Solomon, D. and R. Nayar (2004). The Bethesda System for Reporting Cervical Cytology: Definitions, Criteria, and Explanatory Notes, Springer.


Bibbo, M. and D. Wilbur (2008). Comprehensive Cytopathology: Expert Consult: Online and Print, Elsevier Health Sciences.


Gupta, P. and Z. Baloch (2011). Cytohistology: Essential and Basic Concepts, Cambridge University Press.


DeMay, R. M. (2012). The Art & Science of Cytopathology, ASCP Press.