1-17 Palpable Fine Needle Aspiration Biopsy: Procedure, Techniques, and Specimen Handling
Contents
General
Amy Ly, M.D.
Fine needle aspiration (FNA) is widely used for evaluating palpable superficial masses and cysts as well as deep-seated, nonpalpable radiologic abnormalities under image-guidance. The capabilities and limitations of FNA, specific to the evaluation of a specific organ or anatomic site, are discussed in other sections.
In 1930, Martin and Ellis published the first significant North American description of FNA methodology for palpable lesions.1 In spite of the long history of FNA and its application to the care of patients, there is no best practice for performing an FNA, and rigorous comparisons of biopsy techniques are lacking. Although the most common techniques for performing an FNA of a palpable mass are applicable to all superficial sites, there are nuances in method -- some idiosyncratic -- that depend on geographic or institutional custom and/or previous training and experience. Even for individual pathologists, details learned in training are often modified in practice by factors such as height, handedness, hand size, and finger strength.
Hands-on practical training in FNA technique is critical to developing the hand-eye coordination required. When compared with physicians who had no formal training in FNA technique, those who received such training obtained diagnostic samples more frequently.2 The best way to become proficient is to perform procedures under the direct supervision of someone who is proficient and provides feedback. Good training is important, but continued performance of procedures is necessary to maintain competence.
Most complications associated with FNA of superficial sites are similar to those of a blood draw: minor pain, bleeding, and bruising.10 A hematoma develops occasionally. Bleeding is stopped by applying firm pressure to the biopsy site for several minutes. This is sufficient even in patients with a coagulopathy.20 Some patients experience a vasovagal response; positioning the patient supine while performing the biopsy prevents falls in the rare case that a patient faints. If the needle encounters a nerve, the patient may experience radiating/referred pain.21 In such situations, the needle should be removed and the patient observed. The condition is transient and its resolution should be documented in the patient’s record.
More serious complications are rare. A pneumothorax can occur when aspirating a lesion near the chest wall, including the breast, supraclavicular area, and axilla; it occurs in less than 1:200 FNAs. 22-27 The risk is greater in thin patients and can be reduced by choosing a needle trajectory that is tangential to the rib cage. The clinical manifestations are immediate chest and shoulder pain. Mesothelial cells might be seen on the slides.
There have been case reports of death resulting from FNA sampling of a carotid body tumor and carotid artery dissection after “blind” FNA of a neck node.28, 29 Ultrasound guidance can be helpful when sampling near a major vessel.
Seeding of malignant tumor cells along the needle tract has been reported. When large core biopsy needles (e.g., 17g) are used, the rate of needle tract seeding can be as high as 12.5%.30 The risk with FNA, however, is exceedingly low, ranging from 0-0.009%.31-33 The risk increases with the depth of the lesion, needle size, and number of passes.33, 34 Although the limited data available suggest that needle tract seeding by malignant tumor cells does not have clinical implications, disease progression and decreased survival have been ascribed to FNA and core biopsies.35-39 Seeding of the tract by benign tumor cells can also occur.40, 41
FNA procedures pose a risk to the aspirator as well. Whenever the needle tip is exposed, the aspirator is at risk for a needle stick injury. Although the frequency is not well-documented (and likely underreported), the most frequent site of needle stick injury is the index finger of the non-dominant hand (59.6%), which typically occurs during sampling of the lesion.42 Vigilance and attention to the location of the needle tip is important to avoid a needle stick injury. Universal precautions must always be exercised, including wearing a properly fitted N95 mask when performing an FNA on a patient with known or suspected tuberculous infection.
REFERENCES
1. Martin HE, Ellis EB. Biopsy by Needle Puncture and Aspiration. Ann Surg 1930;92(2): 169-81.
2. Ljung BM, Drejet A, Chiampi N, et al. Diagnostic accuracy of fine-needle aspiration biopsy is determined by physician training in sampling technique. Cancer 2001;93(4): 263-8.
3. Guidelines of the Papanicolaou Society of Cytopathology for fine-needle aspiration procedure and reporting. The Papanicolaou Society of Cytopathology Task Force on Standards of Practice. Diagn Cytopathol 1997;17(4): 239-47.
4. Duston MA, Skinner M, Shirahama T, Cohen AS. Diagnosis of amyloidosis by abdominal fat aspiration. Analysis of four years' experience. Am J Med 1987;82(3): 412-4.
5. Libbey CA, Skinner M, Cohen AS. Use of abdominal fat tissue aspirate in the diagnosis of systemic amyloidosis. Arch Intern Med 1983;143(8): 1549-52.
6. Guy CD, Jones CK. Abdominal fat pad aspiration biopsy for tissue confirmation of systemic amyloidosis: specificity, positive predictive value, and diagnostic pitfalls. Diagn Cytopathol 2001;24(3): 181-5.
7. Ansari-Lari MA, Ali SZ. Fine-needle aspiration of abdominal fat pad for amyloid detection: a clinically useful test? Diagn Cytopathol 2004;30(3): 178-81.
8. Westermark P, Stenkvist B. A new method for the diagnosis of systemic amyloidosis. Arch Intern Med 1973;132(4): 522-3.
9. Orlinsky M, Hudson C, Chan L, Deslauriers R. Pain comparison of unbuffered versus buffered lidocaine in local wound infiltration. J Emerg Med 1992;10(4): 411-5.
10. Pitman MB, Abele J, Ali SZ, et al. Techniques for thyroid FNA: a synopsis of the National Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference. Diagn Cytopathol 2008;36(6): 407-24.
11. Zavala DC, Schoell JE. Ultrathin needle aspiration of the lung in infectious and malignant disease. Am Rev Respir Dis 1981;123(1): 125-31.
12. Kreula J, Bondestam S, Virkkunen P. Sample size in fine needle aspiration biopsy. Br J Surg 1989;76(12): 1270-2.
13. Hoda RS. Non-gynecologic cytology on liquid-based preparations: A morphologic review of facts and artifacts. Diagn Cytopathol 2007;35(10): 621-34.
14. Afify AM, Liu J, Al-Khafaji BM. Cytologic artifacts and pitfalls of thyroid fine-needle aspiration using ThinPrep: a comparative retrospective review. Cancer 2001;93(3): 179-86.
15. Parfitt JR, McLachlin CM, Weir MM. Comparison of ThinPrep and conventional smears in salivary gland fine-needle aspiration biopsies. Cancer 2007;111(2): 123-9.
16. Dey P, Luthra UK, George J, Zuhairy F, George SS, Haji BI. Comparison of ThinPrep and conventional preparations on fine needle aspiration cytology material. Acta Cytol 2000;44(1): 46-50.
17. Tulecke MA, Wang HH. ThinPrep for cytologic evaluation of follicular thyroid lesions: correlation with histologic findings. Diagn Cytopathol 2004;30(1): 7-13.
18. Kulkarni MB, Prabhudesai NM, Desai SB, Borges AM. Scrape cell-block technique for fine needle aspiration cytology smears. Cytopathology 2000;11(3): 179-84.
19. Zajdela A, Zillhardt P, Voillemot N. Cytological diagnosis by fine needle sampling without aspiration. Cancer 1987;59(6): 1201-5.
20. Jadusingh IH. Fine needle aspiration biopsy of superficial sites in patients with hemostatic defects. Acta Cytol 1996;40(3): 472-4.
21. Alkan S, Kosar AT, Erdurak SC, Dadas B. Transient vocal cord paralysis following ultrasound-guided fine-needle aspiration biopsy for a thyroid nodule. J Otolaryngol Head Neck Surg 2009;38(1): E14-5.
22. Mayall F, Chang B. Pneumothorax following fine needle aspiration (FNA) of small axillary lymph node. Cytopathology 1998;9(4): 283-5.
23. Priola AM, Priola SM, Cataldi A, et al. Diagnostic accuracy and complication rate of CT-guided fine needle aspiration biopsy of lung lesions: a study based on the experience of the cytopathologist. Acta Radiol 2010;51(5): 527-33.
24. Catania S, Boccato P, Bono A, et al. Pneumothorax: a rare complication of fine needle aspiration of the breast. Acta Cytol 1989;33(1): 140.
25. Gateley CA, Maddox PR, Mansel RE. Pneumothorax: a complication of fine needle aspiration of the breast. Br Med J 1991;303(6803): 627-8.
26. Goodson WH, 3rd, Mailman R, Miller TR. Three year follow-up of benign fine-needle aspiration biopsies of the breast. Am J Surg 1987;154(1): 58-61.
27. Kaufman Z, Shpitz B, Shapiro M, Dinbar A. Pneumothorax. A complication of fine needle aspiration of breast tumors. Acta Cytol 1994;38(5): 737-8.
28. Ustymowicz A, Guzinska-Ustymowicz K, Kordecki K, Lewszuk A, Krejza J. Carotid artery dissection - an important complication after fine-needle aspiration biopsy. Med Sci Monit 2004;10 Suppl 3: 120-2.
29. Engzell U, Franzen S, Zajicek J. Aspiration biopsy of tumors of the neck. II. Cytologic findings in 13 cases of carotid body tumor. Acta Cytol 1971;15(1): 25-30.
30. Llovet JM, Vilana R, Bru C, et al. Increased risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma. Hepatology 2001;33(5): 1124-9.
31. Maturen KE, Nghiem HV, Marrero JA, et al. Lack of tumor seeding of hepatocellular carcinoma after percutaneous needle biopsy using coaxial cutting needle technique. AJR Am J Roentgenol 2006;187(5): 1184-7.
32. Smith EH. Complications of percutaneous abdominal fine-needle biopsy. Review. Radiology 1991;178(1): 253-8.
33. Wu M, Burstein DE. Fine needle aspiration. Cancer Invest 2004;22(4): 620-8.
34. Roussel F, Nouvet G. Evaluation of large-needle biopsy for the diagnosis of cancer. Acta Cytol 1995;39(3): 449-52.
35. Liebens F, Carly B, Cusumano P, et al. Breast cancer seeding associated with core needle biopsies: a systematic review. Maturitas 2009;62(2): 113-23.
36. Rodgers MS, Collinson R, Desai S, Stubbs RS, McCall JL. Risk of dissemination with biopsy of colorectal liver metastases. Dis Colon Rectum 2003;46(4): 454-8; discussion 58-9.
37. Hix WR. Chest wall recurrence of lung cancer after transthoracic fine needle aspiration biopsy. Ann Thorac Surg 1990;50(6): 1020-1.
38. Metcalfe MS, Bridgewater FH, Mullin EJ, Maddern GJ. Useless and dangerous--fine needle aspiration of hepatic colorectal metastases. Br Med J 2004;328(7438): 507-8.
39. Navarro F, Taourel P, Michel J, et al. Diaphragmatic and subcutaneous seeding of hepatocellular carcinoma following fine-needle aspiration biopsy. Liver 1998;18(4): 251-4.
40. Lee KC, Chan JK, Ho LC. Histologic changes in the breast after fine-needle aspiration. Am J Surg Pathol 1994;18(10): 1039-47.
41. Douville NJ, Bradford CR. Comparison of ultrasound-guided core biopsy versus fine-needle aspiration biopsy in the evaluation of salivary gland lesions. Head Neck 2012; 00: 000–000.
42. Kumar N, Sharma P, Jain S. Needle stick injuries during fine needle aspiration procedure: Frequency, causes and knowledge, attitude and practices of cytopathologists. J Cytol 2011;28(2): 49-53.
Additional Resource
Video demonstration of FNA Technique by Dr. Britt-Marie Ljung, Papanicolaou Society website (http://www.papsociety.org/fna.html).
All the equipment needed to perform an FNA (Table 8.1) is small and lightweight enough to be hand-carried in one container. Such portability allows FNAs to be performed on demand and in virtually any setting. The equipment occupies only a small area of counter space when arranged for specimen preparation.
TABLE 8.1 FINE NEEDLE ASPIRATION 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, up 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., RPMI, saline)
8. Local anesthesia and needle/syringe to administer (e.g., 2% lidocaine, 27g needle/1 cc syringe)
9. Alcohol fixative (commercial spray fixative or Coplin jar filled with 95% ethanol)
10. Gloves
11. Pen/pencil for labeling slides (e.g., Leica pen, Sakura Tissu-Tek pencil)
12. Plastic slide holders or slide trays (for transporting slides)
Steps for a successful fine needle aspiration (FNA):
Determine if the FNA is warranted 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 Determining if an FNA is Warranted
A patient presenting for an FNA has almost certainly been referred by another physician. The patient’s clinical history should be reviewed when available, preferably before seeing the patient. A focused physical examination should be performed, confirming that the lesion is indeed palpable (and an FNA appropriate) and ensuring that the correct site is aspirated. It is helpful to ask the patient to point to the mass. If the lesion is not palpable or cannot be safely sampled, it should not be aspirated. By reviewing the results of imaging studies and performing a focused physical examination, the aspirator should assess the size, shape, and relationship of the lesion to nearby structures like large blood vessels. Imaging studies document the internal qualities of the lesion (e.g., vascularity and the relative proportion of solid vs. cystic areas) and its distance from the skin surface. This information guides the approach to the lesion (e.g., the length of needle to use). During the brief examination, the aspirator should inquire about a significant bleeding disorder.
Consenting the Patient
The consent process involves a detailed description of the procedure, including its purpose and potential complications, allowing for questions from the patient. The consent form needs to be signed by a witness. (The physician performing the FNA can act as the witness.)
Sample Explanation of the Procedure
“Hello Ms. Doe, I’m Dr. Ly from the Department of Pathology. I understand that Dr. Jones has sent you here for a fine needle aspiration of a mass in your neck. The goal is to determine the diagnosis for the mass. Let me explain what the procedure involves. Feel free to ask questions at any time.
I will use a very thin needle to take a sample of the mass. The needle is the same size or smaller than the ones used to draw blood. 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. Sometimes I will need to do it a 4th time if I think I will need additional material to make a diagnosis. I usually take a small break after the 1st or 2nd needle stick and do a quick check with a nearby microscope to see how much material there is. I will not make a diagnosis at this time – I am only checking to ensure that I am in the mass and getting enough material to make a diagnosis.
Most patients feel a pinprick when the needle goes through the skin like during a blood draw, and while the needle is moving back and forth, most patients feel a dull pressure, pulling, or soreness. I can inject lidocaine into the skin over the lump if you like. It will be another small needle and you may feel a burning sensation for a few seconds. If you cannot tolerate the procedure because of pain, I will stop and take the needle out.
This procedure has a few minor risks that you should know about. Bleeding and infection are the most common, but I clean the skin with alcohol before each needle stick to minimize the chances of infection. You will probably experience a small amount of bleeding and possibly bruising. After each needle stick, my assistant will apply firm pressure with a gauze pad to minimize this.
Do you understand the purpose of this procedure and the risks involved, and do you agree to the procedure? If so, please verify for me your full name and date of birth, and I’ll ask you to sign this consent form.”
Readying the Equipment
The biopsy apparatus is assembled by loading a syringe onto the syringe holder and attaching a needle. 22g or smaller needles are considered “fine.”3 Commonly, 23g and 25g needles measuring 1.0 to 1.5 inches long are used for palpable lesions. Larger gauge needles (19g to 22g) are used for aspirating abdominal fat to test for amyloid deposition.4-8 The shortest needle that reaches the furthest area of the lesion from the skin should be chosen. Shorter needles (<1.0 inch long) are sufficient for small nodules close to the skin surface. Needles vary in design; those with beveled tips are preferred, but FNA does not require a specific needle type to be successful. Once set up, the needle cap is loosened, and the equipment placed conveniently. If local anesthesia is to be given, it should be prepared at this time.
Because the sample must be prepared immediately before it dries/clots, several clean glass slides should be labeled with at least 2 patient identifiers (e.g., name, date of birth, medical record number), and alcohol slide fixative and a container filled with liquid transport medium should be at hand. These will be used to make smears, rinse the needle, and allocate material for special studies if necessary.
Positioning the Patient and Immobilizing the Lesion
The patient is positioned so that he or she is comfortable and the lesion can be palpated and immobilized. The patient should lie on his or her back when feasible; this is a safe position if there is a vasovagal response. Pillows, rolled towels, and foam shapes can be used for support. Changing the patient’s body position can dramatically affect the accessibility of the lesion. Breast masses, for example, are often best appreciated with the patient’s arm raised above the head. Neck nodules easily palpated in the sitting position may seem to disappear when the patient lies on his back. Becoming ambidextrous at FNA allows more flexibility in how the patient is positioned.
If the mass is beneath a band of skeletal muscle like the sternocleidomastoid, position the patient such that the muscle is relaxed and move the muscle aside. In addition to being painful, passing a needle through skeletal muscle clogs the needle with skeletal muscle.
The exact methodology for stabilizing and immobilizing the mass varies by the site, the size of the mass, and the characteristics of the aspirator’s hands.
Once the method of immobilization and the needle trajectory have been determined, the skin is cleaned with an alcohol swab and local anesthesia injected (if desired). Buffered lidocaine solution tends to be less painful than unbuffered.9 Local anesthetic is advisable if the mass is tender to palpation or if the procedure involves a sensitive site like the nipple/areola. It is best not to inject so much local anesthetic that excessive skin swelling obscures the mass. This is particularly true with smaller nodules. Local anesthesia requires a few minutes to take effect.
Sampling the Lesion
Once the mass is fixed with the non-aspirating hand, the skin is cleaned with an alcohol swab at the planned needle entry site. The loosened needle cap is removed and the aspirating hand stabilized by resting the syringe barrel against the thumb or forefinger of the non-aspirating hand. This guards against any physiologic hand tremor and ensures precise needle placement, but is not be needed after insertion of the needle. The needle is inserted into the lesion and the syringe plunger pulled back to generate several cubic centimeters of vacuum. The vacuum is maintained until the needle is removed from the patient. With a straight wrist, the needle is moved back and forth quickly and repeatedly in a sawing motion (“excursions”) for a dwell time no longer than 15-20 seconds (approximately 40-60 excursions) along the original needle trajectory, alternately advancing into the mass and withdrawing to a superficial location without exiting the patient. Slower needle action will yield less material. A shorter dwell time (2 to 5 seconds) is recommended for vascular lesions like thyroid nodules.10 Some practitioners also rotate the hand in a clockwise or counterclockwise fashion while it is moved within the lesion to achieve a “coring” effect, but this is not necessary. Each time the needle advances into the lesion, its cutting tip dislodges small tissue fragments; this cutting action is essential for a successful FNA. Negative pressure alone without needle movement will not procure enough tissue for diagnosis in solid lesions.1 The vacuum in the syringe helps conduct the tissue fragments into the needle shaft and hub. A slight acceleration of the needle as it advances into the mass enhances the cutting action of the needle tip. Keeping the needle tip within the mass avoids diluting the specimen with adjacent non-lesional tissue. Material can be seen accumulating in the needle hub, although absence of visible material does not signify an inadequate sample. If blood is rapidly entering the hub, withdraw the needle immediately, especially in a vascular site like the thyroid gland.
There are nuances to the technique for different sites and types of lesions. Sampling with thinner needles (25g or 27g) is preferred for vascular organs like the thyroid, as well as for fibrous lesions like a fibroadenoma of the breast.3, 10, 11 When sampling a sclerotic lesion, the needle should be moved more vigorously.
To sample more of the mass with one needle pass, withdraw the needle tip to a superficial location while maintaining vacuum, then redirect it to a different area by changing the angle of entry. “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 is completed or when material or blood is visible in the needle hub, which can occur in less than 15 seconds. Withdraw the needle from the patient in a controlled manner and only after you have released the vacuum in the syringe. Failure to release suction before withdrawing the needle from the patient pulls the aspirated material into the barrel of the syringe, making it difficult to expel for smear preparation. Pressure to the site is applied immediately with gauze to minimize bleeding. The patient or an assistant should perform this step, because the aspirator needs to prepare the sample immediately.
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. Other areas of the mass are sampled on subsequent passes, especially if the initial material is necrotic, cystic, or otherwise non-diagnostic. Sampling the mass along its long axis tends to yield more cellular specimens compared with moving the needle along the short axis.12
VARIATIONS ON BIOPSY TECHNIQUE
Vacuum suction can be created without a syringe holder in one of two ways. The syringe barrel can be gripped with all the fingers of the aspirating hand while the thumb pulls back the plunger. Alternatively, the plunger is gripped with all fingers and the barrel pushed by the index finger. The latter method requires more finger strength and is a bit easier for those with longer fingers.
The FNA biopsy can be performed without suction (the Zajdela or “French” technique),19 using only the needle or the needle attached to a syringe with the plunger either pulled out part way or completely removed. The needle or syringe is held like a pencil in the aspirating hand, which is stabilized by resting the wrist on an available fixed surface (e.g., the examining table or, with his/her permission, the patient). Without suction, the amount of material harvested is generally lower, but the preparations are also less bloody. This method places the aspirating hand closer to the sampled mass, which allows greater ability to “feel with the needle” and more needle control. It is especially useful when sampling very small or very vascular lesions.
All of the above sampling methods may also be performed using ultrasound guidance if the lesion is difficult to palpate or image-documentation of needle placement inside the lesion is desired. The ultrasound probe is held in place by either the non-aspirating hand or by an assistant. The needle may be positioned parallel or perpendicular to the length of the ultrasound beam.
“Feeling with the Needle”
Learning to feel with the needle is an important skill. Cancer is often described as “gritty to needle,” like pushing a needle through the flesh of a pear. Aspirating a fibroadenoma of the breast feels like pushing a needle into a rubber stopper or leather. Fat is “soft to needle,” meaning that the needle encounters minimal or no resistance. Calcifications are rock-hard. The closer the aspirating hand is to the mass, the more tactile information is perceived. Feeling with the needle allows detection of differences within a mass and is useful for sensing whether the needle has entered or exited the mass. This information is very useful for clinical-pathologic correlation.
POST-PROCEDURE INFORMATION FOR THE PATIENT
Evaluate the patient before allowing him or her to stand up. If the patient is dizzy or light-headed, have the patient remain supine longer. Apply firm pressure for several minutes to the procedure site to minimize bruising, longer if the patient has a history of coagulopathy or is on blood thinners.
Your parting words to the patient might go something like this: “The final report should be ready in a couple days and the results will go to Dr. Jones, who will then contact you. The report may take a little longer if additional tests are needed. You can go about your daily routine, including showering and swimming. You might feel some soreness; this should go away in a few days. In the meantime, apply an ice pack and/or take Tylenol if needed. Also, the lump might seem bigger than it was; 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, or redness/pain/discharge at the biopsy site, call Dr. Jones. He knows you have had this procedure and will know what to do.”
MANAGEMENT OF ADVERSE AND UNEXPECTED EVENTS
If the needle enters an artery, bright red blood shoots into the syringe barrel in a pulsatile fashion. The needle is immediately removed and firm pressure applied to the site for several minutes. The blood in the syringe is best submitted for cell block preparation.
If the patient experiences unusual symptoms (e.g., radiating tingling or pain), the procedure is stopped and the needle removed. Any specimen already procured is prepared, and the patient is observed. It is advisable to wait until symptoms have resolved before performing additional passes. If the patient experiences extreme pain (e.g., schwannomas are typically painful when aspirated) the procedure should be abandoned. Repeat sampling under sedation/anesthesia should be considered if tissue biopsy is still desired.
Familiar with emergency procedures (e.g., calling a code) is advisable in the very unusual event that a patient has a change in heart rate or experiences difficulty breathing.
If the patient moves unexpectedly during the procedure, the risk of a needle stick injury can be reduced by removing the needle from the patient only when it is safe to do so.
Needle stick injuries must be documented and appropriate medical care sought immediately as per institutional guidelines. Many institutions have a 24-hour hotline and/or dedicated beeper for handling needle stick injuries.
Complications of FNA and their resolution should also be documented in the medical record.
REFERENCES
1. Martin HE, Ellis EB. Biopsy by Needle Puncture and Aspiration. Ann Surg 1930;92(2): 169-81.
2. Ljung BM, Drejet A, Chiampi N, et al. Diagnostic accuracy of fine-needle aspiration biopsy is determined by physician training in sampling technique. Cancer 2001;93(4): 263-8.
3. Guidelines of the Papanicolaou Society of Cytopathology for fine-needle aspiration procedure and reporting. The Papanicolaou Society of Cytopathology Task Force on Standards of Practice. Diagn Cytopathol 1997;17(4): 239-47.
4. Duston MA, Skinner M, Shirahama T, Cohen AS. Diagnosis of amyloidosis by abdominal fat aspiration. Analysis of four years' experience. Am J Med 1987;82(3): 412-4.
5. Libbey CA, Skinner M, Cohen AS. Use of abdominal fat tissue aspirate in the diagnosis of systemic amyloidosis. Arch Intern Med 1983;143(8): 1549-52.
6. Guy CD, Jones CK. Abdominal fat pad aspiration biopsy for tissue confirmation of systemic amyloidosis: specificity, positive predictive value, and diagnostic pitfalls. Diagn Cytopathol 2001;24(3): 181-5.
7. Ansari-Lari MA, Ali SZ. Fine-needle aspiration of abdominal fat pad for amyloid detection: a clinically useful test? Diagn Cytopathol 2004;30(3): 178-81.
8. Westermark P, Stenkvist B. A new method for the diagnosis of systemic amyloidosis. Arch Intern Med 1973;132(4): 522-3.
9. Orlinsky M, Hudson C, Chan L, Deslauriers R. Pain comparison of unbuffered versus buffered lidocaine in local wound infiltration. J Emerg Med 1992;10(4): 411-5.
10. Pitman MB, Abele J, Ali SZ, et al. Techniques for thyroid FNA: a synopsis of the National Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference. Diagn Cytopathol 2008;36(6): 407-24.
11. Zavala DC, Schoell JE. Ultrathin needle aspiration of the lung in infectious and malignant disease. Am Rev Respir Dis 1981;123(1): 125-31.
12. Kreula J, Bondestam S, Virkkunen P. Sample size in fine needle aspiration biopsy. Br J Surg 1989;76(12): 1270-2.
13. Hoda RS. Non-gynecologic cytology on liquid-based preparations: A morphologic review of facts and artifacts. Diagn Cytopathol 2007;35(10): 621-34.
14. Afify AM, Liu J, Al-Khafaji BM. Cytologic artifacts and pitfalls of thyroid fine-needle aspiration using ThinPrep: a comparative retrospective review. Cancer 2001;93(3): 179-86.
15. Parfitt JR, McLachlin CM, Weir MM. Comparison of ThinPrep and conventional smears in salivary gland fine-needle aspiration biopsies. Cancer 2007;111(2): 123-9.
16. Dey P, Luthra UK, George J, Zuhairy F, George SS, Haji BI. Comparison of ThinPrep and conventional preparations on fine needle aspiration cytology material. Acta Cytol 2000;44(1): 46-50.
17. Tulecke MA, Wang HH. ThinPrep for cytologic evaluation of follicular thyroid lesions: correlation with histologic findings. Diagn Cytopathol 2004;30(1): 7-13.
18. Kulkarni MB, Prabhudesai NM, Desai SB, Borges AM. Scrape cell-block technique for fine needle aspiration cytology smears. Cytopathology 2000;11(3): 179-84.
19. Zajdela A, Zillhardt P, Voillemot N. Cytological diagnosis by fine needle sampling without aspiration. Cancer 1987;59(6): 1201-5.
20. Jadusingh IH. Fine needle aspiration biopsy of superficial sites in patients with hemostatic defects. Acta Cytol 1996;40(3): 472-4.
21. Alkan S, Kosar AT, Erdurak SC, Dadas B. Transient vocal cord paralysis following ultrasound-guided fine-needle aspiration biopsy for a thyroid nodule. J Otolaryngol Head Neck Surg 2009;38(1): E14-5.
22. Mayall F, Chang B. Pneumothorax following fine needle aspiration (FNA) of small axillary lymph node. Cytopathology 1998;9(4): 283-5.
23. Priola AM, Priola SM, Cataldi A, et al. Diagnostic accuracy and complication rate of CT-guided fine needle aspiration biopsy of lung lesions: a study based on the experience of the cytopathologist. Acta Radiol 2010;51(5): 527-33.
24. Catania S, Boccato P, Bono A, et al. Pneumothorax: a rare complication of fine needle aspiration of the breast. Acta Cytol 1989;33(1): 140.
25. Gateley CA, Maddox PR, Mansel RE. Pneumothorax: a complication of fine needle aspiration of the breast. Br Med J 1991;303(6803): 627-8.
26. Goodson WH, 3rd, Mailman R, Miller TR. Three year follow-up of benign fine-needle aspiration biopsies of the breast. Am J Surg 1987;154(1): 58-61.
27. Kaufman Z, Shpitz B, Shapiro M, Dinbar A. Pneumothorax. A complication of fine needle aspiration of breast tumors. Acta Cytol 1994;38(5): 737-8.
28. Ustymowicz A, Guzinska-Ustymowicz K, Kordecki K, Lewszuk A, Krejza J. Carotid artery dissection - an important complication after fine-needle aspiration biopsy. Med Sci Monit 2004;10 Suppl 3: 120-2.
29. Engzell U, Franzen S, Zajicek J. Aspiration biopsy of tumors of the neck. II. Cytologic findings in 13 cases of carotid body tumor. Acta Cytol 1971;15(1): 25-30.
30. Llovet JM, Vilana R, Bru C, et al. Increased risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma. Hepatology 2001;33(5): 1124-9.
31. Maturen KE, Nghiem HV, Marrero JA, et al. Lack of tumor seeding of hepatocellular carcinoma after percutaneous needle biopsy using coaxial cutting needle technique. AJR Am J Roentgenol 2006;187(5): 1184-7.
32. Smith EH. Complications of percutaneous abdominal fine-needle biopsy. Review. Radiology 1991;178(1): 253-8.
33. Wu M, Burstein DE. Fine needle aspiration. Cancer Invest 2004;22(4): 620-8.
34. Roussel F, Nouvet G. Evaluation of large-needle biopsy for the diagnosis of cancer. Acta Cytol 1995;39(3): 449-52.
35. Liebens F, Carly B, Cusumano P, et al. Breast cancer seeding associated with core needle biopsies: a systematic review. Maturitas 2009;62(2): 113-23.
36. Rodgers MS, Collinson R, Desai S, Stubbs RS, McCall JL. Risk of dissemination with biopsy of colorectal liver metastases. Dis Colon Rectum 2003;46(4): 454-8; discussion 58-9.
37. Hix WR. Chest wall recurrence of lung cancer after transthoracic fine needle aspiration biopsy. Ann Thorac Surg 1990;50(6): 1020-1.
38. Metcalfe MS, Bridgewater FH, Mullin EJ, Maddern GJ. Useless and dangerous--fine needle aspiration of hepatic colorectal metastases. Br Med J 2004;328(7438): 507-8.
39. Navarro F, Taourel P, Michel J, et al. Diaphragmatic and subcutaneous seeding of hepatocellular carcinoma following fine-needle aspiration biopsy. Liver 1998;18(4): 251-4.
40. Lee KC, Chan JK, Ho LC. Histologic changes in the breast after fine-needle aspiration. Am J Surg Pathol 1994;18(10): 1039-47.
41. Douville NJ, Bradford CR. Comparison of ultrasound-guided core biopsy versus fine-needle aspiration biopsy in the evaluation of salivary gland lesions. Head Neck 2012; 00: 000–000.
42. Kumar N, Sharma P, Jain S. Needle stick injuries during fine needle aspiration procedure: Frequency, causes and knowledge, attitude and practices of cytopathologists. J Cytol 2011;28(2): 49-53.
Additional Resource
Video demonstration of FNA Technique by Dr. Britt-Marie Ljung, Papanicolaou Society website (http://www.papsociety.org/fna.html ).
PREPARING THE SAMPLE
Making Smears
To prepare smears, the needle is detached from the syringe, the plunger drawn back to fill the syringe barrel with air, and the needle reattached. This is a very important step but one that carries the risk of a needle stick. Although the risk is lower with Luer-Lok syringes, attaching and detaching needles from these syringes takes more effort and time. One way to minimize this is to detach and reattach the needle by clamping the hub with a hemostat.
To expel the material, the plunger is depressed back into the syringe. It is advisable to hold the needle hub securely on the syringe during this step to avoid having the needle detach and fly away under the increased pressure. Touching the needle tip, bevel-down, to the glass slide minimizes spraying of the material. Spraying causes the sample to dry, which is counter-productive if one is planning to wet-fix the slide in alcohol, and it may aerosolize infectious particles. Aspirated material can also be squirted directly into a liquid medium.
If the amount of material is small, one smear is made. If there is more material or blood, more smears should be made. Because drying begins the moment material is expressed onto a slide, it is important that smears be made as quickly as possible.
The “one-smear” method. The slide with the expelled material is held in one hand (usually the non-dominant hand), frosted side up. The thumb rests on the frosted section, and the remaining fingers are placed along the back side of the slide. The dominant hand holds a clean slide (the “spreader” slide) at a 90° angle to the first slide. The lower edge of the spreader slide is brought into contact with the first slide, and the leading edge of the spreader slide is gently lowered (rotated) until the slide contacts the first slide and compresses the expelled material. Maintaining contact between the slides, the spreader (top) slide is smoothly pulled over the material to distribute the material evenly. If done correctly, the smeared material forms an oval shape on the slide. The spreader slide contains minimal material and, for this reason, is discarded in some laboratories.
The “two-smear” method. The slide with the specimen is oriented horizontally with the frosted side up, and a second slide is placed over it frosted side down. The two slides are gently pressed together until the material is flattened between them, and the slides are pulled apart to make two identical smears. It is more difficult to maintain the parallel orientation of the slides with this method, and there is a higher likelihood of preparation artifact (e.g., uneven distribution of material on the slide or scraping of material by the slide edge).
Splitting Material for Multiple Smears
An abundant harvest can be divided to make two or more smears.
Method 1. This process is similar to the “one-smear” method. The slide with the expelled material is held in one hand (usually the non-dominant hand), frosted side up. The slide is positioned at about a 45° angle from vertical with the thumb on the frosted area, and all other fingers along the back of the slide. With the other (dominant) hand, the spreader slide is held at 90° to above over the first slide. The lower edge of the spreader slide is brought into contact with the first slide, and its leading edge is lowered (rotated) until the slide contacts and slightly compresses the expelled material. Some material will transfer to the spreader slide. The spreader slide is then separated from the first slide. The first slide is set aside and a clean slide picked up while held in the same newspaper-reading position below the spreader slide. A smear with this second slide is made in the same way. This process can be repeated to make multiple smears.
Method 2. Instead of expelling all the aspirated material onto one slide, a small drop of material is expressed onto multiple slides. This method requires more control of the plunger. With a single spreader slide, a smear is made on each slide.
Fixing the Smears
Generally, at least one alcohol-fixed and one air-dried smear should be made from each needle pass. The advantages and disadvantages are shown in Table 8.2. Alcohol fixation provides better nuclear detail, whereas air-drying allows better visualization of cytoplasmic quality and extracellular material like mucin and cartilage. For rapid evaluation, an air-dried smear can be stained with a Romanowsky-type stain and examined without a cover slip. Although more time-consuming, an alcohol-fixed slide can be stained with either a rapid Papanicolaou or toluidine blue stain and examined with a cover slip. Air-dried smears should be dried quickly to avoid slow-dry artifacts. Thick, wet slides are often fanned to expedite drying. When preparing alcohol-fixed smears, the slide should be immersed in 95% ethanol or sprayed with an alcohol-based fixative without delay after the smear is made to avoid air-dry artifacts.
Handling Cystic Masses
If the mass is cystic, fluid fills the syringe barrel under negative pressure. As much fluid as possible should be aspirated; applying pressure on the mass can assist with this. The fluid can be discarded if appropriate (e.g., clear fluid from a breast cyst) or expelled directly into a container for subsequent processing. The patient is re-examined, and any residual mass sampled on a subsequent pass. Some cystic lesions are best aspirated under ultrasound guidance, as this allows the aspirator to target the solid area of a heterogeneous mass.
Retrieving Material from the Needle Hub
Some aspirated material may remain in the needle hub after attempts at expulsion onto glass slides. To extract this material, the needle is detached from the syringe and its tip pushed into the rubber top of a blood draw tube or a needle safety device such that the needle tip is not exposed.The needle hub is placed in the middle of a clean glass slide. In a coordinated manner, the glass tube is rocked back and forth with one hand, while the other hand flicks the needle hub. This technique takes some practice. Alternatively, with the needle tip firmly in the rubber top or safety device, the needle is inverted and its hub tapped against a clean glass slide to dislodge tissue fragments.
In most cases, an FNA should not be performed 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.
Rinsing the Needle and Reserving Material for Ancillary Studies
To harvest as much of the sample as possible, the needle should be rinsed using a liquid medium. The needle tip is placed in a container filled with the medium; a small amount of liquid is drawn into the syringe by pulling back on the plunger, then expelled back into the container by pushing in the plunger. This is repeated several times. Excessive force should be avoided as this may mechanically damage the cells. Note that smears should be made before the needle is rinsed to avoid drying artifacts.
The needle can be rinsed with saline, a culture medium like RPMI, or a commercial hemolytic transport solution (e.g., CytoLyt®, CytoRich Red®) for cell block and/or liquid-based preparations (e.g., ThinPrep, SurePath). For routine assessment, the accuracy of thin-layer preparations is comparable to that obtained with smears. One should be aware of slight differences in the cytologic appearances of cells in thin-layer preparations, however, such as smaller and more three-dimensional cell clusters, smaller and darker nuclei, and a cleaner background.13-17
The choice of medium for sample collection depends also on what ancillary studies are needed for diagnosis. The most versatile sample is the needle rinse in saline or culture medium like RPMI; such sample can be submitted for flow cytometric assessment of lymphoid markers in the case of a suspected lymphoma, or for a karyotype in the case of a suspected soft tissue neoplasm. On the other hand, some techniques like fluorescence in situ hybridization (FISH) and molecular assays that amplify DNA are very robust and can be performed successfully regardless of the cytologic substrate, whether a smear, cell block, or liquid-based preparation, so long as certain cellular adequacy criteria are met.
Making a Cell Block from a Smear
If an adequate cell block was not obtained after sedimenting the needle rinse sample, the material on a smear, even if previously stained, can be re-purposed into a cell block. A cellular smear containing large tissue particles is best for this purpose. The slide is soaked in xylene until the coverslip falls off on its own. (This may take several days.) The material is scraped off the slide with a scalpel blade onto lens paper or a sponge and submitted for usual processing as a paraffin-embedded cell block.18
References
1. Martin HE, Ellis EB. Biopsy by Needle Puncture and Aspiration. Ann Surg 1930;92(2): 169-81.
2. Ljung BM, Drejet A, Chiampi N, et al. Diagnostic accuracy of fine-needle aspiration biopsy is determined by physician training in sampling technique. Cancer 2001;93(4): 263-8.
3. Guidelines of the Papanicolaou Society of Cytopathology for fine-needle aspiration procedure and reporting. The Papanicolaou Society of Cytopathology Task Force on Standards of Practice. Diagn Cytopathol 1997;17(4): 239-47.
4. Duston MA, Skinner M, Shirahama T, Cohen AS. Diagnosis of amyloidosis by abdominal fat aspiration. Analysis of four years' experience. Am J Med 1987;82(3): 412-4.
5. Libbey CA, Skinner M, Cohen AS. Use of abdominal fat tissue aspirate in the diagnosis of systemic amyloidosis. Arch Intern Med 1983;143(8): 1549-52.
6. Guy CD, Jones CK. Abdominal fat pad aspiration biopsy for tissue confirmation of systemic amyloidosis: specificity, positive predictive value, and diagnostic pitfalls. Diagn Cytopathol 2001;24(3): 181-5.
7. Ansari-Lari MA, Ali SZ. Fine-needle aspiration of abdominal fat pad for amyloid detection: a clinically useful test? Diagn Cytopathol 2004;30(3): 178-81.
8. Westermark P, Stenkvist B. A new method for the diagnosis of systemic amyloidosis. Arch Intern Med 1973;132(4): 522-3.
9. Orlinsky M, Hudson C, Chan L, Deslauriers R. Pain comparison of unbuffered versus buffered lidocaine in local wound infiltration. J Emerg Med 1992;10(4): 411-5.
10. Pitman MB, Abele J, Ali SZ, et al. Techniques for thyroid FNA: a synopsis of the National Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference. Diagn Cytopathol 2008;36(6): 407-24.
11. Zavala DC, Schoell JE. Ultrathin needle aspiration of the lung in infectious and malignant disease. Am Rev Respir Dis 1981;123(1): 125-31.
12. Kreula J, Bondestam S, Virkkunen P. Sample size in fine needle aspiration biopsy. Br J Surg 1989;76(12): 1270-2.
13. Hoda RS. Non-gynecologic cytology on liquid-based preparations: A morphologic review of facts and artifacts. Diagn Cytopathol 2007;35(10): 621-34.
14. Afify AM, Liu J, Al-Khafaji BM. Cytologic artifacts and pitfalls of thyroid fine-needle aspiration using ThinPrep: a comparative retrospective review. Cancer 2001;93(3): 179-86.
15. Parfitt JR, McLachlin CM, Weir MM. Comparison of ThinPrep and conventional smears in salivary gland fine-needle aspiration biopsies. Cancer 2007;111(2): 123-9.
16. Dey P, Luthra UK, George J, Zuhairy F, George SS, Haji BI. Comparison of ThinPrep and conventional preparations on fine needle aspiration cytology material. Acta Cytol 2000;44(1): 46-50.
17. Tulecke MA, Wang HH. ThinPrep for cytologic evaluation of follicular thyroid lesions: correlation with histologic findings. Diagn Cytopathol 2004;30(1): 7-13.
18. Kulkarni MB, Prabhudesai NM, Desai SB, Borges AM. Scrape cell-block technique for fine needle aspiration cytology smears. Cytopathology 2000;11(3): 179-84.
19. Zajdela A, Zillhardt P, Voillemot N. Cytological diagnosis by fine needle sampling without aspiration. Cancer 1987;59(6): 1201-5.
20. Jadusingh IH. Fine needle aspiration biopsy of superficial sites in patients with hemostatic defects. Acta Cytol 1996;40(3): 472-4.
21. Alkan S, Kosar AT, Erdurak SC, Dadas B. Transient vocal cord paralysis following ultrasound-guided fine-needle aspiration biopsy for a thyroid nodule. J Otolaryngol Head Neck Surg 2009;38(1): E14-5.
22. Mayall F, Chang B. Pneumothorax following fine needle aspiration (FNA) of small axillary lymph node. Cytopathology 1998;9(4): 283-5.
23. Priola AM, Priola SM, Cataldi A, et al. Diagnostic accuracy and complication rate of CT-guided fine needle aspiration biopsy of lung lesions: a study based on the experience of the cytopathologist. Acta Radiol 2010;51(5): 527-33.
24. Catania S, Boccato P, Bono A, et al. Pneumothorax: a rare complication of fine needle aspiration of the breast. Acta Cytol 1989;33(1): 140.
25. Gateley CA, Maddox PR, Mansel RE. Pneumothorax: a complication of fine needle aspiration of the breast. Br Med J 1991;303(6803): 627-8.
26. Goodson WH, 3rd, Mailman R, Miller TR. Three year follow-up of benign fine-needle aspiration biopsies of the breast. Am J Surg 1987;154(1): 58-61.
27. Kaufman Z, Shpitz B, Shapiro M, Dinbar A. Pneumothorax. A complication of fine needle aspiration of breast tumors. Acta Cytol 1994;38(5): 737-8.
28. Ustymowicz A, Guzinska-Ustymowicz K, Kordecki K, Lewszuk A, Krejza J. Carotid artery dissection - an important complication after fine-needle aspiration biopsy. Med Sci Monit 2004;10 Suppl 3: 120-2.
29. Engzell U, Franzen S, Zajicek J. Aspiration biopsy of tumors of the neck. II. Cytologic findings in 13 cases of carotid body tumor. Acta Cytol 1971;15(1): 25-30.
30. Llovet JM, Vilana R, Bru C, et al. Increased risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma. Hepatology 2001;33(5): 1124-9.
31. Maturen KE, Nghiem HV, Marrero JA, et al. Lack of tumor seeding of hepatocellular carcinoma after percutaneous needle biopsy using coaxial cutting needle technique. AJR Am J Roentgenol 2006;187(5): 1184-7.
32. Smith EH. Complications of percutaneous abdominal fine-needle biopsy. Review. Radiology 1991;178(1): 253-8.
33. Wu M, Burstein DE. Fine needle aspiration. Cancer Invest 2004;22(4): 620-8.
34. Roussel F, Nouvet G. Evaluation of large-needle biopsy for the diagnosis of cancer. Acta Cytol 1995;39(3): 449-52.
35. Liebens F, Carly B, Cusumano P, et al. Breast cancer seeding associated with core needle biopsies: a systematic review. Maturitas 2009;62(2): 113-23.
36. Rodgers MS, Collinson R, Desai S, Stubbs RS, McCall JL. Risk of dissemination with biopsy of colorectal liver metastases. Dis Colon Rectum 2003;46(4): 454-8; discussion 58-9.
37. Hix WR. Chest wall recurrence of lung cancer after transthoracic fine needle aspiration biopsy. Ann Thorac Surg 1990;50(6): 1020-1.
38. Metcalfe MS, Bridgewater FH, Mullin EJ, Maddern GJ. Useless and dangerous--fine needle aspiration of hepatic colorectal metastases. Br Med J 2004;328(7438): 507-8.
39. Navarro F, Taourel P, Michel J, et al. Diaphragmatic and subcutaneous seeding of hepatocellular carcinoma following fine-needle aspiration biopsy. Liver 1998;18(4): 251-4.
40. Lee KC, Chan JK, Ho LC. Histologic changes in the breast after fine-needle aspiration. Am J Surg Pathol 1994;18(10): 1039-47.
41. Douville NJ, Bradford CR. Comparison of ultrasound-guided core biopsy versus fine-needle aspiration biopsy in the evaluation of salivary gland lesions. Head Neck 2012; 00: 000–000.
42. Kumar N, Sharma P, Jain S. Needle stick injuries during fine needle aspiration procedure: Frequency, causes and knowledge, attitude and practices of cytopathologists. J Cytol 2011;28(2): 49-53.
Additional Resource
Video demonstration of FNA Technique by Dr. Britt-Marie Ljung, Papanicolaou Society website (http://www.papsociety.org/fna.html).
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.
