Technique of Fine Needle

Aspiration Biopsy and handling

specimens

Lisnawati
Departemen Patologi Anatomik
FKUI/RSCM - 2013
 Objective
• History and definition of FNAB
• Aims of FNAB
• Indications and Contraindication
• Procedure of FNAB
• Advantages, limitations and complication of
FNAB
• Handling specimens
• Examples
 History
 1853 : James paget  cell aspirates from breast
cancer
 1904 : Greig and gray  trypanosomes from
lymph node
 1921 : Guthrie  malignant lymphoma from
lymph node
 1930 : Martin and Ellis diagnose a variety of
swellingin memorial hospital in New York
 FKUI : begin 1989
 Definition
• Procedure to get representative samples from lesion
in the body that use fine needle with or without
aspirator
 FNAB
 1. Superficial organ/ nodule
› Lymph node
› Thyroid
› Breast
› Salivary gland
› Others nodule
 2.Deep organ  by imaging guidance
› liver
› Intraabdominal mass
› Unpalpable mass
› etc
 Aims
• FNA is not a screening test procedure
• Distinguish non-neoplasms from neoplasms
• Distinguish benign from malignant lesions
• Classify neoplasms and others pathologic processes
 Contraindications
 Marked hemorrhagic diathesis increases the risk of a
significant hemorrhagic
 Highly vascular tumors
 Aneurysm or a vascular malformation
 Deep organ(specific for each organ)  severe cough,
bullous emphysema, pulmonary hypertension,
respiratory failure in the case of lung aspiration
 Liver severe jaundice, suspicious of hemangioma or
hydatid disease
 Advantages of FNAB
• The patient
– Minimal pain and post aspiration discomfort
– Anesthesia is rarely necessary
– Can be used in high risk patients
– Usually an outpatients procedure
– Save time and hospitalization
– Rapid alleviation of anxiety
– More time to adjust to other procedures
 Advantages of FNAB
 Clinical management
› Easily repeated
› Allows sampling of multiple area with minimal trauma
› Minimal disturbance of tissue planes for the sole purpose of
diagnosis
› Confirm malignancy of a nodule, but leaves it intact to monitor
therapy by clinical examination or by repeated aspiration
› Therapeutic for some masses ( cysts and abscesses)
› Does not require extensive training of physicians
› Quick feedback help in training and planning other
investigative procedures
 Advantages of FNAB
• The laboratory
– Simple, inexpensive equipment
– Excellent cell preservation due to rapid
fixation
– Allows studies requiring freshly harvested
cells
– Material can be obtained for other
examination ( microbiology, molecular
technique, cytogenetic studies, enzymatic
assay, stem cell culture etc)
 FNA Procedure
• Preparation by the FNA doctor
• Discussion with the patient
• Physical examination
• FNA technique
• Making a good smear
• Tissue triage
 Preparation by the FNA doctor
• Obtain clinical information
– Medical record
– Talk to referring physician
• Prepare the room
– Clean, organized
– Chair to family member
• Check for needed supplies
– Syringe, needles, object glass, formalin for cell block
– Patients specific needs – culture media, etc
 Discussion with the patient
• Put the patient at ease
• Let the patient know you are familiar with their
history and why they have been referred to FNA
• Obtain clinical history from the patient
• Perform physical examination
• Document what you discuss and find on physical
exam
 Physical examination
• Lesion specific
– Location
– Size
– Characteristics of nodule : multi nodules, cystic, firm,
hard, mobile, immobile etc

• Other examined sites

– Other compartments of the head and neck
– Regional lymph node
 Equipment
• Syringes – 5 cc/10 cc
• Needles – 25 gauge
• Aspiration device – Cameco FNA gun
• Glass slides
• Alcohol 95% for fixation
• Formalin for cellblock
FINE NEEDLE ASPIRATION BIOPSY (FNAB)

Representative
and adequacy
of the samples

operator

Technique of Imaging
collecting guidance
sample (USG,CT)
Technique of collecting sample
Spinal needle, 20 ml dyspossible syringe, piston/gun
FNA PROCEDURE :
- EQUIPMENT

- PATIENT PREPARATION

- SAMPLING
FNA TECHNIQUE
- OBTAIN INFORMED CONSENT

- STERILIZE SKIN

- IMMOBILIZE NODULE WITH FIRST TWO FINGERS OF NON DOMINANT HAND

- SAMPLE NODULE WITH REPEATED EXCURSION OF THE NEEDLE THROUGH

THE NODULE

- OBTAIN A MINIMUM OF THREE SEPARATE SAMPLE

Technique of smear
Good smear
 KEY TO SUCCESFUL FNA
• Thorough sampling
• Between three and six independent passes are recommended
• Repeated excursion of the needle through the nodule is
essential
• Minimize sample volume and blood contamination
• Optimize sample preparation
 HANDLING SAMPLE
• Immediately put the slide (after make smear)
into alcohol fixative 95% -96% minimally 30
minutes.
• A part of slides let in the air until dry ( if
possible use hairdryer or fan to make dry fast )
• Don’t forget to write down the patient label on
the slide
• Send to laboratory with form and completely
clinical data
FIXATION
 Don’t forget your formaline

Maud vesselic, et all, unpublish

 CELL BLOCK CYTOLOGY

• The main motive for making cell blocks is to obtain tissue for
immunohistochemistry
• The high cell block adequacy rate can be attributed to a
reaspiration of the lesion
• The ability to perform a second aspirate depends on a reporting of
the first aspirate
• The use of cell block immunohistochemistry is technicaly
unsophisticated and may be readily adopted by small laboratories
• Cell Block is useful for categorization of tumours that otherwise
may not be possible from smear themselves
• Advantage for less experienced cytopathologist
(cell block=histology)
 CELL BLOCK

ASPIRATE SPECIMEN CELL BLOCK

FORMALIN
IN THE
NEEDLE/SYRINGE FIXATION -IHC

THE PROCESS SAME WITH HISTOPATHOLOGIC SPECIMEN

 Protocol for preparation of aspirated material can be used

BAHAN
ASPIRASI

MASUKKAN KE
ALKOHOL 96% FIKSASI KERING DALAM
FORMALIN

PAPANICOLAOU GIEMSA
STAINING SENTRFUGE
STAINING

PARAFFIN
EMBEDDED
TROMBIN CLOT

HEMATOXYLIN SPECIAL
SPECIAL STAINING IMMUNOHISTOC
(MUCIN, GLIKOGEN
EOSIN DLL)
DLL)
HEMISTRY
 GENERAL REPORTING
• Depend on the organ
• Some based on Bethesda/Papanicolaou Society/Paris
classification/International Cytology
• General reporting
– INSUFISIENSI /UNSATISFACTORY ( NOT REPRESENTATIVE)
– NEGATIVE (BENIGN LESION)
– INCONCLUSIVE ATYPIA
– SUSPICIOUS FOR MALIGANCY
– POSITIVE FOR MALIGNANCY
Mutu sediaan baik
Mutu sediaan baik. adekuat
Mutu sediaan baik
Mutu sediaan kurang baik
Mutu sediaan kurang baik
Mutu sediaan kurang baik
 FNAB  DEFINITIVE
DIAGNOSIS ?

Depend on :
- Organ
- disease (diagnosis)
- need ancillary technique ( Imunocytochemistry,
molecular technique, etc )
- consensus
FNAB OF THE BREAST
Protokol penatalaksanaan pasien (National Cancer Institute Consensus Conference on
the uniform approach to breast FNAB )
Mastitis granulomatosa
Fibroadenoma mamma
 Breast
cancer

Invasive ductal
carcinoma
 FNAB of SALIVARY GLANDS
 FNAB  accepted by head-neck surgeon as an excellent
 Zaijcek, 1974 ; Batsakis et al, 1992; Boccato et al 1992
 primary methods of evaluating space occupying
lesion of the salivary glands
 FNA of salivary glands :
› Is the mass of salivary gland origin ?
› If the mass is of salivary gland origin, is it neoplastic or non-
neoplastic ?
› If the mass neoplastic, is it benign or malignant ?
› If the mass is malignant, is it primary or metastatic ?
Adenoid cystic
carcinoma
Adenoma
pleomorfik
 FNAB of the THYROID
• The primary objective :
– Select the case :
• Require surgery for neoplastic
• Inflammmatory abnormality  followed clinically or
treated medically
• Aspiration biopsy
– 25 gauge needle
– Larger caliber needles  NOT RECOMMENDED
(bleeding)
 Ground glass appearance

PAPILLARY CARCINOMA OF THE THYROID

COURTESY OF PROF. SHOTARO MAEDA, NMS

FOLLICULAR CARCINOMA OF THE THYROID

COURTESY OF PROF.S HOTARO MAEDA, NMS

 FNAB OF THE BONE AND SOFT TISSUE
TUMORS
Triple diagnosis :
1. Clinical diagnosis
2. Radiology diagnosis
3. Cytology/Histopathology diagnosis
osteosarcoma
 chondrosarcoma

COURTESY OF PROF.S HOTARO MAEDA, NMS

 GIANT CELL TUMOR OF THE BONE

COURTESY OF PROF.S HOTARO MAEDA, NMS

FNAB OF THE LUNG
 Endosonography and Chest medicine

ESTS, Deleyn P , Eur Cardio T Surg 2007 ACCP, Detterbeck F, Chest 2007

Janes and Spiro, AJRCCM 2007

COURTESY OF DR. MAUD VESSELIC, LUMC

 Scopes and Ultrasound Processor

COURTESY OF DR. MAUD VESSELIC, LUMC

 Transesopfageale echografie + naald punctie

COURTESY OF DR. MAUD VESSELIC, LUMC

 Small cell lung carcinoma

Cells showing increasd cytoplasma that may be mistaken for non-small

cell carcinoma

Syncytial group with nuclear molding and paranuclear cytoplasmic globules (so-called blue
bodies)
FNAB- Mediastinum :
Thymoma
Hepatocellular carcinoma
Hepatocellular Carcinoma
THANK YOU