PART TWO
Diagnostic Cytology
5. Take time to examine the patient thoroughly. Discuss
3.
your preliminary assessment of the patient's lesion.
This is an opportunity to describe what will take
place during the aspiration and what is to be
accomplished with it. A patient information bro-
4.
chure describing the procedure is helpful and can be
sent to the patient in advance of the appointment or
provided in the waiting room before the patient is
5.
examined. It is important to review that information
6.
with the patient and answer any questions.
6. Obtain informed consent. This consent should indi-
cate that name of the patient who is having the aspira-
tion, the name of the doctor performing the aspiration
and a listing of discussed complications. Generally
there are two potential though rare complications
that need to be presented to the patient, bleeding and
7.
infection. These are very general complications that
can occur anytime the skin surface is breached with
8.
any object, needle, knife, etc. The standard consent
form that is used for small procedures is usually suffi-
ciently generic that a specific one for FNA need not be
designed. Following current patient safety guidelines
of the Joint Commission for Accreditation of Health
Care Organizations (JACHO), it is important to use
two identifiers for a patient, name and medical record
9.
number being preferred. It is also important to review
with the patient and an assistant, usually a nurse, the
procedure site, correct side if a lateralized site (right
breast, left breast), a then take a short "time out" to
again review all of the above. Documentation of these
steps is obviously important.
While for many years the author did not obtain formal writ-
ten informed consent, in compliance with the current interest of
maximizing patient safety and for a fully documented record of
the FNA procedure, informed consent is now obtained in every
case within the clinics and for all deep aspiration biopsies and
for any FNAs performed on children (minors). Patients already
admitted to the hospital have signed a general consent form for
diagnosis and treatment, which the author believes is satisfactory.
Some practitioners may feel that written informed consent is not
required for superficial aspiration biopsy that verbal consent will
suffice. If only verbal consent is obtained it should be thoroughly
documented in the patient's record. Obtaining permission for
aspiration biopsy should be in conformity with clinic and or hos-
pital policy. It is best to review this matter with your office of risk
management or your medical liability insurance carrier, or both.
The best defense against problems, however, is a caring attitude
toward patients and taking time to fully inform them of what you
are doing and how it may help resolve their medical problem.
Performing the Aspiration
Listed here are the steps for actual performance of the aspiration
biopsy.
1. Grasp the lesion to be biopsied with one hand,
most often with two fingers, or push the mass into a
position where it seems fixed and stable.
2. Prepare the skin with an alcohol sponge as you would
for a venapuncture. The author currently swabs the
skin twice with two different alcohol sponges.
Lay the syringe pistol with the appropriate gauge
needle attached to the syringe with the needle point
against the skin and at the predetermined puncture
site and angle.
Using a smooth but quick motion, insert the needle
through the skin and into the immediate subcutane-
ous tissue.
Next, advance the needle into the mass.
To test that the target has been punctured, feel for
differences in resistance or the presence of a capsule
as the needle is advanced. Move the syringe pistol
slightly from side to side. If the mass has been pene-
trated, it will move under the palpating fingers unless
it is completely fixed to underlying or surrounding
tissues.
Apply suction to the aspirating syringe, about one-
third of the total length of the syringe.
With suction held steady, the needle is moved back
and forth within the lesion, using short, rapid strokes,
and within the same or nearly the same original
direction of the needle. The needle sampling should
describe a narrow cone with the apex of the cone at
the junction of the hub of the needle and the needle
itself.
During the actual aspiration, watch carefully the junc-
tion of the needle and the tip of the syringe for the
appearance of any specimen. Absolutely critical for
obtaining high-quality aspirates is to keep the speci-
men within the needle. Aspirating excessive blood or
fluid immediately dilutes the cellular
components of the biopsy.
10. When the specimen first appears at the junction of
the syringe tip and needle, release the trigger of the
syringe pistol, allowing the vacuum in the syringe
to equate to normal. A sample may not always be
observed in the hub of the needle even after 10 or 12
rapid strokes of the needle within the tumor. This is
not
an indication of an unsuccessful aspiration. When
approximately this number of excursions of the
needle has been completed, if no sample is seen, stop
the aspiration by releasing the trigger of the syringe
pistol, allowing the vacuum in the syringe to return to
normal.
11. Now that there is no longer any vacuum in the
syringe, gently and slowly withdraw the needle from
the mass.
12.Immediate pressure is applied to the puncture
site with a sterile gauze pad. This is best done by
an assistant (nurse) since the aspirator will be
immediately occupied with preparing smears and
otherwise triaging the sample
It is very important
not
to withdraw the needle from the
lesion with any vacuum pressure still in the syringe. If there is
vacuum present in the syringe, or the needle is withdrawn with
vacuum applied, the small aspiration sample will be pulled up
into the syringe. Extracting the aspiration biopsy from the barrel
of the syringe is quite difficult, the cellular material begins to
dry almost immediately, and a good quality specimen is com-
promised or could be irretrievably lost. Some aspirators pro-
pose that a small amount of balanced salt solution or heparin
be added to the syringe, the former to avoid drying artifacts, the
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