PART TWO
Diagnostic Cytology
staining of various types of lymphoid cells and may be used to
determine clonality.
Organization of the Aspiration Biopsy Service
A pathology-based aspiration biopsy service may be organized
as part of different practice settings—hospital, independent lab-
oratory, or free-standing clinic. Abele and Miller have detailed
their experience of evolution from a hospital-based service to a
free-standing clinic.47 It is important to have dedicated person-
nel familiar with the needs of patients in all of these practice
venues. The utility of FNA must first be proved to clinicians. This
is best accomplished by providing on-demand procedures. That
may include not only servicing hospitalized patients and those
in the hospital's outpatient clinics but travel to attending physi-
cians' offices. As the service grows it then becomes necessary to
perform aspirations within designated hours. Sufficient space to
examine patients is required. For the in-hospital clinic it should
be located close to the pathology department but should be
a separate designated area that is quiet and comfortable for
patients and with sufficient support staff to register patients,
provide assistance to the pathologist performing the aspiration,
and take care of all clerical matters.
As described by Abele and Miller, physicians may then
request that FNAs be performed in their office in preference to
some location in the pathology laboratory.47 Fortunately aspira-
tion biopsy does lend itself to travel because there is a minimum
of equipment to transport. The major disadvantage is the travel
from office to office for single biopsies in even a modest-sized
metropolitan area. However, this investment in time does pro-
mote the use of aspiration biopsy, which if successful, leads to
the next phase, the establishment of a free-standing clinic. A
presentation to clinicians is an important marketing strategy for
aspiration biopsy to be accepted.
There are a number of considerations in developing and
planning a free-standing clinic.
1. Location
a. Convenience
b. Ground floor
c. Within an established medical facility
d. Near offices of physicians referring the majority of
the patients
e. Perception that location is medically reputable
2. Patient convenience
a. Easy accessibility to public and private transportation
b. Obvious designated entrance
c. Ample parking off a major street
d. Clinic personnel who can instruct patients how to
reach the clinic from any location
3. The facility
a. Two examining rooms, one somewhat larger than
the other
b. Some counters at waist level for standing
c. Examining table pointed toward outside windows
and away from aspiration instruments and smear
preparation area
d. Space set aside for children
e. Fixed bench for children, with collection of stuffed
animals
f. Toy box with safe, appropriate toys
g. Interior decoration with home-like atmosphere
Complications of Fine Needle
Aspiration Biopsy
A comprehensive review and discussion of the complications
of fine-needle aspiration biopsy has been reported by Powers.45
A number of case reports and reviews have appeared since the
report of Powers.82,83 However, many of these reports are poorly
documented, specifically with reference to needle size. After
thoroughly studying the literature, with restriction of FNA needle
size of 22 gauge and thinner, and estimating the total number
of aspiration biopsies being performed, Powers determined that
the complication rate for FNA was approximately 0.03% of cases.
This percentage risk would make FNA one of the safest invasive
diagnostic procedures.45
Complications of fine-needle aspiration biopsy of superfi-
cial masses include needle track seeding; pneumothorax with
breast, axillary, and supraclavicular masses, transient acute
swelling (thyroid) hematomas, and histologic alterations. Tis-
sue alterations have occurred with aspiration biopsy of lymph
nodes, thyroid, salivary gland, and breast. These have rarely
posed a problem in interpretation of the excised tissue.45 Tissue
alterations also occur with core needle biopsies and have cre-
ated some problems specifically with an initial interpretation
of intraductal carcinoma of the breast followed by subsequent
excision for the determination of invasion and/or the meaning
of finding tumor in lymphovascular spaces. Some of these tissue
alterations may be attributed to faulty technique by inexperi-
enced clinicians performing the procedure.84 Often larger than
22 gauge needles or microcore needles of 21 gauge are being
used in these cases, with vigorous attempts to obtain tissue cores
rather than traditional aspiration biopsy to prepare smears.85
Serious and sometimes life-threatening complications may
occur with aspiration of deep organs or masses. With transthoracic
aspirations, these include pneumothorax, massive hemorrhage,
air embolism, and cardiac tamponade. No cases of massive
hemorrhage have occurred with 22-gauge or thinner needles.
Two cases of air embolism have been reported from aspiration
with 22- and 23-gauge needles, the latter also using a 19-gauge
guide needle. A single case of tamponade has occurred with a
22- gauge needle. The patient survived.45 Several cases of needle
track seeding of tumor have been reported with transthoracic
FNA, but in 10 of 13 patients either the gauge was not given or
the needle was 20 gauge or larger. Three cases were documented
where the aspiration biopsy was performed using a 22- or
23- gauge needle, with one case also using a guide needle of
19 gauge.45
Twelve cases of complications leading to death have resulted
following aspiration biopsy of the liver. Two of these occurred
using 22-gauge needles. In a third case, the gauge is not given, but
the needle is stated to be "fine."45 Needle track seeding has also
been reported with transabdominal aspiration biopsy. Organs
involved include liver, pancreas, kidney, and a variety of miscel-
laneous sites. Two of eight reported cases after liver FNA devel-
oped subcutaneous tumor implant. A 22-gauge needle was used
in these cases. Four of ten similar cases occurred with 22-gauge
needles used for aspiration biopsy of the pancreas. The implants
were most often subcutaneous or dermal nodules, while one
was a peritoneal nodule. In one of five cases after FNA using
a 23-gauge needle there was a dermal tumor implant.45 Over-
all therefore the complication rate is quite low. Risk factors that
should be considered that may influence the development of
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