Abstract
This chapter describes in detail the technique of ultrasound (US)-guided fine-needle aspiration from the placement of the fine needle in the target to the rendering of a cytopathological diagnosis. The technique of fine-needle aspiration biopsy of solid masses is detailed, focusing on the critical step of manual aspiration. Tips and tricks are offered for the preparation of the slides, to ensure delivery of the best material possible to the cytopathologist. The importance of teamwork between the breast imager and the cytopathologist is emphasized.
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Local anesthetization prior to fine-needle aspiration of a suspicious internal mammary lymph node. Transverse view shows the diffusion of the hypoechoic xylocaine solution through the muscular fibers of the pectoralis major muscle as the 21-gauge needle is advanced. (See also Videoclip 5.8). (MOV 2450 kb)
Fine-needle aspiration of a deep-seated infraclavicular lymph node in an obese patient. The angle of insertion of the needle is about 75°. The needle shaft is not well visualized, but the bevel remains well seen inside the metastatic node. (MOV 3456 kb)
Fine-needle aspiration of a metastatic axillary lymph node. Videoclip shows the slow motion of the needle, which is constantly visible inside the boundaries of the metastatic deposit. While the needle is moved in different directions within the tumor, negative pressure (aspiration) is constantly applied by pulling the plunger of the syringe. Suction is stopped prior to withdrawing the needle from the lesion. (MOV 7808 kb)
Fine-needle aspiration performed for staging of a breast cancer in the right upper outer quadrant. Ultrasound has detected an additional, mammographically occult, nonpalpable, suspicious 0.5-cm nodule in the subareolar region. Videoclip shows the exhaustive sampling of the tiny lesion, which is firm and difficult to penetrate. A single pass with a 20-gauge needle yielded sufficient material to confirm malignancy. (MOV 16585 kb)
Fine-needle aspiration sampling technique. Note the changes in the direction of the needle in a fanlike manner to enhance sampling of the lesion. (MP4 10756 kb)
Fine-needle aspiration sampling technique. Videoclip shows the fanlike aspiration technique with the needle being directed in multiple directions to sample most of the volume of this benign reactive intramammary lymph node in a single pass. (MOV 56706 kb)
Fine-needle aspiration sampling technique. Videoclip shows the fanlike reorientation of the needle in different directions to sample most of the volume of this 0.7-cm axillary lymph node. A single pass was sufficient to confirm metastatic disease. (MP4 7279 kb)
Fine-needle aspiration sampling technique. Videoclip shows the exhaustive sampling of a metastatic deposit in an axillary lymph node. The needle is placed first in the center of the deposit and then is redirected upward and downward to sample as much of the tumor volume as possible. (MOV 5102 kb)
Fine-needle aspiration sampling technique. The thumb, index finger, and middle finger of the hand that holds the syringe are used to pull the plunger. Moderate suction is applied constantly during the to-and-fro movements of the needle inside the target lesion. The appearance of material in the translucent plastic hub of the needle signifies that the entire lumen is also loaded with material and that the amount of the aspirate is likely sufficient to make several slides. (MOV 5566 kb)
Use of additional forceful aspirations at the end of an FNA that has not yet brought any material into the hub of the 20-gauge needle. After the standard aspiration technique, there is no visible material in the hub of the needle. To increase the applied suction, the transducer is set aside, the syringe is grasped with both hands, and a few forceful aspirations are performed to draw adequate material into the hub. This single “enhanced” FNA pass allowed the cytological diagnosis of fibroadenoma. (MOV 57225 kb)
Recovery of the aspirate from the syringe first and then from the hub of the needle (see text for details). (MP4 19407 kb)
A trick to recover material "stuck" in the needle’s hub. After the tip of the needle is immobilized, the hub is pinched, lifted, and released to fall back on the glass slide. The vibration shakes and dislodges the material, while the outer component of the radial force applied pushes it out of the hub onto the slide. With a 20-gauge needle. (MP4 8200 kb)
A trick to recover material "stuck" in the needle’s hub. After the tip of the needle is immobilized, the hub is pinched, lifted, and released to fall back on the glass slide. The vibration shakes and dislodges the material, while the outer component of the radial force applied pushes it out of the hub onto the slide. With a 21-gauge needle. The maneuver works better with a 21-gauge needle because it is more flexible than a 20-gauge needle. (MP4 11927 kb)
Preparation of the smears. The aspirated material is squirted first on a slide through forceful pushes of the plunger. Then the operator makes the smear with another slide (the spreader). (MOV 11206 kb)
Fine-needle aspiration of a suspicious axillary lymph node as part of the regional staging of a patient recently diagnosed with breast cancer. This videoclip includes the technique of ultrasound guidance of the needle (without local anesthetization), the aspiration technique, the extensive sampling of the node, the preparation of the smears (shown in Videoclip 6.13), and the review of the slides with the cytopathologist, who has been given the necessary clinical and imaging information and can confirm the diagnosis of metastatic adenocarcinoma consistent with the breast primary tumor. (MOV 28110 kb)
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Fornage, B.D. (2020). Fine-Needle Aspiration. In: Interventional Ultrasound of the Breast. Springer, Cham. https://doi.org/10.1007/978-3-030-20829-5_6
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DOI: https://doi.org/10.1007/978-3-030-20829-5_6
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