Percutaneous Fine-needle Aspiration Biopsy
1981; King Faisal Specialist Hospital and Research Centre; Volume: 1; Issue: 2 Linguagem: Inglês
10.5144/0256-4947.1981.141
ISSN0975-4466
AutoresMohammed Akhtar, Muhammad Ali, John T. Godwin,
Tópico(s)Lung Cancer Diagnosis and Treatment
ResumoCurrent Concepts in MedicinePercutaneous Fine-needle Aspiration Biopsy Mohammed Akhtar, MD M. Ashraf Ali, and MD John T. GodwinMD Mohammed Akhtar Director, Electron Microscopy Laboratories Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre Search for more papers by this author , M. Ashraf Ali Staff Pathologist Department of Pathology and, Laboratory Medicine, King Faisal Specialist Hospital and Research Centre Search for more papers by this author , and John T. Godwin Chairman Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre Search for more papers by this author Published Online:1 Oct 1981https://doi.org/10.5144/0256-4947.1981.141SectionsPDFCite ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutINTRODUCTIONFine-needle aspiration biopsy (FNAB) is a technique whereby a very small quantity of tissue, fluid, and cells is aspirated, using a syringe and a thin-bore needle, from a lesion for cytologic examination. It must be clearly distinguished from other forms of needle biopsy in which large-bore needles are used, to obtain a core of tissue for histologic examination. Large-bore needle aspirations often increase the risk of complications.Although biopsy by aspiration had been performed, intermittently, in the second half of the past century and early part of this century, the technique was first popularized in the United States by H. E. Martin and E. B. Ellis in 1930.1 They utilized 18-gauge needles which, in addition to providing material for cytologic examination, also provided fragments of tissue suitable for histologic examination. Subsequently, several excellent articles were published attesting to the effectiveness of FNAB as a diagnostic technique.2,3 During the three decades from 1930 to 1960, this technique was generally ignored in North America where large-bore needles became more popular. The European physicians, particularly Swedes, on the other hand, continued to develop aspiration using fine needles. Consequently, FNAB has gained wide acceptance in Scandinavia where this technique is regarded as a reliable method for establishing a definitive pathologic diagnosis.In recent years, there has been a resurgence of FNAB interest in North America as indicated by a spate of publications on the various aspects of fine-needle aspiration.4,7In this paper, we describe the technique of FNAB and discuss briefly the scope and limitations of this technique in an attempt to define the role that FNAB could possibly play in the management of cancer patients.MATERIALS AND METHODSPatient examination and case history review are extremely important to determine the depth of the mass to be aspirated and its location in relation to other structures.Equipment20.0 ml disposable syringe.20 to 25 gauge disposable needles of 1¼” to 3¼” length.Alcohol and povidone-iodine prep sponges.Sterile gauze pads.Glass slides with frosted ends.95 percent ethyl or methyl alcohol for fixation.Vial containing three percent gluteraldehyde for electron microscopy.The area through which the needle will be introduced is prepared with an alcohol sponge. For transthoracic and transabdominal aspiration, the area should be prepared with povidone-iodine as well.The mass is grasped firmly in one hand or pinned between the examining fingers and the needle is introduced quickly. A vacuum pressure is then applied to the syringe and the needle is moved about within the mass. With the needle still within the mass, the vacuum pressure is allowed to equate slowly and the needle is withdrawn. Pressure with sterile gauze is then applied to the aspiration site.For transabdominal and transthoracic aspiration, local anesthesia with one percent lidocaine is given, and the long spinal needle with stylet is used. Variation in resistance indicates when the mass has been reached. The stylet is withdrawn and aspiration is performed as described. Modern radiologic imaging techniques such as ultrasound, computerized tomography (CT) scan, television fluoroscopy, and angiography are extremely useful for identifying the location of the lesions and insuring proper placement of the aspiration needles. These techniques should always be utilized when available.Advancing the plunger of the syringe, a small drop of the aspirate is expressed on the slide. A cover glass or another slide is used to spread the material in the manner of a blood smear. It is important not to appose the slides because cellular distortion may result due to surface tension. Usually four to six smears are obtained from one aspiration. Some of these are allowed to air-dry while others are fixed immediately in 95 percent alcohol.The air-dried smears are stained by Diff-Quik® method or by May-Grunwald-Giemsa stain. Alcohol fixed smears are stained by Papanicolau's stain or hematoxylin and eosin stain.APPLICATIONThe technique was initially applied to lesions such as superficial lymph nodes and breast lumps. Other organs such as prostate, lung, thyroid, and salivary gland are also suitable for FNAB. Biopsy material may be obtained in this way from intra-abdominal organs such as spleen, pancreas, liver, kidney, retroperitoneal masses, and lymph nodes. Thus, almost any lesion, on which a fine needle can be used, is a candidate for FNAB.ADVANTAGESBecause it is a minor procedure, fine-needle aspiration biopsy has an advantage over operative and other forms of biopsies. The technique may be used for multiple lesions, may be repeated, and is particularly suitable for debilitated patients. The procedure can be performed in a doctor's office or an out-patient clinic, and the results can be obtained within 15 minutes. For some patients, it may eliminate the need for hospitalization and surgery, and for others, pre-admission test results may shorten hospitalization. The technique does not require the services of surgeons and anesthesiologists and is inexpensive. This would be ideally suited for use in underdeveloped countries.DISADVANTAGES AND COMPLICATIONSThe major disadvantage of FNAB is the relatively small sample obtained for examination. This demands a pathologist with considerable experience in interpretation of normal histology and diseases of all types. The greatest danger comes with sample misinterpretation by inexperienced observers who are unaware of the many diagnostic pitfalls.Complications of FNAB depend on the site of the biopsy and the size of the needle. In the case of superficial lesions, complications are minimal and are limited to occasional small hematomas. Although the needle may pass through a number of solid and hollow viscera such as the liver, stomach, and bowel, the rate of complications is low. N. Stormby and M. Akerman found no complications in 1000 liver aspirations.8 A. Lundquist noted only one complication, intrahepatic hematoma, in 2611 liver aspirations.9 Single instances of biliary peritonitis after liver aspiration and pancreatitis after pancreatic biopsy have also been reported. 10,11 There is a single case report of death from intraperitoneal hemorrhage following a liver aspiration. The patient had cirrhosis with hepatoma and was in liver failure.12Complications are more common following intrathoracic biopsy but can be minimized by using 23- to 25-gauge needles. The most frequent complication is pneumothorax which is usually minor but may occasionally be extensive enough to require treatment. Other less frequent complications include intrathoracic hemorrhage and hemoptysis. In a recent survey of 1562 intrathoracic aspiration biopsies, the rate of complication was as follows: pneumothorax requiring treatment, six percent; major intrathoracic hemorrhage, seven percent; and mortality, zero to one percent.13Complications following transrectal FNAB of the prostate are generally minor and include epididymitis, transient hematuria, hemospermia, and febrile reactions. The only serious complications reported so far are four cases of coliform septicemia, one of which was fatal.14 As compared with transperineal punch biopsies, the complication rate is significantly lower.Another theoretical complication of FNAB is seeding of tumor cells along the needle tract. This has occasionally been reported following biopsies using large-bore needles such as Vim-Silverman and Menghini needles. In spite of many thousands of biopsies performed over the years, there is only one documented case of tumor recurrence attributed to FNAB.15SUCCESS RATE, SENSITIVITY, AND ACCURACYA number of factors contribute to the success rate of this simple, easily-learned technique. Probably the most important is the practical experience and technical skill of the person performing the biopsy. Another factor is the location of the lesion. If, for example, the lesion is superficial, the possibility of obtaining adequate material is quite high. For deeper lesions such as intra-abdominal and intrathoracic masses, the success rate will depend upon the accuracy with which the needle is inserted into the lesion. Recently, the modern imaging techniques of ultrasonography and computed tomography have become very valuable in aiding in proper placement of the needle for aspiration biopsy. Increasing use of these techniques has resulted in a significant increase in the rate of tumor detection by FNAB.The sensitivity of this technique is generally quite high as an aid to detecting malignancy, although it will vary from organ to organ. In breast biopsies, the sensitivity rate has reached 66 to 80 percent, and in other tissues, such as lungs, it is even higher.4,16Accuracy of a diagnosis made on the basis of FNAB depends to a large extent on the expertise of the pathologist. Of course, it is variable but accuracy rates ranging from 80 to over 95 percent have been achieved.5 Fine-needle aspiration biopsy has a low incidence of giving both false-positive and false-negative findings which are common with conventional histopathology and cytopathology.17,18 The technique is quite accurate when done correctly and the difficulties of interpretation can be mastered with experience.ROLE OF ELECTRON MICROSCOPY IN INTERPRETATION OF FNABFNAB is highly accurate in discriminating between benign and malignant processes. However, it is generally felt that this technique is much less suited for recognizing cell types and histologic patterns of growth. This is because FNAB is usually composed of cells which are dislodged from their natural environments, and the relationship of cells to one another and to stroma is disrupted. Thus in case of moderately to poorly differentiated carcinoma, the diagnosis of carcinoma is easily made with FNAB; however, further categorization of carcinoma into squamous or adenocarcinoma may not be possible. Similarly, a diagnosis of malignant lymphoma can generally be made without much difficulty, but further classification of the lymphoma is often difficult.These limitations, inherent in the technique of FNAB, can be remedied with the use of electron microscopy. In recent years, considerable knowledge and experience have been gained regarding the ultrastructure of various tumors. Based on this knowledge, the ultrastructural diagnosis has become much more precise and reliable. The tumors, which are especially amenable to ultrastructural diagnosis, include malignant melanoma, neuroendocrine tumors, and soft tissue sarcomas. In addition, electron microscopy is particularly helpful in distinguishing poorly differentiated carcinoma from malignant lymphoma. Electron microscopy is also valuable in the differential diagnosis of small round cell tumors of childhood such as neuroblastoma, Ewing sarcoma, Wilms' tumor, rhabdomyosarcoma, and malignant lymphoma.In a recent study carried out in our laboratory, it was shown that the diagnoses of various tumors using electron microscopy of FNAB were much more precise and specific than was possible with light microscopy alone.19 Hopefully, with the help of electron microscopy, the diagnostic efficiency of FNAB could be enhanced much further and thus, in selected cases, this technique could become the procedure of choice for establishing a pathologic diagnosis.ROLE OF FNAB IN MANAGEMENT OF CANCER PATIENTSAlthough there has been a much greater acceptance of fine-needle aspiration in recent years, several fundamental questions regarding this technique still remain unanswered. What is the role of fine-needle aspiration biopsy in the management of cancer patients? Can the cytologic diagnosis based on fine-needle aspiration biopsy form the basis for ablative surgery or other radical treatment such as chemotherapy or radiotherapy? Should the cytologic diagnosis be confirmed by histologic examination prior to any definitive treatment? If that is the case, what is the use of fine-needle aspiration cytology?In Scandinavian countries where FNAB has been used for many decades, the cytopathologist, in judging an aspiration biopsy as positive, assumes the responsibility for radical treatment, such as mastectomy. Operative biopsy is thus reserved for cases in which FNAB results are either negative or inconclusive. In other countries, including the United States, FNAB is only used as an initial diagnostic procedure and information obtained from examination of FNAB is used as a guide for planning further diagnostic work-up and for preliminary discussions with the patient. Definitive treatment, however, is instituted only following histopathologic confirmation of the diagnosis.At the King Faisal Specialist Hospital and Research Centre, where approximately 800 aspiration biopsies have been performed since July 1977, our attitude towards the place of FNAB in the diagnostic sequence is similar to that in the United States, i.e., definitive treatment is instituted only after histologic confirmation of the diagnosis. However, we believe that a positive FNAB diagnosis could be accepted as definitive and final under certain clinical situations.If the patient has a histologically proven malignant neoplasm, FNAB is done on a suspected metastatic or recurrent lesion.If the patient is terminally ill with a suspected widespread malignant tumor for which no treatment is possible, FNAB is done to confirm the presence of malignant neoplasm and rule out any treatable conditions.It is our belief that, with the passage of time, as more and more experience is gained with aspiration biopsy, and as most of the diagnostic pitfalls inherent in this technique are recognized, FNAB will ultimately replace a significant proportion of frozen sections and tissue biopsies for the diagnosis of cancer. Until that time, however, a cautious and conservative approach to the application of this undoubtedly valuable technique is warranted.CASE REPORTSIn this section we briefly present four cases in which a diagnosis was established by FNAB.Case 1A 35-year-old woman presented at the out-patient clinic with a mass in the left breast. Fine-needle aspiration biopsy revealed clusters of malignant epithelial cells which were interpreted as duct cell carcinoma. Figure 1. This diagnosis was confirmed by histopathologic means and the patient underwent mastectomy.Figure 1. FNAB of breast mass revealing a cluster of malignant epithelial cells. Diff-Quik® staining, magnified 200 times.Download FigureCase 2A 57-year-old man had laryngectomy for transglottic squamous cell carcinoma. Six months later the patient developed right neck mass. FNAB results revealed metastatic squamous cell carcinoma. Figure 2. Because the patient had an histologically proven primary squamous cell carcinoma, no further biopsy was considered necessary.Figure 2. FNAB of neck mass showing keratinized malignant squamous cells. Diff-Quik® staining, magnified 480 times.Download FigureCase 3An 18-year-old boy had a right cervical mass. A Tru-Cut® biopsy revealed a large cell lymphoma. Three months later, the patient developed a right testicular enlargement. Fine-needle aspiration biopsy of the testis revealed involvement by malignant lymphoma. Figure 3.Figure 3. FNAB of right testis featuring clusters of large lymphocytes indicating involvement by malignant lymphoma. Magnified 480 times.Download FigureCase 4A seven-year-old girl presented with a large mass involving right chest wall. FNAB results revealed a malignant tumor composed of small round cells. Figure 4. The differential diagnosis included such possibilities as malignant lymphoma, rhabdomyosarcoma, neuroblastoma, and Ewing sarcoma. Electron microscopy studies revealed that most of the tumor cells contained abundant intracytoplasmic glycogen indicating a Ewing sarcoma. Figure 5.Figure 4. FNAB of mass in right chest wall. The tumor is composed of closely packed small round cells. Magnified 480 times.Download FigureFigure 5. Electron micrograph depicting atypical tumor cell. The cytoplasm is full of glycogen while other organelles are sparse. Magnified 15,000 times.Download FigureARTICLE REFERENCES:1. Martin HE, Ellis EB: "Biopsy by needle puncture and aspiration" . Ann Surg 92:169–811930. Google Scholar2. Stewart FW: "The diagnosis of tumors by aspiration" . Am J Pathol (Suppl) 9:8011933. Google Scholar3. Godwin JT: "Aspiration biopsy: technique and application" . Ann NY Acad Sci 263:1348–731956. Google Scholar4. Tao LC, Pearson FG, Delarue NC, et al.: "Percutaneous fine-needle aspiration biopsy. I" . Its value to clinical practice Cancer 45(6): 1480–851980. Google Scholar5. 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Riska H, Friman C: "Letter: Fatality after fine-needle aspiration biopsy of liver" . Br Med J 1 (5956): 5171975. Google Scholar13. Herman PG, Hessel SJ: "The diagnostic accuracy and complications of closed lung biopsies" . Radiology 125(1): 11–141977. Google Scholar14. Esposti PL, Elman A, Norlén H: "Complications of transrectal aspiration biopsy of the prostate" . Scand J Urol Nephrol 9(3):208–131975. Google Scholar15. Sinner WN, Zajicek J: "Implantation metastasis after percutaneous transthoracic needle aspiration biopsy" . Acta Radiol (Diagli) 17(4): 473–801976. Google Scholar16. Kline TS, Joshi LP, Neal HS: "Fine-needle aspiration of the breast: diagnoses and pitfalls. A review of 3545 cases" . Cancer 44(4): 1458–641979. Google Scholar17. Wallgren A, Silfverswãrd C, Hultborn A: "Carcinoma of the breast in women under 30 years of age: a clinical and histopathological study of all cases reported as carcinoma to the Swedish Cancer Registry, 1958-1968" . Cancer 40(2):916–231977. Google Scholar18. Frost JK: "Diagnostic accuracy of cervical smears" . Obstet Gynecol Survey 24:893–9081969. Google Scholar19. Akhtar M, Ali MA, Owen EW: "Application of electron microscopy in interpretation of fine-needle aspiration biopsies" . Cancer (in press). Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 1, Issue 2October 1981 Metrics History Published online1 October 1981 KeywordsBiopsyneedle Microscopyelectron Neoplasms/diagnosisInformationCopyright © 1981, Annals of Saudi MedicinePDF download
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