Breast, Lymphnode, and Soft Tissue Fine Needle Aspiration Biopsy

• Indications:
o Evaluation of palpable masses
o Aspiration of breast cysts
o Differentiation of benign from malignant lesions. In breast disease, stereotactic large-gauge needle biopsy by radiologists has become the technique of choice for evaluation of breast lesions. However, FNA continues to be a valid technique and is essential for centers lacking stereotactic facilities.

• Contraindications:
None

• Anesthesia:
Anesthesia is not routinely used for FNA. However, if needed, a small amount of 1% lidocaine may be infiltrated locally, taking care not to distort the palpable lesion.

• Equipment:
o Alcohol prep
o 10-ml syringe
o 1 1/2-inch 25-gauge needle
o Syringe holder (optional)
o Glass microscope slides (two)
o Spray fixative
o Gauze

• Positioning:
o Breast: For upper quadrant lesions, the patient is placed in an upright seated position. Lower quadrant lesions are better managed in a supine position.
o Lymph node and soft tissue: depends on location of lesion.

• Technique:
o Prep the area for aspiration with an alcohol prep pad as if for phlebotomy.
o Palpate the lesion and immobilize the mass between the fingertips of the nondominant hand.
o Using the dominant hand, advance a 25-gauge needle with an attached 10-ml syringe into the lesion.
o Note the consistency of the mass upon entering it with the needle (firm, soft, rubbery, doughy, gritty).
o Once the lesion is entered, a full 10 ml of suction is applied to the syringe.
o While maintaining suction, move the needle back and forth through the lesion several times in different directions.
o Release the syringe plunger and allow it to return to a neutral position prior to removing the needle from the lesion. At this point the specimen is within the needle and hub and should not be in the syringe.
o Remove the needle from the patient, and have the patient apply pressure to the puncture site with a gauze pad.
o Detach the needle from the syringe.
o Fill the syringe with air.
o Reattach the needle onto the syringe.
o Touch the needle tip to a glass microscope slide with the bevel at a 45 angle to the slide surface.
o Expel material within the needle onto the slide.
o Make a smear by using a second glass slide to gently press down and draw out the material to a feathered edge. If the material is more liquid, it is pulled in the same fashion as a blood smear, except that before the feathering process is completed, the spreading slide is raised, leaving a line of particles across the slide. The spreading slide is then turned and again pressed down against the line of particles and drawn out into a feathered edge.
o Air dry or apply cytological fixative to the slide per the protocol of the cytopathology laboratory that will be processing the specimen. (If a fixative is applied, it must be applied very quickly, usually within seconds of preparing the smear.)
o Most cytopathologists require 3 “6 needle passes (samples) for an adequate pathological diagnosis.
o If a cyst is aspirated, the cyst fluid should be sent for cytology. The region of the cyst should then be re-examined; if a residual mass is felt, it should then undergo FNA.

• Complications and Management:
o Bleeding and hematomas
Breast FNA can be associated with significant hematomas and ecchymoses.
Apply firm direct pressure to puncture sites immediately following aspiration.
o Pneumothorax
More likely in thin patients and deep lesions
If tension pneumothorax suspected, decompression with 16-gauge intravenous line (IV) into second intercostal space and then tube thoracostomy
If 10% to 20% pneumothorax, observation and serial chest radiographs.
If .20% pneumothorax, tube thoracostomy.
o Infection
Extremely rare in FNA but has been reported.
Antibiotics as appropriate.