FINE NEEDLE ASPIRATION

Transcription

1 FINE NEEDLE ASPIRATION Sarajevo 18th June 2016 Mehmet Akif Demir, MD Sahlgrenska University Hospital Clinical Pathology& Genetics Gothenburg Sweden Why FNA? Cost effective Less invasive Accurate Diagnostic quality getting better: refinement of cytologic criteria availability and application of ancillary studies to be better: Experienced physician skilledin palpation The sample: adequate, representative, interpretable Patients comfort Diagnosis in time Interpretation by pathologist withspecial interest and trainingin cytopatology WHO should perform FNA? The best (especially for palpable lesions): Trained cytopathologist In a speciallypreparedroom With radiological support Deep located lesions: Trained radiologist together with cytopathologist Endoscopic needle aspirations Specialized clinician with ROSE (Rapid On Site Evaluation) Why? Why? Continues Feedback makes you better in FNA/smear technique& diagnosis! (Anamnesis, radiological findings) Palpation Cytomacroscopy Microscopy Choosing stainings or ancillary methods on site. Repeat FNA whilepatient is still in the office Time! Diagnosis/preliminarydiagnosis faster thanfna thatperformedin other departments. A limited number of individuals with better quality Experienced cytopathologist can train other physicians from any specialty interested in learningthe procedure. Uniformityin techniqueand smearpreparation Contributes to a standard education of new generations. 1

2 Ancillary personal Coordinator (to schedule patients) Nurse or cytotechnician on site Aspiration room and equipment A comfartable examination table A curtain for privacy when the patient undresses Counter space witha sink Storage area for equipments, stains and supplies Microscope if needed Equipment Syringe holder(s) 10 ml preferred Needles 23 gauge mostly, and 23, 25 gauge needles Alcoholsoaked swabs and gauze pads Slide holders Glass slideswiththe frostedend usedfor labeling Present for children;)95% alcoholfor wet-fixed smears Balancedsolution (pbs) Vials for liquidbased cytology Sterile swabs for bacterialanalysis Gloves 2

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4 Patient Should be prepared mentally for the procedure Present yourself, shake hand Relaxed patient = better result Explainhowsimple the methodis. Explainthat youusuallyneedthree passes(+/- 1) Do not performfna ifthe patient is not ready for it. Ask patient to show the location ofthe lesion thatshouldbe sampled. Give patient opportunity to ask questions Informed consent form (if the material will be used for research) Optimal position is crucial(even for you!) FNA technique Clean the skin Evaporate alcohol Immobilize the lesion The assistant prepares and hands the equipment to the cytopathologist step by step Distractthe patient The assistent holdsand squeezespatients hand whilefna is beingdone 4

5 FNA technique FNA technique step by step: Wedo not do injectionsofanyanesthetic. Anesthetic injektion is painfull Palpation of the small lesion can be difficultafter injektion May cause interpretation artefacts Weusuallyuse23 gauge needles. If needed21 (especiallyin soft tissue) and 25 or veryrarely27 gauge (in small lesions) We use anesthetic creams especially for children. And a present at the end offna to appreciatethe child 1. The needleis guidedintothe lesion 2. Plungerpulls back How much suction? 3. Verticalto-and-fromovements in some lesions slightly circular or scrapethe wall of the needle tract 4. Attention to the material collectingin the needlehub! The material should remain in the hub Stopp negative pressure (suction) when you have material in the hub 5. The suctionmust be released beforewithdrawingthe needle. Othwervise you will aspirate the material intothe syringe. In thiscaserinse it in a balanced solution. 6. Removethe needlefrom the syringe 7. Takesomeair intothe syringe 8. Attachthe needleto the syringe 9. Expellthe material on to the slide. 10. Preparesmears 11. Rinseneedlesaftereachsmear: therearealwayssomecells leftwithinthe needleand in the hub. 12. If needed, takea samplefor immunocytochemistry, molecularanalysis, cellblock, cell culture Nonaspitration technique-particularly in small lesions Nonaspitration technique-only needle(without syringe) 1. Remove plunger 2. Attach the needle 3. Clean the skin 4. Holdthe aspiration deviceas onewouldholda pencil 5. Proximal part ofthe aspirator s hand rests on patients bodyto get some stability 6. Insert the needleinto the lesion 7. Rapid, back-and-forth movements 8. Withdraw the needle 9. Insert the plunger into the barrel 10. Prepare smears Holdthe needlebetween thumb and 3rd fingers Close the hub withthe 2nd finger Insert the needleintothe lesion Rapid, back-and-forth movements Withdraw the needle Insert the needleto the syringe(withair in the barrel) Prepare smears Some details Yumuşak doku tümörünün işaretlenmesi Three passes(maybe 1-5) Prepare smearsas soonas possible Especiallyin soft tissuetumors, wetry to stick from the same pointand mark the punctured site with ink. Try to get material from different parts ofthe lesion After each puncture, nurse or patient himself/herself should apply pressure witha gauzepadat the needlesite to prevent hematoma! Patient or accompanying person may be light-headed or faint; be ready! Check duringthe FNA process ifthe patient begantoofellfaint Better to start with supine position 5

6 Nål Tusch Smear preparation Prepare some slides and/or cover glas in advance (nurse) Write patient name and or personal number (nurse) Turnthe bevelofthe nedledown to avoidsplashing ofmaterial when expelling it. A dropcloseto frosted edge(2 different placeson the same slideor several slides if there is good enough material in the needle) Smear preparation Prefer peripheral blood smear technique (air-plane taking off!) To avoid crush artefacts Creates a tailwheremostofthe cells lies att the periphery. Depending on the viscousity of the material draw Slowly(lymf node aspirations) Faster (cyst fluid) If the material is thickor mucinous(colloidor mucin): do not use bloodsmear technique. Putthe cover glass on to the material parallelto the glass slide, press slightly and thensmearin a fanlikefashion. Smear preparation Thick fragments on the slidescanbe transferred intoa vial for cellblock Cyst fluid: a coupleofsmears, the rest ofthe fluid shouldbe centifugated (for cellblock or cytospin) Letters (A,B, ) or numbers (1,2 or I,II, ) describingthe site or locations should be written after FNA procedure. Alcoholvial/jarshould be on site to putsmears immediately intothe vial. 6

7 Tail Let the dropp flowslaterally Cellblock Not bad! Hmm! Hvala vam puno na pažnji. Mehmet Akif Demir, MD Sahlgrenska University Hospital, Clinical Pathology and Genetics, Gothenburg- Sweden 7