Atlas of Primary Care Procedures, 1st Edition

Gynecology and Urology

42

Fine-Needle Aspiration of the Breast

Fine-needle aspiration (FNA) cytology is a rapid, safe, inexpensive, and atraumatic method of sampling cystic and solid breast masses. It is commonly performed in the office setting by a primary care clinician, surgeon, or occasionally, a cytopathologist. FNA can reliably diagnose benign and malignant conditions (Table 42-1) and has a false-negative rate for experienced practitioners of 3% to 5%. The accuracy of the procedure somewhat depends on the skill of the clinician in performing the biopsy and of the pathologist in reading the smear. FNA may also be used to assess recurrent masses after lumpectomy.

TABLE 42-1. APPROXIMATE FREQUENCY OF COMMON FINDINGS IN WOMEN WITH BREAST LUMPS

 

Finding

Frequency

 

Fibrocystic changes

40%

No disease

30%

Miscellaneous benign changes

13%

Cancer

10%

Fibroadenoma

7%

 

One of the major benefits of using FNA on a breast mass is the ability to determine whether a lesion is cystic or solid. Typically, mammography cannot distinguish between a cystic or solid lesion. However, when the needle is inserted into the lesion and negative-pressure applied, fluid is readily obtained from a cyst. After the cyst is drained, the site should be examined to exclude a persisting mass, which would require a biopsy to rule out the presence of cystic carcinoma. If the cyst completely disappears, the patient should be reexamined in 1 month. If the cyst recurs, it can be drained one additional time and reexamined in another month. If it recurs a second time, the patient should be referred for excision of the lesion to exclude cystic carcinoma.

FNA, like all breast diagnostic techniques, is imperfect. However, the triple diagnostic technique of clinical breast examination, FNA, and mammography can provide very useful information for the woman, especially when all three techniques suggest the lesion is benign. This allows many clinicians to reassure the patient with simple outpatient testing. Lesions that appear suspicious on any of the triple diagnostic tests should be referred for biopsy (Table 42-2).

TABLE 42-2. COMMON MORPHOLOGIC FEATURES OF INVASIVE CANCER

 

·   Focal lesions extending progressively in all directions

·   Lesions adherent (fixed) to the deep chest wall fascia

·   Lesions extending to the skin and producing retraction and dimpling

·   Lymphatic blockage producing skin thickening, lymphedema, and peau d'orange (orange peel) changes

·   Main ductal involvement producing nipple retraction

·   Widespread infiltration of the breast producing acute redness, swelling, and tenderness (i.e., inflammatory carcinoma)

 

Adapted from Cotran RS, Kumar V, Robbins SL, et al. Robbins pathologic basis of disease. Philadelphia: WB Saunders, 1994:1089–1111.

When a mass is discovered, the breast can be reexamined at the optimal time of the menstrual cycle (i.e., days 4 to 10 of the cycle). Mammography is usually performed before that office visit if the woman is of an appropriate age. If FNA is performed before mammography, allow at least 2 weeks to elapse before attempting mammography, so that any hematoma at the site is not erroneously described as a malignancy. Mammographically identified, nonpalpable lesions should not be approached with FNA in the office setting.

The basic principle of FNA involves moving a 22- to 25-gauge needle back and forth within a lesion, under suction from a 10- to 20-mL syringe, to shave

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and aspirate cells and small tissue samples from the lesion. Several devices are available to make it easier for the clinician to maintain suction during the sampling process. A simple 20-mL syringe and needle also may be used, but this is considered inferior because effort and attention must be diverted from the movement of the needle to maintaining suction. The FNA-21 (Cooper Surgical) is an elegant device with a spring within the syringe. The spring provides negative pressure, allowing the clinician to focus on placement of the needle tip. Skin anesthesia often is unnecessary for FNA, but local 1% lidocaine or local cold therapy may be used if desired. Sterile drapes are usually unnecessary.

Recommended follow-up protocols for FNA results are shown in Table 42-3. When inadequate smears are obtained, the procedure can easily be repeated, often resulting in a satisfactory specimen. However, if an adequate sample cannot be obtained, the clinician should vigorously pursue other biopsy options because cancers may be missed, especially lobular cancer and ductal carcinoma in situ.

TABLE 42-3. BREAST NEEDLE ASPIRATION CYTOLOGY OF SOLID LESIONS AND RECOMMENDED FOLLOW-UP

 

Result

Suggested Follow-up

 

Scant or insufficient cells for diagnosis

Repeat needle aspiration or biopsy if clinical suspicion is high

Benign—fibroadenoma

Reassurance or symptomatic treatment if cellular changes are not complex or associated with atypical hyperplasia

Benign—fibrocystic

Symptomatic treatment if not associated with atypical hyperplasia

Benign—other (includes fat necrosis, lipoma, inflammation, papilloma, and other benign ductal epithelium)

Reassurance and clinical follow-up

Atypical cells

Clinical follow-up can be considered reactive or degenerative atypia (seen in fibrocystic change); mammogram and biopsy for most atypia (especially if severe atypia)

Suspicious for malignancy

Surgical referral and biopsy

Malignant cells

Surgical referral and biopsy

 

The major risk of the FNA procedure is failure to place the needle tip into the lesion. Significant complications of FNA, such as pneumothorax, are rare. Some patients experience mild soreness, hematoma formation, and skin discoloration. The patient with controlled anticoagulation may safely undergo FNA if parameters are in the therapeutic range and adequate site compression is used after the procedure to avoid hematoma. All patients undergoing FNA of breast lesions should wear a supportive brassiere after the procedure.

In the past, there was concern about the possibility of spreading malignant cells by the needle. However, occurrence of this problem has not been documented. Infection is rare, and prophylaxis for bacterial endocarditis is not required.

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INDICATIONS

  • Presence of a palpable suspicious mass in the breast

CONTRAINDICATIONS

  • Local infection
  • Absence of a qualified cytopathologist capable of interpretation of the FNA slides
  • Lack of clinician training with the procedure
  • Severely immunocompromised patients (relative contraindication)

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PROCEDURE

The FNA21 device has the advantage of total focus of the physician's muscles and attention on the needle tip, instead of on creating suction and on movement. In contrast, the mechanical movement for the Cameco pistol syringe (Figure 1B) is produced by motion of the arm and elbow. A 21-gauge butterfly with extension tubing can be attached to any device or syringe, with a nurse applying the back pressure and the clinician focusing full attention on the needle tip (Figure 1C). We recommend the FNA21 or the butterfly technique because of the greater tactile sense and control of the needle.

 

(1) Various FNA-assist devices.

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Palpate the lesion, and mark the skin to indicate the point of needle entry. Prep the skin with 70% isopropyl alcohol or povidone-iodine. Attach the needle, and draw approximately 1 mL of air into the syringe.

 

(2) Attach the needle, and draw approximately 1 mL of air into the syringe.

PITFALL: Avoid injecting air because this may cause a vascular air embolus.

Use the nondominant hand to surround and stabilize the lesion. Surrounding the lesion allows the sensory portion of the fourth and fifth fingers to feel the needle tip enter the lesion as the lesion moves against these fingers. Rarely, the glove may need to be removed from the nondominant hand if it interferes with palpation of the lesion. Make sure the patient understands why the glove is being removed.

PITFALL: Use care to avoid putting the needle tip through the breast and into the examiner's hand.

 

(3) Use the nondominant hand to surround and stabilize the lesion.

PITFALL: Isolating the lesion by using the nondominant hand to press the lesion down against the chest wall increases the risk of a pneumothorax.

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Insert the needle into the lesion, and fully withdraw the plunger to create a vacuum. If the FNA-21 needle is used, release the spring to create back pressure once the needle tip enters the lesion. Make 10 to 20 up-and-down passes, keeping the needle in the lesion. The sample will fill the needle and possibly part of the hub. With the needle still in the lesion, return the plunger to the resting position to release the suction. Then withdraw the needle from the skin.

PITFALL: Do not let the needle come out of the skin while a vacuum is present in the syringe. This causes the sample to be drawn up into the syringe, where it may be difficult to remove.

 

(4) Insert the needle into the lesion and fully withdraw the plunger to create a vacuum.

PITFALL: It is not necessary to change the angle of the needle during the FNA, because it is the passage of the needle into the center of a lesion and the subsequent back-and-forth motion of the needle tip around the initial needle pass that allow shaved fragments of cells to enter the syringe. Moving the needle tip off this initial path in the center of the lesion often results in the needle moving out of the lesion and causes undo errors.

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With the needle pointed downward, use the air in the syringe to deposit the sample onto the slide (Figure 5A). Place another glass slide upside down on top of the original slide, and then gently pull the slides in opposite directions to smear the cellular contents over both slides (Figure 5B). Apply spray fixative as when obtaining a Papanicolaou smear. This technique usually yields two to four slides. If a solid-core specimen is expressed from the needle (rare), wash it from the slide into a vial of preservative, and submit it for histologic examination (Figure 5C). Remove the syringe from the needle, replace it with a fresh one, and repeat the procedure if desired.

 

(5) With the needle pointed downward, use the air in the syringe to deposit the sample onto the slide.

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If a lesion is cystic and fluid is obtained, draw as much as possible into the syringe. If the cyst completely disappears and the fluid is not bloody, the fluid does not have to be sent for analysis. Otherwise, submit the fluid on slides or in a sterile (without anticoagulant) blood collection tube.

 

(6) If a lesion is cystic, draw as much fluid as possible into the syringe.

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Apply compression to the aspiration site with a gauze pad for 5 to 10 minutes to help minimize bruising. Place several folded gauze pads under a snug brassiere to form a compression dressing. Instruct the patient to leave it in place for several hours to prevent hematoma formation. A small ice pack can be applied to the FNA site for 15 to 60 minutes after the procedure.

 

(7) To help minimize bruising, compress the insertion site with a gauze pad for 5 to 10 minutes.

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CODING INFORMATION

 

CPT® Code

Description

2002 Average 50th Percentile Fee

 

19000*

Aspiration drainage of a breast cyst; one cyst

$138

19001

Aspiration drainage of a breast cyst; each additional cyst

$72

10021

FNA without imaging guidance

$102

 

CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING

The Cameco syringe pistol ($286) is available from Precision Dynamics Corporation, 13880 Del Sur Street, San Fernando, CA 91340-3490 (phone: 1-800-772-1122; http://www.pdcorp.com, although this item is not on their web site) and from Morton Medical Ltd., 262a Fulham Road, London SW10 9EL (phone, UK only: 0207 352 1297; phone outside of the UK: +44 207 352 1297;http://www.mortonhealthcare.co.uk/products_index.htm).

The FNA-21 Fine Needle Aspiration Device ($13 each) is a sterile, single-use, spring-loaded syringe and 21-gauge needle. It is available in 1 sample pack and in 3, 12, and 24 packs. It is available from CooperSurgical (phone: 1-800-243-2974; fax: 1-800-262-0105).

BIBLIOGRAPHY

Al-Kaisi N. The spectrum of the “gray zone” in breast cytology. Acta Cytol 1994;38:898–908.

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Erickson R, Shank JC, Gratton C. Fine-needle breast aspiration biopsy. J Fam Pract 1989;28:306—309.

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Hamburger JI. Needle aspiration for thyroid nodules: skip ultrasound—do initial assessment in the office. Postgrad Med 1988;84:61–66.

Hammond S, Keyhani-Rofagha S, O'Toole RV. Statistical analysis of fine-needle aspiration cytology of the breast. A review of 678 cases plus 4,265 cases from the literature. Acta Cytol 1987;3:276—280.

Ku NNK, Mela NJ, Fiorica JV, et al. Role of fine needle aspiration cytology after lumpectomy. Acta Cytol 1994;38:927–932.

Layfield LJ, Chrischilles EA, Cohen MB, et al. The palpable breast nodule. Cancer 1993;72:1642–1651.

Lee KR, Foster RS, Papillo JL. Fine-needle aspiration of the breast: importance of the aspirator. Acta Cytol 1987;3:281–284.

Lever JV, Trott PA, Webb AJ. Fine-needle aspiration cytology. J Clin Pathol 1985;3:1–11.

Stanley MW. Fine-needle aspiration biopsy: diagnosis of cancerous masses in the office. Postgrad Med 1989;85:163–172.

Vural G, Hagmar B, Lilleng R. A one-year audit of fine needle aspiration cytology of breast lesions. Acta Cytol 1995;39:1233–1236.