Vinod B. Shidham ,  MD, FRCPath, FIAC Professor Co-editor-in-chief & Executive editor, CytoJournal (www.cytojournal.co...
Acknowledgement Shidham & Atkinson Cytopathologic Diagnosis of Serous Fluids Elsevier  (W. B. Saunders Company) Some o...
Introduction FNAB has two important components- Performing the procedure  & Interpretation of the aspirated specimen
Introduction With following two important considerations Onsite adequacy evaluation- with appropriate triage  for appropri...
Onsite adequacy evaluation- with appropriate triage  For appropriate ancillary tests Preferably the performer and interpre...
Performing the procedure  is relatively  simple   if   appropriate sequences  are followed with  strict order with  proper...
Cytopathology (FNA Biopsy)
Cytopathology (FNA Biopsy)
Surgical pathology (Core Biopsy)
Surgical pathology (Core Biopsy)
Surgical pathology (Core Biopsy) Tissue section 4 to 6 micron section
Cytopathology (FNA Biopsy)
Cytopathology (FNA Biopsy)
Aspiration of  loose cells
Aspiration of  loose cells
Aspiration of  loose cells
Aspiration of  loose cells
Aspiration of  loose cells
Aspiration of  loose cells
Aspiration of  loose cells
Aspiration of  loose cells
Aspiration of  loose cells
Aspiration of  loose cells
Aspiration of  loose cells
Aspiration of  loose cells
Aspiration of  loose cells
Aspiration of  loose cells
Smear Cytopathology (FNA Biopsy)
FNA Biopsy Critical steps 2. Apply vacuum 1. Locate the lesion,  insert  the needle tip 3.  Maintain vacuum  & sample ...
Pancreatic mucinous cyst (Pap stained  LBC ) DD - Mucinous cystic neoplasm (MCN)  versus  Intraductal papillary mucinous n...
From: Shidham VB  and  Atkinson BF.  Cytopathologic Diagnosis of Serous Fluids ,  Elsevier (Saunders) 2007  (ISBN-13: 9781...
Tissue section Wet-fixed smear Air-dried smear Effect of processing on  cell  sizes  and  details
Processing of Smear Wet fixed smears (for H&E and PAP) a. 95% ethanol b. 95% ethanol with 5% acetic acid c. Spray fixa...
Processing of Smear Shidham V, Kampalath B, England J.  Routine air drying of all the smears prepared during fine needle a...
Processing of Smear
Processing of Smear
Processing of Smear
Air-dried Wet-fixed
Air-dried Wet-fixed
Pancreatic ductal adenocarcinoma- Mod to poorly differentiated (Diff-Quik stain- Direct Smear)
Pancreatic ductal adenocarcinoma- Mod to poorly differentiated (Diff-Quik stain- Direct Smear)
Pancreatic ductal adenocarcinoma- Mod to poorly differentiated (Pap stain- Direct Smear-RH)
Pancreatic ductal adenocarcinoma- Mod to poorly differentiated (Pap stain- Direct Smear-RH)
Contamination  & Sampling artifact
Gut lumen Biopsy needle Lesions to be sampled
FNA of  cystic  lesions. FNA of  solid  lesions. Potential of sampling artifact
Practicing FNAB  on  phantom lesion
How?  Without risk to the patients Suitable approach  to  train & practice  needed Phantom lesion  described is easy t...
Video  Preparation of Phantom and practicing FNAB procedure Shidham V.B.,  Varsegi G.M., D’Amore K., Shidham A. (2009).  P...
Preparation of Phantom and practicing FNAB procedure 9.26 minutes demo video article FREE  on web at- http://www.jove.com/...
Certificate of training & practice  provided after the training  prior to beginning FNAs on patients
Which is also relatively  simple   if   appropriately trained as  surgical pathologist with  cytopathology training the  p...
Broad differential diagnosis of mass lesion Non-Neoplastic: Granuloma Neoplastic: Carcinoma Cohesive  Epithelial structure...
Immunoprofile evaluation- Immunohstochemistry on cell block sections, Flowcytometry On cytospins and  other cytology prepa...
FNAB passes  for Cell block
Shidham V.B., Hunt B., Jardeh S.S., Barboi A.C., Devata S., Hari P. (2010).  Performing and Processing FNA of Anterior Fat...
Performing  FNAB  predominantly for cell block  FREE  on web at-   http://www.jove.com/index/Details.stp?ID=1747 9.41 minu...
Processing of  FNA aspirate  to be submitted to laboratory  for Cell block Let the remaining aspirate clot in the syringe ...
Processing of  FNA aspirate  to be submitted to laboratory  for Cell block Let the remaining aspirate clot in the syringe ...
Processing of  FNA aspirate  to be submitted to laboratory  for Cell block Let the remaining aspirate clot in the syringe ...
Processing of  FNA aspirate  to be submitted to laboratory  for Cell block Let the remaining aspirate clot in the syringe ...
HE stained cell block section Cell-block sections Important for immunocharacterization
GIST (Cell-block- HE & Immuno) HE CK S-100 SMMS vimentin CD117
Proper processing - Including  direct smear  preparation For PAP and Romanowski stains  Proper triage -  Based on  clinica...
Aspirate  triage  &  processing Direct  smears Air-dried Romanowski stain Pap stain  (postfixed  in 95% ethanol after ...
Aspirate  triage  &  processing Direct  smears Air-dried Romanowski stain Pap stain  (postfixed  in 95% ethanol after ...
Aspirate  triage  &  processing Needle  rinse Direct  smears Air-dried Romanowski stain Pap stain  (postfixed  in 95% ...
Aspirate  triage  &  processing Needle  rinse Direct  smears Air-dried Romanowski stain Pap stain  (postfixed  in 95% ...
Aspirate  triage  &  processing Needle  rinse Cell- block Direct  smears Air-dried Romanowski stain Pap stain  (postfi...
(contd) Aspirate  triage  &  processing Flow cytometry Cytogenetics   (RPMI) EM (2.5% glutaraldehyde)
(contd) For other tests such as  Microbiology cultures  Molecular tests Aspirate  triage  &  processing Flow cytometry...
(contd) For other tests such as  Microbiology cultures  Molecular tests Cell block sections for special stains-  Fungal st...
Summary Strength FNAB is well  established,  minimally invasive,  low cost,  simple procedure .
Weaknesses  (Relative limitations) Although simple, being a  skill   it demands  training  and  practice   structured trai...
Weaknesses  (Relative limitations) Although simple, being a  skill   it demands  training  and  practice   structured trai...
Weaknesses  (Relative limitations) Although simple, being a  skill   it demands  training  and  practice   structured trai...
Peer-reviewed,  open access,
Peer-reviewed,  open access,  teaching material with many pictures.
Peer-reviewed,  open access,  teaching material with many pictures. Hard copy and online availability.
Peer-reviewed,  open access,  teaching material with many pictures. Hard copy and online availability. Opportunity for fre...
Q/A
Detroit [email_address] Thank you
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
Overview of FNA procedure- S. K. Navale Medical College, Pune, India
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Overview of FNA procedure- S. K. Navale Medical College, Pune, India

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Overview of FNA procedure-
Strengths, weaknesses, and training
S. K. Navale Medical College, Pune, India.
Dec 23, 2011

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Transcript of "Overview of FNA procedure- S. K. Navale Medical College, Pune, India"

  1. 1. Vinod B. Shidham , MD, FRCPath, FIAC Professor Co-editor-in-chief & Executive editor, CytoJournal (www.cytojournal.com) Vice-chair - AP Director of Cytopathology, Residency training program, Cytotechnology School, Cytopathology fellowship, & GI fellowship Dept of Pathology, Wayne State University Medical School Karmanos Cancer Institute & Detroit Medical Center Detroit, MI 48201, USA [email_address] Overview of  FNA procedure - Strengths, weaknesses, and training S. K. Navale Medical College, Pune, India Dec 23, 2010
  2. 2. Acknowledgement Shidham & Atkinson Cytopathologic Diagnosis of Serous Fluids Elsevier (W. B. Saunders Company) Some of the sketches and tables used are from the following reference.
  3. 3. Introduction FNAB has two important components- Performing the procedure & Interpretation of the aspirated specimen
  4. 4. Introduction With following two important considerations Onsite adequacy evaluation- with appropriate triage for appropriate ancillary tests Preferably the performer and interpreter is same to allow benefits of continuity of the process from clinical insight into the lesion to cytomorphologic scrutiny . If the performer and interpreter can not be the same all efforts and resources should be available to achieve continuity amongst the entities involved. Any compromise will lead to suboptimum results in long run.
  5. 5. Onsite adequacy evaluation- with appropriate triage For appropriate ancillary tests Preferably the performer and interpreter is same To allow benefits of continuity of the process From clinical insight into the lesion To cytomorphologic scrutiny If the performer and interpreter can not be the same (due to logistics or local conditions)- Resources should be available to achieve the continuity Any compromise risks suboptimum results in long run Introduction (contd) With following two important considerations
  6. 6. Performing the procedure is relatively simple if appropriate sequences are followed with strict order with proper application and release of vacuum as needed Although simple, being a skill it demands training and practice Introduction (contd)
  7. 7. Cytopathology (FNA Biopsy)
  8. 8. Cytopathology (FNA Biopsy)
  9. 9. Surgical pathology (Core Biopsy)
  10. 10. Surgical pathology (Core Biopsy)
  11. 11. Surgical pathology (Core Biopsy) Tissue section 4 to 6 micron section
  12. 12. Cytopathology (FNA Biopsy)
  13. 13. Cytopathology (FNA Biopsy)
  14. 14. Aspiration of loose cells
  15. 15. Aspiration of loose cells
  16. 16. Aspiration of loose cells
  17. 17. Aspiration of loose cells
  18. 18. Aspiration of loose cells
  19. 19. Aspiration of loose cells
  20. 20. Aspiration of loose cells
  21. 21. Aspiration of loose cells
  22. 22. Aspiration of loose cells
  23. 23. Aspiration of loose cells
  24. 24. Aspiration of loose cells
  25. 25. Aspiration of loose cells
  26. 26. Aspiration of loose cells
  27. 27. Aspiration of loose cells
  28. 28. Smear Cytopathology (FNA Biopsy)
  29. 29. FNA Biopsy Critical steps 2. Apply vacuum 1. Locate the lesion, insert the needle tip 3. Maintain vacuum & sample different areas of the lesion by inserting back & forth 4. Release the vacuum completely by releasing the syringe piston 5. Remove the needle
  30. 30. Pancreatic mucinous cyst (Pap stained LBC ) DD - Mucinous cystic neoplasm (MCN) versus Intraductal papillary mucinous neoplasm (IPMN)
  31. 31. From: Shidham VB and Atkinson BF. Cytopathologic Diagnosis of Serous Fluids , Elsevier (Saunders) 2007 (ISBN-13: 9781416001454). Preparation of direct smears.
  32. 32. Tissue section Wet-fixed smear Air-dried smear Effect of processing on cell sizes and details
  33. 33. Processing of Smear Wet fixed smears (for H&E and PAP) a. 95% ethanol b. 95% ethanol with 5% acetic acid c. Spray fixative Air dried smears (for Diff-Quik and many other stains including H&E and PAP ). For H&E and PAP- ADS are saline rehydrated and postfixed in 95% ethanol with 5% acetic acid . ( 95ml of 95% ethanol with 5% of glacial acid, stable in screw capped bottle for more than 6 months)
  34. 34. Processing of Smear Shidham V, Kampalath B, England J. Routine air drying of all the smears prepared during fine needle aspiration and intraoperative cytology studies: An opportunity to practice a unified protocol, offering the flexibility of choosing variety of staining methods. Acta Cytologica 2001;45:60-68.
  35. 35. Processing of Smear
  36. 36. Processing of Smear
  37. 37. Processing of Smear
  38. 38. Air-dried Wet-fixed
  39. 39. Air-dried Wet-fixed
  40. 40. Pancreatic ductal adenocarcinoma- Mod to poorly differentiated (Diff-Quik stain- Direct Smear)
  41. 41. Pancreatic ductal adenocarcinoma- Mod to poorly differentiated (Diff-Quik stain- Direct Smear)
  42. 42. Pancreatic ductal adenocarcinoma- Mod to poorly differentiated (Pap stain- Direct Smear-RH)
  43. 43. Pancreatic ductal adenocarcinoma- Mod to poorly differentiated (Pap stain- Direct Smear-RH)
  44. 44. Contamination & Sampling artifact
  45. 45. Gut lumen Biopsy needle Lesions to be sampled
  46. 46. FNA of cystic lesions. FNA of solid lesions. Potential of sampling artifact
  47. 47. Practicing FNAB on phantom lesion
  48. 48. How? Without risk to the patients Suitable approach to train & practice needed Phantom lesion described is easy to make Training FNAB procedure
  49. 49. Video Preparation of Phantom and practicing FNAB procedure Shidham V.B., Varsegi G.M., D’Amore K., Shidham A. (2009). Preparation and Using Phantom Lesions to Practice Fine Needle Aspiration Biopsies. JoVE. 31. doi: 10.3791/1404 Video article is available FREE on web as open access at- http://www.jove.com/index/Details.stp?ID=1404
  50. 50. Preparation of Phantom and practicing FNAB procedure 9.26 minutes demo video article FREE on web at- http://www.jove.com/index/Details.stp?ID=1404
  51. 51. Certificate of training & practice provided after the training prior to beginning FNAs on patients
  52. 52. Which is also relatively simple if appropriately trained as surgical pathologist with cytopathology training the physician component is the backbone from performing the procedure to final correlation with various clinical components. Ultimate aim is final interpretation of the aspirated specimen
  53. 53. Broad differential diagnosis of mass lesion Non-Neoplastic: Granuloma Neoplastic: Carcinoma Cohesive Epithelial structures (glands, papillary, etc.) Lymphoma Non-cohesive pattern Clumped chromatin Sarcoma Spindle cells Melanoma Wide morphologic spectrum Important mimicker- DD for MOST lesions without specific diagnostic clues)
  54. 54. Immunoprofile evaluation- Immunohstochemistry on cell block sections, Flowcytometry On cytospins and other cytology preparations (if required) Molecular studies for- Diagnosis, prognosis, and surveillance Retrieval of cells for other indications- Cell harvesting (tissue banking etc), Cell transplantation (islet cells etc) In addition to morphologic studies:
  55. 55. FNAB passes for Cell block
  56. 56. Shidham V.B., Hunt B., Jardeh S.S., Barboi A.C., Devata S., Hari P. (2010). Performing and Processing FNA of Anterior Fat Pad for Amyloid. JoVE. 44 . doi: 10.3791/1747 Video article is available FREE on web as open access at- http://www.jove.com/index/Details.stp?ID=1747
  57. 57. Performing FNAB predominantly for cell block FREE on web at- http://www.jove.com/index/Details.stp?ID=1747 9.41 minutes demo video article
  58. 58. Processing of FNA aspirate to be submitted to laboratory for Cell block Let the remaining aspirate clot in the syringe for 5 to 7 minutes (slightly longer than the clotting time). 1
  59. 59. Processing of FNA aspirate to be submitted to laboratory for Cell block Let the remaining aspirate clot in the syringe for 5 to 7 minutes (slightly longer than the clotting time). 1 Aspirate 10% formalin from the container in which the specimen is to be submitted for cell block processing. This dislodges the clot from syringe wall. 2
  60. 60. Processing of FNA aspirate to be submitted to laboratory for Cell block Let the remaining aspirate clot in the syringe for 5 to 7 minutes (slightly longer than the clotting time). 1 Gently and firmly remove the plunger of the syringe . 3 Aspirate 10% formalin from the container in which the specimen is to be submitted for cell block processing. This dislodges the clot from syringe wall. 2
  61. 61. Processing of FNA aspirate to be submitted to laboratory for Cell block Let the remaining aspirate clot in the syringe for 5 to 7 minutes (slightly longer than the clotting time). 1 Transfer the aspirated formalin with dislodged cot in to the specimen container with 10% formalin fixative 4 Gently and firmly remove the plunger of the syringe . 3 Aspirate 10% formalin from the container in which the specimen is to be submitted for cell block processing. This dislodges the clot from syringe wall. 2
  62. 62. HE stained cell block section Cell-block sections Important for immunocharacterization
  63. 63. GIST (Cell-block- HE & Immuno) HE CK S-100 SMMS vimentin CD117
  64. 64. Proper processing - Including direct smear preparation For PAP and Romanowski stains Proper triage - Based on clinical and on-site cytomorphologic evaluation Cell block (submit directly in 10% formalin ) Flow cytometry (& cytogenetics)- RPMI Microbiology cultures Electron microscopy ( 2.5% glutaraldehyde ) Molecular studies Onsite adequacy evaluation Onsite adequacy evaluation by a trained cytotech, pathologist, or cytopathologist is crucial component of FNA for:
  65. 65. Aspirate triage & processing Direct smears Air-dried Romanowski stain Pap stain (postfixed in 95% ethanol after saline rehydration)
  66. 66. Aspirate triage & processing Direct smears Air-dried Romanowski stain Pap stain (postfixed in 95% ethanol after saline rehydration) Wet-fixed in 95% ethanol (for PAP stain ) &/OR
  67. 67. Aspirate triage & processing Needle rinse Direct smears Air-dried Romanowski stain Pap stain (postfixed in 95% ethanol after saline rehydration) Pap stain (SurePPath) Pap stain (ThinPrep) OR other LBC fluid (weak fixative) Wet-fixed in 95% ethanol (for PAP stain ) &/OR
  68. 68. Aspirate triage & processing Needle rinse Direct smears Air-dried Romanowski stain Pap stain (postfixed in 95% ethanol after saline rehydration) Pap stain (SurePPath) Pap stain (ThinPrep) OR other LBC fluid (weak fixative) Wet-fixed in 95% ethanol (for PAP stain ) &/OR OR Needle rinses in isotonic fluid For Cytspins or smears by other methods from the centrifuged cell buttons
  69. 69. Aspirate triage & processing Needle rinse Cell- block Direct smears Air-dried Romanowski stain Pap stain (postfixed in 95% ethanol after saline rehydration) Pap stain (SurePPath) Pap stain (ThinPrep) OR other 10% Formalin PEFF cell-block HE & immuno- stained cell block sections LBC fluid (weak fixative) Wet-fixed in 95% ethanol (for PAP stain ) &/OR OR Needle rinses in isotonic fluid For Cytspins or smears by other methods from the centrifuged cell buttons
  70. 70. (contd) Aspirate triage & processing Flow cytometry Cytogenetics (RPMI) EM (2.5% glutaraldehyde)
  71. 71. (contd) For other tests such as Microbiology cultures Molecular tests Aspirate triage & processing Flow cytometry Cytogenetics (RPMI) EM (2.5% glutaraldehyde)
  72. 72. (contd) For other tests such as Microbiology cultures Molecular tests Cell block sections for special stains- Fungal stains- GMS, PAS Mucin stain Aspirate triage & processing Flow cytometry Cytogenetics (RPMI) EM (2.5% glutaraldehyde)
  73. 73. Summary Strength FNAB is well established, minimally invasive, low cost, simple procedure .
  74. 74. Weaknesses (Relative limitations) Although simple, being a skill it demands training and practice structured training and practice session is highly recommended for continued efficiency of this very promising and critical modality in patient care in this era with increasing incidence of cancer. Summary (contd)
  75. 75. Weaknesses (Relative limitations) Although simple, being a skill it demands training and practice structured training and practice session is highly recommended for continued efficiency of this very promising and critical modality in patient care in this era with increasing incidence of cancer. Precise execution of vacuum application & release is critical. On-site adequacy evaluation and proper triage is highly recommended - To avoid inadequate sampling To minimize chances of sampling artifact To prevent inappropriate processing with suboptimal results Summary (contd)
  76. 76. Weaknesses (Relative limitations) Although simple, being a skill it demands training and practice structured training and practice session is highly recommended for continued efficiency of this very promising and critical modality in patient care in this era with increasing incidence of cancer. Precise execution of vacuum application & release is critical. On-site adequacy evaluation and proper triage is highly recommended - To avoid inadequate sampling To minimize chances of sampling artifact To prevent inappropriate processing with suboptimal results Lack of continuity from performing to interpretation. Contamination of non-representative material such as- mucin and mucosal lining in EUS FNAs Sampling artifact due to difficult lesions (accessibility, technical limitations, sclerotic, necrotic etc). Summary (contd)
  77. 77. Peer-reviewed, open access,
  78. 78. Peer-reviewed, open access, teaching material with many pictures.
  79. 79. Peer-reviewed, open access, teaching material with many pictures. Hard copy and online availability.
  80. 80. Peer-reviewed, open access, teaching material with many pictures. Hard copy and online availability. Opportunity for frequent updates
  81. 81. Q/A
  82. 82. Detroit [email_address] Thank you

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