Radiologically guided fnac

1. Dr.Sonali Timaniya

2. Introduction
Cytology is a useful tool to screen and diagnose
various pathological lesions in the body without
causing significant trauma to the patient.

3. Cytopathology Methods
 Exfoliative cytology
 Abrasive cytology
 Fine needle aspiration cytology

4. Exfoliative cytology
Spontaneously shed cells in body fluids
 Urine
 CSF
 Sputum
 Effusions in body cavities (pleura, pericardium, peritoneum)

5. Abrasive cytology
Dislodges cells from body surfaces
 Imprint
 Scraping
 Endoscopic brushing of mucosal surfaces
 Washing (lavage) of mucosal or serosal surfaces
 Swab

6. Fine Needle Aspiration Cytology
FNAC is widely used for deep seated lesions of the
body. This helps avoid open biopsy or laproscopic
surgery in many situations.
 Superficial nodules and organs easily targeted
 Deep organs –radiological guidance is needed

7. Indications of image guided deep
seated lesions
 To diagnose the character & type of primary lesion
 To assess non palpable and deep seated lesion
 To know the staging of malignant lesion
 To collect material for ancillary studies such as flow
cytometry , microbial culture etc.

8. Advantages of guided lesions
 Area of interest or more representative part of tissue can
be sampled.
 Small lesion can be sampled.
 Non palpable and deep seated lesion can be asessed.
 Injury of major structure is avoided.
 Necrotic tissue or cystic area is avoided.

9. Imaging modalities
The deep seated lesions can be aspirated under the
guidance of – Ultrasonography
- Computerised Tomography
- Magnetic Resonance Imaging
- Fluoroscopy
- Ultrasound guided Endoscopy

10. Ultrasound
 Ultrasound is the only real-time guidance which allows
imaging in any plane and only suitable guidance for
biopsy of fetal tissue.
 If the suspected tumor is in the deeper planes and
cannot be seen or felt by the physician, then the patient is
asked to get an ultrasound-guided biopsy.
 High frequency sound wave is applied and the reflection
of the wave from tissue interface is recorded to construct
the image.

11. Technique of USG guided biopsy
 The longest part of examination is identifying the lesion,
positioning the patient, identifying the site of puncture
and direction of the needle.
 The depth of the lesion from the skin surface is measured
to determine the length of the needle required.
 Continuous real time ultrasound is used to visualize the
needle entering the lesion and also during aspiration to
ensure that the needle stays within the lesion.

12. Procedure
Preprocedural evaluation
 Patient consent and pre-procedure targeted physical examination
 A pre-procedure targeted ultrasound examination
Equipment
 22 gauge to 27 gauge needle with a stylet .
 Generally a 3.5 – 5 Mhz transducer is used for biopsy, however a
linear/superficial probe is useful in case of neck masses and breast
lesions.
 1%/2% lidocaine without epinephrine
 Betadine and spirit swabs
 50cc and 20cc syringes
 10 glass slides for tissue separation

14. Positioning
 For most of the lesions as in case of liver, pancreas, GIT, neck
etc., the patient is positioned in supine or lateral decubitus
position with maximum access to the location of the lesion.
 For lung or pleural biopsy patient can be either made to sit
upright or lie down in lateral decubitus position .
 For FNA biopsy from breast, patient is positioned in the
dorsal decubitus or lateral decubitus.
Probe Sterilization
The transducer must be sterilized before its use by betadine and
spirit swabbing.

15. Biopsy procedure
 The transducer is ideally held in the optimal longitudinal
position to visualize the lesion.
 Prior to insertion of needle ,the alignment of transducer is
checked.
 Under real time guidance the needle is introduced through
skin,1-2 cm proximal to the transducer and then advanced
along the line of the transducer.
 The length of the needle should become visible and tip is seen
to puncture the lesion, then inserted few more millimeters.
 It is only when the needle and lesion are in line ,that a
successful puncture can occur.

16. Indications
 a suspicious solid mass
 a distortion in the structure of the viscera
 an area of abnormal tissue change
Sites
 thyroid
 non-thyroid neck
 breast
 liver
 lymph nodes
 lung
 gastrointestinal tract
 Mediastinum
 Pancreatic mass

17. Advantages
 Real time
 Easy to do
 Portable
 No radiation exposure
 Angular approach can be done
 Better precision

18. Disadvantages
 Significant obscuration due to air or bone may affect the
image.
 Not very high resolution
 Completely operator dependant

19. Postprocedural care
 There is no standardized postprocedure care for FNA.
Compression of the biopsy site with gauze is common to
control minor local bleeding.
 If the lung is biopsied, a post procedure radiograph may be
obtained.
 In case of liver and pancreas biopsy, patient is made to lie in
right lateral and prone positions respectively.

20. Complications
3
 Uncommon with appropriate FNA technique, usually
limited to bleeding or infection.
 Pneumothorax is a risk of lung biopsies. Either a
postprocedure radiograph or ultrasound may be
obtained to look for this complication.

21. Endoscopic ultrasound-Guided
FNAC
Technique:
 At first, lesion is localised by endoscopic ultrasound.
 A 22 guage needle with an internal stylet is used for
FNAC.
 The needle with stilette is introduced through endoscope
to the mass under EUS guidance.
 The stilette is withdrawn and aspiration is done with the
help of 20 cc syringe by applying negative suction.
 After suction the needle is withdrawn and material is
expelled by reintroducing the stilettewithin needle.

22. Endoscopic Cytology Can Be Used in
 Staging of esophageal, gastric and rectal cancer
 Evaluation of abnormalities of the gastrointestinal
wall or adjacent structures (submucosal masses,
extrinsic compression)
 Evaluation of thickened gastric folds
 Diagnosis and staging of pancreatic cancer
 Evaluation of pancreatic abnormalities (suspected
masses, cystic lesions including pseudocysts,
suspected chronic pancreatitis)

23.  Staging of ampullary neoplasms
 Diagnosis and staging of cholangiocarcinoma
 Diagnosis and evaluation of deep seated
lymphadenopathy
 Diagnosis of diseases of spleen
 Parasitic infestation
 EUS guided mediastinal lymph node FNA

24. Gastrointestinal Endoscopic Cytology
 Important modality in the evaluation of
luminal gastrointestinal diseases as well
as diseases of the spleen, pancreas,
gallbladder and biliary ductal system.
 Sampling techniques can be
1.Blind lavage
2.Blind abrasive
3.Directional brush and wash method
using an endoscope

25. Sample Collection
 After introduction of the endoscope, the upper G I is
inspected, any lesion found is photographed, then first
cytological and then biopsy sample is obtained.
 Cytological sample can be collected by two ways:
 Directional brush and
 Directional wash

26. Directional Brush Sampling
 For brush sample collection smaller brushes enclosed within
transparent teflon sheath,. The brush sample when obtained, is
pulled back within the teflon sheath, and the whole sheath is
withdrawn.
 To obtain the sample the brush is plunged firmly and briskly into
the mucosa 5 – 10 times so that the lamina propria is penetrated.
Otherwise it fails to obtain a reliable sample and may lead to a
false-negative result.
 Cytological brushing also has the many advantages such as
acceptance by the patients, good penetration to the basement
membrane, collecting cells from all three epithelial layers and
early diagnosis of upper GIT lesions.

27. Directional Wash Sampling
 Simple
 To obtain the wash sample, the opening of a teflon
tube is directed at a particular lesion at close quarters
and forceful injection of buffered saline solution is
aimed at the site.
 Immediate suction with a syringe that injected the
fluid results in salvage of cells in that area.

28. Wash v brush
 For collection from the stomach, washing is superior, but
in both the esophagus and colon, brushing techniques are
more accurate.

29. Limitation

30. Advantage
Fiber cells

31. Gastrointestinal Stromal Tumor
 The cellular aspirate from a obtained from a duodenal mass
reveals sheets of spindled cells with wispy cytoplasm. The
nuclei are elongated with some showing nuclear angulation

32. EUS FNA Of Pancreatic Lesions
 ERCP permits visualization of pancreatic duct and
hepatobiliary tree.
 EUS FNA has become a preferred method for
localization and aspiration biopsy of the pancreatic
lesions.
Objective:
 To detect and determine the extent of the lesion
 To obtain pre operative tissue diagnosis and staging
for malignancies for a clinically suspicious
malignancy.

33. Approaches to perform EUS FNA for lesions
located at different sites in pancreas.
Location of the
lesion
Approach
Head/Uncinate
process
Transduodenal
Body/Tail Transgastric

34. Solid Pancreatic MassesDifferential Diagnoses For Solid Pancreatic Masses
Benign Malignant
Chronic pancreatitis Carcinoma
Islet cell tumour Ductal adenocarcinoma and its
variant
Abscess Metastatic carcinomas
Infection Acinar cell carcinoma
Malignant islet cell tumour
Metastatic non epithelial
malignancy

35. Cystic Pancreatic Masses
Differential diagnoses for pancreatic cystic lesions
Non neoplastic Neoplastic
Pseudocyst Mucinous cystic neoplasms
Lymphoepithelial cyst Intraductal papillary mucinous
neoplasm
Dermoid cyst Solid cystic papillary neoplasm
Islet cell tumours
Serous microcystic adenomas
Macrocystic adenomas

36. Normal ductal epithelial cells

37. Chronic Pancreatitis
 Endoscopic ultrasound-guided fine-needle aspiration sample from a case of chronic
pancreatitis that shows a cohesive 2-dimensional group of ductal epithelial cells.
Individual cells show a preserved nuclear/cytoplasmic ratio and regular nuclear
membrane (Papanicolaou, ×40)

38. Malignant cells (adenocarcinoma)
cluster of pleomorphic cells

39. Respiratory Tract Cytology By
Bronchoscopy
 Flexible fibreoptic
bronchoscope is used to carry
out the endoscopic cytology of
respiratory tract
Techniques
 Bronchial aspirate and washing
 Bronchial brushing
 Bronchoalveolar lavage
 Transbronchial FNA

40. Bronchial Aspirate and Washing
 Introduction of the bronchoscope into the lower
respiratory tract enables the examiner to obtain
samples by means of a suction apparatus that
aspirates the secretion.
 Washing from the visualized area may also be
collected by instilling 3 – 5 ml of balanced salt
solution through the bronchoscope and re-aspiration
of resulting material.

41. Bronchoalveolar Lavage
 Bronchoalveolar lavage involves the infusion and re-
aspiration of sterile saline solution in distal segments of
lung via fiberoptic bronchoscope.
 Diagnostic use
 Lung cancer
 Evaluation of interstitial lung disease
 Opportunistic infection in immuno compromised
patients

42. Bronchoalveolar Lavage
 Therapeutic use
Pulmonary alveolar proteinosis
Cystic fibrosis
Pulmonary alveolar microlithiasis
Asthma

43. Complications of Endoscopic
Cytology
 Complications related primarily to sedation
(cardiovascular and respiratory depression, aspiration)
 Perforation
 Bleeding
 Pancreatitis (ERCP)
 Cholangitis (ERCP)
 Wound infections

44. Computed Tomographic scan
guided FNAC
 Computed Tomographic scan is one of the popular
imaging modalities to guide FNAC.
 CT uses X-ray beam to create multiple tomographic or
cross sectional images of the body depending on the
ability of the tissue to block the Xray.
 This ability of the tissue to absorb radiation depends on
the tissue density.

45.  It provides detailed cross sectional images of the body
which are not limited by same physical properties as are
ultrasound images, such as interference from bowel gas
and bone.
 The computer accumulates the data and produces
multiple images in different planes.

46. Advantages:
 High resolution
 Exact localisation of needle possible
 Operator independent
 Deep lesion near vital structure needs CT guidance
Disadvantages:
 Costly
 Time taken procedure
 Good radiation exposure

47. Magnetic resonance image
guidance
 Radiofrequency energy is used
 No radiation exposure
 Costliest
 Time consuming
 Special euipments are needed to avoid the disturbanced
of magnetic field
 Selected cases in breast, lung and soft tissue of head and
neck regions are done.

48. Pitfalls in aspiration biopsy
Occasional errors may include:
 Maintaining negative suction while withdrawing the needle,
aspirated tissue is then sucked into the syringe
 Excessive suction: only 1-2 cc of suction via 10ml syringe is
required to provide adequate tissue, greater aspiration
pressures increase blood aspirates and may traumatize the
tissue.
 Deviation of needles: This may be due to tissue planes or
tough capsules on lesion,e.g-fibroadenoma, which causes the
tip to deviate around mass.

49.  Obtaining bloody aspirates: The use of longer coaxial
needle may prevent hemorrhagic aspirates. French
technique can be use to avoid bloody aspirates.
 Maintaining a fixed system which can tear tissues. It is
important not to hold the needle while the patient is
breathing or moving.
 Poor aspiration technique: Needle manipulation must be
practiced-it should be oscillated 1-2 cm depending on size
of the lesion.

50.  Poor smearing technique: smearing the aspirate on slide
should perform by trained cytologist.
 Forgetting to remove the stilette from needle when using
french technique where no aspiration is used.