ULTRASOUND GUIDED FNA

Cord Sturgeon, MD, FACS

Associate Professor of Surgery

Techniques

Northwestern University

Department of Surgery

Faculty/Presenter Disclosure

Faculty: Cord Sturgeon, MD, MS, FACS

Relationships with commercial interests:

No conflicts of interest to declare

Objectives

Ergonomics: Machine Placement, Physician Positioning, Assistant Role

Optimal Patient Positioning

Bench Set-Up

Equipment (Needle Size, Syringe Holders, Aspiration vs Capillary Action)

Anesthesia (Local, EMLA, Ice-Cube, None)

Needle Placement (Parallel/Perpendicular)

Video of the FNA Procedure

Tips / Pearls

Machine placement and positioning

Exam table approximately at level of ultrasound console

Patient supine with neck extended (pillow behind upper back)

Neck can be at midline or rotated

Examiner can be behind the head or at shoulder of patient

Line of sight

Examiner at the shoulder

Examiner at the head

Assistants and Efficiency

Technical Tips - ergonomics

Maximize the efficiency of the clinic space

Room large enough for everybody and the US

Put the US monitor in front of you

Needles should be passed safely for the patient

and caregivers

Tools of the tradeTransducer jelly

Transducer

antiseptic

23ga needle

25ga needles

Slide box

Kopin jar with EtOH

27ga needle

on TB syringe

Glass Slides

Special Slide

Marker (doesn’t

dissolve in EtOH)

1% Lidocaine with epi Transducer

condoms

4x4 gauze

Alcohol prep pads

ORGANIZED

WORKING

SURFACE

Toys

Aspiration guns

Cameco Syringe Gun

Tao aspirator

Inrad Aspiration Biopsy Syringe Gun

FNA Technique

Confirm indication for FNA

Develop rapport

Informed consent

Comfortable positioning

Documenting the lesion

Select entry point(s)

Local anesthesia?

Identify targets

Sample lesion x3

Proper labels/description

Procedure note

Manage patient expectations

Follow up results

FNA Technique

The actual biopsy

The wall, solid elements, and suspicious calcified areas should be sampled

Cystic areas should be avoided.

Moving the needle back and forth within the nodule with about 3-5 times

per second increases cell yield

A dwell time of 2-5 seconds within the nodule generally provides good cell

yield without excessive blood

2-5 passes are optimal to get an adequate specimen

Evaluate for hematoma

Needle alone – capillary or Zajdela technique

Sampling Techniques

•Capillary (Zajdela)

•Aspiration

No significant difference between these techniques,

but for hypervascular lesions capillary is

recommended

•Cadence 3-5 cycles per second

•Dwell time 2-5 seconds

•Passes 2-5

Topical Anesthetic Options

•Nothing

•Ice

•Lidocaine

•EMLA cream

1% lidocaine injection

Topical Anesthetics

“To provide sufficient analgesia for clinical procedures such as intravenous

catheter placement and venipuncture, EMLA Cream should be applied

under an occlusive dressing for at least 1 hour.”

EMLA Cream (lidocaine 2.5% and prilocaine 2.5%)

5 g tube = $20.00

FNA Techniques

Short Axis perpendicular

Long Axis parallel

Short Axis Technique

Distance between insertion and target shorter

May work best in some “tight” spots

If the needle tip is missed, puncture of unintended targets may occur

Long Axis Technique

Allows visualization of the entire course of the needle

Distance between insertion and target longer

Long axis biopsy technique

FNA Technique

Needle aspiration

Long axis biopsy technique

Long axis biopsy technique

Continuous real-time observation of the needle TIP is important to ensure accurate

sampling and prevent complications such as vessel injury and esophageal or

tracheal puncture.

Long axis biopsy technique

Target the solid components of complex nodules

Short axis technique of FNA

Short axis biopsy technique

Short axis biopsy technique

FNA Technique

US image – aspiration of complex nodule

Set aside time

Block clinic time and work with clinic schedulers to

get patients in on the right day/time

Identify those patients who have already had FNA and

need repeat

Is the patient anticoagulated?

A day dedicated to FNA is ideal

Make friends with your cytopathologist

Find out what they need from you

Air dried

Alcohol fixed

Number of slides

Number of passes per lesion

Review slides alongside cytopathologist

What are your deficiencies in slide prep?

Are you collecting adequate sample?

Prepare high quality slides

Learn to prepare high quality slides

You and multiple staff should both be trained

Seek training and feedback from cytopath techs

Protocol

Develop a protocol for antisepsis

Develop a protocol for expeditious review of FNA

results, dissemination of results and recommendations

to patients and referring doctors

Document and bill appropriately

Collect and review data

Make adjustments with technique or training

10% or greater inadequate rate is unacceptable

Is one slide technician better than another?

Is one FNA technician better than another?

Build it and they will come…

Advertise that you do FNA

Colleagues

Referring physicians

Patients

Internet

NMH Thyroid FNA Trends

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Concluding Tips

Use small needles

Brief dwell time

Use a foot pedal to freeze/store images

Develop a communication system between you and

your tech

Rapid slide preparation to avoid drying artifact

Keep water droplets away from your slides

ULTRASOUND GUIDED FNA

Cord Sturgeon, MD, FACS

Associate Professor of Surgery

Techniques

Northwestern University

Department of Surgery

THANK YOU FOR YOUR ATTENTION

Don’t biopsy everything that walks

Adhere to expert guidelines in selecting lesions to

biopsy

NCCN 2012:

Solid nodule ≥ 1.0cm with suspicious features

Solid nodule ≥ 1.5cm without suspicious features

Complex nodule ≥1.5-2.0cm with suspicious features

Complex nodule ≥ 2.0cm without suspicious features

Simple cyst – not indicated

Don’t biopsy everything that walks

ATA 2009

Risk factors and suspicious >5mm

Risk factors, not suspicious >5mm

Microcalcifications + ≥1cm

Solid and hypoechoic >1cm

Solid and iso or hyperechoic ≥1.0-1.5cm

Complex and suspicious ≥1.5-2.0cm

Complex, not suspicious ≥ 2.0cm

Spongiform ≥ 2.0cm

Pure cyst - not indicated

Long axis biopsy technique

Draining the cystic component first may aid in targeting the

solid components of complex nodules

Slide Preparation

Slide preparation

Alcohol fixed

allow no time for drying

Papanicolaou technique

Shows nuclear features

Air dried

Diff-quick

Shows cytoplasmic features

Colloid