Fine Needle Aspiration of Germ Cell Tumors of Ovary

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    The Global Library of Womens MedicineDedicated to the enhancement of womens healthcare

    An expert clinical res ource f or womens h ealthcare. Constantly updated. Peer review ed. Comprehensive cov erage

    ISSN: 1756-2228

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    This chapter should be cited as follows: This chapter was last updated:

    McGrath, C, Yu, G, et al , Glob. libr. women's med .,(ISSN: 1756-2228) 2008; DOI 10.384 3/GLOWM.102 64

    October 2008

    Fine Needle Aspiration

    Cindy M. McGrath, MDUnive rsity of P ennsylvania Medical Center, Pennsylvania, USA

    Gordon H. Yu, MD As sistant Pro fessor o f Patholo gy, Direct or, Fine nee dle Aspira tio n Clinic , Hospita l of th e Unive rsity of Pe nnsylva nia, Phila de lphia, Pe nnsylva nia,USA

    Karen S. Gustafson, MD, PhDChief Resident, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philidelphia, Pennsylvania, USA

    Ch arles D. Sturg is, MD Direct or o f Cytopatho log y, Dep artment of Pat ho log y, No rthw est ern Unive rsity , Evansto n Hospita l, Evansto n, I llino is, USA

    INTRODUCTIONTECHNIQUESLABORATORY PREPARA TION OF FINE NEEDLE ASPIRATION S PECIMENSCLINICAL UTILI TY OF FINE NEEDLE ASPIRA TIONCY TOMORPHOLOGIC CRITERIA REFERENCES

    INTRODUCTION

    Fine-needle aspiration (FNA) biopsy is a reliable, cost-effective pr ocedur e that may b e useful in the workup of patients with both palpable anddeep-seated mass lesions. An extremely simple procedure technically, FNA biopsy involves the introduction of a small-gauge needle into themass and the extraction of representative cellular material. Numerous large series studying the diagnostic accuracy of this procedure in a variety of organ systems (including the gynecologic tract) have repeatedly confirmed it as both a sensitive and specific test that may be performed with

    minimal morbidity and at a relatively low financial cost to the patient. 1, 2, 3

    Needle aspiration biopsy was first performed in the United States in the 1920s at the Memorial-Sloan Kettering Cancer Center. 4 Surgeons wereencouraged to perform these procedures, largely because of pathologists' concerns that open incisional biopsy might lead to early metastases.Biopsies were initially per formed with the use of relativ ely large needles (18 gauge) after a small skin incision ov er the mass in question. Multiplesmears were then made onto glass slides, which were stained and interpreted by a patho logist. Initial reports of their experienc e appeared in the

    literature in the early 1930s. 5, 6

    Needle aspiration biopsy did not flourish elsewhere in the country, however, and further refinements in the procedure were largely the work of Europeans in the years that followed. With the help of their pathology colleagues, c linicians continued to make useful rev isions to the technique,such as the use of significantly smaller needles (2225 gauge). The technique that we know today as fine-needle aspiration biopsy is the result of these earlier refinements. In addition, much o f their material was stained with a Romanowsky-ty pe stain after the smear was air dried, apreparation used largely in hematopathology.

    A r ev iv al o f inte res t in FNA amo ng US c linic ians a nd pa tho log ists began in the 1960s, and t ec hniq ues tha t were r efine d overs eas b ega n to beadopted in the United States. The popularity of the technique grew steadily as reports of its high diagnostic accurac y and tec hnical simplicity appeared in the pathology and clinical literature. In addition, improveme nts in radiologic imaging techniques led to the detect ion of increasingnumbers of deep-seated mass lesions, often in patients studied for unrelated reasons; such lesions are o ptimally sampled by image-guided FNA asan initial step in their diagnostic workup. Finally, initial concer ns over t racking and subsequent seeding of tumor cells within the needle tract have been quie ted by the ex traor dinarily low inc idence of suc h occ urr enc es o ver t he c ourse of lit erally tens of thousands o f aspir ate bio psie s in the

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    Fig. 1. A. An aspiration gun (Cameco) with attached syringe may be used to easily generatenegative pressure at needle tip. B. Franzen needle guide, which is useful in the aspiration of paravaginal and pararectal lesions. (Photograph courte sy o f Wesley W. Simms, MD.)

    past 50 years. 7, 8, 9

    TECHNIQUES

    Fine-needle aspiration biopsy may be performed with a number of variations. First, the indications for the proce dure are discussed with thepatient. In addition, potential risks or co mplications or both are discussed, including bleeding and infection in the area after the procedure. Therisk of a significant complication is minimal, and although such incidents have been reported, the chances of such an occurrence may be equatedto the risk incurred when undergoing simple venipuncture. Indee d, drawing similarities to venipunctur e often alleviates the patient's anxiety

    toward the procedure. 10 As with venipuncture, local anesthetic is generally not required for FNA of palpable masses, with the rare exception of certain anatomic loc ations (i.e., periareolar breast aspirations). After consent is obtained, slides are labeled and a suitable fixativ e (e.g., 95%alcohol o r spray fixativ e) is made accessible. The area is then prepared with alcohol, and after stabilization of the mass with the fingers of onehand, the needle is placed into the lesion.

    Two sampling techniques may be used. An open-ended needle, without attached negative suction, may be used alone for almost all biopsies(known as the French technique). Short, rapid stro kes within the lesion cause dislodgement of ce lls and allow effectiv e co llection within theneedle via capillary action. A syringe with the plunger removed may be attached for the collection of excess fluid if a cystic lesion is suspected.Regardless of the attachment used, it is critical that the end of the apparatus be open to the atmo sphere to allow proper collec tion of thespecimen; care must be taken not to c ov er this opening with a fingertip during the procedure, partic ularly when using a needle alone. Rapidstrokes are made within the lesion, and care is taken not to extract the tip of the needle completely at any time. After 1520 seconds, the needle isremov ed, pressure is applied to the area with sterile gauze, and slides are prepared immediately . If blood appears in the needle hub at any time,the needle should be remo ved immediately and slides prepared. Any de lay results in clotting of the bloo d within the hub, making retrieval of thespecimen difficult.

    A s ec ond tec hniq ue involv es applica tio n of ne gat iv e pr essure dur ing the p roce dure, t y pic ally with the use of a sy ring e (1 020 mL) plac ed in asyringe ho lder (aspiration gun/handle; Fig. 1A). When using an aspiration gun or handle, one must remember to pull the plunger back only afterthe needle has been placed into the lesion; the plunger should remain pulled while rapid, short strokes are made. More important, it is imperativethat suction be released before the needle is removed, because continued negative pressure results in suction of the material back into the syringepreventing preparation of direct smears. Although rinsing with saline solution may allow retrieval of this material, cell recovery is poor andpreparations are generally inferior to direct smears.

    Aft er r emo val o f the needle , the ma ter ial c ollec ted must be ex pel led ont o g lass s lides using a sy ringe. I f using the open-ended needle te ch niqu e, aready clean syr inge with the plunger pulled back should be attac hed to the needle. If using the negative pressure aspiration tec hnique, the samesyringe c an be used to ex pel the material onto the slides. If material is not expelled on the initial plunging of air through the syringe, remo ve theneedle from the syringe, pull the plunger back fully and reco nnect to the needle and ex pel quickly again. Direct smears should be made withoutdelay. The te chnique for preparing smears is similar to th