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1. FNAC TECHNIQUE DR NAJILA JR1 PATHOLOGY

2. In 1930 Martin and Ellis published first N orth A merican description of FNA methodology for palpable lesion.

3. Used for evaluating palpable superficial masses and cysts as well as deep seated non palpable lesion with image guidance. Can obtain cells from any site of the body. For individual pathologists, details learned in training are often modified in practise by factors such as height, handedness,hand size and finger strength. Hand on training in FNA technique is critical in developing hand eye coordination required.

4. Small ,lightweight Can be performed on demand and virtually in any setting Occupies only small area of counter space. MATERIALS AND SUPPLIES

5. Syringe holder (10 ml cameo syringe pistol or equivalent) Disposable sterile 10 ml plastic syringe Disposable sterile needle with transparent hub Alcohol swabs Sterile gauze pad Glass slides with frosted end for labelling Alcohol fixative ( commercial spray fixative or coplin jar filled with 95% ethanol) EQUIPMENT LIST

6. Local anaesthesia and needle/syringe to administer(2% lidocaine ) Gloves Pen /pencil for labelling Plastic slide holders or slide trays( for transporting slides)

7. Standard safety precautions must be observed during procedure and in handling the harvested specimen Procedure for performing FNA of palpable mass

8. Determine whether FNA is warranted Consent Positioning patient and immobilizing lesion Sample the targeted lesion adequately Prepare the sample for evaluation including appropriate allocation of material for ancillary studies as necessary. Provide post procedure instructions to patient STEPS FOR SUCCESSFUL FNA

9. Clinical history Detailed physical examination( to confirm lesion is palpable and ensure correct site is aspirated) Review the results of imaging studies( relation to nearby structures,internal details of the lesion etc ) Can ask the patient to point to the mass Enquire about bleeding disorders , use of anticoagulants If the lesion cannot be safely sampled,it should not be aspirated Determining whether FNA is warranted

10. Detailed description of procedure Purpose and potential complications Allow questions from the patient Remind the patient that he / she may elect to stop the procedure at any time. OBTAINING PATIENT CONSENT

11. Load syringe into syringe holder and attach needle . Needle 22 to 27G can be used Smaller bore needles used for sampling tissue with less cellularity and extensive fibrosis. Prelabelled glass slides and coplin jar should be ready READYING THE EQUIPMENT

12. positioned so that patient is comfortable and lesion can be palpated and immobilised . Patient should lie if there is vasovagal response. Pillows and rolled towels can be used for support. Immobilizing the mass depends on factors such as anatomical site ,size and mobility of mass and characteristics of operator hand. POSITIONING THE PATIENT AND IMMOBILIZING THE LESION

13. Neck nodules easily palpated with patient in sitting position If mass is deep to muscle ( eg SCM) position the patient such that muscle is relaxed, grasp the muscle belly and pull /push it aside . Local anaesthetic advisable if mass is tender or procedure involves sensitive sites such as nipple or areola Don’t inject so much local anaesthetic that excessive skin swelling may obscure the mass.

14. Patient in a position that allows skin and muscles of neck relaxed Lie flat on back either with or without pillow under the head Ideally angle of needle should be tangential to trachea THYROID

15. Move needle back and forth in one plane only If blood appears immediately ,needle should be moved only 4 or 5 times Perform aspiration from different areas of the mass Sampling with thin needle without suction Measures to minimize bleeding

16. Penetration of blood vessel can be avoided by carefully identifying vessels outline and positioning needle tangentially to it. Small targets adjacent to major blood vessel

17. Lying down or sitting upright position Masses near nipple and aerola can be pushed away ,immobilized and sampled through adjacent skin Subaerolar masses can be approached laterally If mass is located close to chest wall ,move the mass sideways so that it rests on rib Breas t

18. Patient in upright position with arm relaxed and only slightly abducted. If mass is palpable and accessible while lying down, sampling can be done in that position. Masses in the axilla

19. SAMPLIMG THE LESION

20. Introduced by Zajdela in 1987 Capillary p ressure in needle is sufficient to keep the detached cells in the lumen of the needle’ Gets an excellent feel of the consistency of the tissues Admixture with blood is less . Useful in thyroid and other sites with abundant blood supply Not recommened for aspirating cystic lesion. FINE NEEDLE SAMPLING WITHOUT NEEDLE

21. Typically 15-20 needle movements are required, limit the needle movement to 5 if significant blood of appear at needle hub. Never perform FNAC more than 3 to 4 times on given site at single visit. Repeat biopsies increase tissue haemorrhage, reducing diagnostic yield.

22. In small lesions(<1 cm)- aspirate from centre of lesion. In very large lesion (>5 cm)- aspirate from periphery( central necrosis). In medium sized lesion(2-4 cm)- collect samples from two different areas.

23. Learning to feel with needle is an important skill. Cancer is described as”gritty to needle” like pushing needle throughflesh of hard pear Fibroadenoma feels like pushing needle into rubber stopper or leather Fat – “ soft to needle” , no or minimal resistance Calcification – rock hard Feeling with the needle

24. MAKING SMEARS Needle is detached from syringe, plunger drawn back to fill syringe with air and needle reattached Risk of needle prick injury To expel material ,plunger is depressed back into syringe Hold needle hub securely to avoid needle detach and fly away under pressure Touching needle tip to glass slide minimizes spraying of material PREPARING THE SAMPLE

25. 1. ONE SMEAR METHOD 2 TWO SMEAR METHOD TYPES

26. ONE SMEAR METHOD

27. TWO SMEAR METHOD

28. SPLITTING MATERIAL FOR MULTIPLE SMEARS

29. METHOD 1

30. METHOD 2

31. I nstead of expelling all aspirated material onto one slide , express small drop of material onto each slide of several slides.

32. Atleast one alcohol fixed and one air dried smear should be made from each needle pass. Alcohol fixed slide can be stained either with a rapid papanicolaou or toluidine blue stain and examined with a coverslip. Air dried smear can be stained with romanowsky type stain and examined without coverslip FIXATION OF SMEARS

33. If mass is cystic , fluid fills the syringe under negative pressure As much as fluid should be aspirated. Fluid can be expelled into container for proceesing Patient reexamined and any residual mass is sampled on subsequent pass Handling cystic mass

34. RETRIEVING MATERIAL FROM NEEDLE HUB

35. Using liquid medium such as saline solution, culture medium such as Roswell Park Memorial institute medium[ RPMI] , commericial solution [ C ytoLyt,CytoRich Red] for cell block or liquid based preparation. Needle tip is placed in container with medium, small amount is drawn into syringe,then expelled back into container RINSING NEEDLE AND RESERVING MATERIAL FOR ANCILLARY STUDIES

36. Avoid excessive force to prevent damage. Most versatile is needle rinse in sterile saline solution or RPMI. Can be used for microbiological cultures, flow cytometry , karyotyping.

37. If patient is dizzy, make them lie supine Apply firm pressure to minimise bleeding No restrictions for daily routine including showering , swimming Soreness usually go away in few days Lump might seem bigger but return to normal within aweek Consult physician if there is any signs of infection Post procedure information for the patient

38. Minor pain,bleeding , bruising <1% cases develops hematoma Vasovagal response Radiating/referred pain( if needle encounters nerve) Rarely pneumothorax Seedling of benign and malignant tumor cells along needle tract( more with large core biopsy needle eg 17G) COMPLICATIONS

39. risk of needle prick injury Death from FNA sampling of carotid body tumor and carotid artery dissection has been reported.

40. If needle enters artery , remove immediately apply pressure for several minutes. If patient experiences unsual symptoms,stop procedure. Wait until symptoms have resolved before performing additional passes. Provider needlestick injuries must be documented and seek appropriate medical care MANAGEMENT OF ADVERSE AND UNEXPECTED EVENTS

41. Complications and their resolution should be documented in medical record. Familiarity with emergency procedures useful when patient has change in HR or difficult breathing.

42. THANK YOU