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Fine Needle Aspiration
Scenario

You are in the ENT clinic and have found a mass in this patient’s thyroid. Your consultant has asked
you to perform a Fine Needle Aspiration Biopsy and prepare some slides for histology.

Important points not to miss

Always introduce yourself, offer local anaesthetic and check the mass is not pulsatile. Most
candidates have never prepared a slide for histology. Label the slides before the procedure as
writing on wet slides can be difficult and it makes it look like you have done it before. Don’t forget
to take the needle off at the end of the procedure, fill the same syringe with air and then expel the
contents onto the slide. Not all the slides need to be fixed.

Talk Through

Fine needle aspiration is a simple, safe procedure to obtain cellular material for cytological
examination and diagnosis using a 21-gauge or smaller needle. It is a very simple procedure that is
frequently tested in the exam as it is a commonly used procedure in many surgical outpatient
departments. If you have not seen/performed the procedure, this will become very obvious very
quickly.

Indications
There are no absolute indications for fine needle aspiration, but it is used commonly in the assess-
ment of:
• Neck lumps
• Thyroid nodules
• Breast lumps
• Skin lesions
Awareness that a core or excision biopsy is an alternate method is very important. These
techniques will obtain more tissue for diagnostic purposes & provide details about the architecture
of the tissue. However, they are associated with higher complication rates than fine needle
aspiration.

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Consent
Written consent is not essential for fine needle aspiration. If the procedure is being performed in a
high risk situation for example in an anti-coagulated patient or as a radiologically guided
procedure, then obtaining consent should be considered.

The risk of serious complication is significantly less than 1% (around 0.05%)

• Haemorrhage
• Haematoma
• Seeding of tumour
• Location specific e.g. pneumothorax in a slim patient having skin or breast
sampling.

Equipment
• Small dressing pack (includes drape/gauze/gallipot)
• Sterile gloves
• Cleaning solution (2% chlorhexidene spray)
• 21-27G needle
• 5-20ml syringe
• 2-3 microscope slides
• Pencil/wax crayon
• Fixing solution (usually ethanol based)
• Universal container (if cystic fluid present)

*local anaesthetic should be offered, but is likely to be more painful than the procedure.

Note: Fine needle aspiration is not commonly performed as a ‘sterile’ procedure, but for the
purpose of this examination, treat it as such.

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Positioning
This is dependant upon the area for sampling, but ensure both the patient and yourself are
comfortable and you have adequate access to the area for sampling. Make sure the patient is
exposed appropriately, with curtains, sheets and offer a chaperone if you deem it to be
appropriate.

In both neck and breast lumps, these are both best sampled with the patient supine at 30-45o.

Procedure
Introduce yourself, confirm the patient’s identity and confirm the site to be sampled. Ensure the
patient understands the procedure and obtain verbal consent. Ask if any allergies, specifically latex
and chlorhexidine. Position the patient and ensure dignity. Wash your hands and prepare the
equipment including writing the patient’s details on the slides provided (this is much easier
pre-procedure).

Expose the patient adequately, protect clothing/face and use disinfectant spray. Remember, these
are usually alcohol based and work by evaporation, so allow to dry. Cleanse hands with an
alcohol-based agent. Don sterile gloves and drape the patient.

Ensure you examine the lump if you have not already done so. Make sure it is not pulsatile. Inform
the patient they will feel a sharp sensation, but it will only take a few seconds to perform.

Attach the needle to the syringe and advance into the lesion and aspirate. If you aspirate fluid, do
so until dryness. If not, take several passes through the lesion with the syringe aspirating as you
pass. Remove the needle and apply pressure to the area with gauze/cotton wool ball. Apply a
dressing (a simple plaster will suffice) to the wound and allow the patient to dress.

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With the needle removed, detach it from the syringe, fill the syringe with air and re-attach the
needle. Empty the contents of the syringe onto a slide and quickly prepare the slides. This involves
placing two slides together. This takes some practice to do effectively. Apply fixation solution to the
slides and allow it to dry. One slide is usually prepared without a fixing solution

Ensure the appropriate labels are on the sample (confirm with patient) Inform them of what to do
if a complication arises.

Dispose of the sharps and any other equipment in the appropriate bin.

Document the procedure

o Date and time
o Indication
o Consent obtained
o Complications/Difficulties if any

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Mark Scheme

Introduction, confirmation of patient identity 0 1 2

Professionalism 0 1 2
Explanation and Obtaining Verbal Consent 0 1 2
Examination of mass 0 1
Checks for Pulsations/local structures 0 1
Wash hands and prepares skin 0 1
Local Anaesthetic (offered) 0 1
Appropriate equipment 0 1 2
Appropriate procedure 0 1 2
Slide Preparation (Multiple Slides/labelled/fixed) 0 1 2
Post Procedure
Advised patient about infection, haematoma…. 0 1 2
Answers Questions. Is it Cancer…….? 0 1 2

Follow on Questions

Q1. What are the possible cytological results of the FNA?

• Benign
• Malignant
• Inconclusive e.g. cells present but not diagnostic
• Unsatisfactory/inadequate e.g. minimal or no cells present

The answer to this is specific to the lesion being biopsied. The result usually comes with a score of
1-5 (e.g. Thy1/Thy2/Thy3 etc. in Thyroid FNAs). As a general key, 1 is insufficient, 2 is benign, 3 is
indeterminate (my require repeat) and 4/5 are likely malignant. It is important to know the
individual scoring systems for the lesions being investigated.

Q2. What types of thyroid cancer do you know?

• Follicular (difficult to differentiate benign/malignant on FNA)
• Papillary (can be difficult to exclude depending on stain used)
• Medullary
• Anaplastic

FNA is very important in the management of thyroid nodules and expect to know the characteris-
tics of these groups of patients.

Q3.What are the possible complications?

• Haematoma
• Infection
• Needle tract seeding (rare/unproven in thyroid/breast)

Further Reading

Cibas E., Ali S. The Bethesda System for Reporting Thyroid Cytopathology – American Journal of
Clinical Pathology 2009;132:658-665 – A very good, free and quick article to read.

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