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Fine-needle aspiration (FNA) is a diagnostic procedure used to investigate lumps or masses. In this technique, a thin (23–25
gauge Gauge ( or ) may refer to: Measurement * Gauge (instrument), any of a variety of measuring instruments * Gauge (firearms) * Wire gauge, a measure of the size of a wire ** American wire gauge, a common measure of nonferrous wire diameter, ...
(0.52 to 0.64 mm outer diameter)), hollow needle is inserted into the mass for sampling of cells that, after being stained, are examined under a
microscope A microscope () is a laboratory instrument used to examine objects that are too small to be seen by the naked eye. Microscopy is the science of investigating small objects and structures using a microscope. Microscopic means being invisibl ...
(
biopsy A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a diseas ...
). The sampling and biopsy considered together are called fine-needle aspiration biopsy (FNAB) or fine-needle aspiration cytology (FNAC) (the latter to emphasize that any aspiration biopsy involves
cytopathology Cytopathology (from Greek , ''kytos'', "a hollow"; , ''pathos'', "fate, harm"; and , '' -logia'') is a branch of pathology that studies and diagnoses diseases on the cellular level. The discipline was founded by George Nicolas Papanicolaou in 1 ...
, not
histopathology Histopathology (compound of three Greek words: ''histos'' "tissue", πάθος ''pathos'' "suffering", and -λογία '' -logia'' "study of") refers to the microscopic examination of tissue in order to study the manifestations of disease. Spe ...
). Fine-needle aspiration biopsies are very safe minor
surgical Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
procedures. Often, a major surgical (excisional or open) biopsy can be avoided by performing a needle aspiration biopsy instead, eliminating the need for hospitalization. In 1981, the first fine-needle aspiration biopsy in the United States was done at
Maimonides Medical Center Maimonides Medical Center is a non-profit, non-sectarian hospital located in Borough Park, in the New York City borough of Brooklyn, in the U.S. state of New York. Maimonides is both a treatment facility and academic medical center with 711 ...
. Today, this procedure is widely used in the diagnosis of cancer and inflammatory conditions. Aspiration is safer and far less traumatic than an open biopsy; complications beyond bruising and soreness are rare. However, the few problematic cells can be too few (inconclusive) or missed entirely (a
false negative A false positive is an error in binary classification in which a test result incorrectly indicates the presence of a condition (such as a disease when the disease is not present), while a false negative is the opposite error, where the test resul ...
).


Medical uses

This type of sampling is performed for one of two reasons: # A biopsy is performed on a lump or a tissue mass when its nature is in question. # For known tumors, this biopsy is performed to assess the effect of treatment or to obtain tissue for special studies. When the lump can be felt, the biopsy is usually performed by a
cytopathologist Cytopathology (from Greek , ''kytos'', "a hollow"; , ''pathos'', "fate, harm"; and , ''-logia'') is a branch of pathology that studies and diagnoses diseases on the cellular level. The discipline was founded by George Nicolas Papanicolaou in 19 ...
or a
surgeon In modern medicine, a surgeon is a medical professional who performs surgery. Although there are different traditions in different times and places, a modern surgeon usually is also a licensed physician or received the same medical training as ...
. In this case, the procedure is usually short and simple. Otherwise, it may be performed by an interventional
radiologist Radiology ( ) is the medical discipline that uses medical imaging to diagnose diseases and guide their treatment, within the bodies of humans and other animals. It began with radiography (which is why its name has a root referring to radiatio ...
, a doctor with training in performing such biopsies under
x-ray An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10  picometers to 10  nanometers, corresponding to frequencies in the range 30&nb ...
or
ultrasound Ultrasound is sound waves with frequency, frequencies higher than the upper audible limit of human hearing range, hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hea ...
guidance. In this case, the procedure may require more extensive preparation and take more time to perform. Also, fine-needle aspiration is the main method used for
chorionic villus sampling Chorionic villus sampling (CVS), sometimes called "chorionic ''villous'' sampling" (as "villous" is the adjectival form of the word "villus"), is a form of prenatal diagnosis done to determine chromosomal or genetic disorders in the fetus. It ent ...
, as well as for many types of
body fluid sampling Body fluids, bodily fluids, or biofluids, sometimes body liquids, are liquids within the human body. In lean healthy adult men, the total body water is about 60% (60–67%) of the total body weight; it is usually slightly lower in women (52-55%). ...
. It is also used for ultrasound-guided aspiration of
breast abscess Mastitis is inflammation of the breast or udder, usually associated with breastfeeding. Symptoms typically include local pain and redness. There is often an associated fever and general soreness. Onset is typically fairly rapid and usually occurs ...
, of
breast cyst A breast cyst is a cyst, a fluid-filled sac, within the breast. One breast can have one or more cysts. They are often described as round or oval lumps with distinct edges. In texture, a breast cyst usually feels like a soft grape or a water-filled ...
s, and of
seroma A seroma is a pocket of clear serous fluid (filtered blood plasma). They may sometimes develop in the body after surgery, particularly after breast surgery, abdominal surgery, and reconstructive surgery. They can be diagnosed by physical signs, ...
s.


Preparation

* No
aspirin Aspirin, also known as acetylsalicylic acid (ASA), is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, fever, and/or inflammation, and as an antithrombotic. Specific inflammatory conditions which aspirin is used to treat inc ...
or non-steroidal anti-inflammatory medications (e.g.,
ibuprofen Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is used for treating pain, fever, and inflammation. This includes painful menstrual periods, migraines, and rheumatoid arthritis. It may also be used to close a patent ductus arte ...
,
naproxen Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain, menstrual cramps, inflammatory diseases such as rheumatoid arthritis, gout and fever. It is taken orally. It is available in immediate and delayed release formulati ...
) for one week before the procedure * No food a few hours before the procedure * Routine blood tests (including
clotting Coagulation, also known as clotting, is the process by which blood changes from a liquid to a gel, forming a blood clot. It potentially results in hemostasis, the cessation of blood loss from a damaged vessel, followed by repair. The mechanism o ...
profile) must be completed two weeks before the biopsy. * Suspension of
anticoagulant Anticoagulants, commonly known as blood thinners, are chemical substances that prevent or reduce coagulation of blood, prolonging the clotting time. Some of them occur naturally in blood-eating animals such as leeches and mosquitoes, where the ...
s (blood thinners) *
Antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention of ...
prophylaxis Preventive healthcare, or prophylaxis, consists of measures taken for the purposes of disease prevention.Hugh R. Leavell and E. Gurney Clark as "the science and art of preventing disease, prolonging life, and promoting physical and mental hea ...
may be instituted. Before the procedure is started, vital signs (
pulse In medicine, a pulse represents the tactile arterial palpation of the cardiac cycle (heartbeat) by trained fingertips. The pulse may be palpated in any place that allows an artery to be compressed near the surface of the body, such as at the nec ...
,
blood pressure Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...
, temperature, etc.) may be taken. Then, depending on the nature of the biopsy, an
intravenous line Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...
may be placed. Very anxious patients can be sedated through this line, or oral medication (
Valium Diazepam, first marketed as Valium, is a medicine of the benzodiazepine family that acts as an anxiolytic. It is commonly used to treat a range of conditions, including anxiety, seizures, alcohol withdrawal syndrome, muscle spasms, insomnia, a ...
) may be prescribed.


Procedure

The
skin Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation. Other cuticle, animal coverings, such as the arthropod exoskeleton, have diffe ...
above the area to be biopsied is swabbed with an
antiseptic An antiseptic (from Greek ἀντί ''anti'', "against" and σηπτικός ''sēptikos'', "putrefactive") is an antimicrobial substance or compound that is applied to living tissue/skin to reduce the possibility of infection, sepsis, or putre ...
solution and draped with sterile surgical towels. The skin, underlying
fat In nutrition science, nutrition, biology, and chemistry, fat usually means any ester of fatty acids, or a mixture of such chemical compound, compounds, most commonly those that occur in living beings or in food. The term often refers spec ...
, and
muscle Skeletal muscles (commonly referred to as muscles) are organs of the vertebrate muscular system and typically are attached by tendons to bones of a skeleton. The muscle cells of skeletal muscles are much longer than in the other types of muscl ...
may be numbed with a
local anesthetic A local anesthetic (LA) is a medication that causes absence of pain sensation. In the context of surgery, a local anesthetic creates an absence of pain in a specific location of the body without a loss of consciousness, as opposed to a general an ...
, although this is often not necessary with superficial masses. After locating the mass for biopsy, using x-rays or
palpation Palpation is the process of using one's hands to check the body, especially while perceiving/diagnosing a disease or illness. Usually performed by a health care practitioner, it is the process of feeling an object in or on the body to determine ...
, a special needle of very fine diameter is passed into the mass. The needle may be inserted and withdrawn several times. There are many reasons for this: * One needle may be used as a guide, with the other needles placed along it to achieve a more precise position. * Sometimes, several passes may be needed to obtain enough cells for the intricate tests which the cytopathologists perform. After the needles are placed into the mass, cells are withdrawn by aspiration with a
syringe A syringe is a simple reciprocating pump consisting of a plunger (though in modern syringes, it is actually a piston) that fits tightly within a cylindrical tube called a barrel. The plunger can be linearly pulled and pushed along the inside ...
and spread on a glass slide. The patient's vital signs are taken again, and the patient is removed to an observation area for three to five hours. * For biopsies in the breast, ultrasound-guided fine-needle biopsy is the most common. The biopsy is advised.


Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA)

EUS-FNA is a minimally invasive procedure for acquiring biopsies in gastric regions that are hard to reach otherwise (e.g. the pancreas). Endoscopic ultrasound EUS-FNA of cystic lesions, followed by liquid cell analysis, has been used as a diagnostic tool for differentiating benign, potentially malignant, and malignant pancreatic cysts. 'Through-the-needle' cytologic brushes have been developed for increasing the cellular content in the aspirates.


Rapid on-site evaluation (ROSE)

Rapid on-site evaluation (ROSE) is a real-time service during EUS-FNA interventions, that assesses the adequacy of the collected biopsy samples for diagnostics. Sample adequacy is deemed by the number of target cells that allow determining tumor malignancy. ROSE reduces the overall number of needle passes required for an appropriate sample and the number of FNA procedures. ROSE is typically performed in the operating room and starts by transferring an aliquot of the FNA sample onto a glass slide. Then, the sample is manually smeared out to obtain a thin sample layer with cells dispersed along the glass slide. After an air-drying step, the sample is stained, typically with a rapid Romanowky-type stain. Finally, a morphological assessment of the stained cells under a microscope allows to evaluate the adequacy of the collected FNA sample. Research focuses, among other, on portable devices for semi-automated sample preparation for ROSE, with the purpose to simplify the performance of FNA sample preparation and reach to a wider implementation of ROSE.


Post-operative care and complications

As with any surgical procedure, complications are possible, but major complications due to thin-needle aspiration biopsies are fairly uncommon, and when complications do occur, they are generally mild. The kind and severity of complications depend on the organs from which a biopsy is taken or the organs gone through to obtain cells. After the procedure, mild analgesics are used to control post-operative pain. Aspirin or aspirin substitutes should not be taken for 48 hours after the procedure (unless aspirin is prescribed for a cardiac or neurological condition). Since sterility is maintained throughout the procedure,
infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
is rare. But should an infection occur, it will be treated with
antibiotics An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention o ...
.
Bleeding Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...
is the most common complication of this procedure. A slight bruise may also appear. If a
lung The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...
or
kidney The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; blood ...
biopsy has been performed, it is very common to see a small amount of blood in sputum or
urine Urine is a liquid by-product of metabolism in humans and in many other animals. Urine flows from the kidneys through the ureters to the urinary bladder. Urination results in urine being excretion, excreted from the body through the urethra. Cel ...
after the procedure. Only a small amount of bleeding should occur. During the observation period after the procedure, bleeding should decrease over time. If more bleeding occurs, this will be monitored until it subsides. Rarely, major surgery will be necessary to stop the bleeding. Other complications depend upon the body part on which the biopsy takes place: * Lung biopsies are frequently complicated by
pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...
(collapsed lung). This complication can also accompany biopsies in the upper
abdomen The abdomen (colloquially called the belly, tummy, midriff, tucky or stomach) is the part of the body between the thorax (chest) and pelvis, in humans and in other vertebrates. The abdomen is the front part of the abdominal segment of the torso. ...
near the base of the lung. About a quarter to half of patients having lung biopsies will develop pneumothorax. Usually, the degree of collapse is small and resolves on its own without treatment. A small percentage of patients will develop a pneumothorax serious enough to require hospitalization and a
chest tube A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substance ...
. Although it is impossible to predict in whom this will occur, collapsed lungs are more frequent and more serious in patients with severe emphysema and in patients in whom the biopsy is difficult to perform. * For biopsies of the liver,
bile Bile (from Latin ''bilis''), or gall, is a dark-green-to-yellowish-brown fluid produced by the liver of most vertebrates that aids the digestion of lipids in the small intestine. In humans, bile is produced continuously by the liver (liver bile ...
leakages may occur, but these are quite rare. *
Pancreatitis Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormones. There are two main types: acute pancreatitis, and chronic pancr ...
(inflammation of the
pancreas The pancreas is an organ of the digestive system and endocrine system of vertebrates. In humans, it is located in the abdomen behind the stomach and functions as a gland. The pancreas is a mixed or heterocrine gland, i.e. it has both an end ...
) may occur after biopsies in the area around the pancreas. * In biopsies in the area of the breast, bleeding and bruising may occur, less frequently also infection (rarely) or (very rarely, and only if performed near the chest wall)
pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...
. * Deaths have been reported from needle aspiration biopsies, but such outcomes are extremely rare.


Criticism

A study published in 2004 showed that in one case, a needle biopsy of a liver tumor resulted in the spread of the cancer along the path of the needle and concluded that needle aspiration was dangerous and unnecessary. The conclusions drawn from this paper were subsequently strongly criticized.


See also

* Antibody barcoding, a technique for identifying proteins in small tissue samples such as aspirates * FNA Mapping, an application for the assessment of male-factor infertility.


References


External links

* Originally adapted fro
Preparing for a needle aspiration biopsy
(634 KB). Public domain text of the
National Institutes of Health The National Institutes of Health, commonly referred to as NIH (with each letter pronounced individually), is the primary agency of the United States government responsible for biomedical and public health research. It was founded in the late ...
Warren Magnuson Grant Clinical Center.
Video showing ultrasound-guided fine needle biopsy
* Lung * "Lung needle biopsy" Neck * "Fine-Needle Aspiration of Neck Masses" * "Thyroid nodule fine needle aspirate" Bone * "Bone marrow aspiration" * "Bone Marrow Aspiration and Biopsy" Risk
Risk of tumor cell seeding through biopsy and aspiration cytology 2014
{{Authority control Breast surgery Medical diagnosis Cytopathology Biopsy