procedure room requires a patient procedure table (Fig. 1). This can range from a simple bed to a hydraulic procedure table. It is helpful to have a bed that has the capability to raise or lower the head so that the patient can be sitting, semi-recumbent, or flat. A table that can be lowered to 20–24" from the floor helps enable the transfer of patients with poor mobility. A pillow is needed for neck extension for thyroid biopsies. Bolsters for stabilizing patients when rolled onto their side and for placement under their knees to relieve pressure in the lower back are also helpful and appreciated by patients. It is very useful to setup a second monitor projecting the US image on a screen on the opposite side of the bed from the US monitor. This allows for easier setup for biopsy needle guidance.
Consumable items include US probe covers, choice of skin preparation (alcohol, betadine), anesthesia options, US gel, needles, and syringes. Probe covers come in a variety of styles. Skin preparation can be done with alcohol, betadine, or another cleansing agent. Anesthesia ranges from none to cutaneous preparations to injectables (Fig. 2). Needle gauge choice is dependent on the site being sampled, vascularity of the mass, the patient’s coagulation status, type of lesion sampled, and personal preference. Slip-tip syringes are recommended over luer-lock syringes so that the needle can easily and quickly be removed from the syringe, allowing for more rapid smear preparation and less chance for smear artifacts. Standard needles used for drawing blood are sufficient for aspiration biopsies. It is helpful to have a variety of needle gauges and lengths available. This allows the aspirating physician to choose a needle gauge based on the lesion being sampled, patient coagulation status, and Doppler vascularity of the mass. Use of a syringe holder (gun) is at the discretion of the aspirating physician; several styles are commercially available. A needle-only technique can be used to sample many masses. Some clinicians like using an adaptor between the needle and the syringe so that the needle-only technique can be used for needle placement, while an assistant can apply suction on an attached syringe.
Fig. 2. Cutaneous anesthesia options.
Reporting
In September 1996, the National Cancer Institute (NCI) sponsored a consensus conference to define a uniform approach for reporting breast FNA biopsy cytology. Twenty years later, the executive of the International Academy of Cytology (IAC) named a Breast Group including cytopathologists, surgical pathologists, radiologists, surgeons, and oncologists to draft a standardized reporting system for breast FNA that could be employed widely in both developed and underdeveloped countries. The structured report includes management recommendations to enhance the clinicians’ use of breast FNAB and use of cells blocks, immunohistochemistry, in-situ hybridization, and other prognostic and diagnostic markers [7].
In 2007, the NCI sponsored the “Thyroid Fine-Needle Aspiration State of the Science Conference,” and in 2010 “The Bethesda System for Reporting Thyroid Cytopathology” (TBSRTC) monograph was published. Since then, there have been significant developments in molecular studies for thyroid lesions as well as changes in clinical management as reflected in the 2015 American Thyroid Association (ATA) guidelines and the introduction of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) [8, 9]. These revised reporting systems are important for the promotion of cytopathologist USFNA. They reflect the importance of integration of clinical, imaging, and cytologic findings, and integration of ancillary studies which enhance the role of the clinical cytopathologist in the future practice of medicine.
Looking Forward: Elastography
Diagnostic US creates morphologic images of organs. US elastography is a non-invasive test that images tissue stiffness. This imaging modality may be able to generate additional clinically relevant information since pathological processes can alter the elastic properties of tissue. Emerging uses of elastography that could be relevant to the clinical cytopathologists performing USFNA include breast lymph node and thyroid masses. If so, an additional skill can be learned by the clinical cytopathologist and integrated into the cytology report [10, 11].
Disclosure Statement
The author has no conflicts of interest to disclose.
References
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Prof. Susan
