Fine-Needle Aspiration of the Breast

E. J. Mayeaux, Jr., MD, DABFP, FAAFP
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Subject: Fine-Needle Aspiration of the Breast

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Introduction

Fine-needle aspiration (FNA) cytology is a rapid, safe, inexpensive, and relatively atraumatic method of sampling both cystic and solid breast masses. It is commonly performed in the office setting by a primary care clinician, surgeon, or cytopathologist. FNA can reliably diagnose benign and malignant conditions (Table 77-1) and has a false-negative rate for experienced practitioners of 3% to 5%. The accuracy of the procedure somewhat depends on the skill of the clinician in performing the biopsy and of the pathologist in reading the smear. FNA may also be used to assess recurrent masses after lumpectomy. 
Compared with open surgical biopsy, needle biopsy causes less trauma and cosmetic disfigurement. It is performed as an outpatient procedure with local anesthetic. For benign lesions, establishing a definitive diagnosis obviates unnecessary surgical excision and the psychosocial and resource costs associated with protracted follow-up. A definitive diagnosis of cancer allows the patient to make an informed choice concerning follow-up and to obtain counseling prior to surgery. It also facilitates in the planning of multimodal treatment. 
One of the major benefits of using FNA on a breast mass is the ability to determine whether a lesion is cystic or solid. Typically, mammography cannot distinguish between a cystic or solid lesion. However, when the needle is inserted into the lesion and negative pressure is applied, fluid is readily obtained from a cyst. After the cyst is drained, the site should be examined to exclude a persisting mass, which would require a biopsy to rule out the presence of cystic carcinoma. If the cyst completely disappears, the patient should be reexamined in 1 month. If the cyst recurs, it can be drained one additional time and re-examined in another month. If it recurs a second time, the patient should be referred for excision of the lesion to exclude cystic carcinoma. 
 
TABLE 77-1.
Approximate Frequency of Common Findings in Women with Breast Lumps
FNA, like all breast diagnostic techniques, is imperfect. However, the triple diagnostic technique of clinical breast examination, FNA, and mammography can provide very useful information for the woman, especially when all three techniques suggest the lesion is benign. This allows many clinicians to reassure the patient with simple outpatient testing. Lesions that appear suspicious on any of the triple diagnostic tests should be referred for biopsy (Table 77-2). 
When a mass is discovered, the breast can be re-examined at the optimal time of the menstrual cycle (i.e., days 4 to 10 of the cycle immediately after the menstrual period). Mammography is usually performed before that office visit if the woman is of an appropriate age. If FNA is performed before mammography, allow at least 2 weeks to elapse before attempting mammography, so that any hematoma at the site is not erroneously described as a malignancy. Mammographically identified, nonpalpable lesions should not be approached with FNA in the office setting. 
The basic principle of FNA involves moving a 22- to 25-gauge needle back and forth within a lesion, under suction from a 10- to 20-mL syringe, to shave and aspirate small cores of tissue samples from the lesion. Devices are available to make it easier for the clinician to maintain suction during the sampling process. A simple 20-mL syringe and needle also may be used, but this is considered inferior because effort and attention must be diverted from the movement of the needle to maintaining suction. Skin anesthesia often is unnecessary for FNA, but local 1% lidocaine or local cold therapy may be used if desired. Sterile drapes are usually unnecessary. 
Recommended follow-up protocols for FNA results are shown in Table 77-3. When inadequate smears are obtained, the procedure can easily be repeated, often resulting in a satisfactory specimen. However, if an adequate sample cannot be obtained, the clinician should vigorously pursue other biopsy options because cancers may be missed, especially lobular cancer and ductal carcinoma in situ. Infection is rare, and prophylaxis for bacterial endocarditis is not required. 
 
TABLE 77-2.
Common Morphologic Features of Invasive Cancer
 
TABLE 77-3.
Breast Needle Aspiration Cytology of Solid Lesions and Recommended Follow-up

Equipment

Please see the follow appendixes for supply information: 
  • Appendix A: Informed Consent

  • Appendix C: Bacterial Endocarditis Prevention Recommendations

  • Appendix E: Skin Preparation Recommendations

  • Appendix I: Suggested Tray for Soft Tissue Aspiration and Injection Procedures

    • Two sterile plain evacuated blood tubes

    • Needles, 21, 22, 23 gauge

    • Syringe of appropriate size

    • Pistol grip device if desired

    • Slides with frosted ends (three or four)

    • Glass cover slips or extra slides for smearing the specimens

    • Gauze pads, 4 × 4 inches

    • Sterile gloves

    • Alcohol, povidone-iodine, or chlorhexidine swabs

    • Syringe (1 mL) with 30-gauge needle and 1% lidocaine for anesthesia

Indications

  • Presence of a palpable mass in the breast

Contraindications

  • Local infection

  • Absence of a qualified cytopathologist capable of interpretation of the FNA slides

  • Lack of clinician training with the procedure

  • Severely immunocompromised patients (relative contraindication)

The Procedure

Step 1

Several devices may be used for the FNA procedure. A 21-gauge butterfly with extension tubing can be attached to any device or syringe and used with a nurse applying the back pressure and the clinician focusing full attention on the needle tip. The mechanical movement for the Cameco pistol syringe (shown) is produced by motion of the arm and elbow. This device allows for easy application of extensive suction and good control of the syringe and needle. 

Step 2

Palpate the lesion, and mark the skin to indicate the point of needle entry. Prep the skin with alcohol, povidone-iodine, or chlorhexidine solution (see Appendix E). Attach the needle, and draw approximately 1 mL of air into the syringe. 

Step 3

Use the nondominant hand to surround and stabilize the lesion. Surrounding the lesion allows the sensory portion of the fourth and fifth fingers to feel the needle tip enter the lesion as the lesion moves against these fingers. Rarely, the glove may need to be removed from the nondominant hand if it interferes with palpation of the lesion. Make sure the patient understands why the glove is being removed. 
  • PITFALL: Use care to avoid putting the needle tip through the breast and into the examiner’s hand.

  • PITFALL: Isolating the lesion by using the nondominant hand to press the lesion down against the chest wall increases the risk of a pneumothorax.

Step 4

Insert the needle into the lesion, and withdraw the plunger to create a vacuum. If the lesion is a cyst, the fluid will usually flow easily into the syringe. Withdraw all of the fluid and palpate the area to be sure the lesion is completely gone. If residual lesion is present, consider an open biopsy. If the cyst completely disappears and the fluid is not bloody, the fluid does not have to be sent for analysis. Otherwise, submit the fluid on slides or in a sterile (without anticoagulant) blood collection tube. 

Step 5

If the lesion is solid, make 10 to 20 up-and-down passes, keeping the needle in the lesion. The sample will fill the needle and possibly part of the hub. With the needle still in the lesion, return the plunger to the resting position to release the suction. Then withdraw the needle from the skin. 
  • PITFALL: Do not let the needle come out of the skin while a vacuum is present in the syringe. This causes the sample to be drawn up into the syringe, where it may be difficult to remove.

  • PITFALL: It is not necessary to change the angle of the needle during the FNA, because it is the passage of the needle into the center of a lesion and the subsequent back-and-forth motion of the needle tip around the initial needle pass that allow shaved fragments of cells to enter the syringe. Moving the needle tip off this initial path in the center of the lesion often results in the needle moving out of the lesion and causes undue errors.

Step 6

With the needle pointed downward, use the air in the syringe to deposit the sample into monolayer preservative or onto the slide. 

Step 7

When using a slide, place a second glass slide upside down on top of the original slide, and then gently pull the slides in opposite directions to smear the cellular contents over both slides. This technique usually yields two to four slides. 

Step 8

Apply spray fixative as when obtaining a Papanicolaou smear. If a solid-core specimen is expressed from the needle (rare), wash it from the slide into a vial of preservative, and submit it for histologic examination. Remove the syringe from the needle, replace it with a fresh one, and repeat the procedure if desired. 

Step 9

Apply compression to the aspiration site with a gauze pad for 5 to 10 minutes to help minimize bruising. Place several folded gauze pads under a snug brassiere to form a compression dressing. 

Complications

  • The major risk of the FNA procedure is failure to place the needle tip into the lesion. Significant complications of FNA, such as pneumothorax, are rare. Some patients experience mild soreness, hematoma formation, and skin discoloration. The patient with controlled anticoagulation may safely undergo FNA if parameters are in the therapeutic range and adequate site compression is used after the procedure to avoid hematoma. All patients undergoing FNA of breast lesions should wear a supportive brassiere after the procedure.

Pediatric Considerations

This procedure is usually not performed in the pediatric age groups. 

Postprocedure Instructions

Instruct the patient to leave the pressure dressing in place for at least several hours to prevent hematoma formation. A small ice pack can be applied to the FNA site for 15 to 60 minutes after the procedure if desired. The samples are sent for cytologic or histologic analysis using staining and simple microscopy or a monolayer system. Arrange for a follow-up visit to discuss results. 

Coding Information and Supply Sources

Common ICD9 Codes

Suppliers

  • The Cameco syringe pistol ($286) is available from Precision Dynamics Corporation, 13880 Del Sur Street, San Fernando, CA 91340-3490. Phone: 1-800-772-1122. Web site: http://www.pdcorp.com, although this item is not on their Web site.

  • Morton Medical Ltd., 262a Fulham Road, London SW10 9EL. Phone, UK only: 0207 352 1297; phone outside of the UK: +44 207 352 1297. Web site: http://www.mortonhealthcare.co.uk/products_index.htm

Note that the FNA-21 fine-needle aspiration device from CooperSurgical has been discontinued. 

Bibliography

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Conry C. Evaluation of a breast complaint: is it cancer? Am Fam Physician.  1994;49:445–450, 453–454.
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Hamburger JI. Needle aspiration for thyroid nodules: skip ultrasound—do initial assessment in the office. Postgrad Med .  1988;84:61–66. [View Abstract]
Hammond S, Keyhani-Rofagha S, O’Toole RV. Statistical analysis of fine-needle aspiration cytology of the breast: a review of 678 cases plus 4,265 cases from the literature. Acta Cytol.  1987;3:276–280.
Ku NNK, Mela NJ, Fiorica JV, et al. Role of fine needle aspiration cytology after lumpectomy. Acta Cytol.  1994;38:927–932. [View Abstract]
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Lee KR, Foster RS, Papillo JL. Fine-needle aspiration of the breast: importance of the aspirator. Acta Cytol.  1987;3:281–284.
Lever JV, Trott PA, Webb AJ. Fine-needle aspiration cytology. J Clin Pathol.  1985;3:1–11.
Stanley MW. Fine-needle aspiration biopsy: diagnosis of cancerous masses in the office. Postgrad Med.  1989;85:163–172. [View Abstract]
Vural G, Hagmar B, Lilleng R. A one-year audit of fine needle aspiration cytology of breast lesions. Acta Cytol.  1995;39:1233–1236. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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