CHAPTER 10

NEEDLE BIOPSIES
Andrew L. Singer M.D.
Attila Nakeeb M.D.
Needle biopsy is a powerful technique that is most often used to distinguish malignant from benign
disease. Recently it has given the clinician the ability to follow the progression of many benign
processes, such as transplant rejection. With ready access to ultrasound, the surgeon can now safely
sample both palpable and nonpalpable lesions at the bedside or in the outpatient office.
Needle biopsy can be divided into two general categories: (1) fine needle aspiration (FNA), in
which a fine needle is inserted into the tissue and a collection of single cells is obtained for
cytological diagnosis, and (2) large needle cutting biopsies (LNCB), in which a large cutting needle
retrieves a cylinder of tissue for histological diagnosis. The major shortcoming of both techniques is
that when small samples are obtained they may inadequately represent the tissue being sampled.
However, in skilled hands, needle biopsy is a sensitive, inexpensive, and relatively noninvasive
modality for the evaluation of pathology of the head and neck, thyroid, breast, liver, kidney,
pancreas, and subcutaneous and muscular masses.
I. FINE NEEDLE ASPIRATION
A. THYROID

• Indications:
• Evaluation of palpable thyroid masses
• Differentiation of benign from malignant thyroid lesions
P.305

• Contraindications:
None
• Anesthesia:
Anesthesia is not routinely used for FNA. However, if needed, a small amount of 1%
lidocaine may be infiltrated locally, taking care not to distort the palpable lesion.
• Equipment:
• Alcohol prep
• 10-ml syringe
• 1/2-inch 25-gauge needle
• Syringe holder (optional)
• Glass microscope slides (two)
• Spray fixative, gauze
• In many situations, it may be preferable to have a cytopathologist present.
• Positioning:
The patient is placed in a supine position, and a roll is placed behind the shoulders to allow
for neck extension and to bring the lesion closer to the surface (see Figure 10.1).
 Fig. 10.1.
P.306

• Technique:
• Prep the area for aspiration with an alcohol prep pad as if for phlebotomy.
• Palpate the lesion and immobilize the mass between the fingertips of the
nondominant hand (see Figure 10.2).

Fig. 10.2.
• Using the dominant hand, advance a 25-gauge needle with an attached 10-ml syringe
into the lesion. The needle should be directed medially, toward the trachea (see
Figure 10.3).
 Fig. 10.3.
• Note the consistency of the mass upon entering it with the needle (firm, soft, rubbery,
doughy, gritty).
• Once the lesion is entered, a full 10 ml of suction is applied to the syringe. In a
variant of this procedure, the nonsuction technique, no negative pressure is applied to
decrease local trauma and bleeding.
• While maintaining suction (if used), move the needle back and forth through the
lesion several times in different directions (see Figure 10.4).

Fig. 10.4.
• Release the syringe plunger and allow it to return to a neutral position prior to
removing the needle from the lesion. In the nonsuction technique, the plunger will
 already be in neutral
P.307

position. At this point the specimen is within the needle and hub and should not be in
the syringe.
• Remove the needle from the patient, and have the patient apply pressure to the
puncture site with a gauze pad.
• Detach the needle from the syringe.
• Fill the syringe with air.
• Reattach the needle onto the syringe.
• Touch the needle tip to a glass microscope slide with the bevel at a 458–908 angle
to the slide surface.
• Expel material within the needle onto the slide.
• Make a smear by using a second glass slide to gently press down and draw out the
material to a feathered edge. If the material is more liquid, it is pulled in the same
fashion as a blood smear, except that before the feathering process is completed, the
spreading slide is raised, leaving a line of
P.308

particles across the slide. The spreading slide is then turned and again pressed down
against the line of particles and drawn out into a feathered edge.
• Air dry or apply cytological fixative to the slide per the protocol of the cytopathology
laboratory that will be processing the specimen. (If a fixative is applied, it must be
applied very quickly, usually within seconds of preparing the smear.)
P.309

• Most cytopathologists require 3–6 needle passes (samples) for an adequate

pathological diagnosis.
• If a cyst is aspirated, the cyst fluid should be sent for cytology. The region of the cyst
should then be re-examined; if a residual mass is felt, it should then undergo FNA.
• Complications and Management:
• Bleeding and hematomas
• Thyroid punctures may produce significant hematomas and ecchymoses.
• Apply firm direct pressure to puncture sites immediately following aspiration.
• Tracheal puncture
• If the trachea is entered, the suction in the syringe will be lost, and the
aspiration will need to be repeated.
• Puncture is usually of no consequence due to the small gauge of the needle.
• Infection
• Extremely rare in FNA but has been reported
• Antibiotics as appropriate
• Incision and drainage as necessary
B. BREAST, LYMPH NODE, AND SOFT TISSUE
• Indications:
• Evaluation of palpable masses
• Aspiration of breast cysts
• Differentiation of benign from malignant lesions. In breast disease, stereotactic large-
gauge needle biopsy by radiologists has become the technique of choice for
evaluation of breast lesions. However, FNA continues to be a valid technique and is
 essential for centers lacking stereotactic facilities.
• Contraindications:
None
• Anesthesia:
Anesthesia is not routinely used for FNA. However, if needed, a small amount of 1%
lidocaine may be infiltrated locally, taking care not to distort the palpable lesion.
P.310

• Equipment:
• Alcohol prep
• 10-ml syringe
• 1 1/2-inch 25-gauge needle
• Syringe holder (optional)
• Glass microscope slides (two)
• Spray fixative
• Gauze
• Positioning:
• Breast: For upper quadrant lesions, the patient is placed in an upright seated position.
Lower quadrant lesions are better managed in a supine position.
• Lymph node and soft tissue: depends on location of lesion.
• Technique:
• Prep the area for aspiration with an alcohol prep pad as if for phlebotomy.
• Palpate the lesion and immobilize the mass between the fingertips of the
nondominant hand.
• Using the dominant hand, advance a 25-gauge needle with an attached 10-ml syringe
into the lesion (see Figure 10.5).

Fig. 10.5.
P.311

• Note the consistency of the mass upon entering it with the needle (firm, soft, rubbery,
doughy, gritty).
• Once the lesion is entered, a full 10 ml of suction is applied to the syringe.
• While maintaining suction, move the needle back and forth through the lesion several
times in different directions (see Figure 10.6).
 Fig. 10.6.
• Release the syringe plunger and allow it to return to a neutral position prior to
removing the needle from the lesion. At
P.312

this point the specimen is within the needle and hub and should not be in the syringe.
• Remove the needle from the patient, and have the patient apply pressure to the
puncture site with a gauze pad.
• Detach the needle from the syringe.
• Fill the syringe with air.
• Reattach the needle onto the syringe.
• Touch the needle tip to a glass microscope slide with the bevel at a 458–908 angle
to the slide surface.
• Expel material within the needle onto the slide.
• Make a smear by using a second glass slide to gently press down and draw out the
material to a feathered edge. If the material is more liquid, it is pulled in the same
fashion as a blood smear, except that before the feathering process is completed, the
spreading slide is raised, leaving a line of particles across the slide. The spreading
slide is then turned and again pressed down against the line of particles and drawn
out into a feathered edge.
• Air dry or apply cytological fixative to the slide per the protocol of the cytopathology
laboratory that will be processing the specimen. (If a fixative is applied, it must be
applied very quickly, usually within seconds of preparing the smear.)
• Most cytopathologists require 3–6 needle passes (samples) for an adequate
pathological diagnosis.
• If a cyst is aspirated, the cyst fluid should be sent for cytology. The region of the cyst
should then be re-examined; if a residual mass is felt, it should then undergo FNA.
• Complications and Management:
• Bleeding and hematomas
 • Breast FNA can be associated with significant hematomas and ecchymoses.
• Apply firm direct pressure to puncture sites immediately following aspiration.
• Pneumothorax
• More likely in thin patients and deep lesions
• If tension pneumothorax suspected, decompression with 16-gauge
intravenous line (IV) into second intercostal space and then tube
thoracostomy (see Chapter 4)
• If 10% to 20% pneumothorax, observation and serial chest radiographs
• If .20% pneumothorax, tube thoracostomy per Chapter 4
P.313

• Infection
• Extremely rare in FNA but has been reported
• Antibiotics as appropriate
• Incision and drainage as necessary
II. LARGE NEEDLE CUTTING BIOPSIES
A. SILVERMAN NEEDLE BIOPSY (SOFT TISSUE)
• Indications:
To differentiate benign and malignant lesions
• Contraindications:
Coagulopathy (PT or PTT ratio >1.3 times control, or platelets <20,000)
• Anesthesia:
1% lidocaine locally
• Equipment:
• Sterile prep solution
• Sterile gloves and towels
• 5-ml syringe
• 22- and 25-gauge needles
• Scalpel blade
• Silverman needle (see Figure 10.7)

Fig. 10.7.
• Sterile dressing
• Positioning:
The best patient position is when the lesion can be easily palpated and fixed into place by
the examiner using one hand. For most biopsies the supine position is preferred. In thyroid
and neck
P.314

aspirations a roll is placed behind the shoulders, which allows for neck extension and brings
the lesion closer to the surface.
• Technique:
• Sterile prep and drape the lesion to be biopsied.
• Infiltrate the skin overlying the lesion with 1% lidocaine, using a 25-gauge needle.
• Using the 22-gauge needle, infiltrate the subcutaneous tissue down to the mass with
anesthetic.
• Make a 5-mm incision in the skin and subcutaneous tissue with a scalpel.
 • Insert the Silverman needle with the obturator in place into the skin incision to the
edge of the mass.
• Remove the obturator, and place the cutting insert into the outer sheath and advance
into the mass (see Figure 10.8).

Fig. 10.8.
• Advance the outer sheath by rotation over the cutting insert to the tip. This maneuver
severs the specimen within the blades of the cutting insert (see Figure 10.9).

Fig. 10.9.
P.315

• Remove the needle with the outer sheath advanced over the cutting insert. Retrieve
the specimen and send to pathology for processing.
• Apply a clean sterile dressing to wound and apply pressure for 20–30 minutes.
• Complications and Management:
• Bleeding and hematomas
• Apply firm direct pressure to puncture sites immediately following aspiration.
• Correct coagulation abnormalities.
• Infection
• Antibiotics as appropriate
• Incision and drainage as necessary