1853 : James paget cell aspirates from breast cancer 1904 : Greig and gray trypanosomes from lymph

mph node 1921 : Guthrie malignant lymphoma from lymph node 1930 : Martin and Ellis diagnose a variety of swellingin memorial hospital in New York FKUI : begin 1989

Distinguish benign from malignant lesions Classify neoplasms and others pathologic processes

The patient
Minimal pain and post aspiration discomfort Anesthesia is rarely necessary

Can be used in high risk patients

Usually an outpatients procedure Save time and hospitalization

Rapid alleviation of anxiety

More time to adjust to other procedures

Clinical management
Easily repeated Allows sampling of multiple area with minimal trauma Minimal disturbance of tissue planes for the sole

purpose of diagnosis Confirm malignancy of a nodule, but leaves it intact to monitor therapy by clinical examination or by repeated aspiration Therapeutic for some masses ( cysts and abscesses) Does not require extensive training of physicians Quick feedback help in training and planning other investigative procedures

The laboratory
Simple, inexpensive equipment Excellent cell preservation due to rapid

fixation Allows studies requiring freshly harvested cells material can be obtained for other examination ( microbiology, molecular technique, cytogenetic studies, enzymatic assay, stem cell culture etc)

Marked hemorrhagic diathesis increases the risk of a significant hemorrhagic Highly vascular tumors Aneurysm or a vascular malformation Deep organ(specific for each organ) severe cough, bullous emphysema, pulmonary hypertension, respiratory failure in the case of lung aspiration Liver severe jaundice, suspicious of hemangioma or hydatid disease

1. Superficial organ/ nodule

Lymph node Thyroid Breast Salivary gland Others nodule

2.Deep organ by imaging guidance

liver Intraabdominal mass Unpalpable mass etc

FNAB DEFINITIVE DIAGNOSIS ?

Depend on : - Organ - disease (diagnosis) - need ancillary technique ( Imunocytochemistry, molecular technique, etc ) - consensus

Dawson et al (1998) : excellent result in breast cancer diagnosis(35 y.o or younger) Cohen et al (1987) and Ljung et al (2001) : correct diagnosis in 97% - 98% of patients Stahl (1996) : suggested that asking the patient to indicate the location of the lesion is more reliable than actual palpation Procedures may be used :

Palpable lesion ( solid, cystic) Non-palpable lesion ( mammography, USG, MRI

etc)

Smear or cell block suitable for ancillary examination

ER,PR, Ki-67 (proliferation factor), HER-2

Limitation of FNAB
Result of FNA is atypical or suspicious : the procedure should be repeated, another opinion or The lesion should be excised for histopatologic examination

Protokol penatalaksanaan pasien (National Cancer Institute Consensus Conference on the uniform approach to breast FNAB )

PENYEBAB DIAGNOSIS FALSE-NEGATIVE

Kegagalan mendapatkan sampel yang

representative, berhubungan langsung dengan karakteristik tumor (size, lokasi, derajat fibrosis, tipe histologik, diferensiasi), faktor tehnik Kegagalan pengenalan sel ganas, berhubungan dengan pengalaman ahli patologi

PENYEBAB DIAGNOSIS FALSE-POSITIVE

Interpretasi yang kurang tepat pada lesi atipik Preparasi slide buruk

INSUFISIENSI /UNSATISFACTORY( NOT REPRESENTATIVE) NEGATIVE (BENIGN LESION) INCONCLUSIVE (SUSPICIOUS) POSITIVE FOR MALIGNANCY

Invasive ductal carcinoma

FNAB accepted by head-neck surgeon as an excellent Zaijcek, 1974 ; Batsakis et al, 1992; Boccato et al 1992 primary methods of evaluating space occupying lesion of the salivary glands FNA of salivary glands :
Is the mass of salivary gland origin ? If the mass is of salivary gland origin, is it neoplastic or

non-neoplastic ? If the mass neoplastic, is it benign or malignant ? If the mass is malignant, is it primary or metastatic ?

Diagnosis of FNAB :
Influences management of the patients

(Zaijcek,1974;Kocjan et al ,1990; Orell, 1995)

For example :
Benign lesion/neoplasms : surgical

intervention may be delayed or modified Malignant neoplasms : prompt surgical treatment or irradiation

Significant complication rare Kern (1998) : postaspiration necrosis in a case of warthins tumor Layfield et al (1992) : necrosisin a case of pleomorphic adenoma Stephens et al (1999) : xantogranulomatous following FNA of Warthins tumors Li et al (2000) and Mukunyadzi et al (2000) review the histology Salivary glands lesions previously samples by FNAB :
Infarction, necrosis, hemorrhage, inflammmation,

granulation tissue

The primary objective :

Select the case : Require surgery for neoplastic Inflammmatory abnormality followed clinically or treated medically

Aspiration biopsy
25 gauge needle
Larger caliber needles NOT

RECOMMENDED (bleeding)

Adequate/inadequate Benign non neoplastic lesion Cellular follicular lesion Hurtle cell neooplasm Suspicious neoplasm Malignant

Adequacy of aspiration biopsy :

Six clusters of epithelial cells Some centers do not agree case with

pure colloid goiter ?? Depent of type of lesion (cystic or solid)

Ground glass appearance

PAPILLARY CARCINOMA OF THE THYROID

COURTESY OF PROF. SHOTARO MAEDA, NMS

FOLLICULAR CARCINOMA OF THE THYROID

COURTESY OF PROF.S HOTARO MAEDA, NMS

Triple diagnosis : 1. Clinical diagnosis 2. Radiology diagnosis 3. Cytology/Histopathology diagnosis

COURTESY OF PROF.S HOTARO MAEDA, NMS

GIANT CELL TUMOR OF THE BONE

COURTESY OF PROF.S HOTARO MAEDA, NMS

FNAB OF THE LUNG

ESTS, Deleyn P , Eur Cardio T Surg 2007

ACCP, Detterbeck F, Chest 2007

Janes and Spiro, AJRCCM 2007

COURTESY OF DR. MAUD VESSELIC, LUMC

Radial vs Linear Endosonography (2)

COURTESY OF DR. MAUD VESSELIC, LUMC

Scopes and Ultrasound Processor

COURTESY OF DR. MAUD VESSELIC, LUMC

Transesopfageale echografie + naald punctie

COURTESY OF DR. MAUD VESSELIC, LUMC

Small cell lung carcinoma

Cells showing increasd cytoplasma that may be mistaken for non-small cell carcinoma

Syncytial group with nuclear molding and paranuclear cytoplasmic globules (so-called blue bodies)

Immediately put the slide (after make smear) into alcohol fixative 95% -96% minimally 30 minutes. A part of slides let in the air until dry ( if possible use hairdryer or fan to make dry fast ) Dont forget to write down the patient label on the slide Send to laboratory with form and completely clinical data