Hand Surgery Source

Needle Aspiration and/or Biopsy

Diagnostic Study - Description & Definition

Background

The hands are frequently exposed to various types of trauma, and as a result, a number of reactive, reparative, and infectious processes may eventually form mass lesions. The majority of these lesions can be accurately diagnosed with a thorough history and physical examination, but a number of benign and malignant neoplasms may be indistinguishable from nonneoplastic conditions with these methods alone when symptoms are nonspecific. Fine-needle aspiration biopsy (FNAB) is a minimally invasive, quick, and inexpensive technique for obtaining a tissue diagnosis of lesions to distinguish between benign and malignant tumors. FNAB is a highly sensitive and specific diagnostic tool that can help achieve an early diagnosis and prevent unnecessary and expensive open biopsies.1-3

Historical Overview

The use of FNAB can be traced back to 1847 when Kun described a “new instrument for the diagnosis of tumors.” He described an exploring needle incorporating a depression at the tip with cutting edges for extracting tissue from a subcutaneous tumor. The subsequent history of FNAB was complicated by a series of clinical hurdles, as many clinicians and pathologists initially saw it as inferior to tissue biopsy for diagnosing tumors. Many pathologists had vast training and experience interpreting tissue biopsies, but the lack of sufficient background in cytology and knowledge of associated pitfalls made the practice of FNAB initially reserved to major institutions. But a slow approach over the years to these difficulties, and the performance of research studies with encouraging results allowed the technique to eventually find its place in the field of diagnostic pathology. It is believed that FNAB was specifically inspired by Mannheim in Berlin in 1931 after a series in which he used a 1.0-mm diameter needle to perform aspirations. During the 1950s, awareness of the potential benefits of FNAB increased, and in 1974, Zajicek described precise diagnostic criteria that would serve as the model for FNAB services for the rest of the world. Today, pathologists, clinicians, and radiologists utilize FNAB as a diagnostic tool worldwide.4

Description

The standard technique for FNAB involves a 21- or 22-gauge, 1.0- or 1.5-inch-long needle. After the skin has been cleaned, the mass is examined, and if it can be felt, it is subsequently positioned for needle entry. If the mass cannot be felt, imaging such as ultrasound may be needed to find the exact location and guide the needle. At least 3 aspirations are typically carried out in each case, and several passes may be made during each aspiration. After aspiration, the needle is rinsed into cell culture media after making conventional smears. An initial assessment is then performed by staining some of the air-dried smears with a Romanowsky stain, and the remaining slides with a modified Papanicolaou stain after rehydration. From a clinical point of view, lesions are classified as either superficial or deep-seated. Cytologically, aspirates are typically classified into 1 of 5 categories:

  • Benign aspirate without a specific cytohistologic diagnosis
  • Benign aspirate with a specific cytohistologic diagnosis
  • Atypical aspirate
  • Malignant aspirate without a specific cytohistologic diagnosis
  • Malignant aspirate with a specific cytohistologic diagnosis.1,2,5
Normal Study Findings - Images (For abnormal findings images, click on Diagnoses below)
Diagnoses Where These Studies May Be Used In Work-Up (with abnormal findings images)
Comments and Pearls
  • The low morbidity and relatively noninvasive nature of FNAB may alleviate potential complications incurred with open biopsy in this particular area, including nonesthetic scars for lesions that may not need excision, inadequate wound closure, and manipulation that may adversely impact tumor spread or a future potentially curative procedure.
    • The major disadvantages of FNAB are the accumulation of insufficient cells for diagnosis and sampling error, which may be reduced by selecting appropriate lesions for aspiration, correlating clinical features with the radiographic appearance to determine the best aspiration site, and using the proper FNAB technique.1
  • Despite the fact that >50% of the bones in the human body are found in the distal extremities, skeletal lesions are uncommon in these areas. Inflammatory or infectious processes constitute the majority of bone pathology in the distal extremities, whereas benign and malignant neoplasms have been reported to constitute 6% and 15%, respectively.1
  • The hand is a special anatomic region in which many important structures such as nerves, vessels, tendons, and bones are confined in a small space, which makes reoperation after recurrence and further operations for malignancy difficult. thus, it is desirable that the preoperative diagnosis of soft tissue tumors of the hand is precise.5
References
  1. Jakowski, JD, Mayerson, J and Wakely, PE, Jr. Fine-needle aspiration biopsy of the distal extremities: a study of 141 cases. Am J Clin Pathol 2010;133(2):224-31.PMID: 20093231
  2. Garcia-Solano, J, Garcia-Rojo, B, Sanchez-Sanchez, C, et al. On the utility and limitations of fine-needle aspiration of palpable lesions located in the hand. Diagn Cytopathol 2000;23(4):284-91. PMID: 11002373
  3. Ogun, GO. Fine needle Aspiration Biopsy (FNAB) in the initial evaluation and diagnosis of palpable soft tissue lesions and with histologic correlation. Pan Afr Med J 2015;20:44. PMID: 26090002
  4. Rosa, M. Fine-needle aspiration biopsy: a historical overview. Diagn Cytopathol 2008;36(11):773-5.PMID: 18831026
  5. Kitagawa, Y, Ito, H, Sawaizumi, T, et al. Fine needle aspiration cytology for soft tissue tumours of the hand. J Hand Surg Br 2003;28(6):582-5. PMID: 14599833